WASHINGTON New obesity drugs are showing promise in helping some people shed pounds, but the injections remain out of reach for millions of older Americans because Medicare is prohibited from covering such drugs.
Drugmakers and a broad and growing bipartisan coalition of lawmakers are preparing to push for change next year.
As obesity rates rise among older adults, some lawmakers say the United States can’t afford to keep in place a decades-old law that bars Medicare from paying for new weight-loss drugs, including Wegovy and Zepbound. But studies show that the initial price tag for covering these drugs is so steep it could drain Medicare’s already shaky bank account.
A look at the debate over whether and how Medicare should cover obesity drugs:
What obesity drugs are on the market and how do they work?
In recent years, the Food and Drug Administration has approved a new class of weekly injections, Novo Nordisks Wegovy and Eli Lillys Zepbound, to treat obesity.
People can lose up to 15 to 25 percent of their weight with drugs that mimic appetite-regulating hormones by mediating fullness between the gut and the brain when eating.
The cost of drugs beloved by celebrities has largely limited them to the wealthy. Wegovy monthly supply goes up to $1,300 and Zepbound will pay you $1,000. The lack of drugs has also limited supplies. Private insurances often do not cover medicines or set strict restrictions on their use.
Last month, a large international study found that patients who took Wegovy had a 20% reduction in the risk of serious heart problems, such as heart attacks.
Why doesn’t medicine cover drugs?
Long before Oprah Winfrey and TikTok influencers talked about the benefits of these weight-loss drugs, Congress made a rule: Medicare Part D, the health insurance plan for older Americans to get prescriptions, couldn’t cover drugs used to gain weight or lose weight. Medicare covers obesity screening and behavioral treatment if a person has a BMI over 30. People with a BMI over 30 are considered obese.
The rule was included in legislation passed by Congress in 2003 that reformed Medicare’s prescription drug benefits.
Lawmakers refused to pay the high cost of drugs to treat a condition that has historically been considered cosmetic. Also on their minds were the safety concerns of the 1990s with an obesity treatment called fen-phen, which had to be pulled from the market.
Medicaid, a cooperative state-federal program for low-income people, covers the drugs in some areas, but access is patchy.
The conversation is changing
New research shows that the drugs do more than help patients lose weight.
Rep. Brad Wenstrup, R-Ohio, introduced legislation this year that would have Medicare cover now-banned obesity drugs, therapy, dietitians and nutritionists.
For years, there was stigma against these people, then talk about obesity, Wenstrup said in an interview with the Associated Press. Now we were at a place where it said this is a health issue that we have to deal with this.
He believes the intervention could alleviate all kinds of obesity-related ailments that cost the system money.
The problem is so common, Wenstrup said. People are starting to realize that the savings that come with better health must be taken into account.
Last year, about 40 percent of the nearly 66 million people enrolled in Medicare were obese. This roughly mirrors the larger US population, where 42% of adults struggle with obesity, according to the Centers for Disease Control and Prevention.
Specifically, Medicare covers certain surgical procedures to treat medical complications of obesity in people with a BMI of 35 and at least one associated medical condition. Congress approved the waiver in 2006, noted Mark McClellan, former director of the Centers for Medicare and Medicaid Services and the FDA.
The 17-year-old law may provide a blueprint for expanding coverage for new drugs that, in some cases, mirror the results of bariatric surgery, McClellan said. Evidence showed that surgery reduced the risk of death and serious illness from obesity-related diseases.
And that’s been the foundation of coverage all this time, McClellan said.
It is now a matter of costs
Still, the price tag of repealing the rule remains a challenge.
Some studies show that providing diet pills would bankrupt Medicare. An analysis by Vanderbilt University this year put the annual cost of Medicare obesity drugs at about $26 billion if only 10% of enrollees in the system were prescribed the medication.
However, other studies show that it could also save the government billions, even trillions, over many years by reducing some of the chronic diseases and problems caused by obesity.
An analysis this year by the University of Southern California’s Schaeffer Center estimated that the government could save up to $245 billion a decade, with most of the savings coming from reduced hospitalizations and other care.
We looked at the long-term health effects of obesity treatment in the Medicare population, said study co-author Darius Lakdawalla, the center’s director of research. The Schaeffer Center receives funding from pharmaceutical companies, including Eli Lilly.
Lakdawalla said it’s almost impossible to put a cost on how to cover the drugs because no one knows how many people will end up taking them or what the cost of the drugs will be.
The Congressional Budget Office, which is tasked with pricing legislative proposals, acknowledged this difficulty in an October blog post in which the director called for more research on the topic.
Overall, the agency expects the net drug costs to the Medicare program to be significant over the next 10 years.
The cost of legislation is the biggest factor in getting support, Ruiz said.
When we talk about initial costs, I often have to complain to members that CBO doesn’t take cost savings into account in its cost-benefit analysis, Ruiz told the AP. Taken in isolation, this figure does not provide a complete picture of the overall economic benefits of reducing obesity and all associated diseases in our patients.
Who wants the drugs to cover the drugs?
Doctors say weight-loss drugs are only some of the most effective strategies for treating obese patients.
When Dr. Andrew Kraftson develops a plan with his patients at the University of Michigan’s Weight Navigator program, it includes the perfect combination of behavioral interventions, health and diet education, and possibly anti-obesity medications.
But for Medicare patients, he can prescribe little.
A blanket ban on obesity drugs is an old-fashioned way of thinking that fails to recognize obesity as a disease and perpetuates health disparities, Kraftson said. I’m not so ignorant as to think that Medicare should just start covering expensive treatments for everyone. But there is something between all or nothing.
Lawmakers have introduced some variations of legislation that would allow Medicare coverage of weight-loss drugs over the past decade. But this year’s bill has drawn interest from more than 60 lawmakers, from self-proclaimed budget hawk Rep. David Schweikert, R-Ariz., to progressive Rep. Judy Chu, D-Calif.
Passage is a priority for two lawmakers, Wenstrup and Sen. Tom Carper, D-Del., before they retire next year.
The pharmaceutical companies are also ready for the lobbying phenomenon next year, when the drugs get approval from the FDA for weight loss.
Americans should have access to the drugs their doctors believe they should have, Stephen Ubl, president of the lobbying group Pharmaceutical Research and Manufacturers of America, said in a call with reporters last week. We would encourage Medicare to cover these drugs.
Novo Nordisk has already employed eight separate companies and spent nearly $20 million lobbying the federal government on issues including the Treat & Reduce Obesity Act since 2020, the disclosures show. Eli Lilly has spent about $2.4 million on lobbying since 2021.
Advocates in groups like the Obesity Society have been pushing for Medicare coverage of the drugs for years. But momentum may be changing because of mounting evidence that obesity drugs can prevent strokes, heart attacks, even death, said policy adviser Ted Kyle.
The debate has shifted from whether treating obesity is profitable to thinking about how to make the economy work, he said. This is why I now believe that change is inevitable.
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