Obesity is highly correlated with other medical conditions, from cancer to diabetes to heart disease. I wonder if there is a point at which it is cheaper for health insurance companies to offer subsidized or even free GLP-1s to patients than pay out for other specialized medications. For example, my insurance covers flu shots in my community every year because it's presumably less expensive to pay for the shots compared to the increased rate of hospitalization that the flu causes.
You’re thinking too highly about the incentives of the US healthcare system. Since insurance is tied to your employer (and therefore changing every few years), and most people die on Medicare, there’s not much incentive for insurance companies to pay for preventative care that won’t actually help you for several decades.
Actually from what I have heard, GLP-1 are maybe the first category of drugs which have impact within the median tenure of people on a medical plan (~2 years). It is so significant that you can see ROI within that window which justifies in subsidizing/encouraging patients to use it.
Doesn't disagree with your original claim that there is low incentive for any private insurance to care regarding longevity, but figured I could add some color
hmm...doesn't this possibly incentivize ozempic subsidies even more?
If you know a "customer" of yours (an individual employee) is only going to be with you until they either change jobs or go on Medicare, then it seems the name of the game then is to make sure that nothing catastrophic happens to them until you can hand them off to someone else.
In which case, they should definitely go on ozempic. Even if the effects of ozempic immediately come off after usage, it's a short-term enough solution that benefits the insurance company, no?
Yes. For very high risk patients, payers do want this. I’ve even heard of some paying pharmacies $100/fill if done on time for select people.
The problem is, prediabetic and folks who may have crossed 7.0 A1C once, and just overweight folks with docs who are willing to play fast and loose are demanding it. Skipping metformin and other first line treatment options that are way cheaper. For those folks, complications might be the next guys problem.
If you were guaranteed 5% over the total cost of the medical services provided as profit, would you want people to have expensive or cheap medical. Are?
The health insurance companies are paid as a percentage of the amount of care that flows through them. So healthier customers means their profit is 5% of SMALLER_NUMBER.
> So healthier customers means their profit is 5% of SMALLER_NUMBER.
I don't think this is completely true right? Rather, it's more accurate to say that customers that are seen as healthier get to pay less premiums, but customers that are seen as unhealthy have to pay more.
In both scenarios, you, as the insurance company, still want to be minimizing the amount of care you actually pay for.
In other words, to maximize profits, it seems like the best customer is one that's high risk (high premiums), but less likely to require a catastrophic payout. In which case, it feels like an obese high risk patient on ozempic seems like a pretty solid deal.
My understanding is that under ACA their profit is capped and if they don't pay out they have to issue rebates:
> In the simplest terms, the 80/20 rule requires that insurance companies spend at least 80 percent of the premiums they collect on medical claims, effectively capping their profit margins. If insurers fall under this threshold, they must rebate the difference to policyholders.
So that would mean that the only way to increase the profit is to reduce over head and keep more of the 20% or increase the amount of claims. Paying out less in claims would mean they have to give rebates back to the customers.
As with everything health care related I'm sure it's more complicated than that and I'm missing something. For instance my health care plan is through my employer so everyone pays the same premium and the provider doesn't get to set it based on how healthy each employee is (although certainly the whole group is negotiated when the contract comes up for renewal).
> You’re thinking too highly about the incentives of the US healthcare system. Since insurance is tied to your employer (and therefore changing every few years)
Most people don’t change jobs or insurance companies every few years. When they do, it’s often within similar regions and industries so the chances of ending up right back under the same insurance company are significant.
Regardless, the issue is more complicated than your line of thinking. Insurance companies have very small profit margins. Current GLP-1 drugs are expensive, around $1,000 per month.
So each patient on GLP-1 drugs costs an extra $12K per year (roughly) or $120K per decade. That would have to offset a lot of other expenditures to break even from a pure cost perspective, which isn’t supported by the math. So the only alternative would be to raise everyone’s rates.
I know the insurance industry is the favorite target for explaining everything people dislike about healthcare right now, but at the end of the day they can’t conjure money out of nothing to cover everything at any cost demanded by drug makers. These drugs are super expensive and honestly it’s kind of amazing that so many people are getting them covered at all.
I haven't changed jobs and I've had three different health insurance companies in as many years, all of which needed new prior auths for Trulicity/Mounjaro.
A night in the hospital is easily $12k almost anywhere in the U.S.
People with chronic health conditions spend an inordinate amount of time at the doctor and in hospitals. That could save a significant amount of money if that’s reduced or eliminated. Not to mention the time savings.
I could be wrong, but all things being equal doesn’t it make sense to spend $12k/year on medication than $12/year on doctor and specialist visits in addition to medication?
A one off anecdote here - I ended up in hospital for a TIA. I'm in Australia, and this is a public hospital. Free in other words. I have never seen so many seriously obese people in my life. They were all occupying hospital beds. I swear at least half the beds were use occupied by them. Meanwhile, we have ambulance lining the ramps of hospitals, with patients in them, waiting for bed to become free.
To put the this in perspective, where I live spends about $10,000/yr/person on health. That's all kinds of health. I'm not sure $5,000/yr (which is about the price here) of GLP-1 would be a generate proportionate decline, but I would not write it off. The $10K is paid by everybody, the $5k would only be for the obese.
This misunderstands how employer-provided insurance works for most people. Large employers sign up with a company like Cigna to provide a network and administrative process. But the actual healthcare is covered by the employer. So really, Cigna or BCBS don't really give a rip if you're taking a bunch of money out of the pool.
USA: That’s the case if your company is “self-insured”. Some are, some aren’t. I imagine there are financial requirements to self-insure but I’ve never looked.
Most likely, if you’re in a medium to large company (not sure the cutoff, probably somewhere around 500-1000 employees). Smaller companies will generally actually need the insurance company to be the payer as well since otherwise one or two huge payouts could bankrupt them.
The effectiveness of "health education" is somewhere between extraordinarily modest and nonexistent. It's not that people don't know what's healthy, it's that when it comes time to resist compulsion that is difficult, uncomfortable, and undesirable.
> [...] along with the lack of health education in schools.
I don't think that's too much of a factor?
I mean, check how much (or rather how little) people learn of the stuff that _is_ covered in school. Tweaking the curriculum would just mean that instead of not paying attention in algebra, students would not pay attention in 'health education class'.
In my school there was a strong emphasis on what a healthy diet is baked into the curriculum. Along with my family's relatively healthy cooking, that set me up for cooking and eating well on my own through college and life after that. I would edge away from takes related to "it just wouldn't work"
I mean the education system is its own mess for other reasons, but it's not a complete failure
I don’t know if your topic switch was intentional - if so, my apologies and this is just for people outside the US who don’t know…
The article is about life insurance, which is very different from medical insurance.
Medical insurance companies often already go out of their way to pay early to save in the long run (e.g. free preventative care, checkups, etc.). I can’t speak to GLP-1s, but it’s possible that right now there are still active patents when used for obesity that make them crazy expensive for a few more years.
Life insurance is all about models and predictions about when you’re going to die. Any sudden change that massively impacts those models suck, because life insurers are basically gamblers with gobs of historical data they use to hedge their bets.
> Medical insurance companies often already go out of their way to pay early to save in the long run
Literally LOLed when I read this. Health insurance companies might pay lip service to this and make some token gestures like free preventative care, but in my experience health insurance companies frequently shoot themselves in the foot by denying care that later ends up costing them even more when the patient's untreated condition worsens.
Maybe true in US, but here in Europe ie my health insurance gives me rebate on my gym membership (any gym). With some more automated low cost gyms I can get back up to 50% back. This seems like a similar case.
Medical insurance in the US is not incentivized to save money. In fact it's just the opposite. The ACA requires that 80% of premiums be paid out to medical expenses. If an insurance company encourages people to get preventive care and lowers its expenses, that means they also have to lower premiums. So they actually want costs to be as high as possible since they get to keep 20%.
It's not a gamble, it's an application of the law of large numbers. But yes, changes in the underlying assumptions (e.g. mortality rates) can make the whole calculation untenable.
I don't think GLP-1s are particularly expensive, so my top preference would be to just see them easily available. While not quite the same, it's a win that Rogaine/Minoxidil were once prescription-only but for a long time now can be bought at any grocery store and taken to the self-checkout. Still, I think the subsidy approach has been done for smoking problems via nicotine products before, and e.g. nicotine gum cost never seemed that high to me (especially compared to cigarettes).
But it's also worth remembering the relative risks involved. Obesity isn't quite the ticking time bomb / public menace it's often made out to be... For smoking, you'll find studies with relative risk numbers for lung cancer over 5 for casual 1-4 times a day smokers, and the number quickly exceeds 20 for heavier smokers. In contrast, with obesity, the most severe relative risks for things like heart disease or diabetes you'll find topping out around 4 to 5 for the most obese, even then often under 3, with milder 1.1 to 2 for the bulk of obese people. (Here, ~31% of the US has BMIs between 30-40, and ~9% have BMIs over 40.) For other harms, like there was a study on dementia a few years back, you'll also find pretty mild (1.1ish) relative risks, but these end up being similar with other factors like "stress", "economic status", or "low educational attainment". Just some thought for people thinking about subsidizing or providing free stuff, the cost tradeoff with paying for other things later might not work out so neatly, and there's reason to not focus solely on obesity but also do the same sort of analysis with other factors and severity of a factor as well.
On-patent GLP-1s (all of them right now) are actually extremely expensive. Right around $1000 per month.
I don’t want to discourage anyone who needs them from seeking treatment, but their discontinuation rate can be somewhat higher than you’d think from a life-changing drug because many people don’t like certain effects or even encounter side effects.
Weight loss drugs are also a challenging category for OTC because they’re a target of abuse. People with eating disorders and body dysmorphia already seek out black market GLP-1s at a high rate and it would be a difficult situation if they could pick them up impulsively from the medicine aisle. It’s also common for people to misuse OTC medications by taking very high doses hoping for faster results, which has to be considered.
There’s a libertarian-minded angle where people say “Who cares, that’s their own problem. Medications should be free for everyone to take.” I was persuaded by those arguments when I was younger, but now I have a very different perspective after hearing about the common and strange world of OTC medicine abuse from my friends in the medical field. Just ask your doctor friends if they think Tylenol should still be OTC if you want to hear some very sad stories.
> On-patent GLP-1s (all of them right now) are actually extremely expensive. Right around $1000 per month.
what does that mean? in the UK it's for sale from numerous national-chain pharmacies on a private prescription (ie the pharmacy is selling it commercially and customers are paying cash, no insurance and no state subsidy) for less than $US270/month. it seems unlikely to me that the pharmacies or the manufacturers are taking a loss on this, and the UK has at least as strict drug quality standards as the US.
sounds like the US monopoly-holders are just charging a lot more because they can, because the insurance system obfuscates prices and gives everyone involved cover to rip off patients?
People who want to misuse the medication are going to be the ones most willing and able to jump through the bureaucratic hoops. Increasing the difficulty to get the medication will only make it more difficult for legitimate users and won't decrease abuse. In 1920, 1970, and now, heroin was legal, illegal with minimal enforcement, and illegal with harsh enforcement (except in SF), and the same percentage of the population was addicted at each time.
Doctors' jobs are to deal with the cases that go wrong. These anecdotes have no relevance without actual data on how often these problems occur.
> People who want to misuse the medication are going to be the ones most willing and able to jump through the bureaucratic hoops
This thinking seems correct to people who grew up knowing about the dark web, Silk Road, and who believe they could access any substance they want if they wanted it.
It is not accurate for the majority of the population. For the average person, misuse of drugs isn’t a calculated decision. It’s one of convenience and opportunity.
> In 1920, 1970, and now, heroin was legal, illegal with minimal enforcement, and illegal with harsh enforcement (except in SF), and the same percentage of the population was addicted at each time.
This is a very misleading statistic for multiple reasons, as if it was engineered for the purpose of obscuring the problem.
Why pick 3 separate dates and limit only to 1 drug? There is a massive opioid epidemic that was fueled by increased availability of different forms of opioids beyond heroin. In the 1920s and 1970s they didn’t have OxyContin being diverted, Fentanyl flowing into drug distribution networks, or even Kratom products available at the local gas station. The availability and convenience of these different opioids has unquestionably increased opioid addictions.
Even more recently, the widespread legalization of marijuana has led to an increase in the number of daily users and the doses that people consume, even thought the libertarian arguments maintained that no such thing would happen.
At this point I can’t buy any arguments that claim that availability of drugs has no impact on misuse or addiction.
≥At this point I can’t buy any arguments that claim that availability of drugs has no impact on misuse or addiction.
I don't much care whether more people are addicted or not. When alcohol was illegal, booze dealers had machine gun fights in broad daylight on Main Street over it. When's the last time you heard about machine gun fights over whiskey?
Legalize it all. Heroin, cocaine, meth... sell it retail out of liquor stores in plain wholesale packaging. Manufactured by pharmaceutical companies, supervised by pharmaceutical engineers, unadulterated by poisons, measured doses, and include a dose of the antidote in the box. Make the junkies pay a deposit on a red plastic sharps container for their disposable needles.
I do not care how bad you think things will get... they're already that bad, but right now you're able to pretend that they're not. For every soccer mom addicted to oxy that you save, ten undesirables are dying of overdoses of fent in some filthy truck stop restroom somewhere. And we're spending half a trillion every year to do it, too.
> The availability and convenience of these different opioids has unquestionably increased opioid addictions.
You are making my point for me. The harsh restrictions on opioids haven't actually decreased the availability for addicts who are willing to go to black markets and risk dangerous injectibles and fent laced street drugs. All the restrictions have done is make it much more difficult for legitimate users like me. I broke my collar bone a few years back and was barely given any pills and had to live with a lot more pain than I should have. And the justification is that these harsh restrictions make it harder for addicts to get it, but as you pointed out, it actually doesn't even do that.
As for marijuana I would bet that the increase in the number of users has been more due to the decrease in public perception of how harmful it is rather than from its legalization. Is the usage increase limited to the states where it has been legalized? Furthermore, it doesn't matter if the usage increases, only if the problematic usage increases. Is there any indication that this increase corresponds to more serious potheads or just more casual smokers?
The typical grey market buyer exclusively buys vacuum or inert gas sealed sterile vials that contain pre-measured lyophilized powder and then uses BAC water from medical supply stores (or just Amazon) for reconstitution transferring from one vial to the other with a fresh needle.
$1000/mo is very high, yeah, but Ozempic isn't the only thing in town. My price info is from looking at https://www.brellohealth.com/ and similar ($133/mo semaglutide, $166/mo tirzapatide) -- i.e. just getting a prescription for compounded semaglutide. Reading anecdotes on twitter and elsewhere about grey market sources suggest the prices can be even lower. The innovation of Ozempic having the dose in a ready-to-go single-use injector is probably not worth an extra ~$900/mo for most people if they have to pay for it themselves, and if these things were available on shelves (or just over the counter, like sudafed (pseudoephedrine version)) you'd probably see that reflected.
> it would be a difficult situation if they could pick them up impulsively from the medicine aisle
It would be a different situation, not necessarily any more or less difficult. Anorexics and bulimics are already in difficult situations. Without research into the actual patterns of GLP-1 abuse and their problems, I'd still bet on it being a better situation. That is, abusing GLP-1s is probably better than destroying your esophagus from bulimia. But perhaps not.
I was persuaded by libertarian-minded arguments when I was younger, too -- though not typically ones framed from "who cares", but rather those rooted in a framework of freedom. People will always be free to destroy themselves in numerous ways, singling these things out to try and curtail destructive use is an unprincipled exception. Furthermore, the methods typically available for such curtailing (laws, law enforcement, and medical gatekeeping) are crude, heavy-handed, and often inconsistently applied themselves, leaving a lot to be desired in preventing abuse while certainly doing a good job impeding legitimate use which causes harm. When you go drug by drug, we also see the argument from other countries with laxer (or no) regulation not becoming anything like what you might predict if you just listen to what medical professionals say will happen if you got rid of requiring them as middlemen.
I'm older now, and I still believe such arguments, for the most part, despite direct experience with people trapped in cycles of abuse, not just anecdotes from people with an incentive in perpetuating the current system. (If you want sad stories, you can hear them from all sorts of people, not just from doctors. If you want tragedy, open your eyes, it's everywhere. Nevertheless such things by themselves aren't evidence and shouldn't weigh strongly in policy decisions.)
The first qualifier to unpack "for the most part" is that I think if society turned a lot more totalitarian, it would be possible to actually prevent almost all abuse. But if we did, we would also need to crack down on already legal and available things. You bring up tylenol, but I raise you alcohol. I don't drink, I think it's bad for you, tens of thousands of deaths each year support my claim, I don't even need all the rest of the non-death negatives affecting/afflicting far more. I'm not going to advocate making it as illegal as fentanyl. I do think there's a missing consistency here though and it's better for policies to be consistent. But consistency and the medical industry mix as well as oil in water. Modafinil, a stimulant that seems as harmless as caffeine, is regulated in the US as Schedule IV (same as Valium, which Eminem and many others were famously addicted to). But adrafinil isn't regulated that way, you used to be able to get it OTC / ordering online e.g. from walmart pharmacy, there's even an over-priced energy drink containing it now https://adraful.com/ yet it metabolizes to modafinil. Fladrafinil works similarly, is unregulated, and you can buy it in powder form by the gram on Amazon. Or just get modafinil from grey market sites (not even on the dark web) that ship generics from India because its status is never enforced, and save your liver some effort.
The second qualifier is that restricting access can sometimes be a good thing, and worth it on margin, when such restriction is considerately targeted and probably temporary. Part of the cycle of abuse for a lot of people is voluntarily committing themselves to a rehab center where their freedom of choice and access to many things is severely restricted for a while, and after enough cycles, it can work out in the end. That's a targeted restriction on the individual level, and having it forced on someone (involuntary commitment) is something hard to do and generally requires other harmful crime. Since fentanyl was brought up in the other reply chain, it's notable that this year fentanyl related deaths in the US continue to decline, this year by quite a lot. NPR gives 8 guesses as to why that is, with the top one being increase of access (just as I want for everything) for naloxone, which can reverse overdoses: https://www.npr.org/2025/03/24/nx-s1-5328157/fentanyl-overdo... Notably none of the theories are directly related to restricting access on top of current efforts, only in reason 2 (weakened product) do they suggest that some have thought the current enforcement in China, Mexico, and the US might be a factor in that. (I would have naively guessed as one of my theories that the current administration's various efforts could have something to do with it.) And notably none of the theories, except weakly 2 (weakened product) and 7 (skillful use) suggest that removing the barriers to getting fentanyl would lead to significantly more deaths. So while I think there's room for the government to make targeted time-limited society-level decisions that can produce marginal benefits by restricting access to something, the current poster child case of fentanyl doesn't seem like a strong candidate to support that view for either it or other drugs (especially those with more positive uses). (Indeed, a common libertarian point is that a lot of fentanyl harm specifically is because of reduced access to other drugs, so users get surprise-fentanyl from their illicit sources. And no, people getting those other drugs is not from growing up with the dark web, it's still often just "I know a guy who knows a guy" -- or just strolling down to various bus stop hubs in major cities like Seattle and looking for the loiterers with hoodies.)
I think the short answer is that these drugs are only cost effective when applied to people actually experiencing costly diseases, rather than simply being obese. A large part of that has to do with the drugs being very expensive still.
Well no, obviously not, but we do have 20 years of data, and aside from a still-tiny-but-slightly-elevated thyroid cancer risk, there’s really not much showing up in that data.
It's never cheaper for insurance to buy something for everyone. There's extra administrative costs to them being the middle man, so it makes much more sense for insurance to incentivize you to buy it yourself, through premium pricing.
For example, fire extinguishers and security cameras will reduce crime by more than their costs, but instead of charging you for them, plus administrative costs, and shipping them to you, your insurance provider will offer you a discount if you have them. (Really it's a price increase if you don't have them, but regulators don't like it when they call it that.)
Not everyone will benefit from GLP-1, so in this case, the most beneficial solution would be to charge higher premiums for anyone that could benefit from GLP-1 but doesn't use it.
> For example, my insurance covers flu shots in my community every year because it's presumably less expensive to pay for the shots compared to the increased rate of hospitalization that the flu causes.
In the US, insurance companies are generally legally mandated to cover ACIP recommended vaccines at no cost to the insured, which includes flu vaccines for everyone six months or older without contraindications.
Fuck that, not everybody here has massive self-control (on top of other mental) issues. Keep your chemical shit with bad side effects away from me and my kids, we know how to live well and raise kids similarly.
> I wonder if there is a point at which it is cheaper for health insurance companies to offer subsidized or even free GLP-1s to patients than pay out for other specialized medications
Some do. My insurance requires a prior authorization due to the previous shortage, but it's $12/mo
> I wonder if there is a point at which it is cheaper for health insurance companies to offer subsidized or even free GLP-1s to patients than pay out for other specialized medications.
That the NHS is getting to a place where it’ll provide it, I’d say yes.
Everyone likes to bash the US healthcare system, but at the same time it’s remarkable how much subsidized GLP-1 access Americans are getting compared to much of the world. The paradox of discussing healthcare online.
Look at CAR-T therapies (your cells are reprogrammed to fight your cancer). Insured patients got access in the US long before, and to a broader degree, than national healthcare systems.
Today, CAR-T utilization in cancers like lymphoma are double those of Europe in many cases. Interestingly the UK is one of the highest in Europe (despite the controversy over cancer drug spending).
While true that the US has uninsured and not all insurance is equal, suffice to say you stand a better chance to get access to new technologies in the US than most countries.
