According to a recent report, new drugs used for treating obesity are proving to be effective in aiding weight loss. However, due to legal restrictions, Medicare will not cover the cost of these injections, leaving many older Americans unable to access them.

Next year, drug manufacturers and a diverse and expanding group of politicians are preparing to advocate for a shift in this situation.

As the number of obese older adults increases, certain legislators argue that the US cannot sustain continuing to adhere to a long-standing law that bars Medicare from funding new weight loss medications such as Wegovy and Zepbound. However, studies reveal that the initial cost of including these drugs in coverage is exorbitant and could further deplete Medicare’s already unstable finances.

Examining the discussion surrounding the inclusion of obesity medication in Medicare coverage and the potential methods for doing so.

Recently, the Food and Drug Administration has given approval for a new group of weekly injectables, namely Wegovy by Novo Nordisk and Zepbound by Eli Lilly, to address obesity.

The drugs mimic the hormones responsible for regulating appetites, signaling feelings of fullness between the gut and brain while eating. This can result in weight loss of 15% to 25% for individuals.

The price of the medications, popular among famous people, has mostly restricted their availability to the wealthy. A one-month supply of Wegovy costs $1,300 and Zepbound will cost you $1,000. Shortages of these drugs have also limited their availability. Private insurance companies often do not cover them or have strict guidelines for who can use them.

In a recent global study, it was discovered that patients who were prescribed Wegovy had a 20% lower chance of experiencing severe heart issues, such as heart attacks.

Well before the hype from Oprah Winfrey and popular TikTok influencers, there was already a rule in place by Congress. This rule stated that Medicare Part D, the health insurance program for senior citizens to obtain prescriptions, could not cover drugs used for weight gain or loss. However, Medicare does provide coverage for obesity screening and behavioral treatment for individuals with a body mass index (BMI) of 30 or higher, as they are considered obese.

The regulation was added to the bill approved by Congress in 2003, which revamped Medicare’s coverage for prescription drugs.

Legislators were hesitant to cover the expensive expenses for medication used to address a condition that was traditionally seen as being solely for aesthetic purposes. The recent memory of safety issues in the 1990s surrounding the anti-obesity drug fen-phen, which had to be pulled from shelves, also influenced their decision.

Medicaid, a joint program between state and federal governments for those with low income, provides coverage for certain medications in select regions. However, accessibility is not uniform.

Recent research has revealed that medications have multiple benefits beyond aiding in weight loss for patients.

Representative Brad Wenstrup, a Republican from Ohio, proposed a bill alongside Representative Raul Ruiz, a Democrat from California, that would permit Medicare to include currently prohibited medications, counseling, and services from nutritionists and dietitians for the treatment of obesity.

In an interview with The Associated Press, Wenstrup stated that there used to be a negative perception towards these individuals and discussing obesity was also stigmatized. However, now there is a recognition that obesity is a health issue that must be addressed.

He thinks that the intervention could help with various health issues related to obesity, which can be expensive for the system.

According to Wenstrup, the issue is widespread and more individuals are recognizing the importance of factoring in the cost savings associated with improved health.

In the previous year, approximately 40% of the nearly 66 million individuals who were enrolled in Medicare were classified as having obesity. This statistic closely reflects the overall population in the United States, where 42% of adults are affected by obesity, as reported by the Centers for Disease Control and Prevention.

In 2006, Mark McClellan, a former leader of the Centers for Medicare and Medicaid Services and the FDA, stated that Medicare provides coverage for specific surgeries to address medical issues caused by obesity in individuals with a BMI of 35 or higher and at least one associated condition.

McClellan stated that the 17-year-old law could serve as a model for broadening the availability of new medications that have shown similar effects to bariatric surgery. Research has demonstrated that this surgical procedure can decrease the likelihood of death and severe health issues associated with obesity.

McClellan stated, “This has been the underlying foundation for our coverage thus far.”

Despite this, the initial cost of removing the regulation continues to be a barrier.

New studies suggest that providing weight loss medication through Medicare could lead to the program’s financial downfall. According to a recent analysis from Vanderbilt University, prescribing anti-obesity drugs to just 10% of Medicare beneficiaries would cost approximately $26 billion per year.

Additional studies suggest that implementing this solution could result in significant cost savings for the government, potentially amounting to billions or even trillions of dollars over a long period of time. This is due to the potential decrease in chronic health issues and other obesity-related problems.

A recent study by the Schaeffer Center at the University of Southern California suggests that the government could potentially save $245 billion over a period of ten years by reducing hospitalizations and other medical expenses.

“We examined the potential long-term health impacts of addressing obesity among Medicare recipients,” stated Darius Lakdawalla, co-author of the study and research director at the Schaeffer Center. The center is supported by pharmaceutical companies, such as Eli Lilly.

According to Lakdawalla, assigning a price to covering the cost of drugs is extremely difficult due to uncertainty about the number of individuals who will use them and the potential pricing of the drugs.

The director of the Congressional Budget Office acknowledged the challenge of pricing out legislative proposals in a blog post in October. They also called for further research on the subject.

In general, the organization predicts that the medication’s overall expense for the Medicare program will be substantial in the next decade.

Ruiz stated that the main concern in gaining support is the expense of the legislation.

“When discussing the original expense, I frequently need to clarify to my colleagues that the CBO does not factor in cost savings when conducting their cost-benefit analysis,” Ruiz explained to the AP. “Looking at that figure alone does not provide a complete understanding of the overall financial benefits of reducing obesity and its associated health conditions in our patients.”

Physicians state that medications for weight loss are just one component of the most successful approaches for managing obesity in a patient.

Dr. Andrew Kraftson collaborates with his patients in the Weight Navigator program at the University of Michigan to create a comprehensive plan that combines behavioral intervention, education on health and diet, and potentially medication for addressing obesity.

However, when treating Medicare patients, there are restrictions on the prescriptions he can provide.

Kraftson stated that completely banning the use of anti-obesity medication is outdated and fails to acknowledge obesity as a disease, which contributes to unequal health outcomes. They acknowledge that it is not feasible for Medicare to cover costly treatments for all individuals, but there should be a middle ground solution.

Over the past ten years, legislators have proposed different versions of a law that would allow Medicare to cover weight loss medications. However, this year’s bill has caught the attention of over 60 lawmakers, ranging from fiscally conservative Rep. David Schweikert of Arizona to progressive Rep. Judy Chu of California.

Before their upcoming retirement, lawmakers Wenstrup and Sen. Tom Carper, D-Del., have made passage a top priority.

Pharmaceutical companies are preparing for a strong lobbying effort next year as the FDA approves the use of their drugs for weight loss.

“Last week, Stephen Ubl, the president of Pharmaceutical Research and Manufacturers of America, stated that Americans should be able to obtain the medications recommended by their doctors. He urged Medicare to include these medicines in their coverage.”

Since 2020, Novo Nordisk has utilized the services of eight different companies and has allocated approximately $20 million towards influencing the federal government on various matters, such as the Treat & Reduce Obesity Act. According to disclosure reports, Eli Lilly has spent around $2.4 million on lobbying efforts since 2021.

Policy advisor Ted Kyle stated that groups like the Obesity Society have been advocating for Medicare to cover medications for a long time. However, there is now increasing evidence that these drugs can potentially prevent serious health issues like strokes, heart attacks, and even death. This suggests that there may be a change in momentum.

The focus of the discussion has changed from questioning the value of treating obesity to finding solutions for making it economically feasible,” he stated. “This is why I am now convinced that change is unavoidable.”

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Journalists from the Associated Press, JoNel Aleccia in Temecula, California and Brian Slodysko, also contributed to this report.