Five 'What If' Questions About the Politics of Obesity Meds (Plus the Week's Top 10)

Most of what’s being written about the coming impact of anti-obesity medicines falls into the genre of “what-if?”?

As in: What if airlines save billions on jet fuel because passengers are suddenly 10 pounds lighter? What if Conagra makes Slim Jims slimmer? What if people start eating jelly beans one by one? What if Walmart sells fewer groceries? (All of these are real examples from this week’s news.)

These are all fascinating stories, and I’m not saying they’re not worth a little speculation, mostly for entertainment purposes. But there are some bigger what-if questions linked to the intersection of obesity meds and politics that may be more meaningful.?

Here are five “what-ifs” about the way that the rise of effective obesity drugs might impact politics, from most to least realistic:?

1. What if TROA became a campaign issue? The Treat and Reduce Obesity Act would undo a law that bars Medicare from covering weight-loss medicines. The legislation has a ton of bipartisan and organizational support. Still, I’m sure there are members of Congress who are a bit worried about the fiscal impact of opening the Medicare floodgates.? That’s probably especially the case this week, given that the head of the Congressional Budget Office warned that obesity meds’ “net cost to the Medicare program would be significant over the next 10 years.” So is this a wedge issue that could be wielded against fiscal conservatives? If TROA doesn’t pass in the next few months, we might find out in the 2024 election cycle.
2. What if a presidential candidate promises to use Medicare “negotiations” to slash the price of Ozempic? The next president will almost certainly oversee the process of imposing price controls on Ozempic. It would be a doozy of a campaign promise to pledge to use the power of HHS to drive the Medicare price of the medicine down to something absurdly low. (Especially if TROA is, or will be, law.) Is that something a candidate should promise? Is it something that the White House can or should actually do as a matter of law or executive power? Doesn’t matter. Elections now seem to be held in a post-truth vacuum, and I bet overinflated promises about drug-price regulation poll great.?

1. What if obesity meds become a talking point in PBM reform? I’m thinking specifically about provisions around “delinkage,” the idea that the out-of-pocket cost to patients should be based on a PBM’s negotiated price, not the list price. “Delinkage” is not an easy idea for Joe Sixpack to get his head around. Three-quarters of Americans can’t define coinsurance. That screams for a concrete example, and the math on obesity meds might be one way to do that. Using numbers released by AEI this week, the list price on Ozempic is $936. The net is $290. That means someone with 25% coinsurance is paying $234 a month, rather than just over 70 bucks. That’s still a lot of numbers, but people tend to be better at calculations when they have a stake in the answer.

1. What if a presidential candidate pledges to make obesity meds reimbursable under Medicare through administrative action? If TROA doesn’t work, there is another way forward. The health care wonks at Manatt suggested last month that it is “weight loss” medicines that are currently barred from Medicare reimbursement. But “obesity” treatments are a horse of a different color, according to the Manatt theory. So there may be kind of a magic wand that could turn “weight loss drugs” into covered “anti-obesity medicines.” Again, there’s reason to think that this wouldn’t be without legal and administrative challenges, but we’re talking campaign promises …?

1. What if a presidential candidate declared the Medicare patients could use patient assistance? Remember, I’ve ranked these five ideas in descending order of realisticness. The idea that patient assistance in Medicare is not allowed is fairly deeply entrenched in the law, and prescription drug coupons are not well-loved as a concept. (They’re well-loved by the people who benefit from them, but that’s a slightly different topic.) Still, it’s possible that we’re about to enter an era in which Medicare patients have demonstrably worse access than commercial patients. Because commercial patients will either have their obesity meds covered by insurance, or they’ll have access to coupons that cut the cash-pay price by thousands of dollars a year. Medicare patients will have neither. Allowing coupons would help close those gaps.

Are any of the scenarios likely? It’s hard to tell, but they’re at least as important to talk about as the coming conversation about whether Hostess will have to shrink the Twinkie. (That’s not a real story. Not yet, anyway.)

The Top 10 Stories of the Week:?

1. A federal judge affirmed that copay accumulators are a really bad idea, tossing HHS rules that allowed insurance plans to bar the use of copay assistance for deductibles and out-of-pocket maximums.?
2. ICER released a white paper designed to help CMS in their price-control calculus with Eliquis and Xarelto. But it’s not clear to me that the ICER numbers -- even if you trust ICER and believe in the methodology -- justify a price much lower than the existing net prices for the meds.?
3. I could probably write all day, every day, about different facets of the obesity-price-and-spending dialogue. Because there is so much fascinating stuff out there, such as this study that found that 91% of obesity-drug scripts were never filled. (The study looked at claims data between 2012 and 2019, so adjust your conclusions accordingly.)
4. I keep calling the Medicare Prescription Payment Plan -- the IRA provision that allows for drug costs to be spread evenly across the year -- the most important element of the iRA that no one has heard of. This Milliman piece won’t boost awareness of the provision, but it’s a great overview nonetheless.
5. It’s almost earnings time, when we find out exactly how giant the profits are for health insurance companies. This quarter, they might be even bigger for a technical reason highlighted by the Wall Street Journal: insurers tend to stick a lot of their revenue in short-term investment vehicles that are currently paying absurdly high interest rates. Sucks if you’re trying to buy a house. Great if you’re running a health insurance company.?
6. I’m always fascinated with the question of how payers approach utilization management of cancer drugs. This Journal of Managed Care and Specialty Care survey suggests that the answer remains: “carefully.”??
7. It’s no secret that there is a special place in my heart for EQRx, at least the version of EQRx that thought it could use disruptive pricing to alter the pharmaceutical ecosystem. But, as this piece by Fierce points out, EQRx may never have had the assets needed to change the world.?
8. The Merck COVID-19 treatment is moving to the commercial market.?
9. Two updates in the Humira biosimilar universe: Boehringer Ingelheim is launching its low-price version. It’ll come in at an 81% discount. (And probably be ignored by payers.) Pfizer is trying to two-price thing with its version, due to launch this month. The plan is to launch one version, right away at a 5% discount. The 60%-discount version is due later this year.?
10. The makers of all ten medicines selected for price controls are playing along, though they’re doing so “under protest.” I don’t think that’s a surprise or particularly newsworthy, but the media treated it as such, so here it is. At number 10.?