GLP-1 Coverage Is COLLAPSING in 2027

i think we're reaching one of the strangest moments in the entire glp-1 revolution the obesity rates in this country are falling for the first time in my lifetime and probably in yours and the drugs that made it all possible have gotten progressively cheaper since they launched but all of this is happening against the backdrop of an american health care system that seems to be pulling back on covering these medications this week we learned that employers more and more are preparing to drop glp-1 coverage in 2027 we learned that most states are actually opting out of a federal medicaid model that was intended to make obesity medicines both cheaper for states to cover and more accessible for the patients who need them meanwhile another story about a real housewife emily simpson who's reigniting this age-old problem of obesity in the United States conversation we've had since glp-1 conversation started taking place online about a maintenance strategy where she may go several weeks without medication and then dose again if she notices her weight beginning to creep up and these may sound like completely polar opposite stories but i actually think they're deeply connected in a way one is about a american health care system struggling with the cost of the treatment of obesity today and the other is about patients who are just simply trying to figure out what lifelong treatment is going to be for them and actually needs to look like once they get to their weight goals and buried inside that second story is also a much bigger story that i think obesity medicine is eventually going to have to confront and that is what if the future of glp-1s isn't simply treating severe obesity after somebody has already developed it what if lower dose therapy eventually becomes part of maintaining health preventing disease progression and lowering the enormous downstream costs of metabolic disease you see how these stories start to relate together we do not have the science to completely answer that question yet but considering what obesity costs this country in type 2 diabetes and cardiovascular disease and sleep apnea kidney disease fatty liver disease uh decreased productivity and disability i think it's a question that is worth asking that's what we're going to tackle on today's episode of the weekly dose podcast let's do it together welcome back welcome to the on the pen podcast with your host dave knapp welcome back to the weekly dose podcast my friends i'm dave napman of the manjaro that's why i'm here you are on the pen that's ozempic we go b sex endovictosa trulicity manjaro zetbound compound that pen and before we get into it though i want to give you a quick word from voa fit they are the sponsor of the weekly dose podcast listen i've gotten a bunch of comments over the last couple weeks about my glowing skin walter aside and maybe a more defined jawline a lot of comments i don't always love comments about my appearance but that's just the cost of putting yourself out there but you're not making things up you're actually seeing me actually at my lowest weight in 10 years before i even got online and started making content you're not making things up you're actually starting to match how healthy i've been feeling too and i owe it all to finally receiving intensely personalized care from the team at voa fit now i've been with voa fit since before they were a sponsor before you come at me but what are we doing differently we're actually attacking the disease of obesity from not only the glp1 angle and just redlining that pathway as much as we could but from multiple hormonal angles the nutrition and movement angle their whole team is dedicated to making sure that i get the care i need and if other platforms have sort of left you feeling like you need more voa fit will not disappoint you can learn more about voa fit at voa fit.com forward slash otp or you can go to otp links.com we've got different resources there and thank them for being part of what helps bring this podcast to you each and every week and i thank them for actually changing my life and that is no understatement appreciate our friends at voa fit but i want to start this week with access because literally everything we talk about on this channel is rendered irrelevant if you the patient cannot access or get access to your medication and i've been thinking about this well frankly for the better part of the last four years but especially this week the prevailing wisdom in the glp1 access conversation is that obesity care is going to slowly but surely get better access to the branded medications is surely going to improve and we were essentially told that once medicare covered the rest of the payer market would ultimately follow medicare would get rolling and then medicaid would get on board and finally the private insurers and employers would adopt glp1s as the standard of care for obesity but i honestly think we're getting the point where we need to start to accept a reality that in the short term at least parts of that door are starting to look like they're closing and if that sounds overly pessimistic to you check out two really important stories from this past week the first one came from politico over the weekend i'm going to throw this up on the screen here because i think that it's helpful for you to to reference and just sort of visualize the issue that we're facing here so this is a again published by politico and the first thing that you're going to notice on this graph from this recent article is all of the orange on the screen now remember that right because we're going to come back to it so what we have here is a visual representation of states that are choosing or are not choosing to participate in something called the balance model and i don't want to bore you that we've covered it extensively exhaustively over the last six or eight months since it was announced and essentially it's a way for states to purchase uh these medications for obesity for 245 a month which is well below list price and it's well below what you're paying if you're paying cash pay for the upper doses of these medications and the the government was able to do this through a framework called the inflation reduction act now this was signed into law in the first place and it was signed into law in the first place by president joe biden which actually on paper makes this like the happiest little bipartisan accident that's ever happened to benefit the american people because finally the most innovatable innovative innovatable did i just make up a word i think i did the most innovative pharmaceutical drug since penicillin arguably was going to now be more affordable more accessible to the masses so innovations like glp-1 medications and i don't honestly know if we have anything to even compare it to in my life i don't know if we have anything to even compare it to in my life i don't know if we have anything to even compare it to in my life i don't know if we lifetime but innovations like this in the pharmaceutical world don't tend to get cheaper the few years after they launch they get more expensive until ultimately you have this pathway for in terms of biologics biosimilars or generics in terms terms of ndas actually hit the market and affect the pricing of these medications so the fact that we have seen a complete reversal of that trend i think is nothing short of a miracle considering how many people these medications these drugs are ultimately going to help right and it makes sense right serve a quantity of people and that will help make up for the fact that you're charging less for the medications it's made sense we've all talked about this you've talked about it in the comments of my videos for the last several years right it's just a total addressable market is absolutely massive now you would think that this would be one of those stories where everybody looks at and goes fantastic the drugs are cheaper states are going to sign up patients are going to get access everybody's going to go home happy because they get access finally the medications that they wanted that is not what's happening in fact most states are opting out so if you're watching this video i want you to take a look at this map that politico pulled out and we we actually covered this on our live stream yesterday we're live monday wednesday friday on youtube we'd love to have you join us 11 a.m central every monday wednesday friday but this we talked about a little bit yesterday there's a lot of orange on now unfortunately what orange means is these states are not participating in the balance model that will provide cheaper glp ones to the states and ultimately to their population enrolled in their respective medicaid programs so orange means the state isn't participating now just for a quick flyover california is orange texas is orange florida is orange washington is orange or washington as my grandfather would say illinois is orange as uh as you see here like red states are saying no blue states are saying no in fact the only state to say yes is that green one right in the middle just happens to be the state of indiana where eli lily resides so we even have states that already provide some level of glp-1 coverage saying no to this particular model and i think that's important because i know there's going to be a temptation to turn this into politics a political story the trump administration proposes something states reject it uh and then everybody goes to their respective corners and starts to blame the other team that just tends to be how everything works in this country but when i look at this map i don't see red versus blue despite the fact that they just chose different colors to make the map i actually see here something much deeper and i what i see i think is medicaid directors and the people were in charge of these programs actually panicking at the thought of an enormous percentage of their covered population who could qualify for a drug that they simply don't have the funds for today. Now, despite the long-term implications for a patient health and the long-term improvements in patient health in getting treated with GLP-1 for obesity, state budgets are largely focused on the here and the now. What's going on now? How are we going to fund it now? Even if we save money tomorrow, where's the money going to come from today? And obesity affects, unfortunately, an enormous percentage of the population in these states. Medicaid covers an enormous number of Americans. So even if you take a drug that used to cost something like $1,000 for these programs and you dramatically reduce the net price, you're still potentially adding chronic treatment for hundreds of thousands of people inside a single-state program. And this is something I think we need to understand if we're going to have an intelligent conversation about GLP-1 access, because a cheaper drug isn't necessarily a cheap program for these states. Those are two separate things. So you can cut the price of a medication dramatically, say, from $1,000 to $245, right, which is the case in this Medicaid program, but you're still creating billions of dollars in new spending if enough people become eligible for the treatment. And you know by the FDA's approval for these drugs, millions and millions will qualify. So both things. This can be true at the same time. You can reduce the cost of a medication but increase the cost to run the program year over year. And that appears to be sort of part of what states are wrestling with here. They're looking at the potential utilization long-term of these medications, at least in the long-term in the sense of the next maybe five years, and they're looking what happens when you zoom out a little bit and think of hundreds of thousands of people who are using chronic obesity medications. And if I put myself in the chair of somebody running Medicaid, I can understand why. That makes them nervous because even though it's extremely sad for patients, it's extremely short-sighted, I believe, because the long-term implications are much better. It's yet another reality of a very broken healthcare system. If we move to the other side of the coin, right, the patient side, because that's what we talk about here at On The Pen. We want to talk about everything from the patient perspective. The patient is not looking at an actuarial projection like the folks running these programs. The patient is. The patient is looking at her knees that have bothered her now for years and what's going to happen with her mobility. She's looking at her blood sugar, her blood pressure, her CPAP machine. She's looking at her liver scan and fatty liver. She may have spent 20 or 30 years living with obesity while people just told her to eat less or move more. And frankly, that's kind of like telling somebody who's drowning in the ocean, just swim harder, just swim harder, save yourself, swim harder. And now for maybe the last one. Maybe the first time in her life, her doctor is dangling a life preserver over the edge of the boat and saying, hey, we actually have something that can save you. Something that actually targets the underlying biology of the disease that you have. And then she finds out she can't get it. And not because she doesn't qualify or her doctor says she can't get it because of where she lives or who she works for or how old she is. And that's what it's looking like for the patient side. And I talked about this on yesterday's show when we covered this initially, because I think it bears repeating. Because this is devastating for people who have been waiting for coverage. And I think so much of folks in my community who have spent the last couple of years, maybe on the sidelines, because they're trying to follow the science. They're trying to listen to their favorite medical influencers, medical doctors online. And much of their advice is to say, I wouldn't touch compounded medications. I wouldn't touch gray market options. If I were you, you just have to wait for the right path to open up here. And we're working on it. We're working hard to make that happen. And like, just when you see the light at the end of the tunnel through maybe the Medicare program, Medicaid program, sorry, they're not interchangeable, very different things. Medicaid or state run Medicare is federal government and typically the older population. But you have that person who's been watching this light at the end of the tunnel. I say, I've been waiting on the sidelines to do it the right way. Right. And now that light's fading out completely. And once again, that patient stuck with. No treatment, no options, and very little hope if they're going to go the branded medication route. So I just want to take a moment to say, thank God for compounded options. Thank God there are companies like Basque Health, who is now the sponsor of our new studio. Thank you to Basque Health, who provide the infrastructure that allow telehealth companies to democratize access to obesity therapies. And thank God that people are willing to fight the good fight on behalf of the patients. Thank God there are companies like Basque Health, who provide the infrastructure that allow telehealth companies to democratize access to obesity therapies. Now, the Business Group on Health surveyed large employers. This is sort of the other side of the coin. We talked about Medicaid programs not opting in. But on the survey side done by the Business Group on Health, this is about coverage of obesity medicine, GLP-1 obesity medicines, and employers. And among the respondents to this health survey, it's already fallen from 72% in 2025 to 60% in 2026. And around 14% said that they have dropped or are intending to drop coverage in 2027. It is on the decline. Employers are staring down broader healthcare cost growth with cost projections, again, looking to sharply rise. And they are cutting access to obesity therapies, not adding it. So zoom out. You have states hesitating. You need to cover it. We saw all the orange on that map. We only saw one green. Employers are pulling back. And patients are increasingly being shoved in the direction of cash pay programs, whatever that looks like. Maybe it looks like Lilly Direct for those who can afford it or Novocare, but for many people, to telehealth companies who are building entire ecosystems around expanding access to these medications and to treatment. And all of this is happening before we get the next wave of obesity treatments coming to market, which is something we talk about all the time. So we're going to have to wait and see what happens. We're going to have to wait and see what happens. program were created so that we could study that, so we could get honest answers about what is this ultimately going to help long-term. Type 2 diabetes costs money. Sleep apnea costs money. Joint replacements cost money. Cardiovascular disease and heart attacks cost money. Hospitalizations cost money. Lost productivity employers cost money. The cost doesn't disappear just because you start denying the ZEP bound claim or refuse to add obesity care to your health insurance program. You've simply moved the cost somewhere else. And it's more hidden, so it's an easier pill to swallow, so to speak, no pun intended. And with obesity, it is a problem that is simply moved years into the future. And that's the thing that all these employers and states are grappling with right now. And it creates another problem inside our healthcare system, frankly. The paychecks are not going to be able to pay for the paychecks that are going to be paid for. The employer who spends the money treating obesity today, especially when this relates to employers, may not be the one who gets the financial benefit years from now, because of the way that our system is set up. Think about an employer, right? They pay for an employee's medication today. Five years later, that employer changes companies. 10 years later, that person is on another insurance plan. And 15 years later, maybe Medicare is picking up the tab. So the employer paying the pharmacy claim now isn't necessarily going to capture the savings from the heart attack that never happened. And so it's partially an incentive problem. And so we have this structural problem that we're facing here, folks. And I think the Medicaid story exposes it beautifully, frankly, because everybody can agree that obesity creates massive long-term costs on our healthcare system. But the entity writing today's check is not always the one that's going to receive the savings tomorrow, if that makes sense. So we find our in this very bizarre sort of position where scientifically obesity has never been more treatable. But economically, we still haven't figured out who's going to pay the tab. And that matters because when you take a legitimate pathway and make it difficult enough, patients aren't going to stop wanting, demanding, or seeking the therapy. They're going to find a different pathway. And until we can figure it out together, and I do believe, by the way, that it is incumbent upon me and you to help figure that out and be part of the voice of change there. That's why we host the podcast that both our friend, well, the Weight and Measure podcast that both of our friends, Mike and Zach, are hosting here on the podcast because they cover this stuff a lot. It's incumbent upon us to advocate in those spaces. In fact, I'm going to DC in a couple of weeks to do just that with Patch, which is a organization that helps to advocate for access to care for cardiovascular patients. And I'm going to DC in a couple of weeks to do just that with Patch, which is a So long live the programs and the companies and the organizations that are fighting to provide access to the marginalized. But at the end of the day, this is the challenge facing our system. And this is the challenge that has to be addressed. And we need to be the voices and the agents of that change, which brings us to the next story that I want to spend some time talking about this week, which is micro dosing. We tease this at the beginning of the podcast. And the reason I want to spend more time on it is because the story is really fascinating to me. The story that kicked this conversation back up is actually kind of more interesting to me than the headlines around the story made it seem like. Emily Simpson, who is from the Real Housewives of Orange County, kind of awkward that it's Orange County when we saw that California is one of the orange states not participating in the Medicaid program, right? The poor state of California. She told us us weekly that she had lost around 50 pounds. And the way that she uses GLP-1 medications has changed now that she's really lost 50 pounds. And so I'm going to DC in a couple of weeks to do this and see if I can reach her goals. She said that initially she was much more regimented using the medication weekly for roughly 12 weeks to get to her goal, which is very fast. Now she describes what she's doing as micro dosing. That's part of the problem right here is that everybody has a little bit different definition about micro dosing. We've had our friend, Dr. Tina Moore, who was the pioneer of this whole conversation on. She laid it out beautifully in terms of how it should be defined. It's less than the FDA approved dose. Oftentimes, it's much less than the FDA approved dose. But in this gal's case, it doesn't mean taking tiny amounts every day or click counting on a pen. What she described is much closer to intermittent maintenance, right? Where she may go several weeks without taking medication at all. And then if she begins to notice that her weight is creeping back up, she uses it again. And so that's what gets my attention. Because if you strip away the celebrity name and sort of take the pomp and circumstance out of it, what she's describing is a question I hear from this community. Every day, literally every day, I hear this, like, I lost the weight. Now, what am I supposed to do? How do I adjust my medication? And there's not really great protocols for that. There are at Boa Fit, but a lot of doctors don't know how to handle this maintenance. And it's kind of like grasping for straws, right? And so how do I basically keep the results that I have in terms of using the medication? I want to tell you where I land on this before I go any further into the conversation, because I'm generally very pro micro dosing. And I'm not going to you know, one of the things I've said since early on in starting these videos is doctors and patients, doctors and patients, doctors and patients, you are the you are the expert in you and the doctor is the expert in medicine. And together, you should be making choices and nobody else should be informing those or influencing those decisions. It should be you and your doctor. Right? I think there's a very reasonable possibility that lower doses or longer intervals or less intensive exposure may eventually become very legitimate parts of obesity maintenance, and maybe even weight loss maintenance, or weight loss in general, at lower doses. In fact, we're seeing a new trial for Wigovi at low doses of the pill for weight loss. So we're seeing even the pharmaceutical world, they don't tend to run very expensive clinical trials unless they think they're going to get the results that they want. And so we're seeing science move in this direction. So I think they'll eventually become very legitimate parts of obesity maintenance, and maybe even preventative against metabolic disorder in the first place. But what I'm not willing to do is pretend that the science has already established that the behavior is definitely ahead of the data. But we see that all the time in this space. And that's okay. We just need to be honest about it. Because we're seeing like, even in the gray world, so many folks have been stacking different peptides that work on different pathways to treat weight management. Now we're seeing pharmaceutical companies run similar trials in that vein as well. So oftentimes, the real world is ahead of what gets done in the clinical trials. But we do need to wait for the science and the evidence to catch up. So with that sort of as the backdrop, some of the knee jerk reactions that I've seen to this conversation online have been ridiculous. So if you have a patient who has been able to maintain substantial weight loss, appetite control, glycemic improvement, metabolic health improvement, on less medication, why would we automatically view that as a problem? That's the question. And I think Emily Simpson's story gives us a very public example of somebody who's essentially conducting an experiment on herself in concert with her doctor. She also made comments about eating things like In-N-Out burger or having ice cream with her kids. And people go ballistic about this stuff. Listen, if you grew up in diet culture, you are not going to be able to do the same thing. You're not going to be able to understand that finding balance is key. We've done restriction. We've done the pendulum swing of white knuckling a restrictive diet. And we know what the other side of that pendulum brings. And I think that it's detestable when people attack folks using a GLP-1 medication who are just eating like normal human beings. You haven't had an In-N-Out burger. I don't care whether you're a fitness guru. I don't care what you do on your own time. Anybody who says they don't enjoy a McDonald's French fry is a liar. You're lying. It's not humanly possible. And they've done studies on this. Probably it's not humanly possible to not enjoy a McDonald's French fry or perhaps an In-N-Out shake, right? Does it mean that it becomes part of your daily routine? Probably not. But all she's saying here is she does eat these things from time to time. And I think that the knee-jerk reaction, even I was talking about these a couple of weeks ago, protein Doritos. Now I was talking about a Dorito. It's still not open, but it's sitting here next to me because every now and again, I like a Dorito. And if you're saying you don't like a Dorito, you're lying. People should be able to eat like a normal person. And that's why I celebrate. Add some more protein to it. Great. Make it a little bit more nutritive to somebody who's eating those foods or choosing those foods. Doesn't mean I'm going to make it a staple of my diet, but the knee-jerk reaction to this is just insane to me. So she didn't eliminate burgers or ice cream. She chooses to use those things in bigger change for her was moving away from the mindless eating that she struggled with before. And at a very low dose of these medications are actually helping her. It's an end of one study for sure. But I think what we're going to see, and we're seeing clinical trials already start to form around this is that lower doses for the right patient might actually be the right path. And so I think that I'm excited for, for this, uh, science to evolve on this. But I think again, it's important to, to put in context what people are calling it. Microdosing. I would encourage you to go check out the episode that I did with Dr. Tina to learn more about what she's. had to say herself on this issue. And we've done articles as well at obesity.news that help you navigate just, you know, what are you doing? Are you spreading out your dose? Are you doing multi-week dosing? Are you actually doing micro dosing? What we call this stuff is important because none of this is an exact science, but if somebody can use less medication, you know, somebody who needed 10 or 15 milligrams of triseptide during their active weight loss can now maintain on 2.5 or five, or they're stretching their dose intervals. You know, could somebody ultimately use these intermittent treatments? I think a lot of you already are. And that's the point here. I don't think that people should be knocking people who are doing things maybe outside of a normal protocol, especially when they're doing it with their doctor and in concert with medical supervision. Of course we need continued data and we'll get that, but this is it. This is why I'm uncomfortable. When I hear micro dosing, just sort of universally by anyone, uh, dismissed as a social media fad because social media exists obviously, but it's where patients are exchanging ideas about the things that they're doing. And ultimately at the end of the day, we're all just trying to find what works for us, especially when it comes to things like maintenance, or if you're somebody who's using these medications as a potential prophylaxis, because you think in concert with your doctor, that these might provide benefit for you, even though you're not, obese today or diabetic today, you may find value in using lower doses. I think it should be celebrated. I think that the, the more that, uh, these medications are adopted by the broader public, the more that we can open the discussion about the disease of obesity. Listen, nothing teaches somebody quicker that obesity is an underlying metabolic disease and that the, the hunger signals are treatable and, and louder in some people by actually taking the medication and hearing the food noise, stop feeling the calm. Uh, having your body restored to sort of a homeostasis when it comes to that signaling that for many of us has been just interfered with. Uh, I want to connect all of this and bring it back, uh, to, to what we spent a bunch of time at the beginning talking about Medicaid, because one of the reason that States are nervous about the balance model utilization is there's a tremendous number of people who qualify for obesity therapy, even at the dramatic, uh, price of $245 a month. That is a massive population that gets exposed to this. And this is another reason why real patients in real life are actually looking at things like expanded doses or micro dosing, because this is a money thing. This is a money driven issue for many people who are using these therapies, uh, for weight maintenance, weight management. So not every story is a desperate housewife story about how she's using these medications. Oftentimes, the reason that folks are using different protocols is simply driven by money and accessibility to these medications. So every patient should feel empowered to work with their doctor, find what works for them, because this isn't just about what a protocol and a clinical trial said. This is about the real world. And this is about real life. And this is about finding what works for you. So don't spend too much time in the comment section of these types of stories. It's a good jumping off point for places like this to have open dialogue about this, but ultimately, the comment sections are usually full of just hate and anger and people's issues, right? That you don't frankly need to waste your own time and energy on preserve and protect your peace when you see these conversations going on online. That's what I got for you this week. Thanks again to our sponsor, VoaFit. Thank you for Basque Health for providing the studio for us. We've got a really exciting, I was just in my new office today. Electric's done, painting's done, floors are next, install of appliances comes this next week. And we're going to be in this thing in about a week and a half, two weeks. And I can't wait to do that. Thank you to our friends at Basque for helping us get over the hump by becoming our title sponsor for our studio. Thank you for being here. Thank you for being the best part of what we do. If you found this video helpful, please train the algorithm, hit the thumbs up button, but hit the hype button down below. If you're watching on a mobile device, that helps other people. We'll see you next time. Bye. Guys, that helps other people discover this podcast too. And we will catch you friends on the next episode, but don't forget that we're also live Mondays, Wednesdays, and Fridays at 11 a.m. Central. And we hope to see you tomorrow, Wednesday at 11 a.m.