II 114th CONGRESS 1st Session S. 1865 IN THE SENATE OF THE UNITED STATES July 27, 2015 Ms. Klobuchar (for herself, Ms. Ayotte , Mrs. Capito , and Ms. Baldwin ) introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions A BILL To amend the Public Health Service Act with respect to eating disorders, and for other purposes.

1. Short title This Act may be cited as the Anna Westin Act of 2015 . 2. Table of contents The table of contents of this Act is as follows: Sec. 1. Short title. Sec. 2. Table of contents. Sec. 3. Findings. Sec. 4. Definition. Sec. 5. Training and education. Sec. 6. Education and training for health professionals. Sec. 7. Education and training for school and higher education professionals. Sec. 8. Public service announcements. Sec. 9. Clarifying application of existing parity law. Sec. 10. Prohibition on new appropriations. 3. Findings The Congress finds the following: (1) Risk of death among individuals with anorexia nervosa is 18 times greater than among individuals of the same age without anorexia. It is estimated that at least one person dies every 62 minutes from an eating disorder: at least 23 persons each day. (2) Health consequences such as osteoporosis (brittle bones), gastrointestinal complications, cardiac, and dental problems are significant health and financial burdens throughout life. (3) At lowest estimate, 14,500,000 people in the United States suffer from eating disorders. One percent of adolescent boys and 2 percent of adolescent girls suffer from eating disorders. Eating disorders account for at least 4 percent of all childhood hospitalizations. (4) Eating disorders are treatable biopsychosocial illnesses. There is a high rate of comorbidity with other illnesses such as depression, substance abuse, or anxiety disorders. (5) Anorexia nervosa is an eating disorder characterized by self-starvation, weight loss, fear of gaining weight, and disturbances in the way in which one’s body weight or shape is experienced. (6) Anorexia nervosa is associated with serious health consequences including heart failure, kidney failure, osteoporosis, and death. People who suffer anorexia nervosa are 57 times more likely to die of suicide than their peers. (7) Current estimates of the lifetime prevalence of bulimia nervosa are between 0.9 and 1.5 percent among women and between 0.1 and 0.5 percent among men. (8) Bulimia nervosa is associated with serious health consequences, including cardiac, gastrointestinal, and dental problems including irregular heartbeats, gastric rupture, peptic ulcer, tooth decay, and death. (9) Binge eating disorder is characterized by frequent episodes of uncontrolled overeating. Binge eating disorder is common: at lowest estimate, 3.5 percent of women in the United States and 2.0 percent of men in the United States will suffer from this disorder in their lifetimes. (10) Binge eating is often associated with obesity, high blood pressure, elevated cholesterol levels, elevated triglyceride levels, increased risk of bowel, breast, and reproductive cancers, increased risk of diabetes, and increased risk of arthritic damage to the joints. (11) Many suffer from some, but not all, of the symptoms of anorexia nervosa, bulimia nervosa, or binge eating disorder, which is referred to as other specified feeding or eating disorder or OSFED . Between 4 percent and 20 percent of young women practice unhealthy patterns of dieting, purging, and binge eating. (12) Eating disorders are more common in women, but they do occur in men. Rates of binge eating disorder are similar in females and males. (13) Academic evidence has demonstrated a connection between the use of very thin models in advertising and consumer attitudes toward a brand based on such advertising, as well as a material influence of the use of such models on consumer purchase intent, conduct, and reliance. (14) Eating disorders appear across all age groups, races, ethnicities, and socioeconomic groups in the United States and are associated with substantial psychological problems, including depression, substance abuse, and suicide. For children 12 years of age and younger, hospitalizations for eating disorders increased by 119 percent between 1999 and 2006. 4. Definitions In this Act— (1) the term eating disorder includes anorexia nervosa, bulimia nervosa, binge eating disorder, and other specified feeding or eating disorders, as defined in the fifth edition of Diagnostic and Statistical Manual of Mental Disorders , published by the American Psychiatric Association or, if applicable, the most recent successor edition; and (2) the term Secretary means the Secretary of Health and Human Services. 5. Training and education Subject to section 10, the Secretary, acting through the Director of the Office on Women’s Health of the Department of Health and Human Services and in consultation with the Secretary of Education, shall— (1) revise and then reinstate the BodyWise Handbook of the Department of Education and related fact sheets and resource lists available on the public Internet Website of the National Women’s Health Information Center sponsored by the Office on Women’s Health, to include— (A) updated findings and conclusions as needed; and (B) thorough information about eating disorders relating to males and females; (2) incorporate, as appropriate, information from such BodyWise Handbook and related fact sheets and resource lists into the curriculum of the BodyWorks obesity prevention program developed by the Office on Women’s Health, and training modules used in such obesity prevention program; and (3) promote and make publicly available (through a public Internet Website or other method that does not impose a fee on users) the BodyWise Handbook and related fact sheets and resource lists, as updated under paragraph (1), and the BodyWorks obesity prevention program, as updated under paragraph (2), including for purposes of educating universities and nonprofit entities on eating disorders. 6. Education and training for health professionals (a) In general Subject to section 10, the Secretary, acting through the Administrator of the Substance Abuse and Mental Health Services Administration, shall award grants to eligible entities to integrate training into existing curricula for primary care physicians, other licensed or certified health and mental health professionals, and public health professionals that may include— (1) early intervention and identification of eating disorders; (2) levels of treatment (including family-based, in-patient, residential, partial hospitalization programming, and intensive outpatient and outpatient treatment); (3) how to properly refer patients to treatment; (4) steps to aid in the prevention of the development of eating disordered behaviors; and (5) how to treat individuals with eating disorders. (b) Application An entity desiring a grant under this section shall submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require, including a plan for the use of funds that may be awarded and an evaluation of the training that will be provided. (c) Use of funds An entity that receives a grant under this section shall use the funds made available through such grant to— (1) develop a training program containing evidence-based findings, promising emerging best practices, or recommendations that pertain to the identification of, early intervention in, prevention of the development of, and treatment of, eating disorders to conduct educational training and conferences, which may include Internet-based courses and teleconferences, on— (A) how to help prevent the development of eating disordered behaviors, identify, intervene early, and appropriately and adequately treat eating disordered patients; (B) how to identify individuals with eating disorders, and those who are at risk for suffering from eating disorders and, therefore, at risk for related severe medical and mental health conditions; (C) how to conduct a comprehensive assessment of individual and familial health risk factors; and (D) how to conduct a comprehensive assessment of a treatment plan; and (2) evaluate and report to the Secretary on the effectiveness of the training provided by such entity in increasing knowledge and changing attitudes and behaviors of trainees. 7. Education and training for school and higher education professionals (a) Grants Subject to section 10, the Secretary, acting through the Administrator of the Substance Abuse and Mental Health Services Administration, shall award grants to eligible entities— (1) to conduct educational seminars for school personnel on early identification of, intervention in, and prevention of, behaviors that are often associated with the development of eating disordered behaviors; and (2) to make resources available to individuals affected by eating disorders. (b) Educational seminars As a condition on the receipt of a grant under this subsection, an eligible entity shall agree to conduct educational seminars under subsection (a)(1), taking into consideration educational materials made available through the BodyWise eating disorder initiative of the Department of Health and Human Services and relevant research on eating disorders. (c) Eligible entity In this section, the term eligible entity means any State, territory, or possession of the United States, the District of Columbia, any Indian tribe or tribal organization (as defined in subsections (e) and (l), respectively, of section 4 of the Indian Self-Determination and Education Assistance Act ( 25 U.S.C. 450b )), or a public or private educational institution, including an institution of higher education. 8. Public service announcements (a) In general Subject to section 10, the Director of the National Institute of Mental Health shall conduct a program of public service announcements to educate the public on— (1) the types of eating disorders; (2) the seriousness of eating disorders (including prevalence, comorbidities, and physical and mental health consequences); (3) how to identify, intervene, refer for treatment, and prevent behaviors that often lead to the development of eating disordered behaviors; (4) discrimination and bullying based on body size; (5) the effects of media on self-esteem and body image; and (6) the signs and symptoms of eating disorders. (b) Collaboration The Director of the National Institute of Mental Health shall conduct the program under subsection (a) in collaboration with— (1) centers of excellence; and (2) community-based national nonprofit resources that support individuals affected by eating disorders and work to prevent eating disorders and address body image and weight issues. 9. Clarifying application of existing parity law (a) PHSA Section 2726 of the Public Health Service Act ( 42 U.S.C. 300gg–26 ) is amended— (1) in subsection (a)(3), by adding at the end the following new subparagraph: (C) Treatment of permanent exclusions under mental health and substance use disorder benefits A group health plan or health insurance issuer offering group or individual health insurance coverage to which subparagraph (A) applies shall be considered in violation of subparagraph (A)(ii) if the mental health or substance use disorder benefits under such plan or coverage provides for a permanent exclusion from such benefits for a particular condition or disorder. ; and (2) by adding at the end the following new subsection: (f) Residential treatment For purposes of this section, mental health and substance use disorder benefits include residential treatment. . (b) ERISA Section 712 of the Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 1185a ) is amended— (1) in subsection (a)(3), by adding at the end the following new subparagraph: (C) Treatment of permanent exclusions under mental health and substance use disorder benefits A group health plan (or health insurance coverage offered in connection with such a plan) to which subparagraph (A) applies shall be considered in violation of subparagraph (A)(ii) if the mental health or substance use disorder benefits under such plan (or coverage) provides for a permanent exclusion from such benefits for a particular condition or disorder. ; and (2) by adding at the end the following new subsection: (h) Residential treatment For purposes of this section, mental health and substance use disorder benefits include residential treatment. . (c) IRC Section 9812 of the Internal Revenue Code of 1986 is amended— (1) in subsection (a)(3), by adding at the end the following new subparagraph: (C) Treatment of permanent exclusions under mental health and substance use disorder benefits A group health plan to which subparagraph (A) applies shall be considered in violation of subparagraph (A)(ii) if the mental health or substance use disorder benefits under such plan provides for a permanent exclusion from such benefits for a particular condition or disorder. ; and (2) by adding at the end the following new subsection: (f) Residential treatment For purposes of this section, mental health and substance use disorder benefits include residential treatment. . (d) Limitation Nothing in this section or the amendments made by this section shall be construed as adding or expanding the scope of mental health or addiction services included under section 2726 of the Public Health Service Act ( 42 U.S.C. 300gg–26 ), section 712 of the Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 1185a ), or section 9812 of the Internal Revenue Code of 1986. 10. Prohibition on new appropriations No additional funds are authorized to be appropriated to carry out this Act or the amendments made by this Act. This Act and such amendments shall be carried out using amounts otherwise made available for such purposes.