WASHINGTON (AP) — New obesity drugs are showing promising results in helping some people shed pounds but the injections will remain out of reach for millions of older Americans because Medicare is forbidden to cover such medications.
Drugmakers and a wide-ranging and growing bipartisan coalition of lawmakers are gearing up to push for that to change next year.
As obesity rates rise among older adults, some lawmakers say the United States cannot afford to keep a decades-old law that prohibits Medicare from paying for new weight loss drugs, including Wegovy and Zepbound. But research shows the initial price tag of covering those drugs is so steep it could drain Medicare’s already shaky bank account.
A look at the debate around if — and how — Medicare should cover obesity drugs:
WHAT OBESITY DRUGS ARE ON THE MARKET AND HOW DO THEY WORK?
The Food and Drug Administration has in recent years approved a new class of weekly injectables, Novo Nordisk’s Wegovy and Eli Lilly’s Zepbound, to treat obesity.
People can lose as much as 15% to 25% of their body weight on the drugs, which imitate the hormones that regulate appetites by communicating fullness between the gut and brain when people eat.
The cost of the drugs, beloved by celebrities, has largely limited them to the wealthy. A monthly supply of Wegovy rings up at $1,300 and Zepbound will put you out $1,000. Shortages for the drugs have also limited the supplies. Private insurers often do not cover the medications or place strict restrictions on who can access them.
Last month, a large, international study found a 20% reduced risk of serious heart problems such as heart attacks in patients who took Wegovy.
WHY DOESN’T MEDICARE COVER THE DRUGS?
Long before Oprah Winfrey and TikTok influencers alike gushed 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, could not cover medications used to help gain or lose weight. Medicare will cover obesity screening and behavioral treatment if a person has a body mass index over 30. People with BMIs over 30 are considered obese.
The rule was tacked onto legislation passed by Congress in 2003 that overhauled Medicare’s prescription drug benefits.
Lawmakers balked at paying high costs for drugs to treat a condition that was historically regarded as cosmetic. Safety problems in the 1990s with the anti-obesity treatment known as fen-phen, which had to be withdrawn from the market, were also fresh in their minds.
Medicaid, the state and federal partnership program for low-income people, does cover the drugs in some areas, but access is fragmented.
THE CONVERSATION IS SHIFTING
New studies are showing the drugs do more than help patients slim down.
Rep. Brad Wenstrup, R-Ohio, introduced legislation with Rep. Raul Ruiz, D-Calif., this year that would allow Medicare to cover the now-forbidden anti-obesity drugs, therapy, nutritionists and dietitians.
Lawmakers balked at paying high costs for drugs to treat a condition that was historically regarded as cosmetic. Safety problems in the 1990s with the anti-obesity treatment known as fen-phen, which had to be withdrawn from the market, were also fresh in their minds.
Medicaid, the state and federal partnership program for low-income people, does cover the drugs in some areas, but access is fragmented.
THE CONVERSATION IS SHIFTING
New studies are showing the drugs do more than help patients slim down.
Rep. Brad Wenstrup, R-Ohio, introduced legislation with Rep. Raul Ruiz, D-Calif., this year that would allow Medicare to cover the now-forbidden anti-obesity drugs, therapy, nutritionists and dietitians.
The 17-year-old law may provide a blueprint for expanding coverage of the new drugs, which mirror the results of bariatric surgery in some cases, McClellan said. Evidence showed that the surgery reduced the risks of death and serious illness from conditions related to obesity.
“And that’s been the basis for coverage all this time,” McClellan said.
COST IS NOW THE ISSUE
Still, the upfront price tag for lifting the rule remains a challenge.
Some research shows offering weight loss drugs would assure Medicare’s impending bankruptcy. A Vanderbilt University analysis this year put an annual price of about $26 billion on anti-obesity drugs for Medicare if just 10% of the system’s enrollees were prescribed the medication.
Other research, however, shows it could also save the government billions, even trillions over many years, because it would reduce some of the chronic conditions and problems that stem from obesity.
An analysis this year from the University of Southern California’s Schaeffer Center estimated the government could save as much as $245 billion in a decade, with the majority of savings coming from reducing hospitalizations and other care.
“What we did is we looked at the long-term health consequences of treating obesity in the Medicare population,” said the study’s co-author, Darius Lakdawalla, the director of research at the center. The Schaeffer Center receives funding from pharmaceutical companies, including Eli Lilly.
Lakdawalla said it’s nearly impossible to put a cost on covering the drugs because no one knows how many people will end up taking them or what the drugs will be priced at.
The Congressional Budget Office, which is tasked with pricing out legislative proposals, acknowledged this difficulty in an October blog post, with the director calling for more research on the topic.