Estimated read time: 6-7 minutes
- The Biden-Harris administration proposes expanding Medicare and Medicaid coverage for anti-obesity drugs.
- The proposal aims to address obesity-related health risks and reduce costs, despite potential opposition.
- Projected costs include $25 billion for Medicare and $11 billion for Medicaid over a decade.
WASHINGTON — With an estimated 42% of the U.S. population having obesity, the Biden-Harris administration wants to expand coverage of anti-obesity medications in the Medicare and Medicaid programs.
The move, according to a White House fact sheet released Tuesday, would ultimately save money and address the increased risk that comes with excess weight, including diabetes, cardiovascular disease, stroke and some cancers.
The medications include popular but expensive semaglutide-based drugs Wegovy and Ozempic, among others. The Washington Post believes the proposal "tees up a clash with RFK Jr." President-elect Donald Trump has nominated Robert F. Kennedy Jr. to be secretary of the U.S. Department of Health and Human Services. He must be confirmed by the Senate.
The current department secretary, Xavier Becerra, told the Post the proposal to extend the coverage of anti-obesity drugs to 7.6 million people would cost Medicare about $25 billion and Medicaid about $11 billion over the next decade. States would pick up about $4 billion as their share of Medicaid costs.
Becerra said the cost is a "modest fraction" of what's forecast for Medicare spending, estimated at close to $2 trillion to be spent on medications over the next decade.
Medicare provides health coverage to older adults and those with disabilities. Medicaid covers very low-income people.
RFK Jr. opposes the drugs
The proposal is a rethinking of covering weight-loss drugs that is founded on the recognition of obesity as a "chronic disease based on changes in medical consensus," per the Biden administration. The coverage would only extend to those who are obese, not those who are simply overweight.
Right now, weight-loss drugs are specifically excluded from Medicare coverage unless it's to treat diabetes or heart disease. Bariatric surgery is covered in certain cases.
Per the Post, Trump's incoming team doesn't have to finalize the proposal. And RFK Jr. is "an avowed critic of weight-loss drugs such as Ozempic, which he has blamed for obfuscating the root causes of poor health in America."
RFK Jr. told Fox News last month that "they're counting on selling it to Americans because we're so stupid and so … addicted to drugs." He has said he plans to emphasize healthy eating and exercise as part of what he's been calling "Make America Healthy Again."
That could tee up another battle of sorts. As CNN reported, "Dr. Mehmet Oz, whom Trump tapped to head the Centers for Medicare and Medicaid Services, has touted anti-obesity drugs on his talk show and on social media."
About obesity
The Centers for Disease Control and Prevention reported that between August 2021 and August 2023, about 4 in 10 adults were obese, the rates highest in those ages 40-59.
CDC notes that obesity is a chronic condition that is associated with risk for many serious medical conditions, including high blood pressure, stroke and some cancers, among other conditions. Many experts consider obesity a chronic medical condition, not just a contributor to one.
The public health agency notes that it bases numbers on body mass index, which is weight in kilograms divided by height in meters squared. That has some limitations, CDC reports, as "body fat may vary by sex, age, and race and Hispanic origin at a given BMI level." Someone has obesity with a BMI of 30 and severe obesity with a score of 40 or higher.
About 1 in 10 Americans has severe obesity.
The drugs themselves at issue are forms of injectable semaglutide, which mimics the FLP-1 hormone that helps control blood sugar and appetite. Per NBC News, "Drugmakers are working on dozens more GLP-1 drugs, studying their long-term effects and exploring how they might help with other conditions."
The article notes studies suggesting the class of drugs could help people stop drinking alcohol, reduce sleep apnea and otherwise impact health.
"The high cost of anti-obesity drugs, including the GLP-1 medicines Wegovy and Zepbound, has limited Americans' access to the medications. The list price for Wegovy, for instance, is about $1,350 for a four-week supply," according to CNN.
The cost to treat obesity
Per the White House fact sheet: "Over the past few years, there have been major scientific advancements in the treatment of obesity, with the introduction of new life-saving drugs. These anti-obesity medications can help prevent the development of Type 2 diabetes. Furthermore, these drugs reduce deaths and sickness from heart attack and other cardiovascular outcomes by up to 20%. But for too many Americans, these critical treatments are too expensive and therefore out of reach. Without insurance coverage, these drugs can cost someone as much as $1,000 a month."
The proposal would expand coverage of the drugs to obesity, which is a chronic condition for an estimated 3.5 million people on Medicare. The announcement estimates that about 4 million adults on Medicaid would also qualify.
The White House noted that the president is "proud of the fact that the Inflation Reduction Act allows Medicare to negotiate down the price of drugs, a tool that will help Medicare lower the cost of some of the most expensive medications in the program." It noted that Americans pay two to three times more than those in other countries for the same medications.
The fact sheet also reported that older adults on Medicare are benefitting from lower insulin prices, capped at $35 and free vaccines and will see their out-of-pocket medication costs capped at $2,000 starting next year. It said that nearly 1.5 million people with Medicare Part D saved almost $1 billion in their share of medication costs in the first half of 2024 due to the Inflation Reduction Act.
A Congressional Budget Office report in October said that Medicare beneficiaries who are overweight or "have the medical condition of obesity" fare worse in terms of health outcomes and have higher health care costs as a result of their condition than do those who have a healthy weight. It estimates that the medication would cost Medicare about $35 billion from 2026 to 2034. It would actually cost more, but the figure is offset by the $3.4 billion in savings from people on the drugs needing less of other health care spending.
The nonpartisan office notes that many factors could change that estimate of costs, including negotiating the price with the manufacturer, discounts from the manufacturer and changes in the number of people who qualify, among others.
NBC News cited a recent survey from Health Affairs that found fewer than 1 in 5 large companies offer insurance that covers weight-loss drugs.
"Today's proposed action is a major step forward in ensuring that adults with obesity get the same quality care and access to treatments as those with the 230 chronic conditions where obesity is a significant factor," says Nancy Glick, National Consumers League director of food and nutrition policy. "Today, only 10% of people with obesity get help from medical professionals, meaning the disease remains largely undiagnosed and undertreated. If CMS's proposed rule is implemented, it will go a long way towards closing this obesity treatment gap, especially since health insurance companies closely align coverage decisions with Medicare policy."
