USA – Outgoing U.S. President Joe Biden has proposed a significant expansion of Medicare coverage for anti-obesity medications (AOMs), which could provide broader access to treatments like Novo Nordisk’s Wegovy (semaglutide) and Eli Lilly’s Zepbound (tirzepatide).
However, it remains unclear whether this proposal will survive under the incoming Trump administration.
Currently, Medicare and Medicaid do not cover AOMs solely for obesity treatment. These drugs are only covered when obesity is linked to conditions such as diabetes, a restriction based on legislation from over 20 years ago.
The Biden administration’s new proposal seeks to eliminate this limitation, expanding coverage to an estimated 3.4 million people with obesity in Medicare and 4 million in Medicaid, even if they do not have related conditions.
The administration argues that expanding coverage for AOMs could prevent the onset of obesity-related health issues, such as diabetes, heart disease, and stroke.
By intervening early, it could reduce the long-term costs of treating these conditions, which can strain healthcare systems.
The current lack of coverage traces back to a safety controversy in the 1990s. The weight-loss drug “fen-phen” was linked to serious health problems, including heart valve damage and pulmonary hypertension, leading to stricter regulations.
As a result, AOMs like Wegovy and Zepbound are not covered by Medicare for weight loss alone, with out-of-pocket costs for these drugs reaching up to US $1,000 a month.
Under the proposed changes, the out-of-pocket cost for many beneficiaries could drop by as much as 95%. The new coverage criteria are set to take effect in 2026.
According to the Biden administration, the move would allow Americans and their doctors to choose the best course of action for weight management without worrying about the affordability of these medications, ultimately helping reduce national healthcare costs.
Additionally, the proposal would require all state Medicaid programs to cover AOMs, a change that is currently rare.
This follows a vote earlier this year in the House, where lawmakers attempted to ease restrictions on obesity medications, though their plan did not go as far as Biden’s proposal.
Economic modeling of the House bill projected it would cost Medicare around US $1.7 billion over the next decade.
The proposal, however, faces uncertainty, as it will need to pass under the new administration of President-elect Donald Trump.
While Trump has pledged to address chronic diseases in America, his focus on reducing federal spending may challenge the proposal’s survival.
The White House has also highlighted its ongoing efforts to lower drug prices through negotiations, which could affect AOM pricing.
Speculation suggests that Wegovy and Zepbound may be included in the next round of Medicare pricing negotiations, set to take effect in 2027, potentially lowering the cost of these medications in the U.S.
