Reader Question - What is Going On With Medicare and GLP-1 Diet Drugs?
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I’ve received a bunch of reader questions that can be summarized as what the hell is going on with GLP-1s and Medicare?
If you don’t live in the US (or if you do and you don’t know about Medicare) it is our state run insurance program for which only people over 65 and some disabled people qualify (you can find a full explanation of eligibility here, starting on page 3.) .
After the fen-phen tragedy harmed and killed so many people, Medicare stopped covering weight loss drugs. Novo Nordisk, Eli Lilly, and the various astroturf organizations that represent their interests, have been working overtime to try to get Medicare to cover these drugs. They have been working hard to get the drugs approved at the weight loss dose for uses other than weight loss in order to exploit a Medicare loophole that allows for weight loss drugs to be prescribed if they are FDA approved for other uses.
Starting today (July 1), the government is announcing what they are calling the Medicare GLP-1 Bridge. The Bridge will be in effect from July 1, 2026 through December 31, 2027. The goal of the program is a demonstration “to determine whether changes in methods of payment or reimbursement” under Medicare “would have the effect of increasing the efficiency and economy of health services” covered under Medicare through the “creation of additional incentives to these ends.”
As you may know, Medicare is provided in parts and Part D is the prescription drug benefit. The GLP-1 Bridge will operate outside of Medicare Part D. The drug companies will charge the US government “a net price” of $245 per month. Eligible Medicare beneficiaries will pay a $50 copay each month, and the $195 per month per person balance will be paid by US taxpayers. The beneficiaries’ deductible won’t apply to the meds and the $50 they pay won’t count toward their True out-of-pocket (TrOOP) costs. Finally, even for those who receive a low-income subsidy (LIS) there will not be any LIS benefit applied.
People who want the weight loss drugs will need their provider to submit a prior authorization request that attests that the beneficiary is (content note for weight stigma through the italicized quote)
prescribed the requested drug to reduce excess body weight and maintain weight reduction in combination with current and ongoing lifestyle modification including structured nutrition and physical activity consistent with the applicable FDA approved label, AND
The beneficiary is at least eighteen (18) years of age and has a BMI greater than or equal to thirty-five (≥35) at the time of initiation of GLP-1 therapy, or
The beneficiary is at least eighteen (18) years of age and has a BMI greater than or equal to thirty (≥30) at the time of initiating GLP-1 therapy with a diagnosis of one or more of the following: (A) heart failure with preserved ejection fraction, (B) uncontrolled hypertension (defined as systolic blood pressure above 140 mm Hg or diastolic blood pressure above 90 mm Hg, despite concurrent treatment with two antihypertensive medications), or (C) chronic kidney disease stage 3a or above, or
The beneficiary is at least eighteen (18) years of age and has a BMI greater than or equal to twenty-seven (≥27) at the time of initiating GLP-1 therapy with a diagnosis of one or more of the following: (A) pre-diabetes (as defined by American Diabetes Association guidelines), (B) previous myocardial infarction, (C) previous stroke, or (D) symptomatic peripheral artery disease.
There are plenty of issues here. First, risk is predicated on size. Someone with a BMI of 27 to 34.9 has to have other health conditions (conditions that people of all sizes get,) or the drugs’ risks aren’t considered worth the possible benefits, but as soon as that person moves from a BMI of 34.9 to 35, they “qualify” for the drug just for existing at that height/weight ratio and regardless of any actual health indication. Their body/health/quality of life/life is viewed as more risk-able and that’s a clear example of weight stigma in healthcare.
Beyond which it is not at all clear that these drugs will actually provide a benefit for people who do have these health conditions. If they do, research suggests that the benefit won’t be related to weight changes. For example, the semaglutide trial for cardiovascular benefit for those with existing heart disease only showed a 1.5% risk reduction that was not related to weight change, and was not statistically significant for women, Black people, Hispanic people, those under 55 or over 75 (the trial didn’t even accept those under 45), or those with BMI over 35. Yet a Black or Hispanic cis woman, aged 20, with a BMI of 27 would qualify for the drug solely for the purposes of weight change and based on her previous heart issues. This is where I think the weight loss industry pressure on governments/legislation along with ethically questionable marketing campaigns to gain FDA approval based on small effects (with those effects not even correlated with weight loss in most cases,) are really paying off.
Interestingly, the drugs are already approved and available to Medicare patients for Type 2 diabetes, obstructive sleep apnea, cardiovascular disease, and noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH) indications. In fact, after all those criteria, they make it clear that (emphasis mine) “The Medicare GLP-1 Bridge was designed to increase access to GLP-1s for beneficiaries who seek the drug solely to reduce excess body weight or maintain weight reduction.”
As a reminder, the goal of the program is supposedly to determine whether “changes in methods of payment or reimbursement” under Medicare “would have the effect of increasing the efficiency and economy of health services” covered under Medicare through the “creation of additional incentives to these ends.”
It’s not at all clear that how they will make these determinations (and this is coming from the Centers for Medicare & Medicaid Services (CMS) which is headed up by, I can’t believe I have to type this, Dr. Oz, who spent last month reorganizing leadership so it’s not like they’re being led by a crack team over there. Oh, and the central processor for the Bridge program will be Humana, which less than a year ago was ordered to pay $32 million in attorneys fees related to a $90 million settlement they paid for a whistleblower case around….wait for it…alleged Medicare Part D prescription fraud (Humana ultimately coughed up $122 million but did not admit guilt.) Meanwhile the current US regime seems to be trying to kick as many people as possible (people with actual health issues) off of Medicare, but somehow we have money for this. That has got to be one of the most depressing paragraphs I’ve ever written so we’re just going to move on.
We do have some information already from a 2024 report from the Congressional Budget Office (CBO) (content note for the link - the report contains weight stigma.)
So what they found, with a reminder that this was at the current drug prices, not using the $245/month with a $50/month copay bridge model:
More than two-thirds of Medicare beneficiaries can be classified as ‘ob*se’ (34%) or ‘overw*ight’ (35%)
Covering GLP-1 drugs for weight loss would cost Medicare $35 billion from 2026 to 2034
Cost-savings would be minimal, totaling $3.4 billion from 2026 to 2034
28% of Medicare beneficiaries classified as ‘ob*se’ have type 2 diabetes, as well as an additional 16% for those classified as ‘overweight’; even among Medicare beneficiaries who are not classified as ‘overweight’ or ‘ob*se’, 83% have weight-related chronic conditions (heart conditions and certain cancers)
This last one can use some unpacking. First note that the majority of higher-weight Medicare beneficiaries do not have Type 2 diabetes. Now, there is no shame in having T2D (or any health issue) but this certainly pushes back against narratives that claim that most/all higher-weight people have or will have T2D, especially since those on Medicare are predominantly people 65 and over.
The last bit really draws the lie of “weight-related” conditions into sharp relief. The concept of “weight-related” (sometimes called “ob*sity-related”) health conditions, which has been created and promoted by the weight loss industry, is used to describe health conditions that people of all sizes get that are called “weight-related” when higher-weight people have them (I discussed this in detail here). In this report, absurdly, they are still called weight-related when people who aren’t higher-weight have them. Again, more than 80% of people on Medicare who have these conditions are not higher-weight and yet they are still clinging to the idea of these being “weight-related” conditions. Calling them “weight-related” is not just ridiculous (though it is), and doesn’t just drive weight stigma (though it does,) it may also be leading to lack of prevention or early detection because it creates the misinformed assumption that if someone isn’t higher-weight then they won’t have these conditions.
The CBO also cited challenges in their analysis, including “(1) the rapid evolution of real-world clinical data on GLP-1 impact and effectiveness and (2) the difficulty of assessing whether weight-loss alone would reverse the weight-related chronic conditions, as well as any associated cost savings.”
The claim that weight loss would reverse the so-called “weight-related” chronic conditions when 83% of people who aren’t higher-weight have them strains credulity at best. This issue is a serious one because when it comes to actual health benefits of GLP-1s, almost all of the research finds that if there are additional health benefits besides those for T2D, they happen before/without weight loss/they are not correlated with weight loss. The big issue here is that the companies have been testing these additional uses at the weight loss megadose to exploit the Medicare loophole we discussed earlier. That means it’s also possible that if there are health benefits, they may be achievable at doses much lower than the weight loss dose. Those lower doses may offer fewer side effects, a lower price tag, and/or more data about long-term outcomes. Unfortunately, the weight loss dosing generally calls for relentless titration up to the maximum tolerated dose, preferably the maximum allowable dose so the patients may not be on the lower doses for long enough to experience the benefits, or the benefits may be obfuscated or ignored based on conscious or subconscious assumptions about weight, weight loss, and health.
There is more recent reporting as well. In a June 15 piece called “Medicare weight-loss drug coverage could overwhelm doctors,” Axios reported That Dr. Annie Moore, an internal medicine doctor at the University of Colorado said “In our situation we would have to double or triple our pharmacy team, and to my knowledge, that has not happened in preparation for this” but that “A Centers for Medicare and Medicaid Services spokesperson said the agency doesn’t anticipate that the program will create any undue burden on pharmacies or prescribing providers.” I guess we have to decide who is more trustworthy, an internal medicine physician, or Dr. Oz.
In a June 8 article called “Novo and Lilly are competing to win the GLP-1 pill market as they prepare for Medicare coverage,” CNBC reported that at the American Diabetes Association’s (so-called) Scientific Sessions, “Cars drove around advertising Novo’s Wegovy pill, while pictures of Lilly’s Foundayo pill covered some of the floors of the convention center in New Orleans.” The two GLP-1 weight loss drug manufacturers will be fighting for each new patient in the Medicare Bridge program. Lilly plans to highlight the “ease” of their new weight loss pill while Novo plans to lean on the “cardiovascular benefits” of semaglutide (I would bet they will not be telling the truth that the 1.5% reduction in a composite of three major adverse cardiovascular events was not statistically significant for women, Black people, Hispanic people, those over 75, or those with a BMI over 55.)
In what I fear is a telling quote in the CNBC piece, Eli Lilly’s CEO Dave Ricks said that “He thinks the program will be popular with seniors and that longer term, the initiative could help prove that ob*sity care should be “regular health care.” (Of course “ob*sity care” is yet another attempted rebrand for weight loss and, in this case specifically, diet drugs.) He then said “We have to prove that in this pilot and prove cost effectiveness.” I think it’s important to remember that “have to prove” is absolutely not the same thing as “evaluate effectiveness” and concerned if part of their close work with the government involves them manipulating the evaluation process.
Speaking of long-term outcomes, this is where I have the most serious concerns. I’ve previously written about my concerns about Medicare coverage for GLP-1 weight loss drugs. There is significant research that shows that intentional weight loss in senior populations predicts negative outcomes including increased bone breaks, frailty, and overall mortality. I worry that this will be even worse with these drugs given the muscle mass loss that has been shown in previous research. And I am not comforted by the untested claim that this can be negated if people “just lift weights and eat protein.” If, as current research predicts, this leads to negative outcomes and increased mortality, this “demonstration” may not be long enough for that to show up, and we don’t know if the methods by which this is being evaluated are even set up to include those possible downsides.
So the weight loss industry lobbying (and campaigns to convince other people to become lobbyists for them,) has succeeded in getting an inch from Medicare and I would bet all the money in my pockets that they will be trying to take a mile for their shareholders regardless of what is actually best for the lives and health of the higher-weight people they use as their profit center.
You can see full information about the GLP-1 bridge program here (content warning for weight stigma.)
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More research
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*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings’ Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.
Well the silver lining is that this will create a lot of good data from a large sample. Medicare won't cheat on methodology and analysis, no matter what the lobbyists want. This study could even end up being bad for GLP-1s.
Just hope it doesn't kill or hurt too many guinea pigs, er, people in the process.
And "just lift weights and eat more protein" is laughable, privileged and ignorant advice on the face of it. Seniors, even those without access problems, eat differently. As individuals, we eat differently as seniors than we did earlier. There are a number of variables involved and there's no "just" anything. And you aren't going to have 75 year old rushing to join gyms so they can lift weights. Again, many variables here.
Seniors are also notably (and I think appropriately) more resistant to all kinds of "shoulds." Once you can count your likely remaining years on your digits, a lot of things change.
But unfortunately, the diet culture "shoulds" so many of us grew up with are often quite resistant too, and I'm blown away by the number of senior therapy patients I have who are developing eating disorders for the first time. Some are freaked out by their midlife weight gain, and some are "inspired" by some kind of age-related weight loss.
I wish I had a real voice in this.
What sticks out to me is that the duration of the bridge program is 78 weeks. This roughly tracks with the usual time frame I see on GLP-1 studies, which tends to be about 68-72 weeks. Assuming some weeks for promotion and uptake Medicare recipients would be taking these drugs for roughly that time period. This means that the bridge program is in the sweet spot for thr Medicare population on these drugs to show a downward trend in weight before it trends back up again. My guess is that the pharmaceutical companies intend to take this downward trend, correlate it with health improvements, and use it as a pitch for more coverage from private insurance.