Listen to the article
8 minutes

This audio is automatically generated. Please let us know if you have any comments.

In one of its latest major policy actions, the Biden administration proposed a rule Tuesday that would allow Medicare and Medicaid to cover weight-loss drugs for obese patients.

The rule – if approved by the new Trump administration – would significantly expand access to drugs like Wegovy and Zepbound that have shown remarkable effectiveness in helping patients lose weight, but at a hefty price tag of around $40 billion. dollars over a decade for federal and state governments. .

Currently, the law prohibits Medicare from covering weight-loss medications, while only a handful of state Medicaid programs pay for the drugs. But “pPeople with obesity deserve affordable access to medications and support,” CMS Administrator Chiquita Brooks-LaSure said during a call with reporters Tuesday morning.

More than 40% of Americans are obeseaccording to the Centers for Disease Control and Prevention. This percentage should reach 50% by 2030. It’s a serious problem: Obesity can cause or worsen other significant health problems, including heart disease, diabetes, stroke, and some cancers, and for many patients, it stubbornly resists diet and to exercise.

In recent years, drugs known as GLP-1 have attracted attention due to their effectiveness in treating obesity. Patients may lose up to 15% to 25% of their body weight while taking the drugs, which work by mimicking the hormones that communicate satiety when people eat. Research also suggests that GLP-1 may reduce the risk of other obesity-related chronic diseases.

Yet despite growing demand, cost has proven a significant barrier to GLP-1 adoption for many Americans. Even in the The expensive prescription drug market in the United StatesGLP-1s are particularly expensive: annual list price of drugs can exceed $11,000.

The price tag has deterred many employers and payers from coverage — less than one in five employer plans included GLP-1s this year, according to health policy research firm KFF.

Access to new features anti-obesity Medications have also been disparate for the 72 million Americans on Medicaid. Currently, only 13 states cover GLP-1 for weight lossaccording to KFF.

And the 68 million Americans on Medicare have had no access to weight-loss drugs, given legislation passed two decades ago preventing the program from covering the drugs. The CMS authorized some coverage earlier this year, Endorsing Novo Nordisk’s Wegovy for Medicare Enrollees who are obese or overweight with cardiovascular disease.

Now, regulators aim to circumvent the statutory restrictions entirely by revising CMS’s interpretation of the law to recognize obesity as a chronic disease rather than a weight management issue.

The evolving medical consensus around obesity has led to this new interpretation, CMS officials said Tuesday.

“It’s not about weight loss per se. This is the treatment of a chronic illness. Meena Seshamani, director of Medicare, said during the press call.

The new rule would expand access to the drugs to an estimated 3.4 million people on Medicare and 4 million people on Medicaid. to a White House press release.

It would do this by allowing obese patients – people with a body mass index of 30 or more – to receive Medicare coverage for weight-loss drugs. The expanded coverage would not apply to overweight people.

The proposal also reinterprets the Medicaid statute, so anti-obesity drugs can no longer be excluded from the safety net program.

The move will likely be popular among U.S. patients, especially since CMS does not expect the coverage expansion to increase their premiums or out-of-pocket costs, thanks to consumer protection provisions contained in the law on reducing inflation adopted in 2022, according to Seshamani.

Some Medicare enrollees currently on GLP-1 could see their out-of-pocket costs decline by as much as 95%, officials said.

However, expanding coverage could prove costly for taxpayers. The federal government expects to spend about $25 billion on weight-loss drugs under Medicare over 10 years, a figure that could exacerbate existing financial stress on the program.

However, this amount does not include the impact of savings resulting from improved patient health. the Congressional Budget Office estimated savings from GLP-1 coverage will be small, on the order of $50 million to $1 billion per year.

As for Medicaid, the federal government plans to spend $11 billion over ten years, while states will receive an additional $3.8 billion, according to Medicaid Director Dan Tsai.

It’s unclear how states will respond to the proposal, given that Medicaid is already often the No. 1 or No. 2 line item in state budgets.