Overview
Title
To amend title XVIII of the Social Security Act to provide coverage of weight loss agents for certain individuals under part D of the Medicare program.
ELI5 AI
The DEAL with Obesity Act of 2024 wants to help people with less money who use Medicare and Medicaid by paying for special medicines that help them lose weight, so it's cheaper for them to get healthier.
Summary AI
H.R. 10272, also known as the "Dual Eligible Americans Living with Obesity Act of 2024" or the "DEAL with Obesity Act of 2024," aims to amend the Social Security Act to include coverage for weight loss medications under Medicare Part D for certain individuals. The bill highlights that many people who are enrolled in both Medicare and Medicaid have limited financial resources, and coverage for specific weight loss drugs could significantly reduce out-of-pocket costs. With obesity being a major health issue in the U.S., the bill seeks to make these medications more accessible by including them in the Medicare Part D coverage starting in 2026 for eligible individuals, which includes those defined as having obesity or overweight conditions.
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AnalysisAI
General Summary of the Bill
The bill titled "Dual Eligible Americans Living with Obesity Act of 2024" or simply "DEAL with Obesity Act of 2024" seeks to amend title XVIII of the Social Security Act. It aims to provide coverage for certain weight loss drugs under Medicare Part D, specifically targeting individuals with obesity or who are overweight. The bill is structured to become effective with the plan years starting on or after January 1, 2026. This proposal reflects an intent to mitigate the financial burden of weight loss treatment on qualifying individuals and the healthcare system as a whole.
Summary of Significant Issues
One major issue with the bill is its potential bias favoring certain weight loss drugs. The covered drugs must meet specific criteria under the Federal Food, Drug, and Cosmetic Act and the Public Health Service Act. This condition can limit competition and potentially favor certain pharmaceutical companies over others.
Additionally, the bill leaves room for ambiguity. Terms such as "specified individual," "obese," and "overweight" are not clearly defined regarding eligibility criteria for receiving treatment coverage. This lack of clarity could lead to inconsistent implementation and confusion among beneficiaries.
Moreover, there are no specified oversight or review mechanisms within the bill to ensure that the coverage of these weight loss agents is effective and managed properly. Without these measures, there is a risk of potential misuse or financial mismanagement within Medicare funds.
The bill also presents challenges with complex legislative references and technical language. This makes the text less accessible to individuals who are not experts in legislative or healthcare terminology, possibly causing confusion among general stakeholders, including policymakers and the public.
Impact on the Public
If implemented effectively, the bill could significantly reduce the financial burden associated with obesity treatments for eligible individuals. By making weight loss drugs more affordable, the legislation aims to improve health outcomes for those grappling with obesity, a major public health concern affecting millions of Americans. This could also lead to a reduction in obesity-related healthcare costs, benefiting the broader healthcare system.
However, the bill's impact on the public could be negatively affected by its vagueness and lack of clear guidelines concerning who precisely qualifies for the coverage. This confusion might delay the access to necessary treatments for some individuals and could contribute to inequities in healthcare access.
Impact on Specific Stakeholders
Beneficiaries: For beneficiaries of both Medicare and Medicaid who are struggling with obesity, the bill represents a potentially life-changing opportunity for more affordable treatment options, provided they meet the specified criteria.
Healthcare Providers: Healthcare providers might benefit from clearer guidelines about which patients qualify for treatment. However, the lack of specific criteria and oversight could result in complications when attempting to prescribe these medications.
Pharmaceutical Companies: Companies whose weight loss drugs meet the federal criteria stand to benefit from increased access to a substantial new market covered by Medicare. Conversely, companies whose drugs do not meet these criteria could face competitive disadvantages.
State Governments: States might experience changes in Medicaid expenses if more people become eligible for weight-related treatment coverage.
In conclusion, while the Dual Eligible Americans Living with Obesity Act of 2024 aims to provide necessary assistance to fight obesity, it is beset with issues of unclear definitions, potential favoritism, and lack of oversight, which could hamper its effectiveness and fairness. Careful consideration and possible revision would be required to maximize its potential benefits and ensure equitable access to healthcare resources.
Financial Assessment
The proposed legislation, the "Dual Eligible Americans Living with Obesity Act of 2024," includes significant financial considerations related to expanding coverage of certain weight-loss medications under Medicare Part D. Particularly for individuals simultaneously enrolled in both Medicare and Medicaid—referred to as "dual eligibles"—the bill aims to alleviate some of the financial burdens associated with obesity management.
Financial Costs and Savings
The text highlights that a one month's supply of a GLP-1 receptor agonist, a type of weight-loss medication, typically costs between $900 and $1,350. The bill underscores that with coverage, these costs could potentially be reduced to as little as $25 per month. This substantial reduction in out-of-pocket expenses for individuals could be financially transformative, especially given that 87% of these dual eligible beneficiaries earn less than $20,000 annually.
The legislation aims to address a significant health issue, with obesity currently taxing the U.S. healthcare system to the tune of $173 billion annually and projected to possibly reach $550 billion by 2030. The financial focus is clearly on reducing these costs by promoting healthier weight through access to specific medications, thereby preventing more costly medical issues related to obesity.
Relation to Identified Issues
Preferential Treatment: The bill's financial approach to cover particular weight loss drugs, as defined under specific federal acts, might limit competition, potentially favoring certain pharmaceutical companies that market these medications. This raises concerns about whether the legislation provides an undue competitive advantage to certain companies over others, potentially at the expense of broader available solutions.
Eligibility and Clarity: The criteria determining who qualifies as a "specified individual" eligible for this coverage are tied closely to being already eligible for other state-level medical assistance programs. This links back to concerns about clarity and the potential for inconsistent implementation. Decisions regarding who receives financial benefits and by how much remain vague, presenting a risk of financial misuse or uneven distribution of potentially massive savings.
Oversight and Effectiveness: No explicit mechanisms for oversight or regular review of the financial appropriations for this expanded coverage are mentioned. Addressing this gap could prevent potential misuse of funds, ensuring that financial resources are well-managed and targeted effectively toward beneficiaries in need.
Ethical Considerations: By focusing extensively on individuals who are eligible for both Medicaid and Medicare, the financial support does not extend to all populations affected by obesity. This limitation raises questions about equity, suggesting that while the bill may reduce individual financial burdens, it may not comprehensively address the broader financial impact on all individuals with obesity across the U.S.
In summary, while the bill proposes significant savings for dual eligible beneficiaries by covering specific weight loss medications under Medicare Part D, the arrangements also raise questions about competition, clarity, and oversight. Addressing these concerns would help ensure that the financial objectives of this legislation align with equitable healthcare access and fiscal responsibility.
Issues
The bill potentially favors certain weight loss drugs that meet specific criteria outlined in federal acts, namely the Federal Food, Drug, and Cosmetic Act and the Public Health Service Act. This might limit competition and could be seen as preferential treatment for particular pharmaceutical companies. (Section 3)
The process for determining eligibility and defining terms like 'specified individual' and 'obese' or 'overweight' lacks clarity, which could lead to inconsistent implementation and confusion. There is ambiguity in how individuals qualify for receiving weight loss treatment coverage. (Section 3)
There is no mention of oversight or review mechanisms to assess the effectiveness and appropriateness of providing Medicare coverage for these weight loss agents. This absence of checks could lead to potential misuse, waste, or mismanagement of funds. (Section 3)
The findings section does not propose any actions or solutions to the issues presented, making it unclear what Congress intends to do in response. The lack of proposed actions makes it difficult to assess whether any spending might be wasteful or biased. (Section 2)
Complex legislative cross-referencing and technical language throughout the amendment could make it difficult for non-experts to understand, potentially causing confusion among stakeholders, including policymakers and the public. (Section 3)
There is a potential ethical issue regarding equity and access, as the bill primarily benefits those eligible for medical assistance under a state plan or a waiver of such a plan, which might not cover all individuals facing obesity or weight-related health issues. (Section 3)
Sections
Sections are presented as they are annotated in the original legislative text. Any missing headers, numbers, or non-consecutive order is due to the original text.
1. Short title Read Opens in new tab
Summary AI
The opening section of the bill states that it can be called the “Dual Eligible Americans Living with Obesity Act of 2024” or simply the “DEAL with Obesity Act of 2024”.
2. Findings Read Opens in new tab
Summary AI
Congress highlights the significant number of people enrolled in both Medicare and Medicaid who have limited finances, the high costs of obesity treatments, and the substantial health and economic impacts of obesity in the U.S.
Money References
- Congress finds the following: (1) According to the Kaiser Family Foundation, 12.5 million people are dually enrolled in both Medicare and Medicaid. (2) Dual Eligible beneficiaries overwhelmingly possess limited financial resources, with 87 percent having an income of less than $20,000 annually. (3) A one month’s supply of a GLP–1 receptor agonist, on average, costs between $900 and $1,350. (4) Coverage of GLP–1 medications can lower out-of-pocket monthly costs to as little as $25 per month, according to a study published in JAMA. (5) Data from the Centers for Medicare and Medicaid show that 38 percent of Medicaid beneficiaries and 48 percent of Medicare beneficiaries are affected by obesity. (6) Obesity is the second leading cause of death in the U.S., leading to 300,000 deaths per year, according to the National Institutes of Health. (7) Adults in the U.S. living with obesity experience higher annual out-of-pocket medical costs of $2,505, on average, compared to those with normal weight. (8) Obesity in the U.S. costs the healthcare system $173 billion annually and is projected to cost the U.S. $550 billion annually by 2030. ---
3. Providing coverage of weight loss agents for certain individuals under part D of the Medicare program Read Opens in new tab
Summary AI
The section amends the Social Security Act to allow coverage under Medicare Part D for weight loss drugs starting in 2026, provided the drugs are approved for long-term weight reduction in individuals with obesity or who are overweight. It also defines a "specified individual" as someone eligible for medical assistance under a State plan.