Inside the push to get weight loss treatment covered by Medicare

A push to have more obesity care services covered under Medicare is picking up steam in Congress, buoyed by enthusiasm for newer medications and recognition of the massive cost of chronic health issues linked to being overweight.

Under the Medicare Modernization Act passed in 2003, Medicare is prohibited from covering medications used for weight loss. At the time, the reasoning was that certain weight loss drugs carried dangerous side effects.

A bipartisan, bicameral collection of lawmakers reintroduced the Treat and Reduce Obesity Act (TROA) last month, which would allow more health care providers, services and drugs to be covered under Medicare.

Apart from medications, this bill would allow for counseling services and obesity screenings to be covered under the federal health plan. The legislation notes that nearly half of all adults in the U.S. over the age of 60 have obesity and Medicare spending on those patients is at least $2,000 more per year than nonobese beneficiaries.  

According to the National Institutes of Health, almost 1 in 3 U.S. adults are overweight and 2 out of 5 adults have obesity.

The lawmakers sponsoring the bill include Sens. Tom Carper (D-Del.), Bill Cassidy (R-La.) as well as Reps. Raul Ruiz (D-Calif.) and Brad Wenstrup (R-Ohio). Carper has been leading the push to pass the TROA since 2012 when he first introduced it. 

“With obesity rates on the rise in our country, we must do more to combat this epidemic head on. Too many of those in need are being denied care because of the high cost of medications or inaccessible treatment options,” Carper said in a statement to The Hill. 

“We cannot stand idly by while this disease continues to claim lives through related illnesses that are preventable and treatable.”

Drug manufacturers are also leading the push for Medicare coverage through lobbying efforts. As KFF Health News reported, pharmaceutical giant Novo Nordisk, the maker of Wegovy and Ozempic, has been steadily campaigning to have its new class of weight loss drug covered under Medicare.

Drugs like Wegovy and Ozempic have spiked in popularity in recent years. A survey released this month found that 45 percent of adults had some interest in taking a “safe and effective” weight loss drug.

Both Wegovy and Ozempic are semaglutide, which mimics a hormone secreted in response to food intake, encouraging insulin production and suppressing appetite.

Promising data has recently come out in support of Wegovy, with a trial involving 17,600 adults with obesity finding that the risk of serious heart problems was cut down by 20 percent after taking the drug.

Janese Laster is a gastroenterologist and founder of Gut Theory Total Digestive Care in Washington, D.C. According to Laster, “bias in obesity care and the lack of understanding of obesity as a disease” are the main reasons why semaglutides wouldn’t be covered under Medicare.

“Coverage of obesity medications is up for debate and these medications have the potential to resolve the most common underlying factor leading to these other conditions,” Laster said. “People view obesity as a cosmetic, personal moral failing of the patient. However, obesity is a complicated, multifactorial disease.”

Undesirable side effects of drugs like Wegovy have been brought under the spotlight in recent weeks as well, however. A Louisiana woman filed a lawsuit against Novo Nordisk this month, alleging the company downplayed the potential side effects like “stomach paralysis,” when food is slow to empty out of the stomach and into the intestines.

Novo Nordisk is listed among the several dozen organizations that have endorsed the TROA, with fellow drug company Eli Lilly — the maker of the diabetes drug Mounjaro — and the Obesity Action Coalition (OAC) nonprofit also putting their stamp of approval on the bill. Novo Nordisk donates more than $500,000 annually to the OAC, according to the organization.

“Obesity is definitely a chronic disease that older Americans live with and have to manage. So, it’s very relevant for the Medicare population,” Tracy Zvenyach, director of policy strategy and alliances at the OAC, told The Hill. “Obesity is a chronic disease like other chronic diseases like high blood pressure, high cholesterol, diabetes. It needs to be thought of and treated similarly.”

Right now, Medicare beneficiaries with obesity can only access care — ranging from behavioral and nutritional counseling to federally approved medicines — in primary care settings. 

Zvenyach noted the TROA would expand patients’ options to include providers like dieticians, clinical psychologists or specialty clinicians who operate outside of primary care.

“This type of policy change is relevant to all Americans, because when [the Centers for Medicare and Medicaid Services] makes a major policy change such as this proposed change, it can have an effect across all coverages and that would be a positive step toward access to care for people living with obesity,” Zvenyach said.

Even if TROA does advance through Congress this time around, administrative barriers stand in the way.

The Congressional Budget Office (CBO) has yet to score the bill, so its cost has not been determined and it will likely have to wait for other bills to get graded first, according to staffers familiar with the situation.

The bill has been referred to the Senate Finance Committee and stakeholders are hoping that committee Chairman Ron Wyden (D-Ore.) can provide a push for the CBO to assess the bill. Wenstrup’s seat on the House Ways and Means Committee may also provide an additional avenue for encouraging the CBO to score it.

Major appropriations bills to fund agencies like the Food and Drug Administration and the Department of Health and Human Services will be at the top of Congress’s agency when lawmakers return from August recess. If the TROA is to be passed during this Congress, it’s likely to be lumped together with bigger bills.