Weight loss drugs could soon be covered by Medicare and Medicaid

The Biden administration is looking to extend Medicare and Medicaid coverage to include obesity drugs like Wegovy and Zepbound. Weight loss drugs are now excluded from mandatory coverage.

Transcript

ARI SHAPIRO, HOST:

It may soon get easier for people who rely on Medicare and Medicaid to access blockbuster obesity drugs like Wegovy and Zepbound. The Biden administration is proposing a new rule to expand coverage. NPR pharmaceuticals correspondent Sydney Lupkin is here to talk with us about how that could work. Hi, Sydney.

SYDNEY LUPKIN, BYLINE: Hi, Ari.

SHAPIRO: What's the problem that the Biden administration is trying to solve here?

LUPKIN: Yeah. So to understand what the administration is aiming for, you need to know how these programs handle weight loss drugs today. Right now people on Medicare and Medicaid have pretty spotty coverage of drugs like Wegovy, which has the same active ingredient as Ozempic, but is approved for weight loss. That's because of legislation written decades ago that specifically excludes drugs for weight loss from mandatory coverage. Here's Rachel Sachs, a law professor at Washington University in St. Louis.

RACHEL SACHS: That statute was passed when the idea of what a drug for weight loss could be was very different than the idea of these new drugs.

LUPKIN: They weren't as effective, and one of them had just been taken off the market because it was causing heart problems. What's more, obesity wasn't really recognized as a disease. Weight loss was seen as something cosmetic. So because of that old law, right now most Medicare and Medicaid patients have coverage for these drugs only if they have Type 2 diabetes or cardiovascular disease because that means the drugs are not explicitly being used for weight loss. The new rule is trying to end the exclusion and expand access for people with obesity.

SHAPIRO: So what's the strategy here? How is the administration getting around the law?

LUPKIN: It's taking a new slant on what the drugs do. Here's CMS administrator Chiquita Brooks-LaSure.

CHIQUITA BROOKS-LASURE: It is really reinterpreting the law to say that anti-obesity medications are treating obesity, and so we're seeing that as distinct from taking a drug for weight loss.

LUPKIN: So the administration is not changing the law. That requires an act of Congress. And it's not the first time an administration has reinterpreted this law. Twenty-five years ago, the Clinton administration expanded coverage to include weight gain drugs to help people with AIDS, who were also suffering from wasting syndrome. So to be clear, this new rule would expand coverage of Wegovy and Zepbound for people with obesity, but not those who just want to lose a few pounds. The administration estimates that the proposed rule could help 3.4 million people on Medicare and 4 million people on Medicaid.

SHAPIRO: That sounds like a big number. Has there been any pushback? I know these drugs are expensive.

LUPKIN: Yeah. There's wide support for the idea, but a few concerns. I've heard some advocates and legislators say it's an expensive thing to do. These drugs cost around $1,000 a month or more. So the thinking is that before saddling the federal and state governments with the bill, they would have liked if the administration first went after the companies charging such high prices to get them lowered. The Centers for Medicare and Medicaid estimate it would cost both programs about 40 billion total over the next 10 years to cover the drugs. Brooks-LaSure says it would be about 1% of the money spent during that time on prescription drugs for Medicare and 2% on Medicaid.

That said, overall, the idea of treating these patients and not waiting until they develop cardiovascular disease to get them access to these drugs has been well received, especially by the medical community. But as it is, these drugs can be hard to find thanks to their huge popularity. A surge in demand from Medicare and Medicaid patients could put even more strain on that supply.

SHAPIRO: Biden is a lame-duck president, so is this going to stick as he is on his way out?

LUPKIN: You know, it's a good question. A lot is up in the air. Like all proposed rules, this one will go through a public comment period, which ends on January 27. That's about a week after the inauguration, meaning that a lot will be up to the incoming Trump administration. It can decide whether it wants to finalize all or just parts of the proposal or scrap it all together. So it's possible this coverage change could wind up on the cutting room floor. Robert F. Kennedy Jr., Trump's pick for HHS secretary, has been pretty vocal about his aversion to these drugs and a strong preference for dietary changes instead. But if the current administration's plan prevails, the new coverage could be added by 2026.

SHAPIRO: That is NPR pharmaceuticals correspondent Sydney Lupkin. Thank you.

LUPKIN: You bet. Transcript provided by NPR, Copyright NPR.