Turning Age 65 Should Not Be A Reason To Lose Medical Care
Medicines that can help people with obesity lose weight face a distinct affordability challenge to affordability relative to other types of drugs. They are new and have pent-up demand, so they are perceived to be costly, which limits coverage in insurance plans. However, until they are covered, there is limited evidence of how much they cost or can save the health system. However, many employers, including the federal government and some state governments, have decided that there is sufficient evidence of the value of weight loss for people with obesity so they require comprehensive coverage of obesity medicines. However, in the Medicare prescription drug plan (Part D), weight loss treatments are excluded from coverage. A person entering Medicare already undergoing obesity care would have their treatment interrupted unless the law is changed.
In the U.S., 42% of people have obesity, with an associated medical cost of $173 billion. There are now multiple approved medicines for weight loss. However, when the Medicare Modernization Act created a drug benefit in Medicare in 2003, medicines to help people lose weight were excluded. There were few safe and effective approved treatments twenty years ago, but today, there are six FDA-approved treatments. However, as the law specifically excluded medicines from Medicare Part D coverage when used for weight loss, seniors and disabled people are not getting the benefit of this care.
A significant amount of information supports the connection between helping people with obesity lose weight and better health. A study of half a million people over ten years found people with obesity who lost weight had lower rates of sleep apnea, heart failure, and type two diabetes relative to people who didn’t lose weight. Adults with a chronic condition studied over two years who lost weight had less medical spending, in particular, people with diabetes and arthritis, a common condition in the elderly who get their medicines in Medicare. Examining a range of studies, even if some weight is regained, weight loss intervention has both health and cost benefits. Not providing clinically driven support to seniors and disabled people with obesity in Medicare to lose weight affects their health and well-being, and that comes with a cost.
Treatments for cardiovascular disease such as statins, targeted therapies for cancer, and the near curative treatments for Hepatitis C all increased spending in the Medicare benefit, which has been shown over time to be more than cost-effective. But there was no requirement to pass a law to approve the use of those drugs in the Part D benefit. Those treatments have made a sizeable contribution to reducing major events such as heart attacks and healthcare costs. Moreover, the health plans in Medicare Part D secured discounts on those and other drugs, reducing their net costs to the government and beneficiaries. When a class of drugs is excluded, a senior or disabled person is otherwise left on their own, unless that exclusion is lifted, to shoulder the total cost of the prescription without the benefit of the health insurer's leverage in a price negotiation. This exclusion can be removed to allow seniors to remain on therapy affordably in their Part D benefits. This would enable them to receive the same degree of coverage deemed appropriate for federal employees, among others.
Paying for new drugs in any insurance system is a challenge. Drugs are not like surgery or fixing broken bones; the cost of those services is relatively predictable. When there is a breakthrough in scientific knowledge it can be followed by several approved medicines in one therapeutic class as is being seen in obesity treatment. When there is a new therapy and many people could benefit, there can be a significant cost in one year, with savings accrued later. New medicines for obesity present exactly that challenge to the U.S. health system, with an up-front cost with benefits that accrue over time. But at minimum, a person who has been receiving treatment should not be denied care simply because they became a senior citizen, for their health and fairness of treatment.
Recently, the Centers for Medicaid and Medicare Services indicated that some medicines for obesity could be covered due to new evidence about the reduction in the risk of cardiovascular disease for their use. The Medicare drug plans are permitted to limit use only to people with obesity and cardiovascular disease, which is a high-risk and important group but does not include all people with obesity alone or obesity and another condition. However, this type of coverage does not do much to prevent cardiovascular disease from developing in a person with obesity. Moreover, in a study that spanned more than a decade, people with obesity were more likely to have 21 different conditions in distinct organ systems, including cardiovascular, respiratory, neurological, infections, and cancers, relative to people of lower weight. Osteoarthritis, which is not one of the approved uses for the approved anti-obesity medicines, is one of the costlier and more burdensome conditions associated with obesity and is among the prevalent. People with obesity are also more likely to have anxiety and depression; weight stigma is also associated with poor mental health. The diseases related to obesity are far-reaching.
While elderly and disabled people with obesity are not getting to continue their obesity treatment, and taxpayers may be missing an opportunity to make the Medicare program more solvent and more fair.
Kirsten Axelsen is a visiting scholar with the American Enterprise Institute and a biopharmaceutical company consultant.
