As of 2020, approximately 42% of adults and 20% of children in the U.S. population are obese. Unfortunately, obesity has been associated with an increased risk for certain medical conditions (e.g., depression, diabetes, heart disease, sleep apnea, stroke, certain cancers, etc.) as well as an increased risk for an earlier death when compared to people who are not overweight or obese. With these risks in mind, treatments for obesity may be more important now than ever.

Body Positivity
Society too often judges people based on their appearance. Everyone should be accepted regardless of their size, shape, color, or ability. Everyone deserves to feel comfortable in their own skin.

Disclaimer
This article focuses on people who have medical conditions that may be related to their weight, medical conditions that increase their risk for serious health complications. This is not intended to imply that everyone who is overweight or obese will develop conditions like these.

Preventive Medicine

As a family physician, I have always promoted preventive medicine as a way to keep my patients healthy. Eating a balanced diet, performing regular exercise (as able), and getting enough sleep can move you a step closer toward wellness. Your wellbeing is also steered by the health of your relationships, your social interactions, and your ability to find meaning and/or joy in the things you do.

Still, living well does not always mean your health will follow suit. Your genes could predispose you to certain medical conditions. You could be exposed to things in your environment that make you sick. A natural disaster could cut off your access to needed food and supplies.

It’s also important to realize that not everyone has the same opportunities to pursue a healthier lifestyle in the first place. Some people may not have the financial means to afford the fresh fruits and vegetables they want. They may not have the time to exercise because they are holding two or more jobs to support their families. More than half a million people are homeless in the U.S., even though 53% of people in homeless shelters and 40% of unsheltered people are working.

My point? Sometimes you could use a little help.

Medicare and Obesity

Medicare does cover preventive medicine — to an extent. It offers screening tests for abdominal aneurysms, alcohol use, cancer (breast, cervical, colon, lung, and prostate), depression, diabetes, glaucoma, hepatitis, HIV, high blood pressure, lipids/cholesterol, sexually transmitted infections, and smoking. It also offers vaccines to prevent COVID, flu, hepatitis B, and pneumonia. Many of these screening tests are free if your doctor accepts assignment (i.e., they agree to charge no more than what Medicare recommends) while others are only offered to people considered to be at high risk.

When it comes to obesity, Medicare does recommend screening too. But let’s be honest; this simply means weighing you and checking your height. They use that information to calculate a BMI and if your BMI is 30 or more, you qualify for counseling. That counseling is limited to discussions about diet and exercise.

It’s great when a simple lifestyle approach does the trick (I encourage it for everyone!). Some people need to take it a step further to get meaningful results though. That’s where Medicare can fall short.

Weight Loss Medications

When Medicare Part D was created in 2003 (it did not take effect until 2006), there was one important stipulation — no weight loss medications would be covered. That remains the case today. The reasoning was that these medications would be used for cosmetic reasons (i.e., they were not medically necessary). Also, many of these medications could have serious side effects.

Today, few medications have FDA-approval for weight loss. You may remember me ranting and raving about one of them. That was not necessarily because Contrave did not work (it had modest results at best), but because the pharmaceutical companies took inexpensive generic medications and rebranded them to jack up the prices.

These days, the media is full of accounts of people using semaglutide (two brand name versions, Ozempic – not FDA-approved for weight loss, Wegovy – FDA-approved for weight loss, there is no generic available at this time). It claims to decrease weight by as much as 15%, though results will obviously vary by patient. Of course, like every drug, it has its side effects (some can be pretty serious) and no one should be prescribed a drug like this without medical supervision.

Even with supervision, Medicare does not cover these medications for the purposes of weight loss. That could change in the future. Decreasing rates of obesity may help to decrease obesity-related conditions. There is research to show that there would be a significant decrease in the need for hospitalizations, surgery, and skilled nursing care for these conditions. One study went so far as to show that covering these medications would decrease Medicare spending by $175 billion over a decade!

BREAKING NEWS: In March 2024, the FDA granted Wegovy an indication “to decrease reduce the risk of cardiovascular death, heart attack and stroke in adults with cardiovascular disease and either obesity or overweight”. CMS has since stated that Medicare Part D would cover the drug for this indication.

Weight Loss Surgery

Although Medicare does not cover weight loss medications, it does cover some (but not all) bariatric surgeries. The catch is that the procedure cannot be performed for obesity alone. Three criteria must be met for it to even be considered:

• BMI > 35
• At least one medical condition related to obesity (includes diabetes)
• Unsuccessful medical treatment for obesity

The final decision is made by local Medicare Administrative Contractors (MACs) that work for the government. Their interpretation of the Medicare rules can vary. The tricky part may be defining what constitutes “unsuccessful” medical treatment. What treatments does a person need to try? How often? Over what period of time? There could be some hoops to jump through to meet these criteria.

Although there are many bariatric procedures, the only ones potentially covered by Medicare include:

• Open and laparoscopic Roux-en-Y gastric bypass
• Open and laparoscopic biliopancreatic diversion with duodenal switch
• Gastric reduction duodenal switch
• Laparoscopic adjustable gastric banding
• Laparoscopic sleeve gastrectomy

Depending on the procedure performed, Part A or Part B will cover your surgery. When Part A covers, you pay a flat rate of $1,600 (in 2023) for your stay, plus 20% of any physician fees. When Part B covers, you pay 20% for each service you get ranging from the hospital bed to the food you eat. That often costs more than what you’d pay if the surgery was covered by Part A, especially if you stay in the hospital longer than a day. That said, some hospitals bundle multiple services into one payment which could decrease how much you pay out of pocket, i.e., no one line item on our hospital bill can cost you more than $1,600 (in 2023) out of pocket.

Adult Obesity Facts. (2022). Centers for Disease Control and Prevention. https://www.cdc.gov/obesity/data/adult.html

Bariatric surgery coverage. (2023). Medicare.gov. https://www.medicare.gov/coverage/bariatric-surgery

Childhood Obesity Facts. (2023). Centers for Disease Control and Prevention. https://www.cdc.gov/obesity/data/childhood.html

FDA Approves First Treatment to Reduce Risk of Serious Heart Problems Specifically in Adults with Obesity or Overweight. (2024). U.S. Food and Drug Administration. https://www.fda.gov/news-events/press-announcements/fda-approves-first-treatment-reduce-risk-serious-heart-problems-specifically-adults-obesity-or

‌Howard, R., Norton, E. C., Yang, J., Thumma, J. R., Arterburn, D., Ryan, A. M., Telem, D. A., & Dimick, J. B. (2022). Association of Insurance Coverage With Adoption of Sleeve Gastrectomy vs Gastric Bypass for Patients Undergoing Bariatric Surgery. JAMA Network Open, 5(8), e2225964–e2225964. https://doi.org/10.1001/jamanetworkopen.2022.25964

Medicare Prescription Drug, Improvement, and Modernization Act of 2003. (2003). 108th U.S. Congress. https://www.congress.gov/108/plaws/publ173/PLAW-108publ173.pdf

Meyer, B., Wyse, A., Grunwaldt, A., Medalia, C., & Wu, D. (2021). Learning About Homelessness Using Linked Survey and Administrative Data. SSRN Electronic Journal. https://doi.org/10.2139/ssrn.3856841

Minemyer, P. (2024). WSJ: CMS broadens Part D coverage for obesity drugs. Fierce Healthcare. https://www.fiercehealthcare.com/payers/wsj-cms-broadens-part-d-coverage-obesity-drugs

NCD – Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity (100.1). (2022). Centers for Medicare & Medicaid Services. https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=57

Obesity Prevention Source – Health Risks. (2012). Harvard T.H. Chan School of Public Health. https://www.hsph.harvard.edu/obesity-prevention-source/obesity-consequences/health-effects

Sexton, A., Tysinger, B., Nguyen, P., Goldman, D., & Lakdawalla, D. (2023). Benefits of Medicare Coverage for Weight Loss Drugs. USC Schaeffer. https://healthpolicy.usc.edu/research/benefits-of-medicare-coverage-for-weight-loss-drugs/

Twenter, P. (2023). Ozempic pill results in 15% weight loss: Novo Nordisk. Beckers Hospital Review. https://www.beckershospitalreview.com/pharmacy/ozempic-pill-results-in-15-weight-loss-novo-nordisk.html