While the availability of sought-after obesity treatments is increasing, obtaining them is still a complex process. Employers and insurers are reducing coverage for drugs like Wegovy and Zepbound, and Medicare does not include them in its coverage for obesity treatment. On the other hand, some major employers are expanding their coverage, but the long-term commitment is uncertain. The high cost of these treatments, which can amount to hundreds of dollars per month even with discounts, poses a financial barrier for many individuals. This situation raises concerns about the accessibility of life-changing weight loss solutions, which may depend on the duration and extent of coverage individuals have.
The U.S. healthcare system is known for its coverage complexities, and the challenges are amplified for obesity treatments due to their potential eligibility for a large segment of the population. Continuous drug use is essential to maintaining weight loss, adding another layer of complication to coverage issues. Katherine Hempstead, a senior policy adviser at the Robert Wood Johnson Foundation, points out the frustration felt by many individuals who are unable to access these medications.
Coverage varies depending on the payer, as illustrated by the experience of Paul Mack, whose weight loss journey was impacted by changes in his Medicaid coverage. While some large employers and Medicaid programs provide coverage for obesity treatments, individual insurance plans and Medicare often do not. Restrictions such as prior authorization requirements further limit access to these drugs, creating uncertainty for individuals transitioning to Medicare from employer-sponsored coverage.
Concerns about costs and efficacy have led some insurers and state programs to discontinue coverage for weight loss drugs. Dr. Katherine Saunders, an obesity expert, highlights the anxiety faced by patients transitioning to Medicare and losing their drug coverage. The decision by Independence Blue Cross to cease coverage for weight loss purposes due to cost implications reflects the financial strain faced by insurers.
The future of coverage for obesity treatments remains uncertain, especially now that the drugs are more widely available. Experts like Stacie Dusetzina from Vanderbilt University question the sustainability of employer coverage in light of increased spending. While drug manufacturers emphasize the potential cost savings associated with these treatments, access barriers and coverage limitations continue to impact individuals seeking help with weight loss.
Enhancing patient health and preventing potential severe medical conditions such as heart attacks or strokes is a crucial goal. However, health care professionals caution that there are no assurances that the employer or insurer providing coverage for a certain medication will ultimately benefit from the positive outcomes due to the possibility of individuals changing jobs or insurance providers. The question arises: will coverage ever achieve consistency? The path towards extensive coverage of obesity medications remains unclear, despite surveys indicating that Americans support the idea of having Medicaid and Medicare cover these costs.
At the pharmaceutical company Zepbound, the makers of Eli Lilly have observed a steady growth in coverage for their medication, fostering optimism for continued progress. The previous administration under President Joe Biden proposed a regulation that would broaden coverage under Medicare and Medicaid, but its future is uncertain under President Donald Trump’s leadership. Meanwhile, a bill advocating for Medicare coverage has circulated in Congress for years without being scheduled for a vote.
Numerous drug manufacturers are currently conducting trials on various obesity treatments, potentially leading to increased competition, reduced prices, and expanded coverage. However, the inconsistent coverage poses challenges to treatment plans, as noted by Dr. Amy Rothberg, who expresses reservations about prescribing medications due to uncertainties regarding patients’ long-term access. Dr. Rothberg, the director of the weight-management program at the University of Michigan, emphasizes the risk of weight regain when patients discontinue the prescribed medications.
Some insurers mandate lifestyle modifications, such as diet and exercise changes, before covering weight-loss medications. Dr. Lydia Alexander, the president of the Obesity Medicine Association, advocates for these changes to be implemented concurrently with starting the medication. She highlights instances where insurers require a body mass index of 40 or higher, indicating severe obesity, before granting coverage. Dr. Alexander emphasizes the discrepancy between recognizing obesity as a disease and the insufficient treatment approach.
The Associated Press Health and Science Department is supported by the Howard Hughes Medical Institute’s Science and Educational Media Group, with sole responsibility for all content resting with the AP.
