Insurance coverage and type of employment shape inequities in access to semaglutide

Developed initially to manage diabetes, glucagon-like peptide-1 (GLP-1) receptor agonists have skyrocketed in popularity since the US Food & Drug Administration first approved semaglutide (brand name Ozempic/Wegovy) for weight loss in 2021. Approval of tirzepatide (brand name Mounjaro/Zepbound), an even more efficacious medication, soon followed in 2023.

Despite soaring use among celebrities and the public alike, not everyone who can benefit from anti-obesity medications has access to these novel drugs, according to a new study led by Boston University School of Public Health (BUSPH) researchers.

Published in JAMA Network Open, the study found disparities in access to semaglutide. Rates of obtaining a prescription for semaglutide varied widely based on an individual’s insurance plan and type, as well as their job industry, sex, and use of other medications.

Among commercially insured, non-diabetic individuals with obesity, people who identified as female, received point-of-service or preferred provider organization insurance coverage, and took medications such as antidepressants or thyroid or hormone medications were more likely to begin taking semaglutide compared to people who identified as males, or those who were covered by health management organization or exclusive provider organization plans

Individuals employed in certain industries, such as the financial and real estate sectors, were also more likely to be prescribed semaglutide compared to people in other jobs, such as retail.

The findings shed light on the barriers that people with obesity experience in accessing weight-loss treatment in a health care system that often views obesity as a risk factor for other diseases that should be managed through lifestyle changes alone. While obesity can lead to other conditions, it is also an independent disease worthy of pharmacological interventions, even when it affects nondiabetic people who may otherwise be characterized as metabolically healthy, the researchers say.

“The paradigm for treating people with obesity has often been to recommend lifestyle changes, and then if they develop diabetes or another metabolic condition, to treat them with metformin, insulin, or GLP-1 drugs,” says study senior and corresponding author Andrew Stokes, associate professor of global health at BUSPH.

“However, emerging evidence suggests that due to biological resistance to weight loss and systemic external barriers, achieving sustainable lifestyle change can be challenging. The care paradigm is starting to shift, with the understanding that it’s beneficial to treat metabolic health conditions before they progress to an advanced stage.”

The team hopes this new data can help physicians better understand and identify patients who are less likely to access obesity treatment, with challenges ranging from difficulty in obtaining care from obesity medicine practitioners to lack of formulary coverage for weight-management medications.

Currently, only 1 in 4 employers offer insurance coverage for GLP-1 drugs for weight management—with variability in ease of access, due to step therapy and prior authorization requirements—while the majority of employers do cover this class of medications for diabetes.

The study can inform policy changes that expand insurance coverage for GLP-1 drugs across a wider range of insurance plans, employment industries, income levels, sex, and other factors.

“The substantial barriers to access to GLP-1s reflect existing inequities and poor alignment of incentives in our health care system,” says study co-author Katherine Hempstead, senior policy officer at the Robert Wood Johnson Foundation. “Research is needed to help illustrate the size and nature of access gaps so that we can design better coverage policies.”

Ultimately, “there is a need for policymakers to recognize that factors unrelated to whether an individual has a medical necessity for treatment can affect whether or not a person is likely to receive these medications,” says study lead author Meghan Podolsky, research fellow in the Department of Global Health at BUSPH.

“Increasing access will require addressing the significant barriers to care, such as treatment cost, site of care, and the policies that insurance plans can implement, such as step therapy and prior authorizations.”

For the study, the team used national insurance claims data for more than 97,000 commercially insured US adults diagnosed with obesity, but not diabetes, between June 2021 and July 2022. They used a machine learning model to identify the sociodemographic, clinical, and health care factors associated with being prescribed semaglutide, and then quantified the impact of the most important factors.

In addition to insurance type and employment industry, they found that semaglutide initiation was substantially higher among Americans who lived in the northeast region, as well as those who were taking antidepressants, thyroid or hormone medications, and amphetamines.

Participants with the highest body mass index (BMI) values (40 or above) were most likely to access semaglutide, which is not surprising given that this group has the highest risk for developing further metabolic disease.

However, Podolsky says it reflects a trend that physicians may be restricting GLP-1 drugs to patients with the highest weight, and solely recommending lifestyle interventions to patients with BMI values of 35 or less. This approach contradicts the FDA’s approval of the medication for people with BMIs of 30 or higher, or 27 or higher with a comorbidity. These individuals could also benefit from GLP-1 medications, but may face additional challenges in accessing them.

The team will continue studying inequities in GLP-1 access for diabetic and non-diabetic populations, including potential differences according to socioeconomic status, race and ethnicity, and Medicare and Medicaid coverage. Medicare currently only covers GLP-1 drugs for diabetic and cardiovascular treatment, while Medicaid provides limited coverage in certain states.

After criticizing GLP-1 drugs, US health secretary nominee Robert F. Kennedy, Jr. recently suggested that these treatments “have a place” in the health care system, but whether and how access to these medications will change under the second Trump administration remains in the balance.

The study was coauthored by Rafeya Raquib, research fellow in the Department of Global Health at BUSPH; Paul Shafer, assistant professor of health law, policy & management at BUSPH; and Randall Ellis, professor of economics at Boston University College of Arts & Sciences.

Developed initially to manage diabetes, glucagon-like peptide-1 (GLP-1) receptor agonists have skyrocketed in popularity since the US Food & Drug Administration first approved semaglutide (brand name Ozempic/Wegovy) for weight loss in 2021. Approval of tirzepatide (brand name Mounjaro/Zepbound), an even more efficacious medication, soon followed in 2023.

Despite soaring use among celebrities and the public alike, not everyone who can benefit from anti-obesity medications has access to these novel drugs, according to a new study led by Boston University School of Public Health (BUSPH) researchers.

Published in JAMA Network Open, the study found disparities in access to semaglutide. Rates of obtaining a prescription for semaglutide varied widely based on an individual’s insurance plan and type, as well as their job industry, sex, and use of other medications.

Among commercially insured, non-diabetic individuals with obesity, people who identified as female, received point-of-service or preferred provider organization insurance coverage, and took medications such as antidepressants or thyroid or hormone medications were more likely to begin taking semaglutide compared to people who identified as males, or those who were covered by health management organization or exclusive provider organization plans

Individuals employed in certain industries, such as the financial and real estate sectors, were also more likely to be prescribed semaglutide compared to people in other jobs, such as retail.

The findings shed light on the barriers that people with obesity experience in accessing weight-loss treatment in a health care system that often views obesity as a risk factor for other diseases that should be managed through lifestyle changes alone. While obesity can lead to other conditions, it is also an independent disease worthy of pharmacological interventions, even when it affects nondiabetic people who may otherwise be characterized as metabolically healthy, the researchers say.

“The paradigm for treating people with obesity has often been to recommend lifestyle changes, and then if they develop diabetes or another metabolic condition, to treat them with metformin, insulin, or GLP-1 drugs,” says study senior and corresponding author Andrew Stokes, associate professor of global health at BUSPH.

“However, emerging evidence suggests that due to biological resistance to weight loss and systemic external barriers, achieving sustainable lifestyle change can be challenging. The care paradigm is starting to shift, with the understanding that it’s beneficial to treat metabolic health conditions before they progress to an advanced stage.”

The team hopes this new data can help physicians better understand and identify patients who are less likely to access obesity treatment, with challenges ranging from difficulty in obtaining care from obesity medicine practitioners to lack of formulary coverage for weight-management medications.

Currently, only 1 in 4 employers offer insurance coverage for GLP-1 drugs for weight management—with variability in ease of access, due to step therapy and prior authorization requirements—while the majority of employers do cover this class of medications for diabetes.

The study can inform policy changes that expand insurance coverage for GLP-1 drugs across a wider range of insurance plans, employment industries, income levels, sex, and other factors.

“The substantial barriers to access to GLP-1s reflect existing inequities and poor alignment of incentives in our health care system,” says study co-author Katherine Hempstead, senior policy officer at the Robert Wood Johnson Foundation. “Research is needed to help illustrate the size and nature of access gaps so that we can design better coverage policies.”

Ultimately, “there is a need for policymakers to recognize that factors unrelated to whether an individual has a medical necessity for treatment can affect whether or not a person is likely to receive these medications,” says study lead author Meghan Podolsky, research fellow in the Department of Global Health at BUSPH.

“Increasing access will require addressing the significant barriers to care, such as treatment cost, site of care, and the policies that insurance plans can implement, such as step therapy and prior authorizations.”

For the study, the team used national insurance claims data for more than 97,000 commercially insured US adults diagnosed with obesity, but not diabetes, between June 2021 and July 2022. They used a machine learning model to identify the sociodemographic, clinical, and health care factors associated with being prescribed semaglutide, and then quantified the impact of the most important factors.

In addition to insurance type and employment industry, they found that semaglutide initiation was substantially higher among Americans who lived in the northeast region, as well as those who were taking antidepressants, thyroid or hormone medications, and amphetamines.

Participants with the highest body mass index (BMI) values (40 or above) were most likely to access semaglutide, which is not surprising given that this group has the highest risk for developing further metabolic disease.

However, Podolsky says it reflects a trend that physicians may be restricting GLP-1 drugs to patients with the highest weight, and solely recommending lifestyle interventions to patients with BMI values of 35 or less. This approach contradicts the FDA’s approval of the medication for people with BMIs of 30 or higher, or 27 or higher with a comorbidity. These individuals could also benefit from GLP-1 medications, but may face additional challenges in accessing them.

The team will continue studying inequities in GLP-1 access for diabetic and non-diabetic populations, including potential differences according to socioeconomic status, race and ethnicity, and Medicare and Medicaid coverage. Medicare currently only covers GLP-1 drugs for diabetic and cardiovascular treatment, while Medicaid provides limited coverage in certain states.

After criticizing GLP-1 drugs, US health secretary nominee Robert F. Kennedy, Jr. recently suggested that these treatments “have a place” in the health care system, but whether and how access to these medications will change under the second Trump administration remains in the balance.

The study was coauthored by Rafeya Raquib, research fellow in the Department of Global Health at BUSPH; Paul Shafer, assistant professor of health law, policy & management at BUSPH; and Randall Ellis, professor of economics at Boston University College of Arts & Sciences.