CMS Moved to Expand Obesity Drug Coverage. Private Insurers Need to Step Up.

In July 2024, Joseph Zucchi, PA-C, MPAS, wrote about how stigma and misconceptions were creating barriers to GLP-1 obesity medication uptake, on top of systemic barriers like high costs and inadequate insurance coverage. As part of our review of the past year’s biggest events, Zucchi revisited this topic to share his perspective on the proposal from the Centers for Medicare & Medicaid Services (CMS) to expand coverage of these life-changing medications.

Imagine a disease so prevalent it affects more than two-fifths of the adult population and one-fifth of children, yet its most effective treatments remain out of reach for those who need them most. This is the reality of obesity, a condition that drives chronic disease but is met with barriers to care at every turn. Obesity isn’t a mere lifestyle choice or lack of willpower; it’s a complex, chronic disease that heightens the risk of many of the most common chronic conditions: diabetes, heart disease, hypertension, osteoarthritis, and more.

Yet, despite the power of GLP-1 anti-obesity medications to reduce these risks, many insurers continue to deny coverage, leaving millions of Americans to fend for themselves.

Obesity: The Most Costly and Preventable Health Risk Factor

Obesity affects over 40% of American adults, making it one of the most prevalent chronic diseases in the U.S. This disease carries more than just physical weight — it costs us in quality of life, productivity, and billions of dollars in healthcare expenses. It burdens our hospitals and our health system, and, most importantly, it leads to unnecessary suffering and premature death. Obesity-related conditions cost the U.S. over $170 billion annually, and that number is only growing.

Obesity medications, particularly GLP-1 receptor agonists like semaglutide (Wegovy, Ozempic) and tirzepatide (Zepbound, Mounjaro), have changed the landscape of obesity treatment. These drugs address the physiological drivers of obesity by curbing appetite, reducing food cravings, and improving insulin sensitivity. Beyond only helping people lose weight, these drugs are approved for type 2 diabetes and sleep apnea, and can reduce the risk of heart disease and possibly obesity-related cancers.

Yet, despite the health benefits, less than half of private and public insurance plans currently offer coverage for anti-obesity medications.

A Promising Step Forward

A potential turning point came in November, when the White House announced a proposal to expand Medicare and Medicaid coverage for obesity medications. This long-overdue change could provide access to life-changing medications for an estimated 7.4 million Americans.

Historically, Medicare has excluded drugs used for weight-loss from its coverage, leaving millions of older Americans without affordable options for treatment. This exclusion has also made these drugs an optional drug benefit for Medicaid programs, leading to variation by state.

Under this new proposal, CMS would “permit coverage of anti-obesity medications for the treatment of obesity when such drugs are indicated to reduce excess body weight and maintain weight reduction long-term for individuals with obesity.” This would not apply to patients who are overweight but who don’t have obesity. The plan could save about 75% of the cost for Medicaid beneficiaries, and up to 95% of the out-of-pocket costs for Medicare enrollees, reducing financial barriers to treatment.

This proposed rule signals an important shift in the federal approach to obesity management, aligning with the medical community’s consensus that obesity is a chronic disease requiring long-term care. It also highlights the economic and ethical imperative of addressing obesity proactively, rather than reactively.

The Double Standard of Coverage

Even with this encouraging progress, the private insurance landscape remains inconsistent. Insurers readily cover medications for high blood pressure, diabetes, and high cholesterol — diseases often linked to obesity — but frequently balk at covering treatments for obesity itself. This double standard is akin to offering treatment for a heart attack but denying preventive care to avoid it.

Why does a medication become “worthy” of coverage only after someone’s health has declined to the point of needing multiple drugs to manage preventable diseases?

The reluctance to cover obesity medications has consequences that extend far beyond individual patients. Untreated obesity costs employers billions in reduced productivity and contributes to rising rates of chronic diseases. Worse, the lack of coverage drives some patients to seek cheaper, unregulated alternatives, such as compounded or counterfeit drugs. These risky options lack FDA oversight and can lead to overdose and severe side effects. By denying coverage, insurers are not only failing their members but also exacerbating public health risks. Finally, denying coverage reinforces harmful stereotypes. One of the most damaging misconceptions about obesity is that it’s merely the result of poor personal choices, and critics label these medications as a “quick fix.” By expanding private insurance coverage of GLP-1 medications, insurers can align with the medical societies and federal agencies that recognize obesity as a disease.

A Path Forward

The White House’s proposal is a major step in the right direction, but it also underscores the need for broader systemic change.

Beyond insurance plans, pharmaceutical companies must also work to make these medications more affordable, helping to ensure that access isn’t limited by cost. Failing to promote affordability across the board perpetuates our reactive, expensive healthcare model that treats symptoms rather than root causes.

This is a pivotal moment for healthcare in America. The proposed rule from the White House offers hope for millions struggling with obesity, but it must be matched by action from private insurers. Obesity is a disease, and it’s time everyone treats it as one. Our healthcare system cannot afford to turn a blind eye to the preventive power of anti-obesity medications.

Joseph Zucchi, PA-C, MPAS, is a physician assistant and the clinical supervisor at Transition Medical Weight Loss in Salem, New Hampshire.