new Obesity treatment drug Although they have shown promising results in helping some people lose weight, the shots are out of reach for millions of older Americans because Medicare is prohibited from covering such drugs. It will remain unreachable.
Pharmaceutical companies and a broad and growing bipartisan coalition of lawmakers are preparing to change that next year.
As obesity rates rise among older adults, some lawmakers say the U.S. can't afford to maintain a decades-old law that prohibits Medicare from paying for new weight-loss drugs like Wigovy and Zepbound. are doing.But research shows that the initial price to cover these drugs is so high that it could deplete Medicare funding. Already unstable bank account.
Let's take a look at the debate over whether and how Medicare should cover obesity drugs.
What obesity drugs are on the market and how do they work?
In recent years, the Food and Drug Administration has approved Novo Nordisk's Wigoby and Eli Lilly's Zepbound, a new class of weekly injectable drugs to treat obesity.
Using this drug may cause you to lose 15% to 25% of your body weight. The drug mimics the hormones that transmit satiety signals between the intestines and the brain and regulate appetite when humans eat.
The drug, favored by celebrities, is expensive and can only be purchased by the wealthy. Wegovy costs him $1,300 a month, while Zepbound pays him $1,000. Supply is also limited due to drug shortages. Private insurance companies often do not cover drugs or have strict limits on who can access them.
last month, A large international study found a 20% reduction in risk of serious heart disease. Such as heart attacks in patients who took Wegovy.
Why doesn't Medicare cover the drug?
Congress enacted the rules long before Oprah Winfrey and TikTok influencers alike were raving about the benefits of these weight loss drugs. Medicare Part D, the prescription health insurance plan for older Americans, did not cover drugs used for weight gain or weight loss. Medicare covers obesity screening and behavioral treatment for people whose BMI is above 30. People with a BMI of over 30 are considered obese.
The rule was added to a bill passed by Congress in 2003 that overhauled Medicare's prescription drug benefits.
Lawmakers balked at paying high prices for drugs to treat conditions historically seen as cosmetic. It is still fresh in our minds that in the 1990s, safety issues arose with an anti-obesity drug known as fen-phen, which forced it to be withdrawn from the market.
Medicaid, a state-federal partnership program for low-income people, covers drugs in some areas, but access is fragmented.
the conversation is changing
New research shows that this drug does more than just help patients slim down.
Introduced by Rep. Brad Wenstrup, Republican of Ohio law This year, an agreement with Rep. Raul Ruiz, D-Calif., will allow Medicare to cover anti-obesity drugs, treatments, dietitians and nutritionists that are currently banned.
“For years, there was a stigma against these people, and then there was a stigma against talking about obesity,” Wenstrup said in an interview with The Associated Press. “Now we're in a position to say this is a health issue and we need to address it.”
He believes this intervention has the potential to reduce all kinds of obesity-related diseases that are costly to the system.
“The problem is very pervasive,” Wenstrup said. “People are realizing that they need to consider the savings that come with improving their health.”
Last year, about 40% of the roughly 66 million people enrolled in Medicare were obese. This roughly reflects the large population of the United States, where 42% of adults suffer from obesity. Centers for Disease Control and Prevention.
Specifically, Medicare covers certain surgical procedures to treat complications of obesity in people with a BMI of 35 and at least one related medical condition. Mark McClellan, former director of the Centers for Medicare and Medicaid Services and the FDA, pointed out that Congress approved the exception in 2006.
McClellan said the 17-year-old law could provide a blueprint for expanding coverage of new drugs that, in some cases, mirror the results of bariatric surgery. Evidence shows that surgery reduces the risk of death and serious illness from obesity-related conditions.
“And that's always been the basis of reporting,” McClellan said.
cost became an issue
Still, the upfront cost to lift the rule remains a challenge.
Some studies have shown that weight loss drugs provide would guarantee the impending bankruptcy of Medicare.. A Vanderbilt University analysis this year estimated that Medicare's anti-obesity drugs would cost about $26 billion a year if prescribed to just 10% of the system's members.
But other studies have shown that reducing some of the chronic diseases and problems caused by obesity could save governments billions or even trillions of dollars over the years. Masu.
Ann analysis The University of Southern California Schaefer Center estimated this year that the government could save up to $245 billion over 10 years, with most of the savings coming from reductions in hospitalizations and other health care.
“What we did was examine the long-term health effects of obesity treatment in the Medicare population,” said study co-author Darius Lakdawala, the center's principal investigator. . The Schaefer Center is funded by pharmaceutical companies such as Eli Lilly.
Lakdawala said it's nearly impossible to pay for drug coverage because no one knows how many people will end up taking the drug or how much it will cost. Ta.
The Congressional Budget Office, which is tasked with determining the price of legislative proposals, acknowledged the difficulty. October blog post, The director asked for further research on this topic.
Overall, the agency “expects the net cost of this drug to the Medicare program to be significant over the next 10 years.”
Lewis said the bill's cost is the biggest hurdle to gaining support.
“When we talk about initial costs, CBOs often have to educate their members that they are not considering cost savings in their cost-benefit analysis,” Lewis told The Associated Press. “Taking this number in isolation does not paint a complete picture of the overall economics of reducing obesity and all its comorbidities in patients.”
Who wants Medicare to cover medicines?
Doctors say weight-loss drugs are just some of the most effective strategies for treating obese patients.
When Dr. Andrew Craftson plans with patients in the University of Michigan's Weight Navigator program, it includes the “perfect blend” of behavioral interventions, health and dietary education, and, in some cases, anti-obesity drugs. .
But for Medicare patients, he is limited in what he can prescribe.
“A blanket ban on the use of anti-obesity drugs is an outdated concept that fails to recognize obesity as a disease and perpetuates health disparities,” Craftson said. “I'm not ignorant enough to think that Medicare should start covering high medical costs for everyone. But there's something between all or nothing.”
Lawmakers have introduced several variations of legislation over the past decade that would allow Medicare coverage of weight loss drugs. But this year's bill has drawn the attention of more than 60 members of Congress, from self-proclaimed budget hawk Rep. David Schweikert (R-Ariz.) to progressive Rep. Judy Chu (D-Calif.). are gathering.
For Wenstrup and Sen. Tom Carper (D-Delaware), passing it is a top priority before they retire next year.
Pharmaceutical companies are also preparing to lobby for approval from the FDA for use in weight loss next year.
“Americans should be able to get the medicines that their doctors think they need,” Stephen Uble, president of the American Pharmaceutical Research and Manufacturing Association, said on a call with reporters last week. “We urge Medicare to cover these drugs.”
Since 2020, Novo Nordisk has already hired eight separate companies and spent nearly $20 million lobbying the federal government on issues such as obesity treatment laws, according to disclosures. Eli Lilly has spent approximately $2.4 million on lobbying efforts since 2021.
Advocates from groups like the Obesity Association have been pushing for Medicare coverage of the drug for years. But policy adviser Ted Kyle said that momentum may be changing because of growing evidence that obesity drugs can prevent strokes, heart attacks and even death.
“The conversation has shifted from discussing whether obesity treatment is worth it to thinking about how we can make the economy work better,” he said. “This is why I now believe change is inevitable.”
–Amanda Seitz, Associated Press
JoNel Aleccia and Brian Slodysko contributed to this report.
