Cost isn’t the only reason Medicare doesn’t cover Wegovy

Few medications have captured the national attention like Wegovy — and for good reason. In a country with a well-documented obesity epidemic, Wegovy and other members of a new type of weight-loss drug are highly effective: In clinical trials, people on Wegovy typically lose 15% of body weight, and a similar medication, retatrutide, has shown up to 24% weight loss. There is now evidence that they confer benefit beyond weight loss, including a recent large clinical trial demonstrating protection against cardiovascular disease.

Yet Medicare does not cover Wegovy, or any other weight loss prescription. State Medicaid programs may decide to cover weight loss drugs, and only a fairly small number currently offer Wegovy.

It’s easy to assume these restrictions emerged amid hesitation about cost, and for good reason: These new medications are expensive — Wegovy’s annual list price is approximately $16,000 — and patients likely have to stay on them indefinitely to keep off the weight. With trials of potential long-term benefits of these medications still ongoing, the jury is out on whether their potential benefit justifies the cost. For example, a recent informal report from the Congressional Budget Office concluded that while current evidence suggests the cost of these new medications exceeds savings from improved health, the cost-benefit picture remains incomplete with long-term trials underway.

The origin of federal restrictions of anti-obesity medications has nothing to do with these current cost-benefit considerations, however: The Medicare and Medicaid policies are three-decade-old restrictions on weight-loss medication in general — a legislative legacy reflecting a different cultural and clinical understanding of obesity.

The Medicaid restriction became law in 1990 as part of the federal Medicaid Drug Rebate Program. The law states that certain classes of medications may be excluded from Medicaid coverage: In addition to weight-loss drugs it excludes a small number of other medicines, notably those used for “cosmetic purposes” or “symptomatic relief of cough and cold.” In 2003, Congress used this same 1990 Medicaid text as the starting point for Medicare’s restrictions under Medicare Part D, refusing to cover any anti-obesity medications.

These restrictions on anti-obesity medicines reflected the times. They reflected the attitudes of many that obesity was an individual failing: “we consider obesity as the presenting symptom of a basic personality disorder,” wrote one physician in the mid-20th century. They reflected a troubled history of anti-obesity medications through the 20th century, of agents introduced and later restricted after serious side effects became clear. Perhaps most infamously, the manufacturer of “fen-phen” pulled the drug combination off the market in 1997 after its association with heart damage. The laws also reflected the attitudes of the medical community. In 1996, the United States Preventive Services Task Force wrote that there was not convincing evidence that weight reduction decreases mortality. Or as a 1998 New England Journal of Medicine editorial summarized: “we should remember that the cure for obesity may be worse than the condition.”

Cultural and clinical attitudes toward obesity have since shifted. Human genetics studies have established that our DNA predisposes some of us to develop obesity. In 2004, the Department of Health and Human Services recognized obesity as an illness, and in 2013, the American Medical Association did as well. And with medications like Wegovy, there are now highly effective weight-loss agents. All the while, the obesity epidemic worsened: Between 1999 and 2017, the rate of obesity among American adults increased from 31% to 42%.

Despite this shift, the Medicare and Medicaid restrictions still remain law of the land, though there are signs of legislative change. Among the most sustained efforts at reform is the Treat and Reduce Obesity Act, federal legislation which would allow Medicare to cover anti-obesity medications; the act has been introduced annually in Congress since 2013 and currently has bipartisan support. In 2023, the Federal Employee Health Benefits Program, which sponsors health insurance for millions of government workers, directed its insurers to provide coverage for at least one drug like Wegovy.

Some might suggest that these decade-old restrictions bring unintended benefit — by limiting coverage, they allow analysis of the pros and cons of the medications to proceed. Without a doubt, there are crucial ongoing discussions, most notably about cost-benefit considerations. It’s clear these medications are expensive, and their long-term health effects and side-effect profiles are still emerging in clinical trials.

As this debate continues, though, we must recognize the origin of the status quo — these restrictions came to be in a cultural and clinical environment surrounding obesity that today is nearly unrecognizable: Obesity is no longer discussed alongside “cosmetic” conditions as it was in 1990 — it’s a disease we treat.

I’ll be a resident physician later this year, and there are many legitimate reasons why my patients might be reluctant to take these medications: perhaps burdensome copays; perhaps hesitation about common gastrointestinal side effects; perhaps wariness about adding another long-term medication. What I’d hate to be in our way are insurance restrictions reflecting a cultural and clinical legacy many decades out of date.

Daniel Weiner is an M.D./Ph.D. candidate at Harvard Medical School. He would like to thank Dr. Jason Block and Dr. Aaron Kesselheim for their helpful suggestions.