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 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 Safety problems in the 1990s with the anti-obesity treatment known as fen-phen, which had to be withdrawn from the market, were also fresh in their minds.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 dieticians.
“For years there was a stigma against these people, then there was a stigma about talking about obesity,” Wenstrup said in an interview with The Associated Press. “Now we’re in a place where we’re saying this is a health problem we need to deal with this.”
He believes the intervention could alleviate all sorts of ailments associated with obesity that cost the system money.
“The problem is so prevalent,” Wenstrup said. “People are starting to realize you have to take into consideration the savings that comes with better health.”
Last year, about 40% of the nearly 66 million people enrolled in Medicare had obesity. That roughly mirrors the larger U.S. population, where 42% of adults struggle with obesity, according to the Centers for Disease Control and Prevention.
Notably, Medicare does cover certain surgical procedures to treat medical complications of obesity in people with a body mass index of 35 and at least one related condition. Congress approved the exception in 2006, noted Mark McClellan, a former head of the Centers for Medicare and Medicaid Services and the FDA.
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.
Overall, the agency “expects that the drug’s net cost to the Medicare program would be significant over the next 10 years.”
The cost of the legislation is the biggest hang up in getting support, Ruiz said.
“When we talk about the initial cost, I often have to educate the members that the CBO does not take into account cost savings in their cost benefit analysis,” Ruiz told the AP. “Taking that number in isolation, one does not get the full picture of the full economies of reducing obesity and all of its comorbidities in our patients.”
WHO WANTS MEDICARE TO COVER THE DRUGS?
Doctors say weight loss drugs are only a part of the most effective strategies to treat a patient with obesity.
When Dr. Andrew Kraftson develops a plan with his patients at the University of Michigan’s Weight Navigator program, it involves a “perfect marriage” of behavioral intervention, health and diet education, and possibly anti-obesity medication.
But with Medicare patients, he is limited in what he can prescribe.
“A blanket prohibition for use of anti-obesity medication is an antiquated way of thinking and does not recognize obesity as a disease and is perpetuating health disparities,” Kraftson said. “I’m not so ignorant to think that Medicare should just start covering expensive treatments for everyone. But there is something between all or nothing.”
Lawmakers have introduced some variation of legislation that would permit Medicare coverage of weight loss drugs over the last decade. But this year’s bill has garnered 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 top priority for two lawmakers, Wenstrup and Sen. Tom Carper, D-Del., before they retire next year.
Pharmaceutical companies also are readying for a lobbying blitz next year with the drugs getting the OK from the FDA to be used for weight loss.
“Americans should have access to the medicines that their doctors believe they should have,” Stephen Ubl, the president of the lobbying group, Pharmaceutical Research and Manufacturers of America, said on a call with reporters last week. “We would call on Medicare to cover these medicines.”
Already, Novo Nordisk has employed eight separate firms and spent nearly $20 million on lobbying the federal government on issues, including the Treat & Reduce Obesity Act, since 2020, disclosures show. Eli Lilly has spent roughly $2.4 million lobbying since 2021.
Advocates for groups such as the Obesity Society have been pushing for Medicare coverage of the medications for years. But the momentum may be shifting, thanks to the growing evidence that the obesity drugs can prevent strokes, heart attacks, even death, said Ted Kyle, a policy advisor.
“The conversation has shifted from debating whether obesity treatment is worthwhile to figuring out how to make the economics work,” he said. “This is why I now believe the change is inevitable.”