Pamela Torres used to run a seven-minute mile. But when the former track star suffered a severe knee injury in college, she began to rapidly gain weight. She was diagnosed with type 2 diabetes in her 30s and obesity in her early 50s. Torres, now age 68, was prescribed Ozempic, a medication approved to treat type 2 diabetes, in January. She lost nearly 20 percent of her body weight. Her joints didn’t ache as much, and her blood sugar returned to healthy levels. “I bought three new pairs of jeans. I wore a sundress for the first time in a decade,” she says. But these gains have been short-lived because Torres no longer qualifies for health insurance coverage of the drug.
Ozempic has become popular for off-label use for weight loss. Its counterpart Wegovy—which contains the same active ingredient, semaglutide, but is specifically approved for chronic weight management—has also gained popularity, as has the off-label use of the diabetes medication Mounjaro for this purpose. Semaglutide has been shown to help people lose an average of about 15 percent of their weight. These popular weight-loss drugs have provided new opportunities for treating obesity, a condition that affects more than 40 percent of adults in the U.S. New findings suggest they also have the potential to lower the risk of heart disease and stroke.
But the availability and price of these drugs are raising important questions about equity and affordability. Most private insurance companies and federal health programs don’t cover weight-loss drugs, and Ozempic, Wegovy and Mounjaro each cost $1,000 or more per month out of pocket. Medicare, the federal health insurance program primarily for people aged 65 and older, has been explicitly forbidden by law from providing coverage for weight-loss treatments since 2003. The ban was implemented in part because of concerns over the safety of weight-loss drugs at the time, such as the combination of fenfluramine and phentermine, or fen-phen, which was associated with life-threatening hypertension and heart valve issues.
Those restrictions could soon be loosened. In August drug manufacturer Novo Nordisk, which makes Ozempic and Wegovy, announced clinical trial findings that indicate semaglutide does more than help people lose weight. In a trial of more than 17,000 people, the drug cut the risk of cardiac complications, such as heart attacks and strokes, by 20 percent. While Novo Nordisk won’t release the trial’s full results until November, the findings have already put pressure on insurance providers to offer coverage for these blockbuster drugs. In July a bipartisan group of congressional lawmakers reintroduced a bill to reauthorize Medicare coverage of weight-loss medications. As of mid-October, progress on that legislation has stalled, but the release of Novo Nordisk’s results could revive it.
Medicare coverage would put antiobesity drugs within reach of many people, including older adults, who can’t otherwise afford them. It could have a multiplier effect because private insurers often follow Medicare’s lead. Even if insurance providers shift their policies, however, there are lingering concerns about whether and how they will restrict coverage for weight-loss medications—and who might be left behind.
Experts are eagerly watching to see if Congress will allow Medicare to cover these highly sought-after medications. “This lines up as a once-in-a-generation event,” says Ethan Weiss, a cardiologist and entrepreneur at the biotechnology company Third Rock Ventures, who studies metabolic disorders such as obesity and diabetes. “What happens next will shape who can access these weight-loss drugs for decades.”
Effective but with Side Effects
Demand for these weight-loss drugs has surged since their debut in the past few years. The medications, designed to be injected once a week, suppress appetite by slowing down the process by which the stomach empties and thus signaling to the body that it feels full. Semaglutide imitates a hormone called glucagon-like peptide-1 (GLP-1), which prompts the body to produce more insulin and makes a person feel satiated.
Torres and others who have taken these drugs report losing constant cravings for food. “I don’t daydream or obsess over eating as much. I’m grabbing smaller plates, and I’m very satisfied with those portions in a way I wasn’t before,” she says.
These drugs are also reshaping the way doctors and the public perceive obesity, a condition historically seen as a problem of willpower. “Now we have the option to treat obesity like we treat any other disease—with medication,” says Shauna Levy, medical director of Tulane University’s Bariatric and Weight Loss Center. She hopes that recent research highlighting the overall health benefits of weight-loss drugs will prompt Medicare and private insurance companies to categorize obesity treatment as necessary rather than cosmetic.
A once-a-week weight-loss drug could be an especially attractive choice for seniors who haven’t had success with lifestyle interventions such as dieting and exercise. More invasive measures such as bariatric surgery often carry higher risks, Levy says.
But more research may be necessary to understand how seniors fare with the semaglutide medications’ potential side effects. These include nausea, fatigue, lightheadedness, decreased muscle mass and, in rare cases, chronic paralysis of the digestive system. Studies show the side effects of such weight-loss drugs tend to be more common and more severe in older adults, and people age 65 and older are more likely to discontinue weight-loss medications because of those effects.
Last October a doctor prescribed Ozempic to Shawna Weber, a 71-year-old resident of Oregon, after diagnosing her with severe obesity. “I didn’t even make it to Christmas,” Weber says of taking the drug. She shed 20 pounds in three months, but severe cramping, nausea and vomiting spells ultimately caused her to stop using the medication.
Still, related GLP-1 medications have been used to treat diabetes for nearly two decades, which has assuaged some physicians’ fears of large-scale safety issues. “You make a risk-benefit calculation when you prescribe any medication,” Weiss says. “But these are not an entirely new type of drug, and there doesn’t appear to be significant lingering safety concerns with them.”
A Hefty Price Tag
Torres discontinued Ozempic after just a few months of use. But her decision was driven by insurance barriers, not side effects or safety concerns. In June Torres’s pharmacy notified her that she wasn’t eligible for Medicare coverage of the medication because she no longer qualified as diabetic. She has since regained most of the weight she initially lost. “I’m just so, so hungry all the time—like it’s mentally and physically gnawing away at me,” she says. “Paying out of pocket isn’t an option. It feels like there’s nowhere else to go from here.”
A national survey by the nonprofit organization KFF found that nearly half of adults expressed interest in taking a safe and effective drug for losing weight, including 59 percent of those who were currently trying to do so. However, that interest dropped to only 16 percent if the drug was not covered by insurance.
The list prices of Ozempic and Wegovy are about $900 and $1,300 per month, respectively. Adding to the cost, people typically need to take the drugs indefinitely to keep weight off. It’s not surprising that federal health programs and private insurers don’t want to cover these drugs, says Alison Sexton Ward, an economist at the University of Southern California, who specializes in drug pricing policies. Yet the initial cost of weight-loss drugs would be partially offset by the long-term health benefits they may provide, such as the decrease in cardiovascular events shown in the new Novo Nordisk trial, Ward says. “When it comes to the math of what Medicare considers in calculating expenditures, you have to subtract the savings that occur with these drugs.”
But these savings may be less likely to persuade insurers, according to David Rind, chief medical officer at the Institute for Clinical and Economic Review, a nonprofit organization that estimates fair prices for the U.S. health system. “Will this create more pressure on insurers to cover these drugs? Maybe,” he says. “But I think the exchange is insurers saying, ‘You’re going to have to pay more for premiums,’ which will turn some people away.” To reduce prices over the long term, Rind says, companies should develop more weight-loss drugs, thereby fostering competition among drug manufacturers.
Other experts worry that paying for expensive weight-loss medications will divert funding away from coverage for other medical treatments. “There are so many spillover effects. If you pay too much for something, other things get displaced,” says Khrysta Baig, a doctoral candidate in the department of health policy at Vanderbilt University. “That’s where there are equity issues we don’t talk about enough.”
In a study published in March in the New England Journal of Medicine, Baig and her colleagues estimated that, even with modest uptake of the medications, the annual cost of brand-name semaglutide weight-loss drugs to Medicare could be $13.6 billion to $26.8 billion. (For reference, total annual spending for Medicare Part D, the program that helps beneficiaries pay for self-administered prescription drugs, is about $98 billion.)
“If drug manufacturers really wanted to make the medication more accessible, they would lower prices. That could also encourage policymakers to come to the table to provide federal health coverage,” Baig says. “If you want to promote equity, put your money where your mouth is.”
Novo Nordisk did not respond to requests for comment about its drug pricing.
If Medicare and private insurers decide to cover weight-loss drugs, they could control rising costs by imposing strict eligibility criteria for treatment reimbursement. Aside from requiring a medical diagnosis of obesity, they might insist on people having other weight-related health issues or restrict the duration of coverage, Rind says. While this approach may prevent those who are healthy but simply feel pressured to lose weight from taking the drugs, it could also bar coverage for people who genuinely need them.
A Way to Narrow or Worsen Racial Disparities?
Obesity is most prevalent among Black and Hispanic adults, who are also the least likely to receive treatment for the condition. Medicare coverage of weight-loss drugs could potentially reduce these disparities. In April Ward and a team of U.S.C. health economists released a white paper demonstrating that broadening coverage for these medications would generate more social and health benefits for Black and Hispanic adults, compared with white adults, across almost all age categories.
Experts are skeptical. They say that even if Medicare shifts its policies to cover such drugs, access to them may follow the familiar pattern of obesity medicine in the U.S. health care system: “We don’t want a situation where only wealthy, white patients can easily access these drugs, and everyone else is left in the dust,” Levy says. Even in Novo Nordisk’s recent clinical trial of more than 17,000 participants, 84 percent were white, and only 3.8 percent were Black.
Compounding the equity issue, Novo Nordisk has faced repeated shortages of Ozempic and Wegovy. The company announced earlier this year that it would cut back on supplying doses of Wegovy for new patients to preserve the medication for those already taking it. These global supply constraints have already left many people with diabetes, who rely on semaglutide, unable to procure their medication. The shortages have also stoked worries about the company’s ability to meet the skyrocketing demand expected if insurers begin to cover these medications.
“If these drugs are in short supply, we need to think proactively about which patients will be able to obtain them at the end of the day,” Baig says. “We need to think about equity at every step—with diagnosis, treatment and prevention—not just with insurance coverage.”