New obesity drugs are showing promising results in helping some people lose weight, but the injections remain out of reach for millions of older Americans because Medicare is prohibited from covering such drugs. A broad and growing bipartisan coalition of drugmakers and lawmakers is gearing up to push for change next year.
As obesity rates rise among older adults, some lawmakers say the United States cannot afford to maintain a decades-old law that prevents Medicare from paying for new weight-loss drugs, including Wegovy and Zepbound. Prevents from doing. But research shows that the upfront cost of covering those drugs is so high that it could deplete Medicare’s already shaky bank account.
The Food and Drug Administration has in recent years approved a new class of weekly injections to treat obesity, Novo Nordisk’s Wegovy and Eli Lilly’s Zepbound.
People can lose 15 percent to 25 percent of their body weight with drugs that mimic hormones that regulate appetite by communicating fullness between the gut and the brain when people eat.
The Benefits of Regular Exercise for Men and Women: Exploring the Gender Gap
The cost of the drugs favored by celebrities has largely limited them to the rich. Wegovy’s monthly supply reaches $1,300 and Zepbound will give you $1,000. Due to shortage of medicines, supply has also become limited. Private insurers often do not cover medications or place strict restrictions on who can access them.
Last month, a large, international study found that the risk of serious heart problems, such as heart attack, was reduced by 20 percent in patients who took Wegovy.
Long before Oprah Winfrey and TikTok influencers alike were discussing the benefits of these weight-loss drugs, Congress enacted a rule: Medicare Part D, the health insurance plan for elderly Americans to get prescriptions, May not cover medications used to help gain or lose weight. Medicare will cover obesity testing and behavioral treatment if a person’s body mass index is more than 30. People with a BMI over 30 are considered obese.
This rule was included in legislation passed by Congress in 2003 that changed Medicare’s prescription drug benefits.
Lawmakers balked at paying high prices for drugs to treat conditions historically considered cosmetic. Safety issues with Fen-Phen, an anti-obesity treatment that had to be withdrawn from the market in the 1990s, were also fresh in his mind.
Still, the upfront cost remains a challenge for removing the rule.
Some research suggests that offering weight loss drugs will ensure the imminent bankruptcy of Medicare. A Vanderbilt University analysis this year put the annual cost of anti-obesity drugs for Medicare at about $26 billion if only 10 percent of the system’s enrollees were prescribed the drug.
However, other research suggests that it could save the government billions, even trillions, over many years because it would reduce some of the chronic conditions and problems that arise from obesity.
An analysis this year from the Schaefer Center at the University of Southern California estimated that the government could save up to $245 billion over a decade, with most of the savings coming from reducing hospitalizations and other care.
“We looked at the long-term health consequences of treating obesity in the Medicare population,” said Darius Lakdawalla, co-author of the study and director of research at the center. The Schaeffer Center receives funding from pharmaceutical companies, including Eli Lilly.
Lakdawalla said it is almost impossible to put a cost on covering the drugs because no one knows how many people will take them or what the drugs will cost.
The Congressional Budget Office, which is tasked with pricing 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 net cost of prescription drugs to the Medicare program will increase significantly over the next 10 years.”
The cost of the legislation is the biggest obstacle to gaining support, Ruiz said.
“When we talk about initial costs, I often have to educate members that CBO does not take cost savings into account in its cost benefit analysis,” Ruiz told the AP. “Looking at that number in isolation does not give the full picture of the full economics of reducing obesity and all its comorbidities in our patients.”
Smoking and its Lasting Impact on the Immune System
Doctors say weight-loss drugs are just one part of the most effective strategies for treating obese patients.
When Dr. Andrew Craftson develops a plan with his patients at the University of Michigan’s Weight Navigator program, it involves the “perfect marriage” of behavioral intervention, health and diet education, and possibly anti-obesity medication. But with Medicare patients, he’s limited in what he can prescribe.
“A blanket ban on anti-obesity drug use is outdated and does not recognize obesity as a disease and perpetuates health disparities,” said Craftson. “I’m not so ignorant to think that Medicare should start covering expensive treatments for everyone. But there’s something in between all or nothing.”
Lawmakers have introduced few changes to the law that would allow Medicare coverage of weight loss drugs in the last 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 top priority for two lawmakers, Wenstrup and Sen. Tom Carper, D-Del., before they retire next year.
Pharmaceutical companies are also gearing up for a lobbying blitz as weight-loss drugs seek FDA approval next year.
“Americans should have access to the drugs that their doctors believe they should have,” Stephen Uble, president of the lobbying group Pharmaceutical Research and Manufacturers of America, said in a call with reporters last week. “We will be calling on Medicare to cover these drugs.”
Already, Novo Nordisk has hired eight different firms and spent nearly $20 million since 2020 lobbying the federal government on issues including treatments and the Obesity Reduction Act, the disclosures show. Eli Lilly has spent about $2.4 million on lobbying since 2021.
Advocates for groups like the Obesity Society have been pushing for Medicare coverage of the drugs for years. But the momentum may be changing, policy consultant Ted Kyle said, because of growing evidence that obesity drugs can prevent strokes, heart attacks, even death.
“The conversation has shifted from debating whether treating obesity is worthwhile to figuring out how to make the economics work,” he said. “That’s why I now believe change is inevitable.”
