cbo -美国授权医疗保险覆盖抗肥胖药物将如何影响联邦预算 How Would Authorizing Medicare to Cover Anti-Obesity Medications Affect the Federal Budget

congressionalBudgetoffice

NonpartisanAnalysisfortheU.S.congress

HowWouldAuthorizingMedicaretoCover

Anti-ObesityMedicationsAffecttheFederalBudget?

OCTOBER|2024

M

edicarebeneficiarieswhoareoverweightor

whohavethemedicalconditionofobesityaremorelikelytohaveworsehealthoutcomes

andhigherhealthcareexpendituresthan

beneficiariesinthehealthyweightcategory.Amongadultsenrolledinrandomizedcontrolledtrials,treatmentwith

certainanti-obesitymedications(AOMs)hasbeenshowntoleadtosignificantweightlossandimprovedhealthwhenrecipientsusethedrugsconsistentlyandattheprescribedtimeintervals.Thosedrugsincludeglucagon-likepeptide1(GLP-1)receptoragonists,whichwereoriginallyapprovedtotreatdiabetes.

TheMedicareprogramcoverssomeobesity-related

services,includingscreening,behavioralcounseling,andbariatricsurgery(aprocedureperformedonthestomachorintestinestoinduceweightloss).Itisprohibitedby

lawfromcoveringmedicationsforweightmanagementaspartofthestandardprescriptiondrugbenefit.MedicarecoversGLP-1-basedproductsonlyforbeneficiarieswhousethemformedicallyacceptedindicationsotherthan

weightmanagement.Currently,thoseacceptedindica-

tionsarediabetesandcardiovasculardisease.PolicymakershaveintroducedlegislationtoauthorizeMedicaretocoverthosemedicationsmorebroadly.

Inthisreport,theCongressionalBudgetOfficeesti-

matesthebudgetaryeffectsofanillustrativepolicythatwouldauthorizeMedicaretocoverAOMsstartingin

January2026.Thepolicywouldapplytoallbeneficiarieswithobesity,aswellascertainbeneficiarieswhoareclassi-fiedasoverweight.Adoptionofsuchapolicywouldhavetheseeffects,inCBO’sestimation:

•FederalBudgetaryCost.Authorizingcoverageof

AOMsinMedicarewouldincreasefederalspending,onnet,byabout$35billionfrom2026to2034.TotaldirectfederalcostsofcoveringAOMswouldincrease

from$1.6billionin2026to$7.1billionin2034.

Relativetothedirectcostsofthemedications,totalsavingsfrombeneficiaries’improvedhealthwouldbesmall—lessthan$50millionin2026andrisingto$1.0billionin2034.

•CostandSavingsperUser.Weightlossisassociatedwithreductionsinhealth-relatedspendingperuser

thatarelessthantheestimatedfederalcostperuserofcoveringAOMsthroughoutthe2026–2034period.PerAOMuser,theaveragedirectfederalcostwouldberoughly$5,600in2026,decreasingto$4,300in

2034.Andaverageoffsettingfederalsavingswouldbeabout$50in2026,reaching$650in2034.

•EligibilityandTake-up.Over12.5millionMedicarebeneficiarieswouldnewlyqualifyforAOMsin

2026undertheillustrativepolicy;0.3million,or

2percentofthenewlyeligiblepopulation,would

useanAOMin2026.DespitegrowthinMedicareenrollmentfrom2026to2034,thenumberofnewlyqualifiedbeneficiarieswouldfallto11.9millionin2034asthosedrugswereapprovedtotreatadditionalconditionsundercurrentlaw.Inthatyear,about

1.6million(or14percent)ofthenewlyeligiblebeneficiarieswoulduseanAOM.

Beyond2034,thepolicy’snetfederalcoststothe

Medicareprogramwouldprobablybeloweronaper-userbasisthaninthefirstdecadefortworeasons.CBOexpectsthatthecostofthedrugswillfallovertimeandthatthesavingsfromimprovedhealthwillgrowover

time.Nevertheless,thepolicywouldstillincreasefederalspendingbetween2026and2044.

ThebudgetaryeffectsofauthorizingAOMcoverageinMedicarearehighlyuncertain.Estimatesofcostsandtake-upratesaresensitivetotherapidlyevolving

Notes:Unlessthisreportindicatesotherwise,allyearsreferredtoarefederalfiscalyears,whichrunfromOctober1toSeptember30andaredesignatedbythecalendaryearinwhichtheyend.EstimatesoftheMedicarepopulationreflecttheaveragenumberofmonthlybeneficiariesduringafiscalyear.Numbersinthetextandtablesmaynotsumtototalsbecauseofrounding.

2HOWWOULDAUTHORIZINGMEDICARETOCOVERANTI-OBESITYMEDICATIONSAFFECTTHEFEDERALBUDGET?OCTOBER2024

Table1.

ShareofMedicareBeneficiariesWithandWithoutDiabetesandWithCertainOtherChronicConditions,byCategoryofBodyMassIndex,2021

Percent

Category

ShareofMedicarepopulation

Sharewithtype2diabetes

Sharewithouttype2diabetes

Sharewithweight-relatedchronic

conditionsamongbeneficiaries

withouttype2diabetesa

Underweight(BMIbelow18.5)

2

8

92

72

Normalweight(BMIfrom18.5tolessthan25)

29

9

91

76

Overweight(BMIfrom25tolessthan30)

35

16

84

83

Obesity(BMIof30ormore)

34

28

72

87

Datasource:CongressionalBudgetOffice,usingdatafromthe2021MedicareCurrentBeneficiarySurvey.See

/publication/60441#data

.BMI=bodymassindex(ameasureofbodyfatbasedonaperson’sheightandweight).

a.Definedaseverhavingoneormoreofthefollowing:hardeningofthearteries,hypertension,aheartattack,anginapectorisorcoronaryheartdisease,congestiveheartfailure,otherheartconditions(forexample,valve-orrhythm-relatedconditions),astroke,highcholesterol,orcertaintypesofcancer.Althoughother

chronicconditionsareassociatedwithexcessweightandobesity(suchasfattyliverdiseases),thosearenotincludedinthesurvey’squestionnaire.

evidenceontheeligibility,use,price,andclinicalbenefitsassociatedwiththosemedications.Thosefactorsarealsosensitivetothescopeofthepolicy,includingwhointheMedicarepopulationwouldbecomeeligiblefortreat-

mentwithAOMs.

ObesityAmongMedicareBeneficiaries

ObesityisacommonchronicdiseaseamongMedicarebeneficiaries,anditisassociatedwithadversehealtheffectsandhighercoststoMedicare,whicharepaidbythefederalgovernmentandbybeneficiariesthroughpremiumsandcostsharing.(Beneficiariescanobtainsupplementalcoverage—includingfederallysubsidizedcoverage—forsomeoralloftheircosts.)

PrevalenceofObesityandChronicConditions

Morethantwo-thirdsofMedicarebeneficiariesare

classifiedaseitherobeseoroverweight,accordingtotheirbodymassindex,orBMI.(BMIisameasureofbodyfatbasedonheightandweight;itiscalculatedbydividingaperson’sweightinkilogramsbythesquareoftheir

heightinmeters.)

1

Incalendaryear2021,34percentofMedicarebeneficiarieshadaBMIof30orgreater,placingthemintheobesitycategory(see

Table1

).Anadditional35percentofMedicarebeneficiarieswere

classifiedasoverweight,meaningtheyhadaBMIof25tolessthan30.

2

Excessweightisassociatedwithseveralchroniccon-ditions.Theprevalenceoftype2diabetesincreases

withhigherBMI,forexample.Incalendaryear2021,16percentofMedicarebeneficiariesclassifiedasover-weightand28percentofbeneficiarieswithobesityhadtype2diabetes.EvenamongMedicarebeneficiaries

withouttype2diabetes,higherBMIswereassociatedwithagreaterprevalenceofweight-relatedcomorbid-ities(whicharediseasesormedicalconditionsthataresimultaneouslypresentinapatient).AmongMedicarebeneficiariesclassifiedasoverweightandwithouttype2diabetes,83percenthadweight-relatedchroniccon-

ditions(includingdifferenttypesofcancersandheartconditions).Amongbeneficiarieswithobesityand

withouttype2diabetes,87percenthadatleastoneweight-relatedchroniccondition

.3

AssociationBetweenBMIandHealthCareSpending

Bodymassindexesareoftengroupedintofourcatego-ries:underweight,normalweight,overweight,andobe-sity.Thelastcategory—obesity—canalsobeclassified

accordingtoitsseverity:classI,lowrisk;classII,moder-aterisk;andclassIII,highrisk.Onaverage,healthcarespendingforMedicarebeneficiarieswithobesityexceedsspendingforpeoplewithoutobesity(see

Figure1

).

Amongthethreesubcategoriesofobesity,differences

inspendingarelargerforpeoplewithhigherBMI.Forexample,averagehealthcarespendingisconsiderably

greaterforpeoplewithaBMIof40orabove(obesity

classIII)thanforpeoplewithaBMIof30tolessthan35(obesityclassI)

.4

Inthisanalysis,healthcarespendingincludesspendingbyMedicareandbyotherpayers.

OCTOBER2024HOWWOULDAUTHORIZINGMEDICARETOCOVERANTI-OBESITYMEDICATIONSAFFECTTHEFEDERALBUDGET?3

Figure1.

AverageAnnualHealthCareSpendingperPersonAmongMedicareBeneficiaries,byBodyMassIndex,2015to2019

Thousandsof2019dollars

30

25

20

15

10

5

0

UnderweightNormalweight(3percentof(28percentofbeneficiaries)beneficiaries)

ObesityclassII(8percentofbeneficiaries)

ObesityclassIII(4percentofbeneficiaries)

OverweightObesityclassI(36percentof(21percentofbeneficiaries)beneficiaries)

15192530354050

(93)(118)(155)(186)(217)(248)(310)

BMI(weight,inpounds,foraperson5’6”)

Healthcarespending

amongbeneficiarieswith

obesityexceedsspendingamongpeoplewithnormalweight,onaverage.Withinthethreecategoriesof

obesity,spendingishigherforpeoplewithahigher

BMI,inpartbecauseoftheirgreaterlikelihoodofhavingotherchronicconditions.

Datasource:CongressionalBudgetOffice,usingdatafromtheMedicareCurrentBeneficiarySurveyforselectedyears(2015to2019).See

/

publication/60441#data

.

BMIisameasureofaperson’sbodyfatbasedonheightandweight.ThebarsshownapplytoallpeoplewithagivenBMI,includingpeopleofvariousheightandweightcombinations,eventhoughthisgraphic,forillustrativepurposes,showsthebodyweightforapersonofacertainheight.

Obesitycanbeclassifiedaccordingtoitsseverity:classI,lowrisk;classII,moderaterisk;andclassIII,highrisk.

Toincreasetheprecisionoftheestimatesshownhere,CBOpooleddatafromseveralyearsofthesurvey.TheshareofMedicarebeneficiariesineachBMIcategoryinthisfigurediffersslightlyfromthevaluesshowninTable1,whicharebasedonanalysisofonlythe2021MedicareCurrentBeneficiarySurvey.BMI=bodymassindex.

ThatobservedrelationshipbetweenspendingandBMIatapointintimedoesnotnecessarilyimplythathealthcarespendingwoulddecreaseifaMedicareenrolleewithobe-sitylostweight,however.Estimatingthebudgetaryeffectsofweightlossbycomparinghealthcarespendingamongpeopleatasinglepointintimeispotentiallymisleadingfortworeasons.First,itisuncertainwhetherweightalonecausesthedifferencesinaveragehealthcarespendingforpeopleinvariousBMIcategories.Differencesamong

peopleinhealthrisksandbehaviorcanpersistevenafterweightloss.Second,theextenttowhichtheadversehealtheffectsassociatedwithexcessweightarereversiblethroughweightlossisalsouncertain.Ascertainingthedirecteffectsofweightlossonspendingforhealthcareservicesrequiresadifferenttypeofanalysis.

RecentInnovationsinAOMsand

CoverageofThoseDrugsinMedicareUnderCurrentLaw

GLP-1-basedmedicationshaverecentlybeenapprovedforweightmanagementinatargetedpopulation,and

salesofthoseproductshaveincreasedrapidlysince2021.Undercurrentlaw,MedicareisprohibitedfromcoveringAOMsaspartofthestandardprescriptiondrugbenefit.Policymakershaveconsideredliftingthatprohibition,

however,andhaveintroducedlegislationthatwouldnewlyauthorizeMedicaretocoverthosemedications.

RecentInnovationsinAOMs

Prescriptionmedicationsforweightmanagementhavebeenavailableforoveradecade(see

Table2

).Certain

AOMs,originallyapprovedtotreattype2diabetes,have

4HOWWOULDAUTHORIZINGMEDICARETOCOVERANTI-OBESITYMEDICATIONSAFFECTTHEFEDERALBUDGET?OCTOBER2024

Table2.

SelectedPrescriptionMedicationsCurrentlyApprovedandMarketedforWeightManagement

Molecule

Medication

FDAapprovaldateforweightmanagement

Type2diabetesmedicationwithsamemoleculeandFDAapprovaldatefortype2diabetes

GLP-1-basedproducts

Liraglutide

Saxenda

December2014

Victoza;January2010

Semaglutide

Wegovya

June2021

Ozempic;December2017

Tirzepatide

Zepbound

November2023

Mounjaro;May2022

Otherweight-lossmedications

Orlistatb

Xenical

April1999

n.a.

Phentermine/Topiramate

Qsymia

July2012

n.a.

Bupropion/Naltrexone

Contrave

September2014

n.a.

Datasource:CongressionalBudgetOffice,usinginformationfromtheFoodandDrugAdministration.See

/publication/60441#data

.

Theapprovaldateforweightmanagementindicationsappliestopeoplewhohaveobesityorareclassifiedasoverweight(havingabodymassindexfrom27to

30andaweight-relatedchroniccondition).

FDA=FoodandDrugAdministration;GLP-1=glucagon-likepeptide1;n.a.=notapplicable.

a.Alsoapprovedtotreatcardiovasculardisease.

b.Alsoavailableinalower-doseover-the-counterformulation(marketedasAlli).

recentlybeenshowntoleadtomoresignificantweightlossthanoldermedications.

5

Theproducts,includingGLP-1andglucose-dependentinsulinotropicpolypep-tide(GIP)receptoragonists,havebeenapprovedfor

chronicweightmanagementinadultswithobesityandcertainpeopleclassifiedasoverweight(thosewitha

BMIof27to30andatleastoneweight-relatedcomor-bidity).AsofSeptember2024,marketedGLP-1-basedproductsapprovedforweightmanagementareSaxenda(liraglutide),Wegovy(semaglutide),andZepbound

(tirzepatide).

6

Zepboundisthenewestproduct,havingenteredthemarketinthefourthquarterof2023.Oldernon-GLP-1-basedmedicationsforweightmanagementincludeXenical(orlistat),Qsymia(phentermine/topira-mate),andContrave(bupropion/naltrexone).

ClinicaltrialshaveshownthattheGLP-1-basedmedica-tionsmostrecentlyapprovedforweightlossamongpeo-plewithouttype2diabetes—WegovyandZepbound—areassociatedwithlargerreductionsinbodyweightthanareolderweightlossmedications,includingSaxenda.

7

ManyadditionalAOMsareunderdevelopment,and

someareinlate-stageclinicaltrials

.8

ThosedrugscouldproveevenmoreeffectiveforweightlossthantheAOMsnowonthemarket.

TotalsalesofGLP-1-basedAOMs,netofmanufacturerdiscounts,haveincreaseddramaticallyoverthepasttwo

years(see

Figure2

).Thatgrowthreflectsdemandfor

AOMsamongpatientswithoutdiabeteswhomeettheBMIthresholdsforweight-losstreatment.Inthesec-

ondquarterof2024,salesofbrand-nameGLP-1-basedproductsapprovedforweightlossintheUnitedStatesamountedto$2.7billion,whichwasmorethanfive

timesthesalesinthefourthquarterof2022,whentheytotaled$0.5billion

.9

Mostsalesinthesecondquarterof2024wereforeitherWegovy(52percent)orZepbound(46percent);theremainingsaleswereforSaxenda.CBOexpectsthatsalesofGLP-1-basedproductswillcontinuetorapidlyincreaseasmorepeoplegainaccesstothose

drugs.

CoverageofObesityTreatmentsinMedicareUnderCurrentLaw

Medicarecoverssometreatmentsforobesityunder

PartsAandBoftheprogram.UnderPartA(Hospital

Insurance),Medicarecoversbariatricsurgery.That

surgeryisrestrictedtocertainbeneficiaries,following

rulesissuedbytheCentersforMedicare&Medicaid

Services(CMS).Toqualifyforbariatricsurgery,benefi-ciariesmusthaveaBMIequaltoorgreaterthan35andatleastoneobesity-relatedcomorbidity.Inaddition,theyneedtohavetriedapriormedicaltreatmentforobesity(suchasmedicalnutritiontherapy)thatwasunsuccess-ful.

10

UnderPartB(MedicalInsurance,whichcovers

physicians’services,outpatientcare,andothermedical

OCTOBER2024HOWWOULDAUTHORIZINGMEDICARETOCOVERANTI-OBESITYMEDICATIONSAFFECTTHEFEDERALBUDGET?5

Figure2.

SalesofBrand-NameGLP-1-BasedAnti-ObesityMedicationsAcrossAllPayers,NetofManufacturerDiscounts,2020to2024

Billionsofdollars

1.6

1.4

1.2

1.0

0.8

0.6

0.4

0.2

0

Wegovy

Zepbound

Saxenda

TotalsalesofGLP-1-basedanti-obesitymedicationshaveincreasedoverthe

pasttwoyearsbecauseofgreateruseofGLP-1-basedproducts.Thatgrowth

reflectsstrongdemand

amongpatientsforweight-losstreatment.

Q12020

Q12021

Q12022

Q12023

Q12024

Datasource:CongressionalBudgetOffice,usingsalesinformationfromSSRHealth.See

/publication/60441#data

.

ThefigureshowstotalsalesforSaxenda(liraglutide),Wegovy(semaglutide),andZepbound(tirzepatide).Itdoesnotincludesalesforproductswiththesamemoleculebutfordifferentindications(suchastype2diabetes).

GLP-1=glucagon-likepeptide1;Q1=firstquarter.

services),Medicarecoversbehavioralcounselingby

primarycareproviders.Also,aspartofpreventivecover-age,Medicarepaysforobesityscreeningsandintensivebehavioraltherapy(IBT),suchasnutritionalevaluationandcounseling,forbeneficiarieswithaBMIequaltoorgreaterthan30.

PartDplans,whichadministerMedicare’soutpatient

prescriptiondrugprogram,areprohibitedfromcoveringAOMsaspartofthestandardprescriptiondrugbene-

fitunderthetermsoftheMedicarePrescriptionDrug,

Improvement,andModernizationActof2003.

11

Thoseplanscancoversuchdrugsasasupplementalbenefit,butthatcoverageisnotsubsidizedbythefederalgovernmentandmustbefundedentirelybybeneficiariesthrough

additionalpremiums.Thevolumeofprescriptionsissuedthatwayremainslow.Beneficiariescanalsoelecttopayforthemedicationsentirelyoutofpocket.

AlthoughAOMsarenotcoveredaspartofMedicare’s

standardprescriptiondrugbenefit,somebeneficiarieswho

haveobesityorareclassifiedasoverweightareeligibleforthosetreatmentsiftheyalsohavetype2diabetesorcertaincardiovascularconditions.Asthenumberofindications

forAOMsexpands,CBOexpectsthatmanybeneficiarieswillnewlyqualifyforcoverageofthosemedicationsundercurrentlawandthatspendingforGLP-1-basedproductswillcontinuegrowingquickly.Theexpectedadditional

spendingforthatclassofdrugsisreflectedinCBO’s10-yearbaselinebudgetprojections

.12

Currently,insurersinother(non-Medicare)markets

coverAOMstodifferentextents.NovoNordiskreportsthatmorethanhalfofpeoplewithobesitywhoare

eligibleforcoverageinthecommercialmarkethad

accesstoWegovyasofthesecondquarterof2024,forexample

.13

InMedicaid,coverageofdrugsforweight

managementisoptional.

14

Accordingtoonestudy,ofthe47stateswithpubliclyavailablelistsofpreferreddrugs,ninehadMedicaidprogramsthatcoveredWegovyin

thefirstquarterof2023.

15

CoverageprovidedthroughtheAffordableCareAct’smarketplaceslargelyexcludes

6HOWWOULDAUTHORIZINGMEDICARETOCOVERANTI-OBESITYMEDICATIONSAFFECTTHEFEDERALBUDGET?OCTOBER2024

Table3.

BudgetaryEffectsofaPolicyThatWouldCoverAnti-ObesityMedicationsinMedicare,byFiscalYear

Billionsofdollars

2026

2027

2028

2029

2030

2031

2032

2033

2034

Total

DirectcostsofcoveringAOMs

1.6

1.8

2.9

3.8

4.3

5.1

5.8

6.5

7.1

38.8

Savingsfromimprovedhealth

*

*

-0.1

-0.2

-0.3

-0.4

-0.6

-0.8

-1.0

-3.4

Neteffectonthedeficit

1.5

1.8

2.8

3.7

4.0

4.7

5.2

5.7

6.1

35.5

Datasource:CongressionalBudgetOffice.See

/publication/60441#data

.

ThepolicywouldtakeeffectinJanuary2026.EstimateswerecalculatedrelativetoCBO’sFebruary2024baselinebudgetprojections.AOM=anti-obesitymedication;*=between-$50millionandzero.

GLP-1-baseddrugsforweightmanagement:AsofJune2024,1percentofprescriptiondrugplanscovered

Wegovy,andnoplanscoveredZepbound

.16

People

takingthosedrugswhoarenotyeteligibleforMedicareorwhoareeligiblebuthavenotyetenrolledinthe

programcouldexperiencetreatmentinterruptionsuponenrollment.

RecentLegislationAddressingObesityTreatmentsinMedicare

GiventhehighratesofobesityintheUnitedStatesandtheassociateddetrimentaleffectsonhealth,policymakershaveconsideredandintroducedlegislationtoexpand

accesstoAOMsinMedicare.Forexample,theTreat

andReduceObesityAct(TROA)of2023(H.R.4818andS.2407)wouldauthorizeMedicarePartDtocoverdrugsforweightmanagement

.17

Asintroduced,TROAwouldexpandcoverageto

Medicarebeneficiarieswithobesityandtocertainbenefi-ciariesclassifiedasoverweight—thosewithaBMIof25to30andoneormorerelatedchronicconditions

.18

Thebillalsowouldpermitadditionalhealthcareproviders

andcounselingprogramstobereimbursedfortheIBTservicestheyprovidetobeneficiariestotreattheirobe-sity.(Thatreimbursementiscurrentlylimitedtoprimarycareproviders.)

19

InJune2024,theHouseCommittee

onWaysandMeansorderedthebillreportedwithan

amendmentthatwouldincludeAOMsascoveredPartDdrugsfornewMedicarebeneficiarieswithpriorcontinu-oususeofAOMs

.20

BudgetaryEffectsofAuthorizingMedicaretoCoverAnti-ObesityMedications

CBOanalyzedanillustrativepolicythatwouldautho-rizeMedicaretocoverAOMsforweightmanagement

beginninginJanuary2026.Thepolicy,whichisbroadlysimilartoTROA,wouldapplytoMedicarebeneficiarieswithobesity(inotherwords,thosehavingaBMIequaltoorgreaterthan30),aswellascertainbeneficiarieswhoareclassifiedasoverweight(havingaBMIof27to30)andwithaweight-relatedchroniccondition

.21

Thepolicywouldincreasefederalspendingby

$35.5billion,onnet,from2026to2034,inCBO’s

estimation(see

Table3

).SpendingonAOMswould

amountto$38.8billionoverthatperiodbutwouldbepartiallyoffsetbyreductionsof$3.4billioninother

healthcarespendingbecauseofbeneficiaries’improvedhealth.Beyond2034,thepolicy’snetfederalcoststotheMedicareprogramwouldprobablybeloweronaper-userbasisthaninthefirstdecade,CBOestimates,butthepolicywouldstillincreasefederalspendingbetween2035and2044.

TotalFederalCosts

CBOestimatesthattheillustrativepolicywouldincreasefederalcostsby$1.5billionin2026andby$6.1billionin2034(see

Table4

).Thoseestimatesreflectseveral

factors:thenumberofnewlyeligiblebeneficiarieswhoareprojectedtouseaprescriptionAOM;theaveragedurationofthatuse;andthedirectfederalcostperuserafteraccountingformanufacturers’rebatesanddis-

counts,thelow-incomesubsidyinPartD,andaddedincomefromincreasedPartDpremiums

.22

Inaddition,CBO’sprojectionsofthecostsofAOMcoveragereflect

OCTOBER2024HOWWOULDAUTHORIZINGMEDICARETOCOVERANTI-OBESITYMEDICATIONSAFFECTTHEFEDERALBUDGET?7

Table4.

FederalMedicareCostsofAnti-ObesityMedications,inTotalandperUser,byFiscalYear

Dollars

2026

2027

2028

2029

2030

2031

2032

2033

2034

AveragenetpriceofAOMsa

5,900

4,000

4,200

4,300

4,500

4,700

4,900

5,100

5,300

Minus:Beneficiaries’cost-sharingamounts,adjustedtoreflecttheshareofpeoplewhoreceivethelow-incomesubsidyb

Minus:Increaseinpremiumincomec

-300

-300

-300

-300

-300

-400

-400

-400

-400

0

0

0

0

-400

-400

-400

-500

-500

Averageannualfederalcostperuser

5,600

3,700

3,800

4,000

3,700

3,900

4,000

4,200

4,300

NumberofAOMusers(millionsofpeople)

0.3

0.5

0.7

1.0

1.2

1.3

1.4

1.5

1.6

Directannualfederalcost(billionsofdollars)

1.5

1.8

2.8

3.7

4.0

4.7

5.2

5.7

6.1

Datasource:CongressionalBudgetOffice.See

/publication/60441#data

.

ThistablepresentsthebudgetaryeffectsofanillustrativepolicythatwouldauthorizeMedicaretocoverAOMsstartinginJanuary2026.Thepolicywouldapplytoallbeneficiarieswithobesity,aswellascertainbeneficiarieswhoareclassifiedasoverweight.

AOM=anti-obesitymedication.

a.TheaveragenetpriceequalsthelistpriceofAOMsaftersubtractingmanufacturers’rebatesandstatutorydiscounts.CBOexpectsaveragenetpricesforAOMstofallin2027becauseofMedicaredrugpricenegotiations.

b.Estimatesoftheout-of-pocketcostareadjustedfortheaverageannualspendingonprescriptiondrugsbyPartDbeneficiarieswithoutdiabetes.Estimatesoftheaveragefederalcostincludethelow-incomesubsidy,anadditionalbenefitforsomebeneficiaries.Eligibilityandtheamountofthatsubsidydependonabeneficiary’sincomeandassets.

c.AnincreaseinspendingonprescriptiondrugswouldleadtohigherPartDpremiumsinlateryears,whichwouldreducethefederalcostsofcoveringAOMs.

theprevalenceofobesityintheMedicarepopulation,substantialdemandforweightlosstreatmentsamongbeneficiaries,andthepriceofthemedications.

NumberofNewlyEligibleBeneficiaries.Owingto

theexpandedcoverageundertheillustrativepolicy,

12.5millionbeneficiarieswouldbecomeeligiblefor

AOMsin2026,CBOprojects;thatnumberwouldfallslightly,to11.9million,in2034(see

Figure3

).Thesizeofthenewlyeligiblepopulationundertheillustrative

policywoulddecreaseovertheperiodasmorebeneficia-riesbecameeligibletoreceiveAOMsundercurrentlaw.ThosefiguresareinaccordwithCBO’sbaselineprojec-tionsofgrowthinMedicareenrollment.

TocalculatethenumberofbeneficiarieswhowouldnewlyqualifyforcoverageofAOMs,CBOdidthefollowing:

•Determinedthenumberofpeoplesatisfyingthecriteriaintheillustrativepolicy,

•Subtractedthenumberofpeoplewithtype2

diabetesorcardiovasculardiseasewhowillalreadybeeligibleforcoverageofGLP-1-basedmedicationsinMedicare,and

•Subtractedthenumberofpeopleexpectedtobeeligibleforcoverageof