Biden proposes Medicare, Medicaid cover weight-loss drugs for obesity
Key takeaways:
- Around 7.4 million Americans would gain access to anti-obesity drugs under the proposed rule.
- The rule would also reduce the drugs’ out-of-pocket costs by as much as 95% for some Medicare enrollees.
On Tuesday, the Biden-Harris administration proposed a rule that would require Medicare and Medicaid to cover anti-obesity medications.
Millions of Americans with obesity would gain access to drugs like Wegovy (semaglutide, Novo Nordisk), Ozempic (semaglutide, Novo Nordisk) and Zepbound (tirzepatide, Eli Lilly) under the expanded coverage.
“Our loved ones with Medicare deserve care that puts their interests first. HHS is proposing to improve transparency, accountability, and consumer protections in Medicare Advantage and Part D plans so that everyone receives high-quality care,” HHS Secretary Xavier Becerra said in an HHS press release. “To achieve that, we want to remove barriers that delay care or deny people services and medications they need to be healthy.”
Obesity remains one of the most pressing public health issues in the U.S. A recent analysis showed that the prevalence of obesity in the country more than doubled over the last 3 decades, while the number of Americans with obesity could reach 260 million by 2050 if the trends are not addressed.
Meanwhile, several studies have captured the potentially significant impacts that the increasingly used weight-loss drugs could have on the obesity epidemic, with one suggesting that semaglutide could halve obesity in the U.S. by around 46% when given to eligible people.
According to a White House press release, Medicaid and Medicare currently cover the use of anti-obesity medications for certain chronic conditions like diabetes and cardiovascular events.
Under the new proposal, around 4 million Medicaid enrollees and 3.4 million Medicare enrollees with obesity — defined as a BMI of 30 kg/m2 or higher — would gain access to the medications as an obesity treatment, the release noted.
The White House added that the expanded coverage would decrease the drugs’ out-of-pocket costs, which can reach more than $1,000 per month, by as much as 95% for some enrollees.
The rule could further reduce health disparities, as Healio previously reported that low-income patients and Black and Hispanic patients with obesity may be more negatively impacted by the lack of coverage than others.
The proposal “would allow Americans and their doctors to determine the best path forward so they can lead healthier lives, without worrying about their ability to cover these drugs out-of-pocket, and ultimately reduce health care costs to our nation,” the White House release said.
The rule would also address barriers to accessing care and inappropriate use of prior authorization. According to HHS, Medicare Advantage plans overturn 80% of their decisions to deny claims when those claims are appealed to the plan, whereas less than 4% of denied claims are appealed to begin with, which shows that enrollees may not be receiving the care they need.
Comments on the proposed rule can be submitted here until Jan. 27, 2025.
References:
- Biden-Harris administration announces Medicare Advantage and Medicare Part D prescription drug proposals that aim to improve care and access for enrollees. Available at: https://www.hhs.gov/about/news/2024/11/26/biden-harris-administration-announces-medicare-advantage-medicare-part-d-prescription-drug-proposals.html. Published Nov. 26, 2024. Accessed Nov. 26, 2024.
- FACT SHEET: Biden-Harris administration takes latest step to lower prescription drug costs by proposing expanded coverage of anti-obesity medications for Americans with Medicare and Medicaid. Available at: https://www.whitehouse.gov/briefing-room/statements-releases/2024/11/26/fact-sheet-biden-harris-administration-takes-latest-step-to-lower-prescription-drug-costs-by-proposing-expanded-coverage-of-anti-obesity-medications-for-americans-with-medicare-and-medicaid. Published Nov. 26, 2024. Accessed Nov. 26, 2024.