Under a new proposal unveiled by the Biden administration, millions more senior citizens and low-income Americans could gain access to costly anti-obesity drugs, a move that could significantly impact healthcare coverage for many. The proposal, expected to expand eligibility for Medicare and Medicaid beneficiaries, aims to offer coverage for medications that are often priced out of reach for those without insurance.
According to the White House, around 3.4 million Medicare beneficiaries and 4 million Medicaid recipients could be eligible for coverage of anti-obesity drugs, which can cost up to $1,000 a month for the uninsured. The administration projects that some Medicare enrollees could see their out-of-pocket costs drop by as much as 95%, making these drugs much more accessible.
“This 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, ultimately reducing healthcare costs for our nation,” the administration stated.
While the announcement provides an overview of the proposal, many specifics remain unclear, including which drugs will be covered, who will qualify, and the potential costs of implementation. There is also uncertainty about whether the rule can be finalized before President Biden’s term ends in January.
The proposed expansion of coverage has sparked debate about the future of anti-obesity drug access. The incoming Trump administration may not share the same enthusiasm for this initiative. Robert F. Kennedy Jr., appointed by President-elect Trump to lead the Department of Health and Human Services, has previously voiced concerns about anti-obesity drugs, arguing that a more cost-effective solution would be providing healthier food options. However, Dr. Mehmet Oz, chosen to head the Centers for Medicare and Medicaid Services, has publicly supported anti-obesity drugs on his talk show and social media.
Despite the high costs, access to anti-obesity drugs, such as GLP-1 medications like Wegovy and Zepbound, has been limited in the U.S. Wegovy, for example, has a list price of about $1,350 for a four-week supply, making it unaffordable for many without insurance. While Medicare has historically been prohibited from covering obesity medications, recent changes allow Medicare enrollees with cardiovascular disease and obesity or overweight to access Wegovy. This shift in policy has led some Medicare Part D insurers to cover the drug, with roughly 3.6 million beneficiaries potentially eligible for coverage.
However, expanding coverage to include all Medicare enrollees with obesity or overweight could come with a hefty price tag. The Congressional Budget Office has projected that fully expanding GLP-1 drug coverage could cost Medicare up to $35 billion over the next nine years, with minimal savings from improved health outcomes. Additionally, the expansion could drive up premiums for all Medicare beneficiaries.
Currently, only 13 states provide coverage for GLP-1 medications for obesity treatment, although many other states are considering adding the benefit despite concerns over costs. Similarly, while some employer-based health insurance plans cover anti-obesity medications, it remains an option more likely offered by larger employers. Approximately 18% of firms with 200 or more employees currently offer GLP-1 drugs for weight loss, with a quarter of these employers considering expanding coverage in the coming year.
As the proposal moves forward, the future of anti-obesity drug coverage will depend on how it is implemented, its cost-effectiveness, and how it is received by the incoming administration.