WASHINGTON — A significant proposal from the Biden administration could potentially provide millions of obese Americans with access to popular weight-loss injections. This initiative, valued at $35 billion, will require Medicare and Medicaid to cover anti-obesity medications such as Wegovy and Zepbound. The proposal was introduced by the Health and Human Services Department on Tuesday, but its effectiveness will depend on the incoming administration’s support, particularly from President-elect Donald Trump and his appointed head of HHS, Robert F. Kennedy Jr., who has expressed opposition to these drugs.
Understanding how these medications function is key. These weight-loss agents, also referred to as GLP-1s, imitate the hormone known as glucagon-like peptide 1, which plays a critical role in signaling feelings of fullness between the gut and the brain during meals. Well-known brands include Novo Nordisk’s Wegovy and Ozempic, alongside Eli Lilly’s Zepbound and Mounjaro. Clinical trials have shown that individuals using Wegovy or Mounjaro typically shed between 15% to 22% of their body weight, equivalent to 50 pounds or more in some cases, although a minority of users—termed “nonresponders”—have seen negligible weight loss.
The coverage landscape for these medications has been inconsistent. While private health insurers have limited their support, Medicare has historically been unable to cover weight-loss treatments due to existing legislation. Medicaid’s coverage has been variable by state, rendering these medications, which can exceed $1,000 per month, unaffordable for many individuals.
The proposed rule aims to affect the approximately 70 million individuals reliant on Medicaid, as well as the 67 million enrolled in Medicare. If enacted, the Centers for Medicare and Medicaid Services (CMS) would reinterpret federal law to classify these medications as treatments for obesity-related conditions, which could potentially benefit around 3.5 million Medicare beneficiaries and 4 million Medicaid recipients. However, studies indicate that the actual number of those eligible might be higher, with CMS estimating up to 28 million on Medicaid classified as obese. The financial implications of this initiative are substantial, with estimates suggesting it could cost at least $35 billion over the next ten years.
The upcoming administration’s stance on this proposal remains uncertain. A majority of Americans surveyed earlier this year indicated strong support for Medicare coverage of weight-loss drugs, and a bipartisan coalition in Congress has advocated for such coverage. However, within Trump’s circle, opinions are mixed. Kennedy has voiced strong opposition to the drugs being covered, urging lawmakers instead to promote access to healthier foods and exercise programs. Conversely, Dr. Mehmet Oz, a prospective CMS leader, has acknowledged the potential benefits of these treatments but emphasized the necessity for further research into their long-term effects.
Amidst this debate, some lawmakers have expressed optimism about the move, while others remain doubtful. Representative Brad Wenstrup, a Republican sponsor of a bill aimed at enabling Medicare coverage for weight-loss medications, noted that such coverage could ultimately save taxpayers money. He encouraged Congress to also support funding for nutritionists, dietitians, and behavioral therapies targeted at obesity treatment. On the other hand, Senator Bernie Sanders cautioned that without price regulation for the medications, Medicare premiums could surge under the proposed plan.
While the drugs have received praise from health professionals for their effectiveness, certain experts raise concerns about their predominant use in treating obesity. Dr. David Ludwig, an obesity and nutrition expert at Harvard, posits that relying heavily on these medications without addressing the root causes of obesity—such as the consumption of unhealthy foods and lack of physical activity—may not be the best approach. He urges for a comprehensive strategy that combines medication with transformative lifestyle changes.
Dr. Andrew Kraftson from the University of Michigan expresses relief that more of his patients may soon afford these medications, noting their success in treatment. However, he too advocates for increased research and guidelines from health authorities regarding these prescriptions. Kraftson highlights potential side effects for older patients, emphasizing the risk of muscle loss, a significant concern for seniors who face a higher risk of falls.
“I’m advocating for their thoughtful use,” Kraftson insists, stressing the importance of comprehensive patient care over cursory prescriptions. He raises critical questions about the appropriateness of care provided in brief consultations, emphasizing that a deeper understanding of the patient’s health is essential when prescribing these medications.