Some of these new weight-loss drugs will be covered by the authority under the Inflation Reduction Act requiring drug price negotiation, but Ozempic, for example, could be exempt from negotiated prices until 2027, and Mounjaro until 2031.

By Al Norman

According to Georgetown University’s Health Policy Institute, one in four older adults are obese. That’s 15 million Americans over the age of 51. Obesity is not considered a chronic condition — but it puts you at risk for many chronic conditions, such as heart disease, type II diabetes, stroke and some forms of cancer.

Obesity rates have been rising, and are predicted to become a greater health problem in the coming decades. Three out of four obese Older Americans are age 51 to 69. 27 percent of this age group are obese, compared to 17 percent of those over the age of 70. Rates are also higher for older adults with lower incomes and those with less education. Symptoms of illness are more common among obese adults. Older men and women have similar rates of obesity. Black Medicare beneficiaries have the highest rates of obesity.

If you’re on Medicare, you are eligible for “obesity behavioral therapy,” which is described as “obesity screenings and behavioral counseling to help you lose weight by focusing on diet and exercise.” Medicare will cover such counseling if you get such services in a doctor’s office, or some other primary care setting, “where they can coordinate your personalized prevention plan with your other care.” Medicare will also cover bariatric surgery.

But when Medicare was amended 20 years ago to create the Part D prescription drug benefit, it prohibited using Medicare funds to pay for weight-loss drugs, hair growth medications, fertility drugs, and drugs prescribed to treat sexual or erectile dysfunction. Some Medicare Advantage plans will cover fitness programs or gym memberships, but weight loss programs are only covered when they are considered “medically necessary.”

The advent of drugs known as glucagon-like peptide-1 (GLP-1) agonists, which were developed to treat type 2 diabetes, have also been found to be effective for weight loss. The drugs Ozempic, Wegovy and Mounjaro can be taken for weight loss, but they are expensive — and they are not yet covered under current Medicare law. Wegovy costs as much as $13,600 per year.

There has been significant controversy in recent years over the impacts of Medicare’s approval of expensive new Alzheimer’s drugs, and the financial impact it had on Medicare part B premiums.

If the Food & Drug Administration approves the new Alzheimer’s Drug Leqembi, the Kaiser Family Foundation reports it could add an estimated $17 billion to Medicare Part B spending annually, which would result in all Medicare beneficiaries paying higher Medicare Part B premiums, even if they never use such drugs. But these studies do not examine the potential cost-savings to Medicare if weight-loss drugs reduce the incidence of diseases related to obesity, such as heart disease, diabetes and stroke.

Some of these new weight-loss drugs will be covered by the authority under the Inflation Reduction Act requiring drug price negotiation, but Ozempic, for example, could be exempt from negotiated prices until 2027, and Mounjaro until 2031. If weight-loss drugs become part of the Medicare Part D out-of-pocket spending cap of $2,000, these drugs would be less costly.

The drug-makers are lobbying Congress to allow weight-loss drug coverage under Medicare. The Treat & Reduce Obesity Act (H.R. 1577/S.596 bill, introduced by Senator Tom Carper (D-DE) and Rep. Ron Kind (D-WI), has been filed to authorize Part D coverage of medications when used for the treatment of obesity or weight loss management in overweight individuals. If these bills don’t pass, the federal Center for Medicare and Medicaid Services (CMS) could create a demonstration program to allow limited use as a stop-gap measure.

But there’s some controversy over the risks that have been reported with the use of these medications, just as there were concerns over the new Alzheimer’s drugs. One clinical trial of Wegovy, for example, found that roughly 40 percent of the weight participants lost was lean mass. Side effects like nausea, vomiting, and a possible link to rare cases of pancreatitis were reported.

A white paper produced by USC Schaeffer in April, 2023 concluded that “in the first 10 years alone, Medicare coverage of weight-loss therapies would save the program $175 billion to $245 billion … Over 60 percent of these savings would accrue to Medicare Part A by reducing hospital inpatient care demands and the demand for skilled nursing care. Give these findings, policymakers should consider the societal benefits of lifting the moratorium on Medicare coverage for weight-loss drugs and enable Medicare to work with manufacturers to create reimbursement solutions that provide broad access to new treatments.”

Given the uncertain risks and costs involved in this decision, it may be a heavy lift for Congress to take on weight-loss medications as a Medicare benefit anytime soon.

Al Norman has been an op-ed columnist for the 50+ Life for more than three decades. He worked in the field of elderly home care in Massachusetts over the same period of time.