Who’s able to get weight loss drugs like Ozempic and Wegovy?
Who’s able to get weight loss drugs like Ozempic and Wegovy?
Growing up, Karen Butcher always struggled with her weight. As a kid, she and her mom would try all these different diets together, but nothing worked.
As an adult, she’s kept trying — the keto diet, Slimfast shakes, eating just one meal per day, having pre-made meals delivered. None of it has made much difference.
“I have seven kids, and it seemed like every time I had a baby I’d put on another 40, 50 pounds,” Butcher said. “And now here I am at almost 400 pounds.”
At 31, her weight affects almost every aspect of her life.
“I struggle to work. I struggle to be active,” she said. “There’s times I don’t even want to get up. I just want to sit there because I physically feel like I cannot breathe. Or I go to stand and my legs hurt too much and I just have to sit back down.”
She’s also pre-diabetic now, and because of that, her doctor recently asked her if she would be open to trying a GLP-1 drug like Ozempic to lose weight, and hopefully reverse the pre-diabetes.
“I was pretty optimistic when she first brought it up,” Butcher said. “I thought, ‘well, maybe this will help me get a little bit healthier.’”
But when she went to pick up the prescription, she learned that Medicaid in New York State, where she lives, won’t pay for it.
In the last couple of years, data has shown that GLP-1 agonists, including semaglutide and tirzepatide, are effective for weight loss and weight management, and the drugs have taken off. Nearly a quarter of adults who are overweight or obese have tried one so far, according to a recent survey from the health policy nonprofit KFF.
But there are significant disparities in who is able to access these drugs and who isn’t. Low-income people are less likely to get prescriptions for weight loss drugs covered by insurance, even though they are more likely to be overweight or obese.
A recent study from researchers at the USC Schaeffer Center, published in JAMA Health Forum, found that less than 10% of people who picked up semaglutide prescriptions last year were on Medicaid, the federal-state insurance program for people who are low-income.
“Coverage of weight loss drugs in Medicaid is pretty limited,” said Liz Williams, a Senior Policy Analyst with KFF’s Program on Medicaid and the Uninsured.
States are not required to cover prescription weight loss drugs for people on Medicaid, and many choose not to. As of last summer, KFF found just 16 states cover at least one weight loss drug for adults.
“State Medicaid programs do have to cover the drugs approved to treat diabetes,” Williams said. “So, for example, Ozempic is FDA-approved for diabetes, so Medicaid does have to cover Ozempic for that indication.”
But they do not have to cover Ozempic, or any other drug, specifically for weight loss. Medicare, the federal health insurance for adults 65 and up, doesn’t cover weight loss drugs at all.
“You basically have to become sick enough in order to then qualify for the medication,” said Dr. Chris Scannell, a primary care physician and one of the lead researchers on the study at USC.
People who are obese are at higher risk for diabetes, heart disease, stroke, fatty liver disease and many other health issues.
But even though these drugs have been shown to reduce those risks, in many states, “you can’t just treat obesity when you have that as a single disease, but you have to develop these other comorbid conditions to then qualify,” Scannell said. “I think it’s a real clinical shame that these patients wouldn’t be able to access the medication earlier when, if they could potentially lose weight and reduce obesity as a risk factor … they could be halting their disease progression much earlier.”
A big part of the issue is cost. Even some private insurers aren’t covering these drugs for weight loss because they’re expensive, and because so many people would likely qualify; more than 70% of Americans are overweight or obese.
But Kody Kinsley, North Carolina’s Secretary of Health and Human Services, doesn’t believe it’s just about money.
“We only have conversations about not covering certain drugs when they’re related to stigmatized illnesses, whether that be HIV medication, or treatment for opioid use disorder,” he said. “We don’t seem to worry so much publicly about the cost of highly expensive cancer drugs, et cetera. But when it comes to things that are stigmatized, where we see the issue more as a moral failing than a medical issue, we feel like, ‘oh, now is the moment for us to be upset about everything wrong with the health system that drives up prices.’”
The Medicaid program in North Carolina just started covering weight loss drugs last month. Kinsley is not allowed to share how much the state is paying, but said these will not be the most expensive drugs in the state’s Medicaid program.
“The most expensive drug for me in my program is primarily prescribed for eczema, and the cost for that will be almost twice what I will pay for weight loss,” he said. “And nobody is complaining about the cost of eczema.”
To Kinsley, covering weight loss drugs for people on Medicaid was a no-brainer, in a state where nearly half of residents are obese, and heart disease and diabetes are common.
“Fighting obesity is a smart way to go after those problems now, and so financially, it’s a good investment,” he said. “But most importantly, morally, it is just the right thing to do.”
Even in states that do cover these drugs for weight loss, though, it can still be hard for people to actually get them. They often have to be obese, not just overweight, and show that they have tried other drugs first.
“The reality is, very few patients can make it through the gauntlet,” said Dr. Shantanu Nundy, a physician at Neighborhood Health, a community clinic in Northern Virginia. “And so, I think me and my colleagues remain very concerned that, okay, fine, we got it covered, but can we really get it to people?”
Most of Nundy’s patients are uninsured or on Medicaid, and the majority are overweight or obese.
“I always have this sense of dread when I see them because as I go from exam room to exam room, and I can see people in their 20s, 30s, 40s, 50s, and beyond, I’m basically seeing a continuum of all the conditions that crop up,” he said. “I have the 40-something-year-old who’s heading down the path of knee surgery. I have the 50-year-old who I’m talking to about starting them on insulin. I have the 60-year-old who’s going into liver failure because of fatty liver disease.”
For years, he and his colleagues never had any real tools to offer their patients other than counseling them on diet and exercise. When these weight loss drugs first came on the market, Nundy was skeptical, until he really looked at the data.
“There was almost this exuberance that, wow, we have something,” he said. “We felt empowered that maybe we could actually do something to turn the tide. And now I think we’re back to the status quo and the despair of something that we can’t control.”
For Butcher, in New York, it’s almost more frustrating to know that these drugs are out there, but she can’t get them.
When her doctor offered to prescribe a weight loss drug, “I was actually really excited, thinking that this would actually help me flip the whole page,” she said. “And I was actually pretty upset when I learned that I didn’t qualify.”
The only option for her now is weight loss surgery. But as is often the case, she’s been told she’d have to lose a bunch of weight first to qualify.
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