Bill would remove BMI from state health standards

Kentuckians being treated for eating disorders who gain much needed weight in treatment sometimes reach a body mass index threshold that, on paper, makes them seem healthy, triggering the end of insurance coverage for treatment.

Louisville Republican Rep. Ken Fleming wants to change that and is filing legislation in 2026 that would remove body mass index (BMI) from treatment standards for state-qualified health insurance plans marketed through kynect.

A Louisville eating disorder expert said such a change is needed.

"I've had this happen to me too many times to count at this point now: You will have somebody who is in treatment and who needs more treatment, but they gain a little bit of weight because they're eating regularly, because they're in treatment, and then the insurance company says, 'OK, well, they don't need treatment anymore, we're going to discharge them right then,'" said Cheri Levinson, an associate professor with the University of Louisville and the director of Louisville's Eating Anxiety Treatment (EAT) Lab.

"On the opposite end of that, you might have somebody who loses half a pound, and the insurance company says, 'Oh, well, they need a higher level of care, so they can't stay in your treatment program anymore,'" she added. "Essentially, as a clinician or as a clinic providing this type of treatment, you end up in this situation where any sort of movement on weight causes the insurance company to discharge them from the care that they need."

Fleming, who has experience running a mental health agency, said his legislation initially came from a constituent a few years ago who had issues with insurance while in treatment.

"Once an individual reaches the BMI threshold, then coverage can be stopped. But they're missing the point in terms of treating the mental health aspect of it," Fleming said. "And so, once you reach that threshold, there's, I guess, an approach or thought that, 'OK, you reached it. You're fine. Let's move on.' In reality, that's not the case. You may have gotten your body into a better spot, but you still have some elements or some issues or some challenges or some triggers or whatever it might be that could (cause) them to relapse."

Using BMI in general is "extremely problematic," Levinson said.

"We know that BMI is supposed to be a population-based measure, not an individual indicator of health," Levinson said. "Weight gain is only one of the characteristics that's needed for somebody to recover from an eating disorder, and usually you'll have people who are nutritionally restored, … their BMI might look healthy, but they're actually still extremely cognitively sick. Their brain has not healed yet."

Fleming's bill will apply only to state-qualified health plans for individuals and small groups marketed on the Affordable Care Act (ACA) exchange, he said.

That will still cover a substantial number of patients, Levinson said. At least a quarter of her patients getting inpatient and outpatient treatment for eating disorders belong to such plans.

Almost 100,000 Kentuckians purchase health insurance on the ACA marketplace, but that number is expected to drop next year because of premium increases and the end of enhanced federal subsidies. Congress is considering ways to hold down costs.

'We're creating another crisis'

During the federal government shutdown, around 600,000 Kentuckians' food assistance was frozen after the U.S. Department of Agriculture said in late October that it wouldn't use contingency funds to keep SNAP benefits flowing.

Such scarcity is directly related to eating disorders, Levinson said, making such a policy change as Fleming is suggesting timely.

"The primary trigger for eating disorders is problematic restrictions," she said. "People who are food insecure obviously have periods of time when they don't have enough to eat, and not even necessarily by choice. They're restricting, but that restriction can then trigger things like binge eating, can trigger purging, which can trigger all sorts of other problematic behaviors."

It's too early to know the full impact of the SNAP benefits freeze on eating disorders in Kentucky, Levinson said.

"I think that we can infer that as we see more people who are food insecure in this country, we're going to see more people with eating disorders. We're creating another crisis," she said. "You're going to have more people who are on Medicaid who have eating disorders, and (there are) limited resources for people to get treatment that have that type of health care."

Meanwhile, Fleming believes there is appetite to pass his bill in 2026.

"I've gotten a lot of good feedback from my colleagues," he said. "Everybody's pretty much in agreement to … get this through. So we seem, I think, pretty optimistic and positive about it."