Weight-loss drugs. Who pays?

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She says that she struggled with her weight ever since. "Ford of winter was taking me really fast, so I came here with very thin child and by the time I was 18-ager, I was gaining weight at a very rapid pace. I did gymnastics, I played hockey and none of that really helped curb my appetite and my weight gain. Part of my college for me, I had already reached about 300 pounds and was really struggling. I had to spray my ankle nine times and just the quality of life I was living was pretty poor. It was that tipping point, reaching 300 pounds, around 136 kilos, that prompted Yellenna to have weight loss surgery as a teenager and for a while she managed to keep things under control. But decades later, in her 40s, she was still battling obesity. That's when she started taking Zetbound, a once-weekly injection designed to reduce appetite and help people feel fuller for longer. Things like this are known as GLP1s, a class of medicines originally developed for type 2 diabetes, but now increasingly being prescribed to treat obesity. A few years ago I had done IVF and I did three rounds of IVF and gained about 30 pounds. I just turned 41, so back two years ago I was about to hit 40s and realized that the struggle was a lot harder this time around than in previous years. So when I went into my doctor and told him that I'm on the journey to re-lose that weight, he recommended that I get on a GLP1. What impact would you say it had on your life? It has helped me with my head hunger. I just am more able to control what I take in and I'm not constantly thinking about food. A lot of people have food noise and even people who haven't had weight loss surgery, the food noise is terrible. You are thinking about food before your meal, you're thinking about food after your meal and every minute and between. I think that was done for about six months and I had re-lost the regain that I had and 10 pounds more, so I lost about 40 pounds. And then for the first time in my life, I had that normal BMI range. GLP1s are becoming more than just weight loss drugs. They're now also being shown to reduce the risk of heart attack and strokes. And improve outcomes for a range of obesity related conditions like type 2 diabetes, heart disease and sleep apnea, which means these medicines might be expensive up front but could end up saving health systems money in the long run by keeping people healthier and out of hospital. So the big economic question becomes if these drugs prevent other serious illnesses down the line, are they actually good value for money? That's what health economists call cost effectiveness and it is something closely studied by the Institute for Clinical and Economic Review or ISA, an independent non-profit that analyzes how much medicines in the US healthcare system are really worth. Sarah Emmand is its president and CEO. As we think about something like cost effectiveness, what we're saying is if we measure all of the benefits that accrue to patients on a new drug and we measure all of the costs that come with that new therapy, but that also includes any cost savings that might happen because you're healthier and you might not end up in the hospital. If we sum that all together, how much we're paying for health is wildly cost effective when it comes to the GLP1s. The real issue becomes budget impact. Even at the cost that they are now, you would say that they're cost effective. It's really interesting. We did a review of Wagovii semaglety back in 2022 and the data that we had there, they looked like they weren't quite cost effective at the net price at the time because of competition from ZEPBound, which is one of the other major GLP1s, as well as additional aggressive negotiation from payers and the government, the prices have come down and we have new evidence of even more benefits. Those are the two directions things can go to make something look more cost effective. So even if these drugs offer good value for money, someone still has to pay for them. And with around 40% of the US population living with obesity and potentially qualifying for these medicines, that bill could be enormous. And in the US, access depends on who ensures you. Most working Americans get health cover through their employer. MediCare, which covers older Americans, generally does not pay for GLP1 drugs when they're prescribed purely for obesity. And MediCade, for lower income families, only offers treatment for obesity in a small number of states, with several now pulling back because of the cost, which means for most people the decision comes down to employers and private insurers. And that's where access is tightening. There has been a trend towards an increase in restrictions. These restrictions are often employed as cost management strategies, so basically take some steps towards managing ballooning healthcare costs. Amanda Nguyen is a senior health economist at GoodRx, a company that tracks prescription prices and helps patients find cheaper ways to pay for medicines. She's been tracking how employers and insurance companies are restricting access to these drugs. In the US, we're seeing a lot of what we dubbed at GoodRx Research as "coverage with a catch". So that means that even when insurance plans say that they cover a medication like a GLP one, that access often hinges on other requirements. The most common would be prior authorization, which means that the insurer wants to get additional paperwork and clinical justification from the healthcare providers before they will pay. And then also sometimes we'll see step therapy where you're required to try another often less expensive treatment first. Our data shows that these restrictions are really widespread when it comes to coverage. Give us an example of what you mean by that. So for GLP ones prescribed for weight loss, like Zetbound and Wigovie, we find that over 88% of people who have coverage still face restrictions. Jim Winkler is the chief strategy officer at the business group on health. It advises more than 450 US employers from giants like Walmart, news corporation and Morgan Stanley to smaller organizations with just a few hundred staff on their health insurance strategy. I asked him how concerned his members are about the potential cost. In short, very, very worried Sam. One of our members said, "If these drugs cost what blood pressure medication cost, we would not be having this discussion." All of this discussion around should we cover it, should we not cover it, is a function of the fact that these drugs are likely relevant to a higher percentage of the covered population than almost anything else and at a much higher price point. So employers are very worried about it. It is a significant driver of overall healthcare costs for employers right now. For 2026, IS projected cost increase in over a decade. There is research, isn't there, that across 2025, restrictions for the drugs increased and the data suggests that across 2026, those restrictions will increase. Is it really fair to make such restrictions on these drugs? The fairness question is an interesting one, right? Because at the end of the day, in our system, we cover expensive things for lots of conditions. Somebody has a traumatic brain injury and needs complex neurosurgery. We're going to cover that. It's going to be expensive, right? Those other circumstances are much more infrequent and so you absorb them into your plan. Here, we're talking about something that the volume of people in the cost of the drug combined create enough of an uplift in overall healthcare costs that organizations managing the cost for their employers in the self-insured world or insurance companies in the insured world are making decisions focused on how do I mitigate cost in the short term. The challenge is you end up with a situation where there is a direct to consumer marketplace and the people that can afford it can avail themselves of that and the people that can't afford it don't. And that creates an inherent inequity in the healthcare system. You're listening to Business Daily from the BBC World Service. Their company's success helped build a nation. The company is such a big part of Korea's economy. Who are the family behind one of the world's tech giants? The major corporate empire that we now know today. Samsung. Inheritance Samsung from the BBC World Service explores the real-life dramas of the Lee family and their company Samsung. There's a succession style drama underneath of all this. Inheritance Samsung coming soon wherever you get your BBC podcasts. This is not the future we were promised. Black hell that out for a tagline for the show. From the BBC this is the interface. The show that explores how tech is rewiring your week and your world. This isn't about quarterly earnings or about tech reviews. It's about what technology is actually doing to your work and your politics, your everyday life and all the bizarre ways people are using the internet. Listen on BBC.com or wherever you get your podcasts. I'm Sam Fennik and today we're asking whether the US healthcare system can afford obesity drugs for everyone who might need them. Back in Minneapolis, Yelena Kibisoba, who now runs one-to-one coaching sessions for people taking GLP-1 drugs and advocates for those living with obesity, has built a large online following. She's worried though that a two-tier healthcare system is emerging between those who can afford to pay privately for these drugs and those that can't. And her own experience shows how quickly insurance policies around these medicines are changing. As soon as I hit the normal BMI range, the insurance started fighting me on giving me the medication. When I talked to my bariatric doctor, he basically said it's kind of a weird catch-22 where they won't prescribe the medicine until you're back into the overweight or a beast category, then they'll prescribe it to you and then you'll go back down and then they'll stop prescribing. Did you pursue that or did you just think, okay, they've said no, I can't face that fight. Initially, my doctor sent about three or four rounds of letters to the insurance company because we were trying to attack it from all different ways, but nothing seemed to really work. How have you coped with the insurance company now not being able to provide it for you? So I'm lucky enough that I can afford to pay out of pocket. There's a lot of online pharmacies that are pretty reasonably priced, let's say, about $200 a month, but that's reasonably priced for somebody like me. For other folks, that's absolutely not in their price range whatsoever. Historically, prescription drug prices in the United States have been far higher than in other wealthy countries with brand name medicines, often costing two to four times more. Sarah Emmen from the Institute of Clinical and Economic Review says the gap has persisted for decades, driven largely by America's fragmented healthcare system. There are agents in the system like pharmacy benefit managers and health plans who negotiate prices with the manufacturers and sometimes get discounts off of the price that was picked. But how big a discount you get depends on a lot of things, the type of drug, whether or not there's any therapeutic alternative, what type of condition it's treating, and so all of those factors can play a role in whether or not there's discounting happening and how big that discount is happening. And all of that negotiation is secret. So the lack of transparency is another reason that our prices are higher. The other big distinction is those negotiations are happening across hundreds, if not thousands of different payers depending on how you can't, whereas in the UK, for example, there is one agency doing that negotiation on behalf of the entire country. And so when you have such disparate negotiation happening, you have less negotiating power as the purchaser. The market for these medicines is becoming increasingly competitive. And one of the biggest players has just made a major move on price. Novo Nordisk says it will cut the US list price. That's the starting price set by the manufacturer before it negotiates with insurance companies and employers by up to 50% starting in January next year. The company says the lower prices are aimed at making the drugs more affordable. Analysts say how much that translates into real savings for patients remains to be seen. Over the past few years, the price of prescription drugs in the US has become a political issue. Under Joe Biden, Medicare was given the power to negotiate the price of some of its high cost medicines for the first time. More recently, Donald Trump has pushed to lower prices too, reviving what's known as a most favored nation policy, which links US drug prices to the lowest prices paid in other countries. I'm doing what no politician of either party has ever done, standing up to the special interest to dramatically reduce the price of prescription drugs. I negotiated directly with the drug companies and foreign nations, which were taken advantage of our country for many decades to slash prices on drugs and pharmaceuticals by as much as 400, 500 and even 600%. President Trump has also promoted a government-backed website offering direct from manufacturer discounts on 43 selected brand name medicines. But whether this translates into lower costs for people with insurance is still uncertain. It advises US employers on their health insurance strategy. It's unclear at this point how the prices they've negotiated, particularly in the GOP1 space, where they have negotiated lower prices including for the oral version of the drug. How that actually becomes available to people and to whom you could certainly see a scenario where that becomes the day facto benchmark price and employers and their vendor partners negotiate with the manufacturers to say, "I need something much closer to that price." There is a danger that if it's cheaper for someone to buy over the counter than it is for the insurance company and the employers to pay for it, they might just stop completely. Correct. Leaving some people in a very difficult situation. The whole sort of dynamic of what's covered, not covered, what are cash prices compared to insurance pricing has been this sort of interesting kind of small wrinkle in healthcare that is now sort of exploding because of the GOP1 category in particular. It's sort of shining this bright light on a fundamental disconnect in the whole price negotiation process. So some of what's happening in the cash pay market is creating a ripple effect that's causing us to kind of revisit and change the whole pharmacy pricing model in general. But there may already be ripple effects beyond the United States. Some analysts say that when America pushes down prices under a most favored nation policy, drug makers may try to make up the difference elsewhere. And in recent months prices for obesity drugs in the UK appear to have edged higher. So here's the question, if America pays less, does the rest of the world end up paying more? Tomorrow, on Business Daily, we'll be looking at obesity drug prices in other global markets and asking whether they really are value for money. Thanks for listening today and do join me, Sam Fennik, again tomorrow. Like hell that out for a tagline for the show. From the BBC, this is the interface, the show that explores how tech is rewiring your week and your world. Listen on BBC.com or wherever you get your podcasts.