America's screwed-up healthcare system is preventing millions from receiving a new 'life-saving drug'
Like millions of other Americans, Darrell desperately wants to lose weight.
The 76-year-old retiree from Aurora, Colorado, has severe obesity along with a number of other conditions, including high cholesterol, sleep apnea, and chronic back pain. Darrell, who is being identified by his first name to protect his privacy, said his high blood pressure had caused him to suffer multiple strokes. His doctor advised that losing weight could help alleviate some of his health problems, but previous injuries have made it difficult for him to exercise, and numerous diet programs like Weight Watchers haven't worked.
Luckily, his doctor recommended a new option: Wegovy, a drug that's been shown to help users lose an average of 15% of their body weight and lower blood-sugar and blood-pressure levels. The new drug seemed like a godsend, but soon after his doctor prescribed Wegovy, Darrell got a shock. His insurance company, UnitedHealthcare, refused to pay for it.
Darrell's primary insurance is a Medicare Advantage plan, the privatized version of the traditional federal health-insurance program for seniors, sold by UnitedHealthcare. The company, the country's biggest and richest health insurer, wrote in memos reviewed by Insider that it denied coverage for Wegovy because Medicare didn't cover weight-loss medications by law and Darrell's private plan didn't offer the drug as an extra benefit. Without insurance, Darrell can't afford Wegovy's price tag of over $1,300 a month. He appealed the decision and sought help from state insurance regulators, but it made no difference: UnitedHealthcare refused to reverse its decision. The insurer didn't respond to multiple requests for comment.
Five months after his doctor originally told him about Wegovy, Darrell is still unable to get the drug that could change his life. Knowing a treatment exists but is just out of reach is frustrating and stressful, he told me.
"To me, it's a lifesaving drug," he said.
Wegovy is just one of a wave of revolutionary weight-loss drugs, which also includes the buzzy Ozempic, that represents a watershed moment for obesity treatment. A whopping 40% of Americans are obese — and at least $174 billion is spent every year treating the myriad health problems associated with the disease. But high costs and insurance hurdles, such as those Darrell faces, are keeping the drugs from getting to many of the people who need them.
The drug companies, salivating over the prospect of billions in revenue, set prices out of reach for most people whose health plans don't cover them. Health insurers and employers have balked at covering the drugs for fear that a surge in demand would cut into their profits, strain their budgets, and eventually send health-plan premiums through the roof. Silicon Valley-backed startups and online pharmacies are flooding this gap, hoping to capitalize on the rising demand, but it's unclear whether companies are expanding access to those who need it or simply doling out drugs to people who're trying to lose weight for cosmetic reasons.
And while the American healthcare system battles it out, people who most need obesity treatment are stuck in the middle — praying for a chance to get access to these critical drugs.
Demand for weight-loss drugs is surging
Doctors and healthcare professionals searched for a healthy, safe, and effective weight-loss solution for years before the drugs, known collectively as GLP-1 agonists, exploded on the scene. They were developed to treat type 2 diabetes, but the drugmaker Novo Nordisk repurposed them for obesity after clinical studies found they helped users lose weight. The frenzy for the drugs was set off by the Food and Drug Administration's approval of Novo Nordisk's Wegovy in 2021 — the first weight-loss drug approved since 2014 and by far the most effective.
There are a growing number of options in the category. In addition to Wegovy, Novo Nordisk produces Ozempic and Saxenda, while its competitor Eli Lilly manufactures Mounjaro. Only Wegovy and the less-effective Saxenda are FDA-approved for weight loss, and they're limited to people who are obese and those who are overweight with at least one other health condition, but doctors can prescribe the others for off-label, or unapproved, use at their discretion.
Doctor offices have been overwhelmed by patients asking for the drugs. Celebrities and TikTok influencers have sung their praises. Startups prescribing the drugs have flooded social media with ads. And you'd have a hard time watching prime-time television without spotting at least one Wegovy commercial.
Patients are able to bend down and tie their shoelaces for the first time. Patients who've been in a wheelchair and just completely debilitated are now standing up and walking with a cane.
The popularity isn't surprising, Dr. Gitanjali Srivastava, the medical director for obesity medicine at Vanderbilt University Medical Center, told me. The drugs have so far proved effective, improving the quality of life for people who've been struggling with weight-related health issues and stigma for many years, she said.
The drugs have also become controversial, in part because some people are using them to shed pounds for cosmetic reasons, which is not what they're meant for. But there are millions of people who stand to benefit from the drugs. People taking the medications told me that aside from finally losing weight, they felt full after eating for the first time, saw reductions in their blood sugar, and had fewer aches and pains.
"Patients are able to bend down and tie their shoelaces for the first time. Patients who've been in a wheelchair and just completely debilitated are now standing up and walking with a cane. Those are the types of improvements we're seeing," said Srivastava, who consults with drug companies developing the GLP-1 drugs, a common practice among specialists.
The $100 billion tug-of-war
While the drugs represent a breakthrough for millions of Americans, there's just one thing holding up a true health revolution: the price. Drugmakers charge from about $900 to $1,300 or more a month for all the available drugs, which must be taken long term or patients will regain most of the weight they lost.
If these drugs were much less expensive, I think physicians would prescribe them, and I think health plans would be happy to pay for them
These high prices have ignited an intense, system-spanning fight over who will bear the cost. The Institute for Clinical and Economic Review, an independent organization that evaluates the value of new treatments, determined that if just 0.1% of the 142 million people in the US who are overweight or obese used the drug, it could strain the healthcare system's finances.
"If these drugs were much less expensive, I think physicians would prescribe them, and I think health plans would be happy to pay for them," James Chambers, an investigator at the Center for the Evaluation of Value and Risk in Health at Tufts Medical Center who tracks coverage policies, said. He pointed out that the downstream healthcare costs insurers could avoid by helping people lose weight would be significant.
Drugmakers are giddy over the prospective revenue, however, and unlikely to lower their prices anytime soon. After all, the US government allows drug companies to set their prices as high as they want to. The investment firm Jefferies forecast that the market for GLP-1 obesity and diabetes drugs worldwide could reach more than $150 billion each year by 2031, with obesity treatment driving more than $100 billion. While more anti-obesity drugs are likely to come to market, that added competition may not do much to lower prices.
"GLP-1, clearly, everybody is excited about that," Albert Bourla, the CEO of Pfizer, which is developing its own drug in the class, said at the JP Morgan Healthcare Conference in January. "We think it could be a $10 billion product for us in a market that could be $90 billion."
The drugmakers are also able to charge so much because they know many patients won't be the ones paying the high prices: Insurers will. A spokesperson for Novo Nordisk said in an emailed statement that Wegovy's list price wasn't indicative of what a patient with insurance would pay and that some patients without coverage for the drug may tap the company's discount program to save $500 each month. About 40 million people have some level of coverage for Wegovy, the company says.
Given the high list prices and widespread (but off-base) belief that obesity is totally a person's own fault, most insurers and employers have so far balked at fully covering the drug: Only 22% of employer health plans pay for the drugs, by one estimate. And even insurers that cover Wegovy tend to restrict it to people with the most severe obesity, or require patients to try cheaper — and less-effective — medicine or a lifestyle program first, Chambers said.
Srivastava and other doctors complain, though, that insurers' refusal to pay for the drugs prevents many patients from getting the help they need and loads providers with a mind-numbing amount of paperwork. "It's a constant struggle," Srivastava said.
Medicare to the rescue?
If there is one key that could unlock access to expensive weight-loss drugs for Americans, it's Medicare. Private insurers tend to follow Medicare's lead when it comes to drug coverage, experts say, so it's critical that the government-run program pay for it soon. But as it stands, traditional Medicare is strictly prohibited from paying for weight-loss drugs under a 2003 law that put them in the same category as drugs used for cosmetic purposes, like hair loss. Even so, private Medicare Advantage plans can choose to cover them, as can Medicaid for low-income people. Though Medicaid programs in fewer than 20 states do so.
Expanding Medicare coverage could be a tough sell. A perspective published in March in the New England Journal of Medicine estimated that if just 10% of Medicare beneficiaries were treated with Wegovy, the cost to the program would total $26.8 billion a year — or almost one-fifth of Medicare's prescription-drug-plan spending — and premiums for drug plans would increase.
Even so, Chris Gallagher, a policy consultant for the Obesity Action Coalition, which advocates for obesity treatment, said he's optimistic about legislation such as the Treat and Reduce Obesity Act, which would expand Medicare coverage to medications for obesity treatment. More policymakers have come to understand that obesity is a disease, not a lifestyle problem, he said. And earlier this year, the agency overseeing the health plan for millions of federal employees clarified that it couldn't exclude anti-obesity medications from coverage — a huge step forward that provides a road map for other health plans, he said.
For some doctors, the fact that cost is even a consideration for whether to cover the drug stinks of the stigma around obesity. The conversation "insinuates that obesity is a 'lesser disease' that does not deserve to be treated, and that somehow our society could afford not to treat it," Dr. Dan Azagury, the medical director of the Stanford Lifestyle and Weight Management Clinic, told me in an email, adding: "It's the opposite: Treating the disease early is the best way to save costs to the entire system and have a healthier society."
Patients lose out
Years from now, patients may have an easier time getting their hands on weight-loss drugs. We could see a lower-price generic drug introduced when the brand-name drugs lose their patents. Over time, costs could drop as alternatives emerge, and health plans could remove barriers to access.
We've seen this before with other revolutionary drugs. When hepatitis C treatments were introduced a decade ago, with prices as high as $95,000 for a course of treatment, insurers limited access to only the sickest patients and continued to deny coverage even years later. Prices came down, though, as drugmakers developed alternatives, and some state Medicaid programs removed barriers that prevented patients from getting the drugs.
But the sheer prevalence of obesity could mean that the battle over financial responsibility and how to pay for weight-loss drugs will be intense. Until then, some patients whose health plans won't pay for weight-loss drugs said they're buying them at lower costs in countries including Canada and Mexico. Others have taken the risky step of using a "bootleg" version of the drug, which obesity specialists generally warn against.
Meanwhile, venture-backed telehealth startups racing to capitalize on the demand for weight-loss drugs have pitched themselves as a solution for people looking to lose weight. Some have already drawn criticism for advertising or prescribing the drugs to people who aren't overweight and perhaps contributing to shortages of the drugs.
Srivastava, the Vanderbilt doctor, said she's hopeful that as more clinical data became available on the benefits of GLP-1 medications, insurance coverage for the drugs would improve. For instance, Novo Nordisk is now testing whether taking Wegovy reduces the risk for heart attacks, strokes, and cardiovascular death. If the results are positive, insurers won't be able to ignore them, she said. She predicted that in the future, taking GLP-1 drugs could be as common as taking statins, which hundreds of millions of Americans take to reduce cholesterol and prevent cardiovascular disease.
Dr. Disha Narang, the director of obesity medicine at Northwestern Medicine Lake Forest Hospital, said she's optimistic that access would improve given the big lobbying push to ensure obesity is seen as a chronic disease.
"Unfortunately, the rates of obesity and diabetes are not getting any better, and so what happens then is that our overall national expenditure on these conditions just keeps going up and up and up," Narang said. "Just purely from a finance perspective, this is important. This is exactly why this needs to be addressed — and sooner rather than later."
Shelby Livingston is a healthcare correspondent at Insider.