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 regulation that would significantly increase access to anti-obesity drugs including Novo Nordisk’s Ozempic and Wegovy and Eli Lilly’s Mounjaro and Zepbound.
Weight reduction 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 reduction 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 approve the idea, which still has to pass through a 60-day public comment process 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 problems, said it’s “an open question” if the new Trump administration would follow through.
Kennedy was appointed this month to lead the Department of Health and Human Services by President-elect Donald Trump.
Levitt stated, “RFK Jr. has expressed skepticism of these drugs, but Dr. Oz has praised them,” of Trump’s choice to lead the CMS, Mehmet Oz. “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 condition Control and Prevention state that obesity is a chronic condition that increases the risk of heart disease, diabetes, respiratory 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. Nearly 68 million people are covered by Medicare. According to KFF, an additional 154 million Americans have health insurance via their jobs.
According to research, there are notable differences in who gets prescribed medications for weight loss. Racial differences in access to semaglutide, the active component in Ozempic and Wegovy, were discovered by the health care analytics firm PurpleLab.
According to the company’s data, around 85% of semaglutide prescriptions were written for white individuals in 2023. According to experts, the high cost of the medication poses a barrier for many Americans with low and intermediate incomes when insurance does not cover it.
Some discrepancies may be lessened by extending coverage to individuals who are dependent on Medicare and Medicaid.
Dr. Laure DeMattia, a bariatric medicine expert in Norman, Oklahoma, told NBC News in March that “our Medicare and Medicaid populations are some of the most at-risk and they do not have access to any anti-obesity medication.”
Officials stated during the Tuesday call that individuals might not be able to obtain the care they require. When claims are appealed, Medicare Advantage insurers reverse 80% of their denial decisions, according to government data. Less than 4% of rejected claims, meanwhile, are appealed.
As the medications’ popularity grows and businesses attempt to balance program expenses with the requirements of their employees, the problem is quickly turning into a workplace concern as well.
Less than one-fifth of US major corporations provided health insurance policies that included weight reduction medications, according to survey data that were published in Health Affairs last month.
Lawmakers, including Senator Bernie Sanders of Vermont, have stated that if the federal government offered coverage, the exorbitant cost of the medications may “bankrupt” the health care system. Earlier this year, Sanders headed the Senate’s Health, Education, Labor, and Pensions Committee, which questioned Novo Nordisk’s CEO about the cost of Ozempic and Wegovy.
“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 said in a statement after the Biden administration decision.
“The bad news is that Medicare premiums for all seniors would skyrocket unless Medicare demands that Novo Nordisk and Eli Lilly significantly reduce the prices for these anti-obesity drugs,” Sanders continued. Experts from outside weren’t quite sure.
“Will it cost a fortune? “I don’t believe so,” stated Dr. Susan Spratt, a senior medical director and endocrinologist at Duke Health’s Population Health Management Office in North Carolina. “If we reduce dialysis, stroke, heart attack, sleep apnea, blindness, disability, costs of total care should go down.”
Semaglutide injections are used in weight loss treatments such as Wegovy. The medications function by imitating the GLP-1 hormone, which regulates blood sugar, controls metabolism, and promotes feelings of fullness.
Numerous new GLP-1 medications are being developed by pharmaceutical companies, who are also researching their potential benefits for treating various illnesses and evaluating their long-term consequences.
According to studies, these medications may help patients reduce alcohol consumption and sleep apnea, among other things.
