I was touched by a recent New York Times opinion piece that Sen. John Fetterman, D-PA, wrote. Fetterman is the much-maligned senator elected in 2022 in a contest with Dr. Mehmet Oz, now administrator of the Centers for Medicare and Medicaid Services (CMS).
Fetterman had a stroke during the campaign. He had clear trouble understanding questions during the campaign and equally had a hard time responding. He used technology-based assistive devices to get through debates and other appearances during the election. After winning rather handily in the end, the senator checked himself into a hospital for clinical depression shortly after assuming office.
I said he was much-maligned because during the campaign and after, Fetterman was attacked as being unfit to hold the office of senator. It actually went beyond criticism to being mocked by some for his stroke and clinical depression. Too, he has come under intense criticism for his casual dress on Capitol Hill, his trademark hoodie generating some praise but more condemnation. (I, too, have an affinity for hoodies so was never much concerned about his dress.)
Today, things are incredibly different. Fetterman appears to have fully recovered and has recently stood out as a free-thinking and sober politician leveling complaints about both parties and urging sanity in governance. It certainly took guts to continue his campaign and admit to depression stemming from his physical ailments as well as the immense political pressure felt on election to his post.
Back to the editorial he wrote. Fetterman penned an intensely personal piece on how a GLP-1 weight-loss drug has changed his life. He went on it for his underlying cardiovascular disease and says it has been transformative for him. He has lost 20 pounds and has never felt better. “Even though I started taking it for my heart health, I’ve been struck by how much better it has made me feel across the board. … It’s made a significant impact on my overall health. Aches, pains, and stiffness have vanished. Physically, I feel a decade younger, clearer-headed and more optimistic than I’d been in years. As far as a side effects, I’ve also lost around 20 pounds,” Fetterman wrote.
In the piece, Fetterman urged the new Trump administration to change course and back the Biden administration’s push to have Medicare Part D cover these weight-loss drugs when tied only to obesity and not just when another qualifying disease state is present (e.g., diabetes or cardiovascular disease).
As the senator notes, millions of Americans have seen the benefits of the drug. I have told you in earlier blogs that I am a recent convert on these drugs and am on the same drug Fetterman is. For me, it was an underlying disease state of diabetes. I went on the drug just over a year ago. Over that time, I have lost about 55 pounds. All of my diabetes numbers are now well within the safe zone. My high cholesterol, high triglycerides, and high blood pressure are now gone.
Fetterman is right, too, when he refers to your better emotional health when you are on a GLP-1. While I was always highly motivated, my optimism and outlook seem much greater. I am eating better and exercising. So, like Fetterman, I have never felt better, save for my teen years and college days I guess. I don’t like relatively new drugs for fear that there are side effects that appear down the road. But I cannot question the life-changing nature of GLP-1s and other weight-loss drugs.
Fetterman makes the case that opening up coverage for more disease states as well as obesity could be transformative for people’s lives and our healthcare system. He argues that the government now has the ability to negotiate drug prices and that would mitigate the increased spending on the pricey $1,000-plus-a-month drugs (gross price). He also makes the point that the drugs could reduce chronic disease costs down the road, thereby providing offsetting savings.
There is no doubt Fetterman is right over the long term. Nonetheless, until we do have substantially lower prices in place for GLP-1s and drugs in general, it is hard to make the leap to expand coverage of GLP-1 weight-loss drugs in Medicare. I know this sounds selfish since I just told you how benefit from them, but here is my rationale.
I read with interest that the Congressional Budget Office (CBO) now says the Medicare Part A Trust fund won’t go bankrupt until 2052. That is about 20 years longer than predicted last year. Given all the assumptions that have to be made, it is hard to take a lot of stock in the exact dates Medicare’s hospital fund will run out. On the other hand, though, it is good news that the date appears to be later than once thought.
But the fact is that we are talking bankruptcy of a major government program perhaps in my lifetime but certainly in my children’s lifetime. What’s more, outpatient services are paid from general government funds and beneficiary contributions. Costs in Medicare appear to be growing by as much as 9% right now. Even if this moderates, the sheer costs of Medicare will mean greater and greater government appropriations and increased beneficiary costs in terms of premiums, deductibles, and cost-sharing (even if the predominant 20% cost-share is not increased from a percentage standpoint).
The retail drug program is funded from the same outpatient fund. We see costs in the Part D program surging from GLP-1s for disease states, specialty drugs, and the sheer weight of increased utilization and high prices. Further, the Biden administration and Democratic senators passed a poorly designed and politically motivated Part D cost-sharing reduction plan in the Inflation Reduction Act (IRA). The Democrats didn’t really fund the reductions in beneficiary costs and instead transferred most of it to plans that sponsor the benefit either in Medicare Advantage (MA) or the standalone Part D (PDP) program.
This meant an expected huge surge in costs in the program, so much so that CMS had to step in and create what I think is an extra-legal program to shelter the public from the massive premium increases that would have resulted in the PDP program in 2025. The special premium stabilization program was slated by the Biden administration to run from 2025 through 2027. Even the Trump administration is continuing the program in 2026 because it simply doesn’t know how to get out of the hefty financial commitment and otherwise shelter the public. Costs of the changes will only rise in the future.
The Part D cost-sharing fiasco shows the danger of well-meaning benefit expansions. The IRA change is literally threatening to increase premiums in the PDP program phenomenally over time. Already, premiums and cost-sharing have increased notably and benefits and offerings have been cut. The PDP program financially is a mess in large part due to the IRA.
The Trump administration looks mean to refuse to increase weight-loss drug access. But in many ways, it is being fiscally prudent right now. Anytime you increase one benefit in a government program that is unpaid for and generates increased costs, it is inevitable that it is funded by premium hikes, cost-sharing increases, and benefit reductions elsewhere in the program. So those who need GLP-1 coverage would win, but so many others would lose. More important, the move by Biden was not only fiscally irresponsible but brazenly political.
On the issue of Medicare drug negotiations noted by Fetterman, I am with him in principle. I support these negotiations. But for the 10 drugs from year one of negotiations, the Medicare drug price negotiations have only reduced drug prices by an average of 22% on a net (post rebate) basis. While some GLP-1s are on the docket for negotiations in 2025 (for an effective date of January 1, 2027), we don’t know yet what the negotiated price will be. If it is the average of 22% down, the savings would be too small in the short-term considering the ongoing growth of GLP-1 costs due to the use for diabetes and other disease states and the new costs for those with obesity. There also are concerns that many do not stay on the drug over the long-term to mean savings. Admittedly, at least part of the erosion of adherence to GLP-1s may be about the overall price.
Thus, extending GLP-1s now to obesity in Medicare would compound the negative effects caused by the IRA Part D cost-sharing changes, further compromising the financial stability of the PDP program as well as eroding benefits further in both PDP and MA.
The solution: be aggressive on price negotiations for GLP-1s in 2025 and get the price down for 2027 close to what is paid in other developed nations. In general, the prices outside the U.S. is a range of below $100 to less than $450 depending on the actual drug.
Then, a more deliberate discussion can be had about short- and long-term costs and the benefits of expanding GLP-1 coverage.
#glp1s #weightlossdrugs #drugpricing #branddrugmakers #medicareadvantage #partd #pdp #spending
— Marc S. Ryan
