Crunch Time for TROA!

| September 1, 2022

by Christopher Gallagher

Funding: No funding was provided for this article.

Disclosures: Christopher Gallagher works with the Obesity Action Coalition, Obesity Society, American Society for Metabolic and Bariatric Surgery, and Obesity Medicine Association. 

Mr. Gallagher is a Washington Policy Consultant for the Obesity Action Coalition (OAC), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), and Obesity Medicine Association (OMA) in Washington, DC.

Bariatric Times. 2022;19(9):9.


Earlier this year, we looked at the growing momentum for expanding public and private health plan coverage for comprehensive obesity care, particularly, the expanding congressional support for S. 596/HR 1577, the Treat and Reduce Obesity Act (TROA).1 This critical legislation will expand Medicare coverage so seniors can access United States (US) Food and Drug Administration (FDA)-approved medications for chronic weight management, as well as intensive behavioral counseling services from a more diverse range of healthcare providers. 

As House Members and Senators return from their August recess, they will be entering the final months of the 117th Congress and, hopefully, will evaluate various avenues for passing TROA. Since my March commentary, a few major things have happened that are giving me hope that Congress will act on this bill, which now has more than 170 House and Senate cosponsors.

First, in a February 17, 2022, carrier letter2 and a subsequent March 16, 2022, technical guidance letter,3 the federal Office of Personnel Management (OPM) spelled out specific guidance for health insurance carriers that administer Federal Employee Health Benefit (FEHB) plans, “clarifying that FEHB Carriers are not allowed to exclude anti-obesity medications from coverage based on a benefit exclusion or a carve out,” and “FEHB Carriers must have adequate coverage of FDA approved anti-obesity medications (AOMs) on the formulary to meet patient needs and must include their exception process within their proposal.”

In rolling out this new guidance, OPM is quite clear, emphasizing that “obesity has long been recognized as a disease in the US that impacts children and adults,” and “obesity is a complex, multifactorial, common, serious, relapsing, and costly chronic disease that serves as a major risk factor for developing conditions such as heart disease, stroke, Type 2 diabetes, renal disease, nonalcoholic steatohepatitis, and certain types of cancer.”

In 2014, OPM encouraged carriers to cover obesity treatments and prohibited plans from excluding coverage based on the carrier’s belief that obesity is a lifestyle condition or that treatment is cosmetic. Despite this nudge from OPM for FEHB carriers to get their act together, many plans continued to exclude or carve out coverage for AOMs. Many leaders from the Obesity Care Continuum and Strategies to Overcome and Prevent (STOP) Obesity Alliance who have worked with OPM for nearly a decade on this issue see this new guidance as a possible game changer and hope that the Medicare program and Congress take note! Nothing is more problematic for policymakers than explaining how federal employees are getting critical benefits that are off limits to Medicare beneficiaries.

At the state level, obesity advocates are leveraging the OPM guidance across the country, and many state employee health and Medicaid plans are beginning to act! For example, it appears that the Iowa state employee health plan and Pennsylvania Medicaid program are taking regulatory action to provide AOM coverage in 2023. This continued success at the state level for expanding coverage will also lead to intensifying pressure on Medicare to take administrative action to eliminate its dated and discriminatory prohibition on Part D coverage for obesity drugs.

Second, we are seeing early results of new medications that have entered the market this year or are on track for FDA approval in 2023. Recent studies have demonstrated profound weight loss numbers associated with medications such as semaglutide4 and tirzepatide.5 While supply chain and affordability issues may still impact the widespread availability of these AOMs, patients are hopeful about these new treatment options and may begin standing up more vociferously for access to obesity care. 

We will need everyone to push on their Senators and Member of Congress to support passage of the TROA during these final months of the 117th Congress! Please help us let Congress know that it’s time for action on TROA by sending a letter to your members of Congress via the Obesity Action Coalition’s (OAC) Action Center. You can do so at https://www.obesityaction.org/troa/?utm_source=spotlight-action. Working together, we can get TROA across the finish line! 

References

  1. Gallagher C. Momentum Growing for Action on Obesity Care! Bariatric Times. 2022;19(3):12.
  2. US Office of Personnel Management. Federal Employees Health Benefits Program Call Letter. 2 Feb 2022. https://www.opm.gov/healthcare-insurance/healthcare/carriers/2022/2022-03.pdf. Accessed 18 Aug 2022.
  3. US Office of Personnel Management. Technical Guidance and Instructions for 2023 Benefit Proposals. 16 Mar 2022. https://www.opm.gov/healthcare-insurance/healthcare/carriers/2022/2022-04.pdf. Accessed 18 Aug 2022.
  4. Wilding JPH, Batterham RL, Calanna S, et al. Once-weekly semaglutide in adults with overweight or obesity. N Engl J Med. 2021;384(11):989–1002.
  5. Jastreboff AM, Aronne LJ, Ahmad NN, et al. Tirzepatide once weekly for the treatment of obesity. N Engl J Med. 2022;387(3):205–216.

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Category: Commentary, Current Issue

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