Employer Health Insurance Coverage Dropping Weight-Loss Drugs Like They're Carbs
It's hard to describe America's weight problem without sounding like a crass standup comedian from the early 1980s. Over 42% of American adults are obese. Some 25% of people between the ages of 17 to 24 are too heavy to join the military. Obesity and obesity-related illnesses cost the healthcare system $173 billion per year before you factor in the costs associated with the increased incidences of type 2 diabetes, cognitive impairment, reduced lifespans, and reduction in productive working years. It's a mess.
We aren't going to waste time here talking about why obesity rates have skyrocketed from 13% in 1960 to 42% in 2023. There are almost as many contributing factors as there are fitness gurus, weight loss plans, diet pills, specialized meal plans, supplements, workout routines, and all the other goods and services that comprise the $299 billion weight loss industry.
None of this is news to most Americans. We all know we have a big and growing problem. What is news, however, is the emergence of a real-deal, honest to goodness weight loss drug … one that insurers don't want to cover.
It's Real(ly Expensive)
Their formal names are semaglutide and liraglutide, though you may know them by their street names: Ozempic, Wegovy, Victoza, or Saxenda. They belong to a family of drugs called glucagon-like peptide-1 receptor agonists, or GLP-1 drugs. Though the drugs were intended to help diabetes patients control their blood sugar, one of their side effects has garnered the most attention: rapid and sustained weight loss.
That's right, the data shows that semaglutide and liraglutide-based drugs can help people lose upwards of 15% of their body weight over a one-year period. Just one injection per week (for the rest of your life) and you, too, can finally shed those unwelcome pounds in a relative hurry.
There's just one (dozen) problem(s) with the drugs. The first, and most obvious, is that they're expensive. Bloomberg Intelligence estimates that the drugs can cost $17,500 over a 32-week period — which equates to $546.87 per week, or $28,437.50 per year — in 2023, making them some of the pricier medications on the market.
Surprise! Insurers DO Care About Money
To the surprise of absolutely no one, health insurers have been kicking GLP-1 drugs off of their “approved" lists as quickly as they can. The drugs are expensive, popular, and could help almost every American feel better and get healthier, so of course insurers want nothing to do with them. It's especially tempting for insurers if the population thinks that obesity is more of a cosmetic concern than an actual health issue.
That's not true — we've already touched on the amount of money obesity and obesity related issues cost the health system and the country as a whole — but of course insurers are concerned with current expenses. And this would be the end of the story, but health insurers are running into an obstacle that they neither have nor foresaw: the human heart.
Uh Oh, It's Medicine
At least one recent study has complicated things for health insurers. According to the study, obese or overweight people who had a history of heart problems were 20% less likely to suffer a cardiovascular event when taking Wegovy compared to those who took a placebo over the course of the study. Heart problems are some of the biggest killers in the U.S.
It may soon become much harder for health insurers to refuse to cover medicine with real, tangible heart benefits than it is to refuse to cover weight loss treatments. So, does that mean that your employer health plan will start or continue to cover Wegovy and other GLP-1 drugs? Will employers see an increase in costs by a need to cover these drugs? If denied coverage for a prescription for Ozempic to reduce the risk of heart disease, will more employees have legal recourse?
Only time will tell.
- What to Do if Your Health Insurance Claim is Denied (FindLaw's Learn About the Law)
- Obamacare Basics: What is the Affordable Care Act? (FindLaw's Learn About the Law)
- Healthcare Law (FindLaw's Learn About the Law)
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