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Policy Proposal Seeks to Include Weight-Loss Drugs in Medicare Coverage
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The proposed rule would increase access to semaglutide for millions of Americans.
A proposal from the Department of Health and Human Services would cover weight-loss drugs such as semaglutide (Wegovy, Ozempic; Novo Nordisk) under Medicare and Medicaid, expanding access to the therapy for millions of Americans. The potential ruling, proposed under the Biden administration, faces some challenges; however, increased access to the therapy can aid in weight loss to decrease risk of adverse health events and contribute to efforts to reduce obesity in the United States.1
Ozempic | Image Credit: © Kassandra - stock.adobe.com
According to a report published in Lancet, approximately 75% of Americans over the age of 25 have obesity or are overweight, with increasing prevalence amongst adolescents since 1990. Obesity is a known risk factor for various conditions including cardiovascular disease and type 2 diabetes (T2D), which accounts for 90% to 95% of all T2Ds cases. Despite acknowledgement of this issue, there are various barriers that prevent effective methods for improving obesity rates, including poor access to health food and drug costs.2,3
“It’s going to require a lot more attention and a lot more investment than we are currently giving the problem,” said Sarah C. Armstrong, MD, professor of pediatrics and population health sciences at Duke University, in a New York Times article. “Obesity comes from genetic, physiological, and environmental interactions. It’s not the fault of any one individual who has the disease.”2
Primary treatment for obesity and overweight are lifestyle modifications as well as GLP-1 receptor agonists or semaglutide, which promote feelings of satiety to reduce hunger. The agents Ozempic and Wegovy received FDA approval in 2021 and 2024, respectively, for adults with obesity or overweight. Considered a “miracle drug,” the success of semaglutide, including its popularity in Hollywood, has led to an uptick in use across populations. Additionally, various studies suggest its benefits for alcoholism, as well as reducing the risk of Alzheimer disease.4-8
Historically, Medicare and Medicaid do not cover semaglutide, preventing many patients from accessing this efficacious therapy. According to the Centers for Medicare and Medicaid, roughly 28 million individuals on Medicaid are considered obese. The proposed rule would extend coverage to around 4 million individuals prescribed semaglutide to reduce excess body weight and maintain long-term weight reduction. Without coverage, these drugs can cost up to $1300 a month for weekly injections.9
"This proposal would allow Americans and their doctors to determine the best path forward so they can lead healthier lives, without worrying about their ability to cover these drugs out-of-pocket, and ultimately reduce health care costs to our nation," the White House told CBS News.10
The proposal is expected to cost taxpayers about $35 billion over the next decade. If passed, coverage of semaglutide under Medicare and Medicaid would take effect in 2026.9
However, considering emerging health policy change proposals under the Trump administration, there is some uncertainty around whether the rule would be passed. Robert F. Kennedy, nominee for secretary of the HHS, has built his platform on the expansion of healthy foods and gym memberships to address chronic health conditions like obesity.10
“For half the price of [semaglutide], we could purchase regeneratively raised, organic food for every American, 3 meals a day and a gym membership, for every obese American,” Kennedy said in a roundtable with federal lawmakers in 2024.10
Despite the importance of healthy food and its benefit for weight loss, it can be difficult for all Americans to have access to the resources necessary for a healthy, preventative lifestyle. Food deserts in rural areas and poverty are significant barriers to nutritional wellness for many individuals, meaning policy changes are crucial to overcome such obstacles. Despite the long-term benefits and implications of such policies, it may not imminently address the issue of obesity and overweight, as genetics have also been shown to play a role.7 Therefore, coverage of semaglutide in conjunction with expanding access to healthy food may be essential for effectively addressing obesity and subsequent chronic diseases.
