Richard Burr: Insurance coverage for obesity allows patients to benefit from science

But science only goes so far. Policymakers, governments and health insurance companies should keep pace with scientific advancement so Americans can afford these innovative treatments as they become available.

Anti-obesity medications (AOMs) are a prime example. Multiple AOMs on the market today can help people living with obesity to lose weight. Obesity in the U.S. is a common and expensive disease affecting more than 40% of Americans, costing our health care system more than $170 billion per year. Nearly half of North Carolinians are living with obesity. It is even more common in rural counties than in metropolitan counties, which is further exacerbated by the decreased likelihood of weight management experts, nutritionists and other specialists on staff within rural health facilities, as well as by decreased access to healthy and affordable food.

After the U.S. Food and Drug Administration approved an additional indication for cardiovascular risk reduction in March, the Centers for Medicare and Medicaid Services issued guidance clarifying that Medicare Part D drug plans could cover certain AOMs if they are approved for other health bene?ts and prescribed accordingly. While this is a step forward, individuals who solely need to access these treatments for obesity or have other common comorbid conditions with obesity that are not yet investigated in a clinical trial are still unable to do so.

Medicare Part D drug plans have been barred from covering AOMs since the creation of the program in 2003, when there were very few medicines that could treat obesity. While there are efforts to change the law, most notably the bipartisan Treat and Reduce Obesity Act, congressional action takes time, and more work remains to ensure comprehensive access for Americans on Medicare.

Though Medicaid has a similar ban on AOM coverage, a longstanding statutory exception to the law allows state Medicaid programs to decide for themselves whether to cover AOMs. As of July 2023, 16 state Medicaid programs reported covering at least one AOM for obesity for adults under fee-for-service with additional states considering AOM coverage.

When it comes to commercial health insurance, there is a lack of transparency in the extent to which these plans cover AOMs for obesity. Researchers have found that most top commercial health plans with available data do, in fact, cover drugs for obesity with varying utilization management limitations. Obesity affects each individual differently. As all medications do not work the same way, coverage of multiple AOM options so that the decision of which treatment should be prescribed is made by patients and their physicians, not their health insurance company or the government.

Sixty-?ve percent of adults with obesity are in the early stages of the disease, where body mass is on the lower end of the qualifying range. Intervention is at its most cost-effcient when treating obesity early. This can save the person from developing comorbidities like Type II diabetes and hypertension that worsen as patients move up in obesity classes and create greater costs for the health system. Growing evidence suggests that reducing obesity rates saves the health system money because of improved health outcomes. The true bene?t of AOMs to the health economy will become clearer with evidence from real-world use.

We have treatment options. Public and private payors should comprehensively cover AOMs so Americans can live healthier lives. Our medicine cabinets look different than they did in 2003 and will continue to evolve as new treatments are discovered - our nation's coverage paradigm needs to be updated to re?ect the 21st century treatments available today and be prepared to cover the treatments and cures of tomorrow.

Former U.S. Sen. Richard Burr is a principal policy adviser and chair of the health policy strategic consulting practice at DLA Piper, which represents pharmaceutical, biotechnology and other companies in life sciences and health care.