dr Deborah Horn wants to provide her obese patients with the best possible care. But too often, the conversation at appointments isn’t focused on choosing the best treatment options, which sometimes include anti-obesity drugs.
Instead, the conversations focus on costs and insurance coverage.
“When we sit in front of a patient and think about how best to help that patient, and if medication is the best way, health insurance should really be the last thing on our mind,” says Horn, medical director of UTHealth Houston Center for Obesity Medicine and Metabolic Performance. “Unfortunately, the coverage with the status of access will be the first thing there.”
Over 40% of adults in the United States are obese, which the Centers for Disease Control and Prevention defines as having a body mass index of 30 or greater. While body mass index is not an indicator of health, obesity has been linked to heart disease, stroke, type 2 diabetes and certain types of cancer.
A man prepares Semaglutide Ozempic injection to control blood sugar STOCK IMAGE/Getty Images
Newer anti-obesity drugs such as semaglutide (the active ingredient in Wegovy and the diabetes drug Ozempic) can be very effective for people with obesity. But analysis and reports show that drugs used for weight loss are often not covered by Medicare, most Medicaid programs and some commercial insurance, limiting access to the drugs — which is a $1,300 out-of-pocket monthly supply can cost.
“When patients get Medicare or Medicaid, the conversation turns to what patients can handle financially for themselves,” says Horn. “It’s a frustrating conversation for patients.”
As talks continue about Semaglutide and other similar drugs, Impact x Nightline examines issues surrounding the drugs and the impact they are having on patients struggling with weight loss in an episode now streaming on Hulu.
Medicaid coverage for anti-obesity drugs varies from state to state. “States have the option, but are not required, to adopt weight-loss drugs,” a spokesman for the Centers for Medicare & Medicaid Services said in an email to ABC News.
The coverage does not map accurately to obesity rates across the states.
“Louisiana, for example, has a pretty high obesity rate, they cover anti-obesity drugs in their Medicaid program,” says Timothy Waidmann, senior fellow in the Health Policy Center at the Urban Institute and author of the Obesity across America report. Colorado’s Medicaid program doesn’t cover these types of drugs, and they have the second-lowest obesity rate in the United States, according to America’s Health Rankings.
While Medicare doesn’t cover these types of medications, beneficiaries enrolled in Medicare Advantage plans can have the medications covered.
However, this leaves a majority of Medicare members without coverage for these types of drugs, forcing them to pay or forgo large out-of-pocket expenses.
The coverage gaps could deepen economic and racial disparities related to obesity, experts say. Patients who can afford to pay for the drug out of pocket have access to treatment.
“The biggest fight we have in the clinic is justice in nursing,” says Horn.
Horn, other experts and organizations working on obesity are urging Congress to pass the Obesity Treatment and Reduction Act, which would (among other things) expand coverage of anti-obesity drugs for people on Medicare.
Danish pharmaceutical company Novo Nordisk’s antidiabetic drug ‘Ozempic’ (semaglutide) is in this photo taken on February 23, 2023. Joel Saget/AFP via Getty Images
Right now, coverage for anti-obesity drugs from commercial insurance plans is mixed and often varies from employer to employer, Horn says. But if Medicare takes over the drugs, other plans would likely follow, she says. “If we can get Medicare to pick up the drugs, nobody wants to be worse than Medicare,” she says.
The success rates of the newer drugs like Semaglutide and the new awareness surrounding them could help move the needle and drive more commercial insurance and Medicaid programs to cover the drugs, experts say.
“I think by and large the popularity will only help increase the number of states offering coverage,” says Waidmann.
Older anti-obesity drugs weren’t nearly as effective at weight loss as semaglutide and the other newer compounds, like tirzepatide (the active ingredient in the diabetes drug Mounjaro), says Horn. They result in about the same weight loss as bariatric surgery — which Medicare and most Medicaid programs cover.
“They closed the gap,” says Horn. “We have drugs that are as effective or nearly as effective as surgery. Patients should have a choice.”
But for now, patients who could benefit from these drugs are in a bind. Horn says she has a patient who lost over 100 pounds on semaglutide, but his insurance recently changed and the drug will no longer be covered.
“He’s sitting at home thinking, ‘What’s going to happen next?’ He knows his physiology,” says Horn. “You have the feeling that your hands are tied.”
