Who Gets Wegovy? (Hint: Not Always Those Who Need it Most)

Who Gets Wegovy? (Hint: Not Always Those Who Need it Most)

At first, Cindy Martinez was elated. After decades of living with obesity, a simple, once-weekly shot of semaglutide helped her drop 20 pounds in only a few months “without feeling like I was starving all the time.” The result was less back pain, hope for her prediabetes, and  freedom from the incessant food cravings that had dogged the 48-year-old for much of her adult life. 

After so many previous failed attempts, losing weight without feeling miserable felt like a gift, she says. 

Semaglutide is better known as the active ingredient in a number of brand-name drugs (Ozempic, Rybelsus, and Wegovy). Sometimes called GLP-1 agonists, doctors use these medications at different doses to treat various health conditions, including obesity and type 2 diabetes.

Research shows people with overweight or obesity can lower their weight by 12% to 15% with certain doses of semaglutide. The drug acts on brain signals, which seems to be why many people feel full faster and with less food while they take it. Some people, including Martinez, report that these medications quiet “food noise,” or constant thoughts about eating that fuel excess snacking. 

 Martinez had received the drug for free as part of a clinical trial in the fall of 2022. Once the trial ended (she got her last shot in January), her doctor prescribed the medication. Even though other weight management drugs hadn’t worked very well for Martinez, insurance wouldn’t pay for semaglutide. 

Her health insurer essentially made her feel like she wasn’t sick enough, says Martinez. Obesity wasn’t enough. Prediabetes wasn’t enough. If she developed type 2 diabetes one day, insurance might consider helping out with the costs. 

For now,  she would be left with the full bill if she wanted to take the drug, which, at $1,000 to $1,500 a month, she simply couldn’t afford. She was livid. 

“My dad is a diabetic, and I know how diabetes affects a person’s life,” says Martinez, whose late mother also had the disease. “Why would they let me or anyone else get to that point when we could prevent it?  Why cut somebody’s leg off when we can save it? Let’s not let it get there.”

Not getting coverage for semaglutide drugs is a common problem, says Jorge Moreno, MD, the Yale Medicine obesity specialist who treats Martinez. A doctor’s prescription for obesity and prediabetes often is not enough to get insurance to consider the drug medically necessary. 

“Usually we have to wait for them to get diabetes,” Moreno says, “which is crazy, right?” 

“Treating obesity has a cascading effect on multiple fronts,” he says, as it often helps lower the risk for heart disease, stroke, high blood pressure, and atherosclerosis, among other conditions. 

Research shows that just a 5% to 10% reduction in excess body weight can help with blood pressure, cholesterol, blood sugar control, quality of life, depression, mobility, sexual dysfunction, and urinary incontinence.

And yet many private health insurers and government-sponsored plans like Medicare don’t cover weight loss drugs at all when used for obesity alone. In most states, access through Medicaid is far from guaranteed or affordable for people with low incomes. And it’s not just medications. Other useful treatments like diet and exercise counseling are also rarely covered.

Moreno takes a broad approach to obesity treatment. “You can’t just give someone a pill” to treat obesity, he says. He supports an approach that may include medications, lifestyle changes, and sometimes bariatric surgery. 

“So much goes into it,” Moreno says. “But I do think that increasing access to medications will definitely help with this condition [obesity] that’s so prevalent.”

Why aren’t insurers required to cover weight loss treatments the same as other medical conditions?

“Our health care system, in part due to bias and stigma, still does not completely acknowledge obesity as a disease that requires long-term comprehensive management,” Moreno says.

This lack of access can be frustrating for everyone, but may take a greater toll on certain historically marginalized groups and people of color – people like Martinez, who is Hispanic of Puerto Rican descent. 

There are a number of reasons for this, says Veronica Johnson, MD, an obesity medicine specialist at Northwestern Medicine. (Johnson has consulted with Novo Nordisk, the U.S. producer of semaglutide.) 

The highest rates of obesity by group are in people who are Black, Hispanic, Native American, Alaska Native, and Pacific Islander. Black and Hispanic adults are more likely to have severe obesity and to develop diabetes, high blood pressure, heart attack, and stroke, compared to other groups, Johnson says. Black women are the most likely out of any group to have obesity, and Black men are the most likely to die from obesity-related illnesses. 

These groups are also more likely to be uninsured or face financial hurdles that bar access to quality obesity care. (A lack of native English skills can also be a barrier.) 

There’s already evidence that people who are Black, Hispanic, and low-income are less likely to get semaglutide drugs for type 2 diabetes, compared to more advantaged groups. (There is less evidence on semaglutide access disparities for treating obesity alone, says Johnson, but the data hasn’t been gathered yet.) 

In her practice, Johnson sees that people with excess weight or obesity who can afford to pay thousands of dollars out of pocket for drugs like Wegovy are the most likely to continue taking them and potentially see long-term benefits. 

Most people who seek weight management care from Johnson, she says, are postmenopausal women, usually White. 

“Yet, the people who would benefit the most from it are denied the medication and are left struggling with all the other things that go along with having excess weight,” she  says. “And it’s just frustrating to see it every day and not be able to help them to the best of my ability.”

Society at large still views obesity as a lack of willpower or a lifestyle choice, not a chronic disease like diabetes or high blood pressure that should be treated with medications. But that may be starting to change, says Jamy Ard, MD, a professor of epidemiology and prevention at Wake Forest University School of Medicine who works with The Obesity Society. (Ard has consulted with Novo Nordisk, the U.S. producer of semaglutide.)

“As the newer drugs come online and continue to demonstrate the ability to save lives, that puts a lot of pressure on insurers,” he says. The question, according to Ard, becomes: “Why are you still denying something that has shown a benefit in terms of cardiovascular risk reduction?” 

Without semaglutide, within 6 months, Martinez regained all the weight she had lost during the clinical trial. She says she might even be heavier than when she started the study, but she’s stopped getting on the scale because it’s too depressing to find out. Her back pain and constant hunger pangs have also returned, and she worries that her prediabetes will worsen.

Martinez hasn’t stopped fighting for treatment. She told her boss she can’t believe semaglutide isn’t covered and that should change. As a result, her employer says they’ll try to find an insurance plan that covers Wegovy for prediabetes and obesity. “But that’s not until the end of the year,” she says. 

For now, she’s working with her doctor to control her prediabetes. She’s taking another kind of medication and still trying to exercise more and eat less. But excess weight presses on her hernia and hurts the compressed nerve in her spine, which makes physical activity  a lot harder. 

“People say losing weight is easy to do without medication,” Martinez says. “But they’re wrong because I’ve already tried to do it. What do I have to turn to when nothing else works? What do I have left?” 

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