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New weight-loss drugs are out of reach for millions of older Americans because Medicare doesn’t pay

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New obesity drugs are showing promising results in helping some people lose weight, but the shots will remain out of reach for millions of older Americans because Medicare is barred from covering the drugs.

Drugmakers and a broad, growing bipartisan coalition of lawmakers are preparing to push for a change next year.

As obesity rates rise among older adults, some lawmakers say the United States cannot afford to maintain a decades-old law that prohibits Medicare from paying for new weight-loss drugs, including Wegovy and Zepbound . But research shows that the upfront price of coverage for these drugs is so high that it could deplete Medicare’s already fragile bank account.

A look at the debate around whether – and how – Medicare should cover obesity medications:

WHAT OBESITY DRUGS ARE ON THE MARKET AND HOW DO THEY WORK?

The Food and Drug Administration has approved a new class of weekly injectables, Novo Nordisk’s Wegovy and Eli Lilly’s Zepbound, in recent years to treat obesity.

People can lose up to 15 to 25 percent of their body weight with these medications, which mimic hormones that regulate appetite by communicating fullness between the gut and brain when people eat.

The cost of these drugs, popular with celebrities, has largely limited them to the wealthy. A monthly supply of Wegovy costs $1,300 and Zepbound will run you $1,000. Drug shortages have also limited supplies. Private insurers often don’t cover medications or place strict restrictions on who can access them.

Last month, a large international study found a 20 percent reduction in the risk of serious heart problems such as heart attacks in patients taking Wegovy.

WHY DOESN’T MEDICARE COVER DRUGS?

Long before Oprah Winfrey and TikTok influencers were raving about the benefits of these weight-loss drugs, Congress established a rule: Medicare Part D, the health insurance plan that allows older Americans to get prescriptions, does not could not cover medications used to help gain or lose weight. Medicare will cover obesity screening and behavioral treatment if a person has a body mass index over 30. People with a BMI over 30 are considered obese.

The rule was added to legislation passed by Congress in 2003 that overhauled Medicare’s prescription drug benefits.

Lawmakers have been reluctant to pay high prices for drugs intended to treat a condition historically considered cosmetic. Also front of mind in the 1990s were safety concerns with the anti-obesity treatment known as fen-phen, which had to be withdrawn from the market.

Medicaid, the state-federal partnership program for low-income people, covers medications in some areas, but access is fragmented.

THE CONVERSATION IS CHANGING

New studies show the drugs do more than help patients lose weight.

Rep. Brad Wenstrup, R-Ohio, introduced legislation this year with Rep. Raul Ruiz, D-Calif., that would allow Medicare to cover now-banned anti-obesity drugs, therapy, nutritionists and dietitians.

“For years these people were stigmatized, and then there was a stigmatization of talking about obesity,” Wenstrup said in an interview with The Associated Press. “Now we’re at the point where we’re saying this is a health issue that we need to address.”

He thinks the intervention could alleviate all sorts of diseases associated with obesity that cost the system money.

“The problem is so widespread,” Wenstrup said. “People are starting to realize that you have to take into consideration the savings that come with better health.”

Last year, about 40 percent of the nearly 66 million people enrolled in Medicare had obesity. That roughly mirrors the U.S. population, where 42 percent of adults suffer from obesity, according to the Centers for Disease Control and Prevention.

Notably, Medicare covers certain surgical procedures to treat medical complications of obesity in people with a BMI of 35 and at least one related condition. Congress approved the exception in 2006, noted Mark McClellan, former director of the Centers for Medicare and Medicaid Services and the FDA.

The 17-year-old law could serve as a model for expanding coverage for new drugs, which in some cases mirror the results of bariatric surgery, McClellan said. Evidence showed that the operation reduced the risks of death and serious illness from obesity-related conditions.

“And that’s been the basis of media coverage all this time,” McClellan said.

COST IS NOW THE PROBLEM

Still, the initial cost of lifting the rule remains a challenge.

Some research shows that offering weight-loss drugs would guarantee the impending bankruptcy of Medicare. An analysis this year by Vanderbilt University estimates that the annual cost of anti-obesity drugs to Medicare would be about $26 billion if just 10 percent of the system’s enrollees were prescribed the drug.

However, other research shows that it could also save the government billions, if not trillions, over many years because it would reduce some chronic illnesses and problems linked to obesity.

An analysis this year by the Schaeffer Center at the University of Southern California estimates that the government could save as much as $245 billion over ten years, with the majority of the savings coming from reduced hospitalizations and other care.

“What we did was look at the long-term health consequences of treating obesity in the Medicare population,” said study co-author Darius Lakdawalla, director of research at the center. . The Schaeffer Center receives funding from pharmaceutical companies, including Eli Lilly.

Lakdawalla said it’s almost impossible to estimate the cost of covering the drugs because no one knows how many people will end up taking them or how much the drugs will cost.

The Congressional Budget Office, which is responsible for evaluating legislative proposals, acknowledged this difficulty in a blog post published in October, with the director calling for more research on the topic.

Overall, the agency “expects the net cost of the drug to the Medicare program to be significant over the next 10 years.”

The cost of the legislation is the main barrier to gaining support, Ruiz said.

“When we talk about the upfront cost, I often have to inform members that the CBO does not consider cost savings in its cost-benefit analysis,” Ruiz told the AP. “Taking this figure in isolation does not provide the full picture of the savings from reducing obesity and all its comorbidities in our patients.”

WHO WANTS MEDICARE TO COVER DRUGS?

Doctors say weight loss medications are only part of the most effective strategies for treating an obese patient.

When Dr. Andrew Kraftson develops a plan with his patients at the University of Michigan’s Weight Navigator program, it involves a “perfect marriage” of behavioral intervention, health and diet education, and possibly anti-inflammatory medications. -obesity.

But with Medicare patients, he is limited in what he can prescribe.

“A blanket ban on the use of anti-obesity medications is an outdated way of thinking that fails to recognize obesity as a disease and perpetuates health disparities,” Kraftson said. “I’m not ignorant enough to think Medicare should just start covering expensive treatments for everyone. But there’s something between all or nothing.”

Lawmakers have introduced some variations of legislation that would allow Medicare to cover weight-loss drugs over the past decade. But this year’s bill has drawn interest from more than 60 lawmakers, from self-described budget hawk Rep. David Schweikert, Republican of Arizona, to progressive Rep. Judy Chu, Democrat of California.

Passage is a top priority for two lawmakers, Wenstrup and Sen. Tom Carper, D-Del., before they retire next year.

Pharmaceutical companies are also preparing for a lobbying campaign next year as drugs gain FDA approval for use in weight loss.

“Americans should have access to the medications that their doctors believe they should have,” Stephen Ubl, president of the lobbying group Pharmaceutical Research and Manufacturers of America, said on a call with reporters last week. “We would ask Medicare to cover these medications.”

Novo Nordisk has already employed eight separate companies and spent nearly $20 million lobbying the federal government on issues including the Obesity Treatment and Reduction Act since 2020, according to disclosures. Eli Lilly has spent approximately $2.4 million on lobbying since 2021.

Advocates from groups such as the Obesity Society have pushed for years to have the drugs covered by Medicare. But the dynamic could be changing, thanks to growing evidence that anti-obesity drugs can prevent strokes, heart attacks and even death, said Ted Kyle, a policy adviser.

“The conversation has shifted from debating whether obesity treatment is useful to looking at how to make the economics work,” he said. “That’s why I now believe change is inevitable.”

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Associated Press writers JoNel Aleccia in Temecula, Calif., and Brian Slodysko contributed to this report.

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