Weight Stigma, Eating Disorder Treatment, and Insurance Appeals
Eating disorders are biopsychosocial conditions that are far more complex than definitions and diagnoses based on body size. Eating disorders of all kinds are experienced by people of all sizes.
People of all sizes also have experiences in which insurance creates barriers to the eating disorder care they need and deserve. For higher-weight people, these barriers can be even greater and more difficult to fight. Before we look at the options to navigate these issues, I want to make it crystal clear that you deserve eating disorder care and that if you are experiencing barriers to getting that care, including weight stigma and/or insurance issues, that may become your problem, but it is not your fault.
If you are a loved one or clinician helping a higher-weight patient/client navigate these barriers, it is imperative that you keep this top of mind — the patient/client is never the problem. The patient/client is never too big for insurance, eating disorder treatment, or healthcare of any kind. Sadly, sometimes insurance, eating disorder treatment, and/or healthcare are too small for the patient. To reiterate, this may become the patient’s problem to deal with, but it never was, is, or will be, their fault. Further, as scholars like Dr. Sabrina Strings and Da’Shaun Harrison have taught us, weight stigma is rooted in and inextricable from racism and anti-Blackness. Weight stigma, including within eating disorder treatment, will always disproportionately harm Black and brown people, those of the highest weights, and those with intersecting marginalized identities.
The U.S. healthcare system creates significant additional complexity. While the 2010 Affordable Care Act improved access to care, there are still significant differences in care between different states, insurance providers, and facilities that prevent a unified approach to accessing care and fighting denials. For that reason, I’ve created templates that can be heavily modified to fit various situations.
Weight/BMI-Based Care Denials
Some insurance companies focus on body size when it comes to approving and/or continuing care. This is often based on the (incorrect) assumption that eating disorders are less severe when they occur in higher-weight people. This causes people with BMIs above their insurance companies’ arbitrary thresholds to experience treatment denials and/or be relegated to lower levels of care than they need.
In a similar vein, insurance companies may use BMI/increased BMI as an indicator of recovery, such that those of higher weights may be more likely to lose insurance coverage during treatment before they are truly ready to move on or to move to a lower level of care.
Mishra and Harrop discuss this in their piece “Teaching How to Avoid Overreliance on BMI in Diagnosing and Caring for Patients With Eating Disorders” in the American Medical Association Journal of Ethics.
They point out that the “hallmark symptom” of anorexia nervosa has traditionally been “emaciation with low BMI” and that even in the DSM-5, anorexia is still diagnosed based on the patient having “a significant low body weight.” The “diagnosis” of “atypical anorexia nervosa” has been created despite the fact that the symptoms and harms are the same regardless of size (and, as Mishra and Harrop point out, the prevalence is two to three times higher in higher-weight people.) This has led to a diagnosis that is based not on patients’ symptoms or harms, but simply based on patients’ size. Essentially, “atypical anorexia” is “have anorexia while existing in a higher-weight body.” This, Mishra and Harrop point out, leads to a finding that higher-weight people have odds of receiving inpatient medical care that are six times lower than those who aren’t higher-weight.
For all of these reasons, higher-weight people may need to appeal care denials. In Erin Harrop’s excellent dissertation, which was a “mixed methods study of weight stigma and healthcare experiences in a diverse sample of patients with atypical anorexia,” they found that all participants reported that they were either denied higher-levels or care or experienced insurance coverage ending while they were still in need of higher care levels, leaving some participants accepting lower levels or care or no care at all and others “fighting insurance” to get care.
If you, a loved one, or a client/patient find yourself in this situation, you can find a modifiable template below to appeal that denial.
Accommodation Failures
Facilities may fail to accommodate higher-weight patients. This may include anything from a lack of sturdy armless chairs in a therapist’s office or group session, to a lack of accommodating imaging equipment in a hospital, to a lack of appropriately weight-rated beds in a residential program.
In Erin Harrop’s dissertation, they found that participants had experienced systemic weight stigma, including weight-centric providers, unaccommodating medical equipment, and issues with health insurance.
The idea, spoken or implied, that higher-weight people should have to shrink themselves to fit into healthcare is inappropriate in any circumstance, but it is particularly dangerous for those seeking eating disorders treatment for whom this may serve to perpetuate disordered thoughts and behaviors around eating and body size.
You can ask to be accommodated. This can bring up emotions like stress, shame, fear, embarrassment, guilt, and anger. Those feelings are often rooted in the lie we are told that asking to be accommodated is asking for “special treatment” when, in reality, all we are asking for is what everyone else is already getting. You can find general tips and tricks from the Fat Legal Advocacy, Rights, and Education (FLARE!) Project to ask for accommodations here.
If you don’t want to ask for accommodations or you aren’t able to (both of which are completely valid), or if you ask and are denied, you still have options. First, you can research to find a facility that can accommodate you. Then, you can ask your insurance company for an exception to be able to access treatment in an out-of-network facility that can accommodate you. You can find a template for that below.
One more time before I wrap this up: you should be accommodated and treated with respect and without weight stigma in every aspect of your healthcare, including eating disorder care. If you are not, I want you to be empowered to push back, but even more than that, I want you to know that this isn’t your fault, it shouldn’t be happening, and you deserve better.
