The prospect of Robert F. Kennedy Jr. presiding over the Department of Health and Human Services has sparked a lot of conversation about vaccines.
That’s entirely appropriate, given his long history of dishonest attacks on vaccination and the possibility that he could influence both public policy and public opinion if, as President-elect Donald Trump hopes, Kennedy becomes HHS secretary.
But as the leader of an agency with an annual budget of $1.8 trillion — more than any other Cabinet department — Kennedy would have a hand in all kinds of consequential matters. And this week, it became clear what one of those matters will be: a looming decision over whether the big federal health insurance programs should help expand access to a new generation of anti-obesity drugs.
That choice could affect the lives of literally millions of Americans, and involves pondering genuinely complex questions along with real-world trade-offs. In other words, it’s the kind of decision that calls for thoughtful, careful analysis of the evidence, as well as an open mind.
But Kennedy has already expressed a clear viewpoint, one that will sound familiar to anybody who has heard him expound on health issues before.
The New Anti-Obesity Drugs, And Kennedy’s Skepticism
The drugs in question are known to scientists as GLP-1 agonists — so named because they imitate glucagon-like peptide-1, a naturally occurring hormone that reduces blood sugar and appetites. They have been around and available for about 20 years, but they started to take off commercially in 2017 after the Danish drugmaker Novo Nordisk got approval for a version that patients could inject just once a week.
That drug’s name is semaglutide. Most Americans know it as Ozempic or Wegovy, which is how Novo Nordisk markets two versions of the drug. Semaglutide has proved effective in treating diabetes and heart disease, and in inducing weight loss. It is also expensive. A monthly supply of Ozempic often lists around $1,000 at pharmacies.
Medicare, the federal program for older adults and people with disabilities, covers semaglutide for people when doctors prescribe it as a treatment for diabetes or heart disease. But it does not cover the drug in other cases where doctors prescribe it to treat obesity. That’s because the law authorizing Medicare to pay for drugs specifically prohibits coverage of weight-loss drugs, a category that administrators at HHS have historically determined should include treatments like Ozempic.
For years, a coalition that includes consumer advocates, physician groups and drugmakers themselves has pressured the federal government to find some way of changing that policy. Not only would that help people on Medicare, they noted; it would also help those on Medicaid, a joint federal-state program that covers low-income Americans. States make their own coverage decisions for Medicaid, but frequently use Medicare policy as a guide.
Congress hasn’t responded to those pleas, but on Tuesday, President Joe Biden’s administration did.
HHS Secretary Xavier Becerra announced that his department was introducing a regulation under which Medicare would cover drugs such as Ozempic as a treatment for obesity, even for patients who don’t have a current diagnosis like heart disease. The rationale, HHS officials explained, was a determination that the drugs are a necessary form of medical care when there are clinical indications of obesity, superseding the prohibition on coverage of weight-loss drugs.
The proposal “helps us recognize that obesity is with us,” Becerra told The Washington Post. “It’s severe. It’s damaging our country’s health. It’s damaging our economy.” He described the decision as a “game changer,” which it certainly could be. More than 7 million Americans would become eligible for coverage, according to administration estimates.
But the process of changing federal regulations can take months, or sometimes years. That means the fate of this proposal will be in the hands of Becerra’s successor, which means it could be in the hands of Kennedy. And Kennedy has made his opposition to the drugs clear.
The topic came up during a discussion with Fox News’ Greg Gutfeld in October, when Kennedy suggested that the drugs were an example of the pharmaceutical industry trying to induce sales of its products rather than promote healthier diets.
“If we … [instead spend money on] giving good food, three meals a day, to every man, woman and child in our country, we could solve the obesity and diabetes epidemic overnight,” Kennedy said. He went on to claim that Novo Nordisk is focused on sales of Ozempic in the U.S. rather than Europe, stating that “in Denmark, they do not recommend it for diabetes.”
The Danish company is “counting on selling it to Americans because we are so stupid and so addicted to drugs,” Kennedy said.
His statements were consistent with his longtime support of healthier lifestyles and skepticism of the pharmaceutical industry, positions that large numbers of Americans from all political persuasions share. But Kennedy’s comments were also consistent with his disregard for medical evidence — which, in this case, offers a far more complicated view of why obesity occurs and the role medication can play in reducing it.
“It is wrong to assume that people with high body weight and BMI [body mass index] just sit around and eat low-quality food,” Dr. Jody Dushay, an assistant professor at Harvard Medical School and endocrinologist at Boston’s Beth Israel Deaconess Medical Center, told CNN this month. “Taking medication to treat obesity should not be demonized.”
Kennedy’s statements in that Fox News discussion also misrepresented what’s happening in Denmark. The country’s national health system still covers and supports use of the new anti-obesity drugs, though guidelines urge providers and patients to try cheaper alternatives first. Other European countries have similar policies.
The Real Debate About The Anti-Obesity Drugs
Whether those facts mean Medicare and Medicaid should cover the drugs more widely here in the U.S. is a separate, more complex matter.
There is an ongoing debate about how widely to use and how heavily to rely upon the anti-obesity drugs. It includes the same questions about long-term effects that all relatively new drugs have, not to mention the risks of adverse effects that come with even the oldest, best understood medications. There are also legal questions about whether identifying obesity as a health threat is enough to override Medicare’s prohibition on covering weight-loss drugs.
And then there are the questions of what expanding coverage for the anti-obesity drugs would cost and whether the added expense would be worthwhile.
The Biden administration estimates that covering the drugs in Medicare and Medicaid would require about $40 billion in additional government spending over the coming decade, with the federal government picking up most of it. (The rest would be from states, through their portion of Medicaid funding.)
That high cost is the reason that some voices from the political left, like the watchdog group Public Citizen, were critical of Tuesday’s announcement. The group is among those that have been urging the federal government to start covering the new anti-obesity drugs, but on one condition — it has also been urging the Biden administration to use other sources of executive authority to force down the drugs’ price at the same time, and this week it made that call again.
“The only honest answer is that I’m really uncertain what the Trump administration will do.”
– Matthew Fiedler, Brookings Institution
“Expanding coverage without containing costs would be an early holiday gift for Big Pharma,” Peter Maybarduk, the director of Public Citizen’s Access to Medicines project, said in a press release.
“Weight loss drugs cost only a few dollars to manufacture. But drugmakers charge hundreds of dollars, and charge Americans more than people in any other country.”
In a press call Tuesday morning, Biden administration officials described the cost for the decade ahead as a relatively small amount, given the overall cost of Medicare and Medicaid (which will be into the trillions of dollars over that time span). They added that other reforms they have introduced to reduce the price of drugs have generated more than enough savings to offset the new cost of covering the anti-obesity drugs.
Outside analysts noted that the actual cost might be lower than projections suggest, given the extent to which medical indications for the drugs were already increasing.
“There’s clearly demand and seemingly positive health effects, so inevitably more and more Medicare beneficiaries were going to get squeezed into existing indications,” Loren Adler, an associate director of the Brookings Institution’s Center on Health Policy, told HuffPost. “At that point, I believe there’s a good governance rationale to expand coverage for the broader indication of obesity, and that also makes the fiscal cost not as large as it might seem on first blush.”
One X factor is whether the price of anti-obesity drugs comes down in the future, whether through greater competition as manufacturers introduce new versions or direct action by the federal government. Thanks to the Inflation Reduction Act, the sweeping health and climate legislation that Biden signed in 2022, the federal government now has the authority to force down the prices of certain costly drugs in Medicare by negotiating directly with their manufacturers.
Ozempic is likely to be among the drugs subject to that authority, starting in 2027, because it costs so much and so many people already take it. That could substantially reduce the price Medicare pays, and thus the overall financial burden on the program ― something the Congressional Budget Office predicted in an assessment of what expanding coverage of the anti-obesity drugs would cost.
“If you look at the CBO score, the projection of costs, from 2026 to 2027 they go down, and [the] reason CBO project it goes down is because the drug would be selected for negotiation,” Rachel Sachs, a Washington University law professor and expert on the drug industry, told HuffPost.
The Trump Administration Voices That Might Matter
The actual give-and-take of the price negotiation occurs through a division of HHS called the Centers for Medicare and Medicaid Services. That’s also the agency that would write and finalize any rules about expanding coverage of anti-obesity drugs.
Democracy In The Balance
Already contributed? Log in to hide these messages.
Trump’s choice to lead the agency is Mehmet Oz, aka Dr. Oz — who, it so happens, said on social media last year that “for those who want to lose a few pounds, Ozempic and other semaglutide medications can be a big help. We need to make it as easy as possible for people to meet their health goals, period.”
Still, if there’s potential support for expanding coverage of anti-obesity drugs from Oz, there’s also potential opposition from Trumpland figures who are looking to slash federal spending ― although Trump booster and adviser Elon Musk might not protest, given that he’s spoken publicly about what the drugs did for him.
“The only honest answer is that I’m really uncertain what the Trump administration will do,” Matthew Fiedler, who served on the Council of Economic Advisers during Barack Obama’s presidency and is now also at Brookings, told HuffPost. “What little we do know suggests that RFK Jr. and Oz may have meaningfully different views on the merits of these drugs, to say nothing of the many other people in the administration who will be in a position to influence this decision.”
But one way or another, “HHS would be integrally involved” in these choices, according to Sachs. And that means Kennedy would be in a position to exert influence of his own, if he so desires.
It’s just one of many ways in which the future of federal health policy ― and, by extension, the health of millions of Americans ― could depend on Kennedy’s thoughtfulness and smarts, to whatever extent he has either.