The Biden administration has proposed significant changes to healthcare coverage that would make popular weight-loss medications, such as Ozempic and Wegovy, accessible to millions of Americans with obesity through Medicaid and Medicare. The move comes as the government seeks to reframe obesity as a treatable medical condition rather than just a lifestyle issue.
A shift in healthcare coverage
On Tuesday, the Centers for Medicare and Medicaid Services (CMS) unveiled a proposed rule that would include anti-obesity medications under Medicare Part D coverage. The rule would also mandate Medicaid programs to cover these drugs for obesity treatment. According to Health and Human Services (HHS) Secretary Xavier Becerra, the goal is to eliminate barriers that deny people the medications they need to stay healthy. This marks a significant shift, as obesity is increasingly being recognised as a complex medical condition rather than simply a result of poor lifestyle choices.
Under current CMS rules, weight-loss drugs are generally excluded from Medicare Part D coverage, unless they are prescribed for other medical conditions such as Type 2 diabetes or to reduce the risk of heart disease. However, the new proposed rule would allow weight-loss medications to be covered for people with a body mass index (BMI) of 30 or higher, categorising obesity as an eligible medical condition for treatment. Importantly, this coverage would not extend to those who are overweight but not obese.
Who will benefit?
Approximately 40% of American adults aged 20 and older are considered obese, according to the latest data from the Centers for Disease Control and Prevention (CDC). Obesity is linked to a range of serious health issues, including heart disease, stroke, certain cancers, diabetes, and mental health disorders. These conditions contribute to significant healthcare costs, with obesity-related healthcare expenses amounting to an estimated $173 billion annually in the U.S. In light of these statistics, the Biden administration’s proposal aims to reduce the burden of obesity-related health problems by providing broader access to treatments like weight-loss medications.
Financial implications
While the health benefits of the new rule are clear, the financial costs of implementing the changes are substantial. Projections estimate that including weight-loss drugs in Medicare Part D coverage could cost the program approximately $25 billion over the next decade. Expanding Medicaid coverage for these medications would add an additional $14.8 billion in costs during the same period.
However, supporters of the rule argue that the cost of not addressing obesity is far greater. Weight-loss medications like Wegovy and Ozempic can cost up to $1,000 a month without insurance. By including these drugs in Medicare and Medicaid coverage, the cost burden for enrollees would be significantly reduced, with some beneficiaries seeing out-of-pocket savings of up to 95%. For example, a 28-day supply of Wegovy can cost over $1,300 without insurance, while Ozempic can reach around $900. The proposed coverage would make these medications far more affordable for those in need.
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The political landscape
While the proposed rule is receiving support from public health experts, its future remains uncertain, particularly with the incoming administration. Robert F. Kennedy Jr., selected by former President Donald Trump to lead HHS, has made chronic disease prevention a priority. However, Kennedy is known for his vocal criticism of the pharmaceutical industry, including weight-loss medications. In a recent interview, Kennedy suggested that the U.S. could solve its obesity crisis through healthier eating and lifestyle changes, rather than relying on weight-loss drugs.
This potential change in leadership adds an element of uncertainty to the future of the proposed rule. If Kennedy takes a hard stance against pharmaceutical solutions, the policy may face significant opposition, potentially delaying or even halting its implementation.
President Biden’s plan to provide weight-loss medications through Medicare and Medicaid represents a major shift in how obesity is treated in the U.S. If the rule is enacted, it could provide millions of Americans with access to affordable treatments for a condition that is closely tied to numerous life-threatening health issues. However, the political climate under the incoming administration may impact the rule’s future, making it a critical policy issue to watch in the coming months. As the debate continues, the question remains whether the focus will remain on medications or shift toward broader public health strategies to address the obesity epidemic.
