When health policy issues collide
GLP-1s are so hot right now
Today, I highligh two key US policy issues from the past year: abortion + obesity. These issues trigger morality debates around personhood and responsibility, but I’m not touching that with a 10-foot pole. My interest in these topics lies in how they impact access to care and patient outcomes.
What’s happening with abortion?
According to KFF, the US saw a 10-year downward trend in abortion rates leading up to the Dobbs ruling, attributed partly to broader contraceptive access (though they also note a slight uptick right before the Dobbs ruling could be from a Trump Admin era trend where some states opted to cut access to low or no-cost contraceptive care). The June 2022 Supreme Court ruling on Dobbs v. Jackson Women’s Health overturned Roe v. Wade, which established the constitutional right to abortion before the pregnancy is deemed viable (AKA can the fetus survive on its own?). We know from 2021 CDC Abortion Surveillance Data that the majority of abortions occur before the broadly accepted viability timeline of 24 weeks. Yet, many states have jumped to pass more restrictive abortion laws since 2022.
The Supreme Court held a hearing for the FDA v. Alliance for Hippocratic Medicine last month, which alleges the Food and Drug Administration (FDA) was rash in lifting restrictions to mifepristone (a drug with lots of real-world evidence, given it was approved ~24 years ago) and aims to remove it from the market. Because the FDA uses its scientific expertise to ensure drugs are safe and effective, mifepristone approval should not be reversed. But injecting politics to challenge the FDA’s authority to regulate, approve drugs, and monitor safety could have implications for like….every other drug.
Why is the US so preoccupied with weight?
About 40% of the US population reports a BMI above 30. (We can debate the validity of BMI as a determinant for healthy weight another time.) Obesity is linked to chronic health issues like heart disease, stroke, diabetes, and cancer, which impact US healthcare spending. But it is a multi-factor condition: poor nutrition, sedentary lifestyle, environmental, socioeconomic, and biological. Yet, we stigmatize it as a personal failure. When doctors and other healthcare providers hold strong biases toward their patients living with obesity, they make care decisions that can negatively impact patient outcomes. The general population and healthcare industry have a lot of work to do to tackle anti-fat bias. Where public health has used to chronic disease risk factors and healthcare resource utilization (estimated $173B in 2019) to fuel paternalistic policies, the pharmaceutical industry has responded with anti-obesity drugs. The hottest ones among them? GLP-1s agonists like Ozempic, Wegovy, Mounjaro, and Zepbound—a market J.P. Morgan forecasts will grow over $100B by 2030. While the world is obsessing over who is and who isn’t on GLP-1s, demand for the drugs skyrocketed. Novo Nordisk GLP-1 antagonist drug sales catapulted them to the second most valuable in Europe after LVMH, saving Denmark’s GDP from a no-growth year in 2023. In the US (free market!), these drugs can exceed $11,000 for a year of treatment at their list price, raising affordability concerns. (We can get into the difference between list prices and what patients/insurers actually pay in a future letter if you’d like.) Medicare (covers the elderly + disabled) cannot legally cover weight loss drugs, but Medicare Part D (the drug benny) covers GLP-1s for approved diabetes + cardiovascular indications. KFF found that Medicare Part D spending on Ozempic, Rybelsus, and Mounjaro increased from $57MM in 2018 to $5.7B in 2022. Legislation that could make it easier for patients to access these drugs is on the table. The Treat and Reduce Obesity Act of 2023 would enable more comprehensive Medicare coverage for obesity care (including GLP-1s). The thing about drug coverage is that once Medicare covers something, commercial insurers follow.
Despite existing affordability and access limitations, demand for these drugs soared, causing worldwide shortages. How did the market respond? A drug quality disaster with the rise of faux-zempic and compounded semaglutide (unsafe! ineffective! not FDA approved!) sales. Reuters described life-threatening examples like a woman who mistakenly injected herself with insulin and landed in a diabetic coma.
Okay so, where do these two issues overlap? We know the mechanisms that promote fullness (e.g., delayed gastric emptying) for people taking GLP-1s are a double-edged sword. GLP-1s can change how your body absorbs oral drugs, which are broken down in your gastrointestinal tract before entering your blood. This article from Jezebel sounded the alarm on what this can mean for people taking oral birth control, particularly those who may not want to be pregnant and live in abortion-ban states.
That’s all I have for you today. Have a lovely weekend!
xxsem