In a major setback for advocates of obesity treatment, the Centers for Medicare and Medicaid Services (CMS) recently announced it would not move forward with a plan to expand coverage for weight-loss medications Wegovy and Zepbound under Medicare. These drugs, both GLP-1 receptor agonists, have demonstrated significant benefits for weight loss and related health outcomes, but for now, they will remain uncovered for Medicare recipients who are not diabetic.
Currently, Medicare and Medicaid do cover GLP-1 medications like Ozempic and Mounjaro for patients with diabetes. However, the newer versions—Wegovy, produced by Novo Nordisk, and Zepbound, produced by Eli Lilly—were developed specifically for the treatment of obesity. Without a diabetes diagnosis, Medicare beneficiaries will not be eligible for coverage, leaving many patients without access to these potentially life-changing medications.
Initial Hope for Coverage Expansion
Earlier in 2024, the Biden Administration had proposed extending Medicare Part D coverage for these weight-loss drugs, particularly within Medicare Advantage plans. The move was hailed by obesity advocates and healthcare providers as a crucial recognition of obesity as a chronic, serious disease rather than simply a lifestyle issue. A spokesperson for Novo Nordisk expressed cautious optimism at the time, emphasizing that regulatory recognition of obesity as a chronic disease would be essential. They hoped that, with new leadership at CMS, there would be movement toward aligning Medicare policies with modern medical understanding.
Eli Lilly shared a similar sentiment. A company spokesperson expressed disappointment in CMS’s recent decision, arguing that the regulatory interpretation under the Medicare Advantage-Part D rule was overly restrictive and not the best reading of the statute. They emphasized the importance of continued work with policymakers to eventually secure Medicare and Medicaid coverage for patients struggling with obesity, a move that could impact millions of lives.
Millions Left Without Access
It was estimated that nearly 7.5 million Medicare and Medicaid beneficiaries would have qualified for obesity drug coverage under the proposed expansion. Without it, these individuals will continue to face limited options. Many experts believe this decision represents a missed opportunity to address one of the nation’s most pressing public health challenges: obesity and its widespread complications.
Concerns about costs played a significant role in the CMS decision. A September 2024 healthcare financing report warned that expanding coverage for GLP-1s like Wegovy and Zepbound could lead to substantial increases in government spending, with relatively limited information about the drugs’ long-term effects. This financial risk weighed heavily against the potential short-term benefits of broader coverage.
The Growing Debate Over Long-Term Costs
While concerns about government spending are valid, many healthcare experts argue that denying access to obesity treatments could ultimately cost the system more. Obesity is linked to numerous chronic conditions such as cardiovascular disease, diabetes, stroke, and certain types of cancer. Treating these conditions is extremely expensive over the long term.
Recent scientific research points to additional benefits of GLP-1 drugs beyond weight loss. In March 2024, the FDA approved Wegovy for reducing the risk of cardiovascular death, heart attack, and stroke among adults with cardiovascular disease and obesity or overweight. Similarly, Zepbound recently became the first prescription medication approved to treat obstructive sleep apnea, a serious condition that often goes undiagnosed and untreated in individuals with obesity.
Other studies suggest that GLP-1 drugs may help slow the progression of fatty liver disease, reduce the risk of developing type 2 diabetes in individuals with prediabetes, and may even have potential applications in treating substance use disorders such as alcoholism, smoking, and opioid addiction. Given these wide-ranging effects, many experts believe broader access to GLP-1 medications could lead to massive savings over time by preventing or delaying the onset of costly, life-threatening diseases.
RFK Jr. Considers a New Framework
While CMS has decided against finalizing coverage expansion at this time, there may still be hope for change. Health and Human Services (HHS) Secretary Robert F. Kennedy Jr. has indicated he is considering a “regulatory framework” that could allow Medicare and Medicaid to cover GLP-1 medications for obesity under certain conditions.
Kennedy has emphasized that the high cost of the drugs remains a major hurdle. However, he suggested a model where patients would first attempt lower-cost interventions—such as glucose monitors, diet, and lifestyle changes—before becoming eligible for GLP-1 drug coverage. This stepwise approach could help control spending while still giving patients access to effective medications when other strategies fail.
Kennedy explained that with today’s technology, patients can easily document their efforts using tools like glucose monitors. If those efforts do not succeed, patients could then qualify for coverage of drugs like Wegovy and Zepbound.
Barriers Rooted in Old Laws
One significant barrier to broader coverage is a law passed in 2003 that prohibits Medicare from covering medications solely for weight loss purposes. While GLP-1 drugs are now proving to treat more than just weight issues—such as cardiovascular disease and sleep apnea—their original approval for obesity management complicates how they are classified under current Medicare statutes.
Until Congress updates these laws or CMS develops a workaround framework, millions of Medicare recipients will continue to be locked out of access to some of the most promising treatments for one of the most serious health challenges of our time.
The Road Ahead
As research into GLP-1 medications continues to uncover more health benefits, public pressure to expand Medicare and Medicaid coverage for these treatments is likely to grow. Policymakers will need to weigh the immediate financial costs against the long-term potential savings and health improvements that broader access to obesity medications could bring.
The conversation surrounding GLP-1 drugs is just beginning. As more data emerges on their ability to prevent heart disease, manage sleep apnea, improve fatty liver disease, and even stop the progression of prediabetes to diabetes, the argument for comprehensive coverage becomes increasingly compelling. Whether change happens under current regulations or through new legislative efforts remains to be seen.
