Millions of older Americans who are dealing with obesity could soon get help from Medicare to cover the high costs of weight loss medication, which might reduce their risk of serious heart problems.
However, there are still important questions about who will qualify for this coverage, how many people could benefit, and how much it will cost the nation.
A recent study tries to address these questions. It explores different ways Medicare might decide who is eligible for this weight loss treatment. Depending on the criteria used, the number of eligible people and the costs to Medicare could vary significantly.
For example, the study suggests that around 3.6 million people with obesity may qualify for coverage if only those who have already had a heart attack or stroke, or have heart-related conditions like coronary artery disease or angina, are allowed to receive the medication.
This estimate does not include the 7 million people who already qualify for the drug because they have both obesity and diabetes.
But what about those who have obesity and are at a high risk for heart problems, even if they haven’t had a major heart event yet?
The study finds that if Medicare expands coverage to include people with the highest risk of having a heart attack or stroke in the next 10 years, an additional 5.1 million Americans could be eligible. If Medicare further broadens the criteria to include those with intermediate risk, another 6.5 million people could qualify.
This potential coverage would apply to semaglutide, a drug used for both weight loss (marketed as Wegovy) and diabetes management (sold as Ozempic).
Medicare recently announced that semaglutide may be covered for those with established cardiovascular disease, but the exact definition of this condition hasn’t been clearly laid out.
According to Dr. Alexander Chaitoff, one of the study’s lead researchers, it’s still uncertain who will qualify under these rules, and some high-risk individuals could be left out.
The study was led by Chaitoff, who works at the VA Ann Arbor Healthcare System and the University of Michigan Medical School, and was published in the Annals of Internal Medicine.
Chaitoff and his team launched the research after learning about Medicare’s plan to provide coverage for semaglutide under certain conditions.
Typically, Medicare might stick to a narrow list of conditions similar to those required in the clinical trials that tested semaglutide for weight loss.
However, the researchers suggest that Medicare could take a more preventive approach, similar to what is done with other medications aimed at reducing the risk of heart attacks or strokes.
Chaitoff, who also cares for veterans, notes that the Veterans Health Administration already offers Wegovy to veterans with obesity and related conditions if they participate in a weight management program.
For those enrolled in Medicare, however, it’s up to their individual drug plans to decide what will be covered.
The researchers used data from a national health survey to calculate the cardiovascular risk for Medicare beneficiaries with a body mass index (BMI) of 27 or higher.
They used a tool called the ASCVD risk score, which helps doctors assess a person’s likelihood of developing heart disease or having a stroke within 10 years.
Individuals with a score of 20% or higher are considered at high risk, while those with a score between 7.5% and 20% are at intermediate risk.
People with a high risk score are typically prescribed medications to lower their blood pressure, cholesterol, or blood sugar, and are encouraged to adopt lifestyle changes like quitting smoking, exercising more, and losing weight.
Weight loss is a key recommendation in clinical guidelines for reducing cardiovascular risk in people with both high and intermediate risk scores. However, Medicare’s coverage for weight loss drugs like semaglutide may depend more on a person’s past heart problems than their future risk.
The cost of semaglutide to Medicare could be substantial. The study estimates that if only those with a history of heart attack or stroke are covered and about 30% of them begin and continue using the drug for a year, the cost to Medicare could exceed $10 billion at current prices.
Chaitoff emphasizes the need for Medicare to reconsider how it evaluates coverage for obesity treatments.
With all the evidence showing the connection between obesity and heart disease, it may be time to treat obesity more like other conditions that require preventive medication, rather than waiting for people to have a heart attack or stroke before offering coverage for effective treatments like semaglutide.
If you care about weight, please read studies about diet that can treat fatty liver disease, obesity, and hop extract could reduce belly fat in overweight people.
For more information about weight, please see recent studies about how to curb your cravings for ready-to-eat foods, and results showing what you can eat to speed your metabolism up.
The findings are published in Annals of Internal Medicine.
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