The struggle for consistent coverage of popular weight-loss medications like Wegovy and Zepbound persists, leaving both patients and healthcare providers in a state of uncertainty. Despite significant demand and favorable public opinion for Medicaid and Medicare to cover these obesity drugs, a clear pathway for widespread insurance coverage remains elusive. The Associated Press Health and Science Department, supported by the Howard Hughes Medical Institute’s Science and Educational Media Group, reports that more than a year after Zepbound entered the market to compete with Wegovy, insurance coverage for these drugs is still inconsistent.
Obesity drug coverage in the U.S. health care system faces numerous challenges. Mercer, a benefits consultant, notes that last year, 44% of U.S. companies with 500 or more employees included obesity drugs in their health plans. However, many employers and insurers are now scaling back coverage. For instance, Independence Blue Cross, a Philadelphia-area insurer, has recently stopped covering obesity drugs solely for weight loss for certain customers.
The high cost of treatment is a significant barrier. Even with discounts, prices for these medications can reach hundreds of dollars monthly, making them unaffordable for many individuals without insurance support. Dr. Amy Rothberg reveals her internal conflict over prescribing these medications due to coverage inconsistencies. She expresses concern over how long patients can maintain their treatment.
“We know from the studies that people go off these medications, they regain their weight,” – Dr. Amy Rothberg
“I don’t want to do harm.” – Dr. Amy Rothberg
The absence of Medicare coverage adds another layer of complexity, especially for those transitioning from employer-sponsored insurance to government-funded programs upon retirement. The former administration under President Joe Biden proposed a rule to expand Medicare and Medicaid coverage for obesity treatments, yet significant legislative progress remains stalled in Congress. At present, more than a dozen state-run Medicaid programs offer coverage for such treatments to low-income individuals.
The situation highlights a broader issue within the healthcare system: the recognition of obesity as a disease without adequate treatment provisions. Dr. Lydia Alexander emphasizes this contradiction:
“We’re saying that obesity is a disease, but we’re not treating it like a disease,” – Dr. Lydia Alexander
Patient experiences further illustrate the impact of coverage lapses. Paul Mack, who lost about 70 pounds on Wegovy, faced a setback when he lost drug coverage for several months, resulting in weight regain.
“Patients come to us terrified about switching to Medicare and losing coverage,” – Dr. Katherine Saunders
Coverage complications are not uncommon in the U.S., where cost concerns and uncertain treatment payoffs influence payer decisions. Many patients find themselves in limbo, navigating an unpredictable insurance landscape that leaves both their health and finances vulnerable.
