VISALIA, Calif. — In the farming town of Exeter, deep in California’s Central Valley, Anne Roberson walks a quarter mile down the road each day to her mailbox. Her walk and housekeeping chores are the 68-year-old’s only exercise, and her weight has remained stubbornly over 200 pounds for some time now.

“You get to a certain point in your life and you say, ‘What’s the use?’”

For older adults, being mildly overweight causes little harm, physicians say. But too much weight is especially hazardous for an aging body: Obesity increases inflammation, exacerbates bone and muscle loss and significantly raises the risk of heart disease, stroke, and diabetes.

To help the 13 million obese seniors in the U.S., the Affordable Care Act included a new Medicare benefit offering face-to-face weight-loss counseling in primary care doctors’ offices. Doctors are paid to provide the service, which is free to obese patients , with no co-pay. But only 50,000 seniors participated in 2013, the latest year for which data is available.

“We think it’s the perfect storm of several factors,” says Dr. Scott Kahan, an obesity medicine specialist at George Washington University. Kahan says obese patients and doctors aren’t aware of the benefit, and doctors who want to intervene are often reluctant to do so. It’s a touchy subject to bring up, and some hold outmoded beliefs about weight problems and the elderly.

“It used to be thought that older patients don’t respond to treatment for obesity as well as younger patients,” Kahan says. “People assume that they couldn’t exercise as much or for whatever reason they couldn’t stick to diets as well. But we’ve disproven that.”

Indeed, one study found two out of three older patients lost 5 percent or more of their initial weight and kept it off for two years.

Weight loss specialists place the blame for poor awareness of the new benefit on the federal government’s decision to limit counseling to primary care offices.

“The problem with using only primary care providers,” says Bonnie Modugno, a registered dietician in Santa Monica, California, “is that they completely ruled out direct reimbursement for the population of providers who are uniquely qualified and experienced working with weight management. I think that was a big mistake.” She was referring to registered dieticians like herself, as well as specialists such as endocrinologists, who might be managing a person’s diabetes, and cardiologists, who monitor patients with heart disease. Both conditions can be caused by or made worse by excess weight.

The drafters of the health law deliberately wrote the benefit narrowly out of concerns about widespread fraud, if charlatans were able to bill Medicare for obesity counseling. Modugno says she is sympathetic to that concern, but it is too restrictive as enacted.

“Unless we change the nature of how…the counseling occurs, I don’t see it being available to people in a meaningful way,” said Modugno.

As for Anne Roberson, she says the extra weight she has long carried on her petite frame has begun taking a toll on her joints, her sleep and her mood. On a recent morning, Roberson listened politely to her longtime physician, Dr. Mylene Middleton Rucker, during her first Medicare weight-loss counseling session. Rucker suggested she eat more vegetables and less meat and encouraged her to join an exercise class.

Rucker, who is obese herself, says she doesn’t expect her older patients to lose a lot of weight. “I think you’ll see weight loss of 10 to 20 pounds, but whether you’re going to see people lose 50 to 100 pounds as they’re older, I doubt it.”. Still, Rucker says, even with small amounts of weight loss in her older patients, she expects to see a decrease in the complications of chronic medical diseases, including diabetes-related leg amputations.

Roberson says she has tried to lose weight before, but “you hit a couple of rough weeks and you kinda slough off.” This time, Roberson says firmly, she will have to come back and answer to Rucker.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

The Obama administration has blocked health plans without hospital benefits that many large employers argued fulfilled their obligations under the Affordable Care Act.

Companies with millions of workers, mainly in lower-wage industries such as staffing, retailing, restaurants and hotels that had not offered health coverage previously, had been flocking toward such insurance for 2015.

Plans lacking substantial coverage of hospital and physician services do not qualify as “minimum value” coverage under the law and so do not shield employers from fines of $3,000 or more per worker, the Department of Health and Human Services said late Friday.

The move closes what many saw as a surprising loophole, first reported by Kaiser Health News in September, that let companies bypass the health law’s strictest standard for large-employer coverage while at the same time stranding workers in sub-par insurance. Employees offered such plans would have been ineligible for tax credits to buy more comprehensive coverage in the law’s online marketplaces.

The agency did decide to allow such plans for this year only if employers had signed contracts by Nov. 4.

However, it also granted relief to workers offered such coverage, saying they may receive tax credits according to their income to buy more comprehensive insurance in the online exchanges. Ordinarily, employees offered coverage qualifying as minimum value aren’t eligible for the subsidies.

Despite what Washington and Lee University law professor Timothy Jost called “a lot of pushback” from employers, HHS has now followed through on earlier guidance that it intended to disallow such coverage.

A plan without hospital benefits “is not a health plan in any meaningful sense,” the agency said in a large batch of regulations issued Friday. Scoring such a plan as minimum value “would adversely affect employees (particularly those with significant health risks) who understandably would find this coverage unacceptable. …”

The ruling ends a debate that erupted last summer over HHS’ official, online calculator for determining minimum value in a large-employer plan.

The Affordable Care Act does not specify “essential health benefits” in large-employer plans, such as hospitalization and drugs, as it does for individual and small-business insurance. Instead, the minimum-value test requires large companies to cover at least 60 percent of expected medical costs.

One way to certify a plan as minimum value is to plug its components — benefits, deductibles and so forth — into the official calculator. Many were shocked to learn that the calculator gave passing scores to plans with no inpatient hospital coverage.

Now HHS is saying: Ignore the calculator. Large-employer plans must pay for substantial amounts of hospital care no matter what.

“What remains a mystery is whether the calculator was at fault,” Alden Bianchi, a lawyer who advises many companies that were considering such plans for 2015, said via email. “The regulators don’t say. Rather, they take the [position] (not unreasonable or nutty, in my view at least) that a plan with these services is not real health insurance.”

Even with its allowance for companies that had signed contracts by Nov. 4, HHS stopped short of employer pleas for more flexibility. Industry groups wanted a green light to temporarily offer plans without hospital benefits if companies had made substantial preparations to do so but hadn’t signed a deal.

It’s unclear how many firms will offer such coverage for 2015. Nearly half of the 1,600 employer members of the American Staffing Association, which employ 3 million temporary employees on any given day, had committed to offer or were considering the plans last fall before KHN reported that regulators were moving against them.

While some members followed through and adopted such coverage, most did not, said Edward Lenz, senior counsel for the association, a trade group of temp and recruiting firms.

Calculator-approved plans lacking hospital benefits are comparatively rich in outpatient services such as doctor visits. Consultants selling the coverage had argued it was a good first step for lower-wage, high-turnover employers that had never offered major-medical insurance.

“I’ve had a couple discussions in the last several days with clients who were interested but disappointed they were too late to install them for 2015,” said Edward Fensholt, a benefits lawyer with brokers Lockton Companies. Other companies “leapt on them,” he said.

For employers that planned to offer such coverage but hadn’t pulled the trigger by Nov. 4, “this is very disruptive news,” Bianchi said. “Best I can recall, I have about a half dozen clients that are in this position.”

Anne Lennan is president of the Society of Professional Benefits Administrators, whose members process claims for self-insured employers.

“A very small number of non-hospital plans were implemented by my members — as a percentage of all the plans they administer,” she said via email.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Republican efforts to replace the federal health law have been given new urgency by the Supreme Court.

As soon as this spring, the court could invalidate health insurance subsidies available to millions of Americans if it rules for the challengers in a case called King v. Burwell.

Republicans who hate the Affordable Care Act are rooting for the court to do what they have been unable to accomplish – dismantle a key part of the law. But as the party that controls Congress, some Republicans also fear the potential for a backlash if they don’t have a plan to help those who would effectively be stripped of coverage, many of whom are voters in Republican-led states.

There’s another reason to agree soon on a replacement for the law, instead of continuing their long campaign to repeal it. If Republicans present a reasonable alternative, it could help swing a justice or two who might otherwise worry about the possible ramifications of cutting off the subsidies. Or so the reasoning goes.

“The Republicans would love to give the justices some comfort that if they rule against the Obama administration, there will be something there to deal with the fallout,” says Dean Clancy, a Republican strategist and former aide to House Majority Leader Dick Armey.

Those pushing the case argue that language in the law limits help to pay for insurance to residents of states that have established their own health insurance exchanges. So far only 13 states have – the rest use the federal healthcare.gov exchange.  The administration contends that Congress clearly intended that the subsidy — tax credits based on income — be available in all states, and has declined to discuss any possible contingency plans.

If the court rules against the administration, the impact will fall heavily on Republican-led states, such as Florida and Texas, that didn’t create their own exchanges, increasing pressure on Congress to act.

“I really do believe that this situation has concentrated the minds of many people on [Capitol] Hill,” says Avik Roy, a senior fellow at the Manhattan Institute and a former health advisor to GOP presidential candidate Mitt Romney. If the Supreme Court rules that subsidies cannot be provided through the federal health exchange, he says, Republicans in the House and Senate “realize if they don’t do something, they will be held accountable for that. Because they are running Congress now, so they can’t blame it on the Democrats.”

Still, putting something on the front burner does not guarantee it will get done. Republicans have been vowing to “repeal and replace” the Affordable Care Act almost since it became law in 2010. So far, the GOP-controlled House has held more than 50 separate votes to repeal or otherwise cancel parts of the law. Replacing, however, has been another story.

“Republicans are united around repeal. And they’re united around replace. But obviously they’re not united around ‘replace with what,’” says Dean Rosen, a health policy consultant who was a top aide to former GOP Senate Majority Leader Bill Frist and to the House Ways and Means Committee.

Republican health strategist Terry Holt, a former aide to the GOP House leadership, agrees. He says Republicans “are serious about a replacement” for the Affordable Care Act, “but it’s the law, and it’s harder to change law than to make it.”

There are several efforts underway to come up with a consensus Republican alternative to the health law. The repeal bill the House approved Feb. 3 includes language requiring the four main committees that handle health legislation in that chamber to approve a replacement, but no time limit is specified.  Separately, three of those committee chairmen were tasked by House Majority Leader Kevin McCarthy in January to come up with a health bill, again with no specific deadline.

Across the Capitol, two GOP senators with deep backgrounds in health — Finance Committee Chairman Orrin Hatch, R-Utah, and Richard Burr, R-N.C. — along with House Energy and Commerce Committee Chairman Fred Upton, R-Mich. have unveiled the outlines of a plan that was first floated last year.

And House Ways and Means Committee Chairman Paul Ryan, R-Wis., has said Republicans in the House are working on a short-term “bridge” for those who could get stripped of their insurance subsidies, although again, no specifics have been offered.

Even with new incentives, getting to specifics won’t be easy, says Clancy, for much the same reasons that have kept Republicans from being able to agree on a health overhaul for the past five years.

“There are pro-business Republicans and pro-market Republicans, and you see the divide on lots of issues, including health care,” he says.

For example, the more pro-market, libertarian types “would say let’s get the federal government out of the health insurance business altogether if possible, or at least create a much more voucher-like system with as little centralized control as possible,” he says. But the more traditional pro-business Republicans “are not going to be keen on blowing up the employer-based system.” Currently a majority of Americans still get their insurance through their or a family member’s job.

Another complication, says Rosen, is the impending presidential campaign, and the possibility that several sitting members of the Senate may run. “And you can see that the people who are posturing to be candidates … don’t just want to do Obamacare light,” he said.

Still, the prospect of millions of people in states run by Republican governors and Republican legislatures losing their insurance could be the deciding factor, says Holt. “These are people who have been promised something and are expecting it to continue, and it’s hard to see how you cut people off,” he says.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.