Comment by lotsofpulp
18 days ago
I don’t understand how it’s not legally required to be covered by all insurance in the US given all the health problems downstream of being overweight.
18 days ago
I don’t understand how it’s not legally required to be covered by all insurance in the US given all the health problems downstream of being overweight.
Because then the companies that have been given legal license to monopolize this technology (through the legal technology known as "patents") could charge whatever price they wanted and insurance companies would have to pay for it? The ability for an insurance company to say no is literally their only negotiation leverage.
Every country arranges their payment mechanism slightly differently- the US is worse than pretty much all of them but they are all slightly different- but every form of insurance has to be able to walk away in the negotiations, or else the monopoly producer will hike the price up.
I imagine if you forced insurance to cover but also removed patent protection and allowed generics immediately... drug companies would be even more unhappy than the insurance companies would if you forced them to cover GLP-1's.
> Because then the companies that have been given legal license to monopolize this technology (through the legal technology known as "patents") could charge whatever price they wanted and insurance companies would have to pay for it? The ability for an insurance company to say no is literally their only negotiation leverage.
Insurance companies have to pay $100k+ per month for medicine for anemic people, and many other much higher cost medicines. Why is a couple hundred dollars to fix THE single biggest cause of future healthcare expenses (diabetes, high blood pressure, and cholesterol) not covered?
https://www.desmoinesregister.com/story/news/health/2017/05/...
Insurers routinely pay for $1M+ NICU babies, $100k+ heart surgeries, yada yada, but the US government draws the line at medicine that costs $200 per month that prevents hundreds of thousands of dollars in future spend?
I can’t make it make sense, unless the junk food/alcohol/restaurant/sugar caffeine drink lobby has their tentacles deep in the government.
> I can’t make it make sense
I think the easiest answer is found by looking towards religion. Gluttony being one of the seven deadly sins. Obesity is seen as a moral problem by a lot of people, so paying for its treatment would be broadly unpopular. People who cannot control their appetite need to suffer.
Well, 67% of Americans are overweight and the mandatory drug costs $1k. So premiums must be $670 per person or higher to cover nothing but this drug. The drug manufacturers will know that the insurers must provide it so they’ll use the highest price they used at scale: $1k.
That means that every healthy person is also paying $670 per month just so that the 2/3 of the country can get this drug. But current medical loss ratios are at least 85% and if we did nothing but pay $670 we’d be at 100% loss ratio and the drug paid for.
Boy the economics for the average person look pretty bad, considering they can just get it off the internet for a fraction. I have 240 mg of retatrutide in my fridge for about a dollar a mg in comparison.
I like the way you're thinking about it, but worth mentioning that the net prices paid are likely in the $200-500 range, similar to the cash pay. List price doesn't mean much
This calculation is incorrect because the medicines cost significantly less than $1k per month, and there there would be cost savings from people being less overweight needing less healthcare.
For decades now, every single healthcare study seems to say overconsumption is the root cause, and now that there is a way to combat it, the government is saying the fix to overconsumption at a few hundred dollars per month is not worth it?
Because it is $1K/month, it would raise premiums too much. When it is $100/month like in most other countries, then let's talk.
PS - And, yes, compound versions are $100/month, but insurance doesn't cover those.
Where is it $1k/month??? I just started Wegovy and it is $199/month from Costco with insurance not covering it. I picked up my four shots on Thursday…
That is the starter dose. When you titrate up to maintenance, Costco's price is 350/mo
Do we really need insurance to cover $100/mo meds? Insurance already doesn’t cover OTC vitamins, right?
>Do we really need insurance to cover $100/mo meds?
For people making how much? Low income people are jumping through the hoops to get SNAP. $100 for them is a lot, and which they might just not have. And for insurance it would be cheaper long-run than dealing with diabetes, etc.
Anyway, why a such "submarine" attack on the $100 GLP-1 sources and why now? Well, one way of thinking would be that Trump RX just went online and there, thanks to the well known Trump's care about people's needs, the GLP-1 is $350, so one has to remove the $100 competitors.
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Because not all overweight individuals have the same risk profile thus don’t get the same benefit.
Insurance companies are allowed to limit access to more expensive therapies unless cheaper therapies have been tried and have failed.
Insurance plans are currently allowed to have complete exclusions of all obesity medications, even cheaper therapies
Yes, plans have pretty wide latitude on what they cover. ACA limited quite a lot by not only in plan design, but also what therapeutics must be covered. And you are correct, obesity is not one of them.
Medicare Part D (outpatient drugs) has wide latitude on what medicines they cover - it's actually smart for patients to shop their Part D plans if they are taking an expensive, chronic medication.
The only classes of drugs that Part D plans must included are:
Part D sponsor formularies must include all or substantially all drugs in the immunosuppressant (for prophylaxis of organ transplant rejection), antidepressant, antipsychotic, anticonvulsant, antiretroviral, and antineoplastic classes. (Page 28)
https://www.cms.gov/medicare/prescription-drug-coverage/pres...
It would have to be mandated across the board. Problem with insurance in the US is that it is tied to employment and therefore temporary. The majority of least problems downstream from obesity will be felt by some future insurance company, very likely not your current one.
If I were Trump for a day I'd force Lilly to sell the tirzepatide patent to the federal government (I'd even pay them a fair amount) and then make it a generic. Maybe a subsidized generic, even. Then in a decade or so the citizenry might actually be okay naming things after me. Though it might require dialing back some other activities, but whatever.
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Yes, that's why we see this issue in all of the industrialised world on the rise.
It's always the intellectual bankrupt response to blame individuals for a systemic problem
There’s nothing systemic about overeating at an individual level. It’s a personal choice to have that extra donut or cola. Nobody is forcing it down your throat nor shaming you for refusing.
Quite the contrary with segments of modern society trying to normalize obesity.
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If only everyone could have your willpower, we’d have no addiction or sport injuries or, well, any misadventure from doing anything more interesting than sitting on a couch (which has its own health problems). Alas, most people have flaws.
I'm sure if you were a reasonable person you might realize how many of the diseases we treat are "lifestyle choices". But of course none of that applies to you. Because you are better than that.