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.
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.
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.
Long before Oprah Winfrey and TikTok influencers gushed about the benefits of these weight-loss drugs, Congress made a rule: Medicare Part D, the prescription plan for older Americans, could not cover weight-loss drugs. 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 in legislation passed in 2003 that overhauled Medicare‘s drug benefits.
Lawmakers balked at paying high costs for drugs to treat a condition 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 Safety problems in the 1990s with the anti-obesity treatment known as fen-phen, which had to be withdrawn from the market, were also fresh in their minds.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.
New studies are showing the drugs do more than help patients slim down.
Rep. Brad Wenstrup, Ohio Republican, introduced legislation with Rep. Raul Ruiz, California Democrat, 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,” Mr. 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,” he 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.
Evidence showed that the surgery reduced the risks of death and serious illness from conditions related to obesity.
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, by reducing some 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.
Lawmakers have introduced some variations 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, Arizona Republican, to progressive Rep. Judy Chu, California Democrat.
Passage is a top priority for two lawmakers, Mr. Wenstrup and Democratic Sen. Tom Carper of Delaware, before they retire next year.
Pharmaceutical companies also are readying for a lobbying blitz next year with the drugs getting approval from the FDA to be used for weight loss.
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.
• Associated Press writers JoNel Aleccia and Brian Slodysko contributed to this report.
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