New weight loss drugs out of reach for many older Americans

WASHINGTON — 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 from covering them.

Drugmakers and a 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.

A look at the debate around if — and how — Medicare should cover obesity drugs:

What obesity drugs are on the market?

The Food and Drug Administration in recent years has 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 percent of their body weight on the drugs, which imitate the hormones that regulate appetites by communicating fullness.

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. Shortages for the drugs have also limited the supplies. Private insurers often do not cover the medications or place restrictions on who can access them.

Last month, a large, international study found a 20 percent reduced risk of serious heart problems, such as heart attacks, in patients who took Wegovy.

Why doesn’t Medicare cover them?

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Long before Oprah Winfrey and TikTok influencers gushed about the benefits of these weight loss drugs, Congress made a rule: Medicare Part D, the health insurance plan for older Americans to get prescriptions, could not cover medications used to help gain or lose weight. Medicare will cover obesity screening and behavioral treatment if a person has body mass index over 30. People with BMIs over 30 are considered obese.

The rule was tacked onto legislation passed by Congress in 2003. Lawmakers balked at paying high costs for drugs to treat a condition that was 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 Safety problems in the 1990s with the anti-obesity treatment known as fen-phen, which had to be withdrawn from the market, were also fresh in their minds.

Conversation is shifting

New studies are showing the drugs do more than help patients slim down.

U.S. Rep. Brad Wenstrup, R-Ohio, introduced legislation with U.S. Rep. Raul Ruiz, D-Calif., that would allow Medicare to cover the drugs, therapy, nutritionists and dietitians.

“For years there was a stigma against these people, then there was a stigma about talking about obesity,” Wenstrup said. “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 and that cost the Medicare system money.

Last year, about 40 percent of the nearly 66 million people enrolled in Medicare had obesity. That roughly mirrors the larger U.S. population, where 42 percent 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.

The 17-year-old law may provide a blueprint for expanding coverage of the new drugs, which mirror the results of bariatric surgery in some cases, said Mark McClellan, a former head of the Centers for Medicare and Medicaid Services and the FDA.

Evidence showed that the surgery reduced the risks of death and serious illness from conditions related to obesity. “And that's been the basis for coverage all this time,” McClellan said.

Cost is the issue

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 for Medicare if just 10 percent of its enrollees were prescribed the medication.

Other research, however, shows it could also save the government billions over many years, because it would reduce some of the chronic conditions 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.

“What we did is we looked at the long-term health consequences of treating obesity in the Medicare population,” said the study's co-author, Darius Lakdawalla, the director of research at the center. The Schaeffer Center receives funding from pharmaceutical companies, including Eli Lilly.

Lakdawalla said it's nearly impossible to put a cost on covering the drugs because no one knows how many people will end up taking them or what the drugs will be priced at.

The Congressional Budget Office, which is tasked with pricing out legislative proposals, acknowledged this difficulty in an October blog post. The agency “expects that the drug’s net cost to the Medicare program would be significant over the next 10 years.”

Who wants Medicare to cover the drugs?

Doctors say weight loss drugs are only a part of the most effective strategies to treat a patient with obesity.

When Dr. Andrew Kraftson develops a plan with his patients at the University of Michigan's Weight Navigator program, it involves a “perfect marriage” of behavioral intervention, health and diet education, and possibly anti-obesity medication.

But with Medicare patients, he is limited in what he can prescribe.

“A blanket prohibition for use of anti-obesity medication is an antiquated way of thinking and does not recognize obesity as a disease and is perpetuating health disparities," Kraftson said. “I'm not so ignorant to think that Medicare should just start covering expensive treatments for everyone. But there is something between all or nothing."

Lawmakers have introduced some variation of legislation over the last decade that would permit Medicare coverage of weight loss drugs. But this year's bill has garnered interest from more than 60 lawmakers, from self-proclaimed budget hawk U.S. Rep. David Schweikert, R-Ariz., to progressive U.S. Rep. Judy Chu, D-Calif.

Pharmaceutical companies also are readying for a lobbying blitz next year with the drugs getting the OK from the FDA to be used for weight loss.

“Americans should have access to the medicines that their doctors believe they should have,” Stephen Ubl, the president of the lobbying group, Pharmaceutical Research and Manufacturers of America, said on a call with reporters. “We would call on Medicare to cover these medicines."