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GLP-1 Demand Spotlights Existing Inequities in Obesity Care

By Sojung Yi, MD

Obesity is one of the clearest case studies of health disparities that exist in the U.S., having the biggest impact on Black and Hispanic adults, low-income populations, and people covered by Medicaid, the public health insurance program and safety net for more than 1 in 5 Americans.

The development of GLP-1 medications for weight loss is now rapidly changing conversations about equity in obesity care. With impressive initial clinical outcomes when combined with diet and exercise, as indicated by the FDA, these groundbreaking new drugs have the potential to change millions of lives. However, their current price tag is raising concerns about who can (and cannot) access them.

Existing health disparities in obesity care

While basic services such as preventive screening and counseling are covered by all types of insurance under the Affordable Care Act, coverage for obesity treatment options varies substantially across the country. Bariatric surgery, for example, is widely covered by Medicaid, with 48 states covering some form of care. But only 26 fee-for-service Medicaid programs and 28 managed-care Medicaid programs cover specific nutritional counseling to support modified diets. Additionally, the geographic distribution of obesity management specialists is more concentrated in high-income areas.

Marginalized ethnic and racial communities have historically faced barriers to accessing care in part due to racism and discrimination in health care, stigma, food deserts, and other environmental limitations.

In obesity care as well, Black and Hispanic adults are less likely to receive treatment. When it comes to advanced obesity treatment, such as medications and bariatric surgery, the access gap is even wider. With only 9 states covering anti-obesity medications (AOM) under Medicaid, providers may not reach for AOMs where there is no coverage.

Are GLP-1s widening the equity gap in obesity care?

The Kaiser Family Foundation estimates that coverage for GLP-1s for the Medicare population alone could cost up to $26.8 billion annually.

Although some private insurers cover them for working populations, GLP-1s remain unaffordable for patients covered by Medicaid and Medicare.

One study on GLP-1 access for patients with type 2 diabetes found that Black, Hispanic, and low-income populations are less likely to have used the medication. Even when coverage exists, as it does for type 2 diabetes, GLP-1s are relatively inaccessible for the populations that need them most.

For low-income populations, weight-loss medications have been explicitly excluded from Medicaid coverage. A similar dynamic exists in the Medicare Part D program, even though the prevalence of obesity amongst all Medicare fee-for-service beneficiaries rose from 6.2% in 2010 to 21% in 2019. Under current law, Medicare is prohibited from covering AOM such as GLP-1s for weight loss, though they are covered for diabetes care. What this means is, at this moment in time, the inaccessibility of GLP-1s perpetuates the equity gap in obesity care.

How can we narrow the equity gap?

There have been several legislative and regulatory proposals to cover FDA-approved weight-loss medications. The Treat and Reduce Obesity Act of 2023 was recently introduced in the current Congress. If enacted, it would authorize Medicare to cover prescription medication for treating obesity, including but not limited to GLP1s. However, the price tag of this bill is so high that passage is unlikely.

For people with diabetes, the Inflation Reduction Act of 2022 could help lessen the cost impact of GLP-1 medications on Medicare and Part D enrollee out-of-pocket spending. At the earliest, a negotiated price for semaglutide  may be available for Medicare and Part D enrollees with diabetes by 2027 (based on FDA approval in late 2017) and not before 2031 for tirzepatide (based on FDA approval in 2022). Medicare coverage would represent a significant precedent for private insurance companies to also provide coverage.

The cost barriers do more than limit access to GLP-1s. They also limit our understanding of the drug, and possibly their effectiveness.

Side effects and risk of weight regain are well-documented in adults who have taken GLP-1s, but these studies lack diverse representation. More data from diverse populations is needed to understand whether the side effects and risk of weight regain disproportionately impact low-income populations and Black and Hispanic communities. Limited diversity can result in medications that are less effective or have different side effects for different populations, further emphasizing the disparities in obesity care.

Is equity in obesity care within reach?

Coverage for advanced treatment, such as AOM and bariatric surgery, needs to be expanded. Until the price drops for GLP-1s- through increased insurance coverage, legislative change, availability of generic medications, or some combination of all, it is unlikely that we will see that expansion. And until that point, we will continue to see inequitable access to this type of care. That’s why we need to spotlight reasonable solutions within our reach in the meantime, such as virtual-first care.

Given the FDA’s on-label lifestyle recommendations for GLP-1 usage, and considering the dearth of in-person obesity support in low-income and rural areas, leveraging virtual health tools can be instrumental in expanding access and reducing costs, addressing many of the aforementioned challenges.

It can help people who are medically underserved access opportunities that have disproportionately bypassed them in the past, including personal health coaches and behavior change programs. Virtual-first care can also be personalized with representative staff, culturally sensitive interventions, and contextually tailored approaches.

When content is adapted to the health literacy of a community, sustained results are more attainable.

Increasing access to obesity treatment is only part of the puzzle. To achieve a more equitable approach to obesity care, it is imperative to address disparities in overall access to health care, representation in clinical trials, and the unique cultural and socioeconomic factors that influence the prevalence and management of obesity within low-income and historically marginalized communities. By doing so, we can move closer to a more just and comprehensive approach to obesity care for all.

This Proof Points edition was originally published on LinkedIn on 12/18/23.