Sunday, June 16, 2024

Opinion | How to make powerful new obesity drugs available to all

Opinion | How to make powerful new obesity drugs available to all

The medical sensation of the decade is a set of drugs that help people slim down. With weekly injections, people can drop 15 percent to more than 22 percent of their body weight on average, often 40, 50 pounds — or more. No safe medicine or any other weight-loss strategy except surgery has been so effective. Given that nearly 42 percent of Americans are obese, and thus vulnerable to diabetes, heart disease, stroke and various kinds of cancer, Wegovy, Zepbound and other so-called GLP-1 agonists come as a breakthrough. They offer a way to vastly improve public health — not to mention quality of life among people who struggle to lose weight.

Surely, health insurers, including employers and Medicare, can find a way to pay for these extraordinary drugs. If they don’t, only wealthy people will benefit — while poorer Americans are more prone to obesity. And the opportunity to bring a large share of the population back to good health will be largely lost.

Doing this without drastically inflating the price of U.S. health care and straining public budgets will be hard. The monthly cost for the drugs is upward of $1,000. (Zepbound is $1,060 and Wegovy, $1,350.) If Medicare’s drug-coverage program, Part D, were to cover Wegovy at the list price for all obese beneficiaries, it would cost more than the entire Part D budget — and more than the total amount of excess health-care spending on obese Americans of all ages (estimated to be $260 billion in 2016), according to an analysis in the New England Journal of Medicine.

Part D pays for the drugs only to treat diabetes. The law bars the program from covering weight-loss medications, but Congress could easily remove this obstacle — put in place at a time when overweight status was stigmatized as a personal failing, rather than reflective of deep-seated biological drives, and weight loss was considered only a cosmetic benefit.

The drugs stand to be alarmingly expensive for private insurers, too. If more than a tiny fraction of the people they cover use the drugs, the cost will drive up premiums for everyone. The injections are meant to be taken in perpetuity — people who quit see much of the weight return — which could translate into an enormous addition to America’s already world-beating health-care costs. Yet more and more employers are covering them, as most Americans want them to do.

Limiting demand would be a daunting challenge because almost half the U.S. population meets the Food and Drug Administration criteria for taking them: They have either a body mass index of at least 30 (obesity) or a BMI of 27 (overweight) and at least one weight-related ailment (diabetes, high blood pressure or high cholesterol, for example). Not everyone who qualifies will want the drugs, of course, and many who start taking them will quit. A recent study found that 68 percent of patients stop within a year of starting — presumably, this is at least in part because of unpleasant gastrointestinal side effects. But demand is already so high, the drugmakers are having trouble keeping up.

This demand also keeps prices aloft. The medicines are priced at least 40 percent higher than what would be cost-effective, considering their benefits, according to the Institute for Clinical and Economic Review, a research organization. But the list prices aren’t immutable; they’re subject to negotiation. Private insurers strike deals with drugmakers to pay significantly less. And prices will fall as similar new drugs hit the market — and, in years ahead, as generic versions of the drugs emerge. Note that Zepbound, which the FDA approved for weight loss this month, is cheaper than Wegovy, approved in 2021, even though studies suggest Zepbound may work a bit better.

Insurers can lower their prices by buying the medicines in bulk, guaranteeing drugmakers large markets. This strategy could also work for state Medicaid programs, only a limited number of which now pay for the drugs.

For Medicare specifically, Congress needs to grant Part D the authority to not only cover the medicines but also include them among the medicines for which the program can negotiate prices.

Even as prices fall, the federal government has a responsibility to support broader studies of the drugs’ long-term safety. It must also keep up other efforts to address obesity — including by discouraging ultra-processed food and by encouraging greater physical activity (for example, by improving school lunches, food package labeling, and public spaces and pathways for exercise). The weight-loss drugs are not miracle cures. Many people cannot or do not want to tolerate them, and even patients who shed many pounds often remain obese or overweight. The medicines are one weapon in the obesity fight — but one that, if broadly used, may be powerful enough to make a big difference.

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