CMS proposes coverage of weight-loss drugs

Last week, CMS proposed expanding coverage of weight-loss medications in Medicare and Medicaid programs. The change would allow 7.5 million people enrolled in Medicaid and Medicare to access the drugs.

"In recognition of the prevailing medical consensus that obesity is a disease, [CMS] is proposing to reinterpret the statute to no longer exclude anti-obesity medications for the treatment of obesity from coverage under Medicare Part D and to require Medicaid programs to cover these medications when used to treat obesity," the agency said in an announcement. "This proposal would provide more Americans access to these transformative medications, improving the health and quality of life for millions of people who have obesity."

The proposal is "a game changer," said HHS Secretary Xavier Becerra. "It helps us recognize that obesity is with us. It's severe. It's damaging our country's health. It's damaging our economy."

"Employers will consider that the Medicare program has expanded coverage," said Tracy Spencer, pharmacy practice leader at Aon. "However, their drug cost coverage decisions for obesity and overweight along with associated indications for use such as cardiovascular risk reduction will be based on prevalence, cost, and equity concerns as they pertain to their population taking into account the entirety of increasing health care expenditures managed under their benefit programs and the associated waste in the system."

Commentary

According to the Washington Post, several politicians, providers, and patient advocates have called the proposal a win for public health. Previously, the American Academy of Family Physicians, the American Medical Association, and other medical groups have called for expanding coverage for anti-obesity medications.

"The benefits to patients are really clear," said Christine Gallagher, the associate director for research and policy for the STOP Obesity Alliance. "We know that many people, including over the age of 65, are finding that they have multiple health conditions that result from obesity, and these medications can really help them."

However, some politicians and healthcare groups questioned the proposal, saying there needs to be more research on the drugs, as well as more efforts to lower their prices before expanding access. Currently, Ozempic costs around $1,000 a month if it's not covered by insurance.

"If this proposal is to be financially responsible for seniors and taxpayers, Medicare and Medicaid cannot pay up to 10-15 times more for these drugs than they cost in Europe and other major countries," said Sen. Bernie Sanders (I-Vermont), chair of the Senate health panel.

Separately, Ceci Connolly, president and CEO of the Alliance of Community Health Plans, said that "The proposed expansion is irresponsible without further analysis and stakeholder engagement."

According to HHS' estimates, the proposal would add $25 billion in Medicare costs and $11 billion in Medicaid costs over the next decade, with states assuming $4 billion in additional costs as part of their share of the Medicaid program.

However, the Congressional Budget Office estimated that the cost could be even higher, with coverage of weight-loss drugs potentially costing Medicare an additional $35 billion between 2026 and 2034.

"These drugs are expensive for the federal budget, taxpayers, and Medicare beneficiaries," wrote the Committee for a Responsible Federal Budget. "However, the efficacy of [anti-obesity medication] is groundbreaking with the potential to lead to substantial health improvement."

Separately, Marty Makary, Trump's nominee to lead FDA, has noted the benefits of weight-loss drugs. However, he has also cautioned against their cost and the potential of overprescription.

For her part, Gallagher urges the incoming Trump administration to approve the proposed rule. "This is an opportunity for them to make a difference," she said. "It is one of the best tools right now, and it should be used in connection with the things that they believe in, like better nutrition, physical fitness and behavioral therapy."