Joanna Bailey, a family doctor and obesity specialist, said she doesn't want to tell her patients they can't take Wegoby, but they've gotten used to it.
About a quarter of the patients she sees at her small Wyoming County clinic would benefit from weight-loss drugs called GLP-1s, which include Ozempic, Zepbound and Maunjaro, she says. Some have lost 15 to 20 percent of their body weight with the help of the drugs. But most people in her community don't have insurance, and few can afford the $1,000 to $1,400 a month list price.
“Even the wealthiest of my patients can't afford it,” Dr. Bailey said, noting what many doctors in West Virginia, one of the poorest states in the country with the highest obesity rate at 41 percent, say: “We've separated the haves from the have-nots.”
The disparities were exacerbated in March when the West Virginia Public Employees Insurance Agency, which pays most of the prescription drug costs for more than 75,000 teachers, city workers and other public employees and their families, dropped a pilot program to cover weight-loss drugs.
While some private insurers subsidize the cost of obesity drugs, most Medicaid programs only cover diabetes management, and Medicare covers Wegovy and Zepbound only when prescribed to treat heart disease.
Over the past year, states have been exploring how far they can extend coverage to public employees as demand rises. Connecticut plans to spend more than $35 million this year through a limited weight-loss coverage initiative. In January, North Carolina said it would stop paying for weight-loss drugs after spending $100 million in 2023, which represents 10% of its spending on prescription drugs.
The problem isn't limited to public programs: Blue Cross Blue Shield of Michigan, the state's largest insurer, paid $350 million for weight-loss drugs in 2023, one-fifth of its prescription drug spending. The company announced earlier this month that it would remove coverage for the drugs from most private insurance plans.
West Virginia's public employee program was limited to just over 1,000 employees, but at its peak, it was costing about $1.3 million a month, even with manufacturer rebates, according to VA Director Brian Cunningham. If it were expanded to 10,000 people as planned, Cunningham said, the program would cost $150 million a year, more than 40 percent of current prescription drug spending, and could lead to significant increases in premiums.
“I haven't had sleepless nights since I made the decision,” he said, “but I have a fiduciary responsibility and that's my No. 1 responsibility.”
But the decision was infuriating to Dr. Bailey and other obesity specialists in the state, who said it showed a lack of understanding that obesity is medically classified as a “complex disorder,” in the same category as depression and diabetes.
Laura Davison, director of the weight-management program at West Virginia University Health System, found that patients at her clinic who took obesity medications lost 15 percent more weight than those who relied only on diet and exercise. Drug coverage in state programs like Medicaid is controlled by local lawmakers, and Dr. Davison has lobbied in recent months to keep the public health agency's pilot program alive and to expand coverage of weight-loss drugs more broadly, but without much progress.
“It's pretty much the same for everyone,” she says. “They say, 'I want to treat obesity. I want to help people. It's just too expensive.' But you can't not treat cancer because it's too expensive. Why can't you do that with obesity?”
Christina Morgan, a political science professor at West Virginia University, started taking Zepbound in December as part of a state pilot program for the drug's obesity treatment. By March, she had lost 30 pounds, and her blood pressure and blood sugar had dropped. When she heard the news that the program was being canceled, she was devastated.
“To be honest, I can't afford to pay for it out of my own pocket. It's just not realistic,” she said.
Her doctor warned her about regaining the weight and explored her options before her drug coverage expired in July. There were few options. “She said, 'Listen, I don't want you to get diabetes, but if you do, you can take this medication,'” Dr. Morgan said. “It's unbelievable. They want you to get sicker so they can take this medication.”
In a sense, the fight over access to weight-loss drugs pits doctors, patients, health advocacy groups and drug companies against employers and government health insurance programs.
Novo Nordisk, which sells Ozempic and Wegovi, and Eli Lilly, which sells Zepbound and Maunjaro, are among the biggest donors to America's largest obesity advocacy groups and frequent speakers at medical conferences. Most manufacturers address weight stigma on their websites and present their products as a way to change, in Novo Nordisk's words, “how the world perceives, prevents and treats obesity.” And over the past few years, they've been able to do that, to some extent.
But while Novo Nordisk and Eli Lilly distribute coupons to privately insured patients and provide generous rebates to employers and government programs that cover the drugs, the costs remain enormous for West Virginia's health care system and most patients, meaning social justice declarations from two companies with market capitalizations of more than $1 trillion may ring hollow, Cunningham said.
Levi Hall, a pharmacist at Rhonda's Pineville Pharmacy in Wyoming County, often turns away patients who bring in prescriptions because of a lack of supply or the exorbitant cost. “It's like the Geico commercial, with the guy with the dollar bill on the string and he keeps tugging at it when you get close,” Hall said. “You just can't get it.”
Cunningham is also concerned about the potential long-term side effects of the drugs, which are still unknown, and he noted that West Virginia has good reason to distrust big pharma: The state is at the epicenter of the national opioid epidemic, with some of the highest rates of opioid overdoses and prescription painkillers in the country. It began in the mid-1990s, when Purdue Pharma sold OxyContin to areas with high rates of disability to treat a silent “painkilling epidemic.”
“The drug companies have been very successful in inventing lies, creating a coalition of well-meaning nonprofits, and pressuring doctors to prescribe these drugs,” Cunningham said of the obesity drugs.
Molly Cecil, an obesity specialist in Lewis County, West Virginia, acknowledges the skepticism and says her patients sometimes voice a distrust of big pharma. But she argues that drugs like Ozempic and Wegobee are fundamentally different from prescription opioids like OxyContin, which have been on the market for nearly 20 years, are highly effective and non-addictive. “Obesity is not a silent epidemic,” she adds. “It's a very real epidemic.”
She continued: “So I wonder if some people have issues with anti-obesity drugs, unlike with other illnesses. Why do people question best practices and guidelines for obesity because of industry involvement, but not other areas of medicine that are similarly involved?”
Cecil said the medicine is desperately needed, especially in West Virginia, where healthy foods are expensive and hard to obtain, and eating habits are often passed down through generations, increasing the risk of obesity, diabetes, fatty liver disease and stroke.
“These are really effective treatments that can make a difference in people's lives here,” she said, “but they may as well never have been developed in the first place.”
