New Proposal Aims to Expand Medicaid and Medicare Coverage for Obesity Drugs

The Biden administration has put forth a proposal to revise various Medicare and Medicaid regulations and include obesity medications as part of their coverage. This move marks perhaps one of the final health policy initiatives of Biden’s presidency. The new policies put forth in the plan would take effect in existing programs in 2026, expanding drug access to many who lack this coverage.^1,2

The FDA has previously approved these antiobesity drugs for long-term use: liraglutide (Saxenda), orlistat (Xenical, Alli), bupropion-naltrexone (Contrave), phentermine-topiramate (Qsymia), semaglutide (Wegovy, Ozempic), and Tirzepatide (Zepbound, Mounjaro) | image credit: Sergej Gerasimov - stock.adobe.com

“Increases in the prevalence of obesity in the United States and changes in the prevailing medical consensus towards recognizing obesity as a disease since the beginning of the Part D program in 2006 have compelled CMS to re-evaluate Part D coverage of anti-obesity medications (AOMs) for Medicare Part D enrollees with obesity,” the proposal writes, highlighting circumstances “where the drug’s prescribed use is not for a medically accepted indication (MAI) that is currently covered under Part D.” If made official, pending an endorsement from the Trump administration, their reevaluation would carry important implications for Part D beneficiaries.

AOMs have demonstrated great safety and efficacy throughout numerous randomized controlled trials (RCTs) over the years, as indicated by a 2021 literature review.³ This analysis surveyed 35 RCTs featuring robust data on 5 AOMs FDA-approved for long-term use: liraglutide (Saxenda), orlistat (Xenical, Alli), bupropion-naltrexone (Contrave), phentermine-topiramate (Qsymia), and semaglutide (Wegovy). Liraglutide and semaglutide in particular are members of the glucagon-like peptide 1 (GLP-1) receptor agonist class that has revolutionized obesity management in recent years. Despite their well-documented impact on weight loss and minimal rates of serious adverse events, decades-old legislation has prevented Medicare Part D’s coverage from extending to “weight loss” drugs, no matter that the medications are intended to treat the disease of obesity.¹

The new proposal aims to reinterpret this ruling to allow plan coverage of AOMs when their purpose is to address a patient’s obesity and long-term weight management to hopefully prevent associated complications, comorbidities, and conditions. Notably, this reinterpretation would apply to Medicaid plans as well.²

If the Trump administration supports the proposal, CMS anticipates an additional 3.4 million patients who use Medicare—and 4 million who use Medicaid—could qualify for obesity medications.¹ Earlier this year, a survey from KFF indicated that over 60% of Americans are in favor of Medicare covering GLP-1 agonist medications⁴; however, despite their popularity and growing evidence suggesting the benefits of these drugs for obesity-related conditions (including high blood pressure, sleep apnea, and fatty liver disease, among others), this would be a costly move. This coverage could rack up $25 billion in Medicare spending and $11 billion in Medicaid, with the federal government footing that bill. Cost considerations will weigh heavily on the incoming administration, especially considering CMS estimates that total Medicare spending will exceed $2 trillion in the next decade.¹

The proposal is expected to be published in the Federal Register on December 10.

References

1. Sanger-Katz M. Obesity drugs would be covered by Medicare and Medicaid under Biden proposal. New York Times. November 26, 2024. Accessed November 26, 2024. https://www.nytimes.com/2024/11/26/upshot/obesity-drugs-medicare-medicaid.html

2. Medicare and Medicaid Programs: Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly. Federal Register. Accessed November 26, 2024. https://www.federalregister.gov/public-inspection/2024-27939/medicare-and-medicaid-programs-contract-year-2026-policy-and-technical-changes-to-the-medicare

3. Ahmad NN, Robinson S, Kennedy-Martin T, Poon JL, Kan H. Clinical outcomes associated with anti-obesity medications in real-world practice: a systematic literature review. Obes Rev. 2021;22(11):e13326. doi:10.1111/obr.13326

4. Montero A, Sparks G, Presiado M, Hamel L. KFF Health Tracking Poll May 2024: the public’s use and views of GLP-1 drugs. KFF. May 10, 2024. Accessed November 26, 2024. https://www.kff.org/health-costs/poll-finding/kff-health-tracking-poll-may-2024-the-publics-use-and-views-of-glp-1-drugs/