For those seeking treatment for obesity, the Biden administration intends to mandate that Medicare and Medicaid provide coverage for weight-loss drugs.
The government on Tuesday proposed a new rule that would significantly increase access to anti-obesity drugs like Novo Nordisk’s Ozempic and Wegovy and Eli Lilly’s Mounjaro and Zepbound.
Weight loss medications are not covered by Medicare unless they are prescribed to treat diabetes or to control an elevated risk of heart disease. Medicaid may or may not cover obesity medications, however most states do not.
By categorizing obesity pills as treatment for a “chronic disease,” as opposed to weight reduction therapies, the Biden administration is attempting to reinterpret the statute that prohibits coverage.
“The medical community today agrees that obesity is a chronic disease,” Chiquita Brooks-LaSure, the administrator of the Centers for Medicare and Medicaid Services, stated during a press conference on Tuesday. “These drugs are the beginning of a revolution in the way that weight is controlled.”
The modification would significantly lower the medications’ out-of-pocket expenses. According to a White House official, the cost of a month’s supply of weight loss medications might now reach $1,000 or higher.
According to government officials on Tuesday, the majority of that expense—roughly $25 billion for Medicare and $11 billion for Medicaid—will be covered by the federal government over a ten-year period. The estimated cost to the states will be $3.8 billion.
They don’t anticipate that out-of-pocket premiums will go up.
During the call, CMS Deputy Administrator Dr. Meena Seshamani stated, “The Inflation Reduction Act has made historic strides in lowering the cost of prescriptions for our nation’s seniors and those on Medicare, including a $2,000 out-of-pocket cap and the IRA premium stabilization policies.”
The new Trump administration will decide whether to finalize the idea, which still needs to pass through a 60-day public comment period before it can take effect.
Given that Robert F. Kennedy Jr. hasn’t been particularly interested in the class of pharmaceuticals, Larry Levitt, executive vice president for health policy at KFF, a nonprofit organization that studies health policy issues, said it’s “an open question” if the new Trump administration will follow through.
Kennedy was appointed this month to lead the Department of Health and Human Services by President-elect Donald Trump.
“RFK Jr. has expressed skepticism of these drugs, but Dr. Oz has praised them,” Levitt said, referring toMehmet Oz, Trump’s pick to head the CMS. “Ultimately, this decision is likely to be made by the White House, which may be hesitant to stand in the way of coverage that will probably be very popular among many seniors.”
Over 40% of Americans are categorized as obese. The Centers for Disease Control and Prevention state that obesity is a chronic disease that increases the risk of heart disease, diabetes, breathing issues, stroke, and some types of cancer.
According to the White House source, the new regulation would increase access to the medications for an additional 4 million Medicaid enrollees and 3.4 million Medicare beneficiaries.
As of July, CMS estimates that 72 million Americans were enrolled in Medicaid. Almost68 million are enrolled in Medicare.
According to KFF, an additional 154 million Americans obtain health insurance through their jobs.
According to research, there are notable differences in who gets prescribed medications for weight loss. The health care analytics company PurpleLab found racial disparities in who is able to get semaglutide, the ingredient in Ozempic and Wegovy.
About85% of semaglutide prescriptions were dispensed to white peoplein 2023, the company’s data found. When insurance doesn’t cover the drug, its high cost becomes a barrier for many low- and middle-income Americans, doctors have said.
Some discrepancies may be lessened by extending coverage to individuals who are dependent on Medicare and Medicaid.
Our Medicare and Medicaid populations are some of the most at-risk and they do not have access to any anti-obesity medication, Dr. Laure DeMattia, a bariatric medicine specialist in Norman, Oklahoma,told NBC News in March.
On the call Tuesday, officials said that people may not be getting access to the care they need. Government data shows that Medicare Advantage plans overturn 80% of their decision to deny claims when those claims are appealed. However, fewer than 4% of denied claims are appealed.
The issue is fast becoming a workplace matter, too, as the drugs’ popularity increases and employers balance program costs and their workers’ needs.
Survey results published last month in Health Affairs found thatless than a fifth of large companiesin the United States offered health insurance plans that covered weight loss drugs.
Lawmakers, notably, Sen. Bernie Sanders, I-Vt., have said that due to the high cost of the drugs, it could bankrupt the health care system if the federal government provided coverage. Earlier this year, the Senate Committee on Health, Education, Labor and Pensions, led by Sanders, grilled the CEO of Novo Nordisk over the price of Ozempic and Wegovy.
In a statement following the Biden administration announcement, Sanders said, The good news is that HHS recognizes that vitally important anti-obesity medicines like Wegovy and Zepbound should be made available to all Americans, regardless of income.”
Sanders added, “The bad news is that unless Medicare demands that Novo Nordisk and Eli Lilly substantially reduce the prices for these anti-obesity drugs, Medicare premiums for all seniors would skyrocket.
Outside experts weren’t so sure.
“Will it break the bank? I don’t think so,” said Dr. Susan Spratt, an endocrinologist and senior medical director at the Population Health Management Office at Duke Health in North Carolina. “If we reduce dialysis, stroke, heart attack, sleep apnea, blindness, disability, costs of total care should go down.”
Weight loss drugs like Wegovy are injectable medications of semaglutide. The drugs work because they mimic a hormone called GLP-1, which helps control blood sugar, manage people’s metabolism and help them feel full.
Drugmakers areworking on dozens more GLP-1 drugs, studying their long-term effects and exploring how they might help with other conditions.
Studies have suggested these types of drugs could help peoplecut back on alcoholandreduce sleep apnea, among other uses.
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