Shannon:

So we've got a potentially huge financial impact on the system. If the system does not necessarily want to bear that cost, they are going to pass it on to you in the forms of increased premiums. And that will not be just for people on these drugs. That will be for everybody. Some payers we are seeing, or some plans have made the decision, they don't want to pass those costs on to all of their insured, so they've declined to cover them. So big, big, big financial implications.

Katie:

So there's Ozempic and the other GLP-1 agonists that have the same or similar active ingredients that often get grouped into the category that we colloquially call Ozempic. And then there's the discourse about and the cultural role of Ozempic.

[Audio Clip]:

Ozempic. It is literally the hottest drug in the country right now. But what happens when you stop?

Katie:

Today and next week in this rare two-part series, I am interested in applying the lens of money and class politics to the role of GLP-1 agonists to understand how the culture we exist within determines what type of lives we get to lead, how our appearance affects our access to resources in that context, and ultimately how we learn to treat ourselves as a result as has become common knowledge.

Now these drugs are incredibly expensive, which adds another layer to this conversation about affordability, access, and ultimately what remains no matter which supposed miracle drug comes to market. As Tressie McMillan Cottom wrote in an op-ed for the New York Times, “As long as most Americans cannot afford the drug that democratizes weight, the stigma of obesity is still controlled by those who can afford to be thin.”

To do this, I'm talking to three people. The first is Shannon. She works in health policy for one of the largest healthcare professionals associations in the country. And then we're going to talk to Lili Zarghami, a writer who covered her experience getting on and then off Mounjaro for her PCOS in a three-part series for Jenny Magazine. And then finally we're going to talk to Dr. Mara Gordon, a physician who practices weight neutral medicine.

And alright, in researching today's topic, I have to admit I felt overwhelmed by the range of different angles and different elements to this conversation. And so while it feels like a bit of a cop out to issue some grand disclaimer upfront of like, “This stuff is really complicated!”, I do find it necessary to clarify the lens that we're going to take.

There is a term in project management and software development called “scope creep” or the tendency for the bounds of a project to spiral out of control after it begins. And that is a little bit how producing this series felt. There were a couple moments where I caught myself offhandedly, jotting down an observation, so for example, using the phrase “processed” food and then doing even a little bit more digging, realizing that even that topic is more complicated than meets the eye.

So originally I figured reading the book Magic Pill, the Extraordinary Benefits and Disturbing Risks of the New Weight Loss Drugs, I thought that was going to cover most of my informational needs, but in some ways I walked away from that feeling more conflicted than before. So all that to say, I had to remind myself several times we're going to try our best to stay in our lane of specialty here. We are not here to litigate the scientific or medical ins and outs of weight loss drugs. And we're definitely, definitely not here to reach some sweeping conclusion like you should be on a GLP-1 or you shouldn't be on a GLP-1. Instead, we're here to interrogate what their blockbuster success on the market means and what might be coming next.

Welcome back to The Money with Katie Show. I'm Katie Gatti Tassin. And before we dive in, if you're fatigued with a never ending discourse around weight and thinness, I completely understand and no hard feelings, if you would like to jump off this rollercoaster before it starts barreling down the tracks and join us again after this series ends.

But if you're along for the ride, let's talk about how this episode idea was formed. Because while it's taken a while to fully flourish, the germ of this episode was an email I received last year from a reader we'll call Casey, who sent me an Economist article called “The Economics of Thinness.” Casey described a lifelong struggle with her weight and body image, and she told me about a recent trip to the doctor where she was recommended a GLP-1 agonist the class of drugs known more colloquially by the brand names like Ozempic, or Wegovy, or Mounjaro, or Zepbound.

The kicker was that because of Casey's insurance and a lack of negative health markers, it was going to cost her more than a thousand dollars a month. The article she attached carried an eye-popping sub-headline: “It is economically rational for ambitious women to try as hard as possible to be thin.”

Here's an excerpt: “All women eventually recognize the importance placed upon their bodies. It is as though girls are walking through a forest unaware and are then shown the trees they can, how the trees got there, how long they have been growing, and how deep their roots really go. But there is little they can do about them and it is almost impossible to imagine the world any other way. And the fiction, that clever and ambitious women who can measure their worth in the labor market on the basis of their intelligence or education, need pay no attention to their figure is difficult to maintain upon examination of the evidence on how their weight interacts with their wages or income. The relationship differs in poor countries where rich people are generally heavier than poor ones.”

So it's kind of interesting, right, that our cultural attitude toward a person's weight varies by whether weight is associated with affluence or poverty in a given country. Just put that in your back pocket. And you may be familiar with the common explanations for this trend, at least in the US, that rich people just have access to higher quality food and they have personal trainers and they're often less stressed out and they are more likely to have leisure time. All of these things and these things are true, but as the Economist piece points out, “The problem with all of these explanations is that the correlation between income and weight at the population level in advanced countries is driven almost entirely by women in America and Italy. The relationship between income and weight or obesity is flat for men and downward sloping for women in South Korea, the correlation is positive for men, but this is more than offset by the sharply negative correlation in women in France. The relationship slopes gently downwards for men, but the slope is much steeper for women. These kinds of patterns seem to hold across most rich countries and appear robust to various ways weight or obesity might be measured.”

So at the risk of sounding glib, it's a little bit like that line in Mean Girls that if you're a woman in a rich country, you are not fat because you're poor, you're poor because you're fat. And I hated the way that that felt coming out of my mouth probably as much as you hated hearing it, but hopefully you get the point. It's possible that we've had the correlation here backward all along. Research in countries like Britain, Canada, Denmark and the US found that thin women have higher salaries. The penalty for an obese woman is significant costing her about 10% of her income.

[Audio Clip]:

In fact, the correlation is so strong that for an obese woman of average height losing 65 pounds could have the same impact on her wages as gaining a master's degree.

Katie:

And this prompted Casey to ask me a tender question. Do you think paying for this drug could be an investment in my lifetime earnings?

And for reasons that are probably obvious, just sent me spiraling, it felt somehow more personal and gut wrenching than other conversations that I've had about the extent to which investing in this standard acceptable feminine appearance, also known as the hot girl hamster wheel on the show, could be classified as an economically rational choice, even if it's also bleak as ****.

For some reason, this message—in which another human being struggled to wrestle her own human body into submission under the cold economic logic of return on investment—struck me as indicative of a societal low point in the way that we value people and especially women who do not conform to a Western market informed ideal of what it means to be worthy of basic dignity. And so no wonder that article concluded that it's economically rational to want to be thin, but where does that leave us? Well, for many, I think the answer is conflicted.

We're going to take a quick break and when we come back, we'll explore the GLP-1 agonist landscape.

Previous guest of the show, Samhita Mukhopadhyay captured this parallel between thinness and virtue and the conflict therein. In an essay for the Cut writing about getting a Mounjaro prescription, she wrote, “I walked out of the doctor's office white hot with shame about my health... Despite my doctor's optimism, the thought of taking a weight loss drug felt both like giving up on and a betrayal of the body positivity I had struggled so hard to achieve.”

Speaking of shame, I heard that word or similarly—guilt—a lot while researching this episode, and I think that's telling there's a bootstrappy, Protestant work ethic element to the way we treat our bodies. The moralizing of suffering and valorization of individual effort leads us to associate thinness with virtue in much the same way, I would add that our culture often associates wealth with virtue and a lack of thinness as somehow evidence of a personal failing.

But that parallel should probably be instructive to us. If you spend any time learning about social mobility in the US, a country that is ranked 10th in the OECD for income mobility per the World Economic Forum, you know that the best predictor of whether you'll be rich in America is the social class you are born into, which is a personal characteristic that you have no control over.

To extend this analogy, according to a 2015 paper from the Global Financial Literacy Excellence Center called “Optimal Financial Knowledge and Wealth Inequality”, researchers identified financial literacy as responsible for somewhere between 30 and 40% of wealth inequality in retirement. So put another way, financial literacy or a lack thereof, that is understanding how to manage money and making the accordant choices is estimated to account for about one third of your financial outcome on average and the other two thirds, well, those are attributable to factors that are bigger than you or me. So knowing this, why would we assign personal moral value to the attainment of wealth? And the same question could and should be asked of thinness.

But let's back up a second. Let's understand some of the terms that we'll be using today as well as the business landscape they exist within.

GLP-1s have been studied since the 1980s, most notably with a medicine called Byetta. Per the National Institute of Health, it was approved by the FDA in April, 2005 for glycemic control in type two diabetes patients. And interestingly, the prices of the pens back then were much cheaper than they are today, around 1800 to $2,200 per year.

Flash forward to December, 2017 when the FDA approved Ozempic for the treatment of type two diabetes. Now Ozempic is the brand name that we casually use often when discussing this category of drugs that contain active ingredients that mimic satiety hormones in the human body and Ozempic is for treating diabetes. Wegovy is its weight loss sister and it contains a higher dose of semaglutide, the active ingredient that mimics the human hormone than Ozempic does.

And according to KFF, these drugs have been approved to treat three groups. The first is individuals with type two diabetes. The second is individuals who are considered obese, and the third is individuals who are considered merely overweight with at least one quote, weight related health condition such as cardiovascular disease, high blood pressure, high cholesterol, a prior stroke, a prior heart attack and chest pain.

And the health effects seem promising, based on the clinical trials after 32 weeks on the drug. One study observed pretty significant positive health effects, including better blood pressure, cholesterol, A1C levels and reductions in heart attacks and strokes.

Both Ozempic and Wegovy are manufactured by Novo Nordisk, which is a Danish company that owns the patent for the semaglutide molecule in the US until 2032. These drugs have made Novo Nordisk almost unbelievably large. The company now has the highest market cap of any company in Europe. And is now a good time, maybe a bleak time to do a little victory lap that I have been harping on the need to diversify your holdings outside the US for the last couple of year? Maybe I'll save that for later.

Then you have Novo Nordisk's, American Pharma giant counterparts, Eli Lilly. Eli Lilly produces Zepbound and Mounjaro, which are Wegovy and Ozempic competitors respectively, and they intend to make more.

[Audio Clip]:

So there's more than a hundred million Americans living with a BMI above 30 and we are serving less than a million today. So it's really a fantastic opportunity of helping patients, but also of course growing our business.

Katie:

According to Jia Tolentino's reporting for the New Yorker, “Eli Lilly and Novo Nordisk together have at least 12 more obesity medications in development. Novo Nordisk reportedly spent about a hundred million dollars advertising Ozempic in 2022, and the two companies are spending roughly $10 million annually on lobbying. A primary focus of that lobbying is the proposed Treat and Reduce Obesity Act, which has been introduced and congressional sessions annually since 2012, and which would require Medicare to cover among other treatments chronic weight management drugs. Anticipating the passage of this bill within the next few years, Morgan Stanley has forecast that US revenue from such drugs will increase 400-fold by the end of the decade. Obesity looks set to become the next blockbuster pharma category. It declared in a report last year, which also predicted that social media and word of mouth will create an exponential virtuous cycle around the new medications. A quarter of people with obesity will seek treatment from physicians up from the current 7% and more than half of those who do will begin taking medicine. In March, Weight Watchers acquired the telehealth weight loss company, Sequence, which specializes in prescribing GLP-1 drugs.”

And it's not just industries you would superficially associate with diet culture that are poised to be remade in Ozempic’s image. Other coverage points out that everything from airlines fuel costs to the size of our clothing to the food system itself will change. If these drugs become widely used and widely used, they probably will be. The New York Times FX-Hulu documentary Weight of the World reported that by 2030 its estimated 30 million Americans will be taking them.

Hell, the field of medicine itself might change for someone who medically benefits from these drugs. A lifelong GLP-1 might replace a cabinet full of other drugs, but they no longer need. And theoretically, it is a lifelong commitment as they're designed to treat chronic disease, which is economically speaking for a pharmaceutical company, ideal.

Novo Nordisk's growth accounted for almost all of the economic growth in Denmark in 2023. And as miraculous as these drugs might be scientifically, it's hard not to feel just a little skeptical when you hear the way the drug companies discuss this innovation. According to the New York Times reporting, “The company crowed to investors last year that had hoped to strengthen obesity leadership and double current sales aspiring to surpass $3.5 billion in sales of its obesity products, including Wegovy by 2025.”

[Audio Clip]:

In just a few years, Ozempic has become a household name and a cultural phenomenon. GLP-1 drugs are everywhere and already one in eight US adults have tried them. The Danish company that makes Ozempic is worth more than the Coca-Cola company and McDonald's combined.

Katie:

Maybe part of my queasiness about the business element of all of this drug manufacturing is due to the pretty rough history of weight loss drugs inadvertently creating other serious health issues like fen-phen in the 1990s, which seemed at first like a revolution before it became clear that it caused among other things cardiac valve damage leading to death in some patients.

[Audio Clip]:

The first Illinois lawsuits been filed against the makers of Fen, a Chicago law firm filed a class action suit today. It comes after the Food and Drug Administration last week urged the recall of Fen because of studies that link it to heart problems.

Katie:

Or Belviq, a more recent edition that was recalled several years after its FDA approval when they determined that the potential risk of cancer outweighs the benefits.

Still these drugs have been around in some capacity for 20 years for diabetic patients, so they do carry a much longer track record and therefore a higher degree of confidence in their safety. Regardless, it's worth noting that the FDA currently warns that it has witnessed the development of thyroid tumors in rodents on semaglutide and that it can be dangerous for those with a history of pancreatitis. There are of course the common side effects, nausea, constipation, diarrhea and vomiting, your standard set of GI symptoms.

All that to say, what I found in my digging was a lot of ambivalence, but also a lot of people who described their experiences on these drugs as nothing short of miraculous and life-changing, how previously untenable chronic illnesses abated or how their brain's constant fixation on food went quiet for the first time, how they felt like they were in control for the first time.

[Audio clip]:

I didn't have that food anxiety that I've had most of my life where it's like, did I eat enough? Did I eat too much? Should I eat in two hours? Should I, no. Oops. My stomach growled like, oh my gosh, I didn't get ahead of my hunger. You know what I mean? All of that was gone. My mind was quiet, it was incredible.

Katie:

And so much of the current cultural conversation around these medications feels like it ping pongs back and forth between whether we should be working to de-stigmatize weight loss drugs or fatness itself. Michael Hobbes, co-host of the brilliant podcast Maintenance Phase that he produces with Aubrey Gordon made an incredible point on this topic, and I'm paraphrasing here: The stigma that surrounds taking Ozempic is also the stigma of fatphobia. It is the same stigma. The moralizing of taking the easy way out only exists because fatness is perceived to be a moral failing and therefore you should be taking the moral way out which is suffering.

To extend our earlier analogy, the stigmatization of being poor is very similar. The belief is that someone is poor because they've done something wrong to deserve it, and therefore they should have to earn their way out of that status. And this is why you typically see actions judged differently depending on your socioeconomic standing, which gives us that joke, like what's classy if a rich person does it but trashy if a poor person does it?

In fact, it feels like this cultural moment perfectly captures a lot of conflicting realities and double-sided mirrors. On one hand, I think it's fair to be skeptical of any supposed band-aid solution to sociopolitical challenges that doesn't meaningfully address the elements of modern life that make us unhealthy, particularly because all pharmaceuticals carry some level of risk. And at the same time, this notion of the band-aid can devolve into objections to the use of Wegovy for weight loss because it's seen as taking the easy way out, which this is the argument that I think Hobbes and Gordon successfully deconstructed.

It can be great that this product which can be lifesaving in some cases exists. And at the same time, it's concerning that it may signal that metabolically healthy people who do not look thin and therefore are not perceived as being healthy, are probably going to have an even harder time accessing healthcare without being recommended that they take this drug because fatness on its own is still widely perceived to be a problem.

So here's the generous take: Many of us are unhealthy, some of us are fat. These are not mutually exclusive. The reality is that all fat people in the west face social pressures and discomfort that thin people do not face. So if there's a drug that can make people thinner and I guess the shaky reasoning goes, therefore necessarily healthier, then that's a net positive.

And then there's the cynical take, which is that the social policies that shape our food and lifestyles in America have made many of us, fat and thin alike, unhealthy. And rather than ending billions in subsidies to make everything out of corn or increasing access to fresh food or creating more walkable communities or providing paid sick time or expanding healthcare coverage or shortening the work week, all work that is long and arduous and expensive, of course we're going to get really fired up about a branded product that the pharmaceutical industry too can make a lot of money from.

Of course, we are going to individualize a social problem that allows us to just sidestep the issue of weight stigma. And of course it feels really important to emphasize that both the generous and cynical explanations assume that fatness is inherently a bad thing and that we should all primarily be aspiring to thinness.

As Vox reports, “That's part of the Ozempic effect. Now that it is theoretically possible for anyone who can afford the out-of-pocket costs to get skinny, all the invisible contradictions of our cultures body politics are suddenly blindingly clear to have a good body. Our culture tells us is to have a thin body. There are bad ways and good ways of getting a thin body, but is there any good way to have a fat body?”

When we come back, we are going to unpack the cottage industry of competitors that have sprung up around these drugs and why they might carry risks that are not yet obvious.

Anytime there's a significant medical breakthrough with extraordinary business potential attached, you have a flood of interest in competition in the field. Cottage industries spring up around it promising the same effects for less money. But when we're talking about human health, this can generate some unwanted outcomes and I wanted to talk to someone responsible for crafting health policy about what trends they're observing in the space.

So I called up Shannon, whose work focuses on how to make sure people get the drugs that they need. Shannon, welcome. You are here in your personal capacity to share your own opinions about what you are observing right now, but can you give us a sense of your professional background?

Shannon:

Sure. I am actually an assistant director, we represent a huge number of the nation's physicians and I work in our Washington, DC office on federal policy and also run a lot of our interaction and advocacy with the executive branch of the federal government, so the federal departments and agencies. But for my portfolio, I work on a lot of different things but have a real focus on drug and device regulation. So that's where my background on the GLP-1s comes in. I've been working on drug policy for about 12 or 13 years now, so seeing a lot of different policy issues and worked on some of these from a lot of different angles.

Katie:

So how would you characterize what you're seeing right now with GLP-1 agonists? How do they kind of fit into the broader trends?

Shannon:

Everybody knows they're one of the hottest topics in healthcare broadly, definitely in drug policy, and it's been really wild, frankly, we're seeing a blockbuster drug come on the market that by all accounts appears to be very highly efficacious in the weight loss space, but we're having a really, really hard time getting the drug to people that actually need it for a host of really wild reasons. We're seeing so many different policy issues come into play right now that are things that frankly a lot of us in this space have really been fighting against for years. So we've got this blockbuster drug that's really, really expensive. We've got drug demand that's through the roof in a way that I don't think we've seen it with a lot of drugs in a really long time.

Those two things coupled together means there's really, really high costs for the healthcare system, which as we all know, tends to get passed on to patients in a variety of different forms. So we're seeing payers not cover these drugs for patients. We're seeing payers have really high cost sharing, so people that have copays for these drugs of hundreds of dollars or we're seeing payers just frankly drop coverage of the drug altogether. And if a patient wants it, then they're on the hook for the full list price of the drug, which is running in the thousands of dollars.

So this demand is also creating drug shortages for these drugs. They're getting better, but I don't think they're fully there yet. And we're also seeing a lot of demand not for clinical obesity necessarily, but for more cosmetic weight loss. And that demand is driving the somewhat cottage industry for compounding pharmacies that have a lot of concerns that come with that avenue as well. We're seeing pharmacy benefit managers play some games in this space, and basically it's every problem that we've had with drug policy and affordability and access is starting to come up with this drug.

Katie:

Yeah, well, there's a lot of coverage about these drugs being in shortage, and yet it seems like every time I turn on my tv, there is another ad for a pharmaceutical startup with millennial pastel branding and a lowercase label like “hims” or “hers” that's selling semaglutide for $99 a month or some lower cost than thousands of dollars. But it's my understanding that Novo still owns the patent for the semaglutide molecule. So how is this happening? How are businesses doing this?

Shannon:

Yeah, don't forget the influencers that have like 20% off codes, which is wild to me for some of these places. But I will say, I'm not necessarily an expert in IP law issues here. And so some of the questions about the patent issues here are questions I still have that I haven't gotten a ton of clarity on. But yes, you are correct. All of these drugs are still under patent protection and some of them don't roll off for quite a while. I think some of them might start coming off in about five or six years, which will be great.

But in the meantime, yeah, we're seeing the rise of these compounding pharmacies and then subsequently these very large telemedicine companies that are partnering with compounding pharmacies or bought their own compounding business that are really using some loopholes in the law to be able to produce these products on the scale that they're producing.

So I personally spent hundreds of hours of my time working on the legislation to regulate compounding pharmacies about 10 or so years ago. But the compounding pharmacy legislation was really aimed at trying to ensure compounded drugs were safe and then trying to prevent exactly what we're seeing happening here. The statutory intent there was to prevent compounding pharmacies from acting as defacto drug manufacturers, which is what we're seeing here.

We were supposed to prevent it on this scale, and really we were supposed to prevent knockoffs of branded pharmaceutical medications. So there are a couple of loopholes or exceptions in that law that do allow compounders to compound branded drugs if those drugs are in shortage, which is what we've seen and which is how they've gotten this opportunity to grow to the extent that they have. But some of these drugs are starting to roll off the shortage list, and so it's going to be a very interesting legal situation for these compounders to move forward.

They're not supposed to be compounding what we call essentially a copy of an FDA approved medication. Compounding pharmacies are supposed to provide very individualized services. A patient that needs a liquid instead of a pill that can't take a preservative-free drug, sometimes they repackage drugs for needs that are not met by the branded market and they fill very important roles there, but they were never supposed to be what we're seeing them doing now. And there's a little bit of questions I think about maybe some of the ethics around how they're trying to skirt some of the loopholes or skirt around the laws to keep doing this going forward.

Katie:

Basically, because these drugs, Ozempic, Wegovy, et cetera, are coming off the shortage lists, that means the compounding pharmacies are not technically going to be allowed to produce exact copies or knockoffs of them anymore, but something called personalized prescribing is still allowed under the law or changing small elements of the prescription. So for example, the dosage that make it slightly different than what the pharmaceutical company is selling and still has under patent. And my understanding of the relationship between the pharma companies and these compounding pharmacies is that it's tense and somewhat inherently adversarial.

Before I looked into all of this as a person who did not have your background, who did not understand how any of this was working, the advertising campaigns that I often see definitely position it as though it is the same thing. There's two different reads of it, right? There's the generous read, which is like, well, pharmaceutical companies make a lot of money on these drugs and we do want to improve access.

And I think there are a lot of Americans who kind of understand that there is often a branded expensive version of a drug and then the generic version, and really what you're paying for is the advertising or the marketing, and that extends beyond the pharmaceutical realm. But just in general, I think there is that that is the dynamic or the perception around some of how this stuff works. But I do think that when I learned that it's actually not technically the same thing, that was a complete curve ball for me with the business practices part of it aside, I think the natural next question is what does that framework then indicate for patient outcomes and patient health?

Shannon:

That's a really interesting question at the end of the day, and I think question that I'm certainly grappling with, given my work on this issue going back a long time, and I think a lot of other folks are most large professional associations and at this point I don't think would recommend the use of a compounded product here. I think folks really need to understand that a compounded product is not an FDA reviewed or cleared product. It does not come with the same assurances of quality of safety, of efficacy as an FDA approved product. And when I say FDA approved product, you do have your branded products, your branded manufacturers that we're seeing right now, your Ozempics, your Wegovys, your Mounjaros, and then ultimately once those kind of roll off patent and their exclusivity expire, we'll ultimately see generics.

Also, I think some of the older originators are actually starting to see some generics now, and those are also FDA reviewed and approved for use. So the compounding issue definitely raises some questions and some risks. Compounders play really important roles in healthcare, like I mentioned, but they are of varying quality and are not regulated to the extent a regular drug manufacturer would be. So you will frequently see situations in which you might question the source of their supplier for the active ingredient in the drug, which can come with varying quality and purity concerns.

You'll also see a lot of these compounders right now, again, in somewhat of an attempt to get around some of the legislative requirements on them are starting to compound with what is likely unnecessary additives. You see a lot of them saying they're advertising as they're compounding with B12, but doing that raises another risk, right? We don’t know how it affects the stability of the product, the efficacy of the product, things of that nature. And then we also are starting to see this kind of concerning problem in that, and the compounded versions come in at a little multi-use vial.

So you basically have to drop your own shot with a syringe. It doesn't come in an auto-injector like the branded medications do that are pre dosed all set up. You just kind of stab yourself and go. And that can really potentially pose a lot of risks and that you can accidentally misdose yourself when you're drawing up your own dose or we've started to see a lot of promotion through social media and things of actual misuse of the dosing, and you should dose yourself more frequently or you should drop a larger dose of this because you'll lose weight faster. If you're not losing the weight, just give yourself more. These drugs are really safe from a broader adverse event perspective, but improper dosing can also carry some very serious risks, mostly gastrointestinal side effects; that can absolutely and have absolutely under people in the hospital. And these telemedicine companies and the compounding pharmacies really don't provide any appropriate oversight and care management for when that happens like you would if you were having it managed by a physician. So definitely a lot of potential concerns.

Katie:

I guess to clarify, if I were to go to a doctor and be prescribed this medication, that physician and I would be in more regular communication about how it's working, they'd be checking in. I assume there would be follow-up tests or I would expect there to be follow-up tests. But if I am engaging with one of these, I guess I'll call it, an online pharmacy where the value proposition is you don't have to talk to a doctor, you don't need insurance, you can just answer this questionnaire and we'll mail you this vial and syringe. Then there is now no longer any sort of interfacing happening with a medical professional that I guess I would assume like a Novo Nordisk would say, “The physician is a key part of this in order for this to go well and for it to be administered safely.”

Shannon:

Yeah, no, absolutely. And again, these drugs are widely safe, but all drugs come with risks. I mean, even your Tylenol, and these ones can be potentially serious. So really truly, when you're talking about this serious of a sterile injectable medication, it is something that you definitely want to work with your physician on. You want a thorough evaluation of your health status of potential contraindications to using this drug, and you want continual management by physician of your care of how it's impacting you, so they can help you adjust dosage, things like that.

And these telemedicine companies, again, you click through a questionnaire for a lot of 'em, you might talk to a prescriber that they employ for a couple minutes and they start mailing you drugs. I do know they provide support if you do have an adverse event, there is some support there, but it's not necessarily the kind of continual care management that you need and that you would get from working with a physician or other healthcare provider directly.

Katie:

To summarize, it's not that any laws are being broken, it's just that there maybe running afoul of the intent of the regulation that they're exploiting. And because this was maybe an unforeseen, no one knew that this was going to happen or that law or that regulation was not designed with the situation in mind. And so now you have, I would assume, regulation trying to catch up.

Shannon:

Yeah, there's a lot going on with the FDA right now. There's some lawsuits that have been initiated back the other way that is just pulling a lot more concerns and making this even bigger and touch more areas of policy than it probably would have otherwise. You are correct. Maybe there's not a specific violation of the laws, but they're certainly being exploited to the full extent to further a business practice that I would characterize as somewhat running afoul of what the statutory intent of the original legislation to regulation.

Katie:

Oh, running afoul of the statutory intent. She said, wonk present, ready to talk about the law.

Shannon:

Let’s get nerdy. Drug policy is my passion.

Katie:

So I'm curious then what you see as the long-term effects in a health system more broadly of the presence of these GLP-1 agonists.

Shannon:

I think it's really probably too early to tell what the long-term impacts are going to be, and from a couple different ways, as we discussed. And everybody knows these drugs are really, really, really expensive, which pose a potentially huge financial burden to the healthcare system into the payers at the end of the day. So if they were to go ahead and cover all these drugs for all the people, they want them, we're talking about a massive budget buster here, and for better or worse, healthcare budgets are not endless and they are constrained. So we've got a potentially huge financial impact on the system. If the system does not necessarily want to bear that cost, they are going to pass it on to you in the forms of increased premiums. And that will not be just for people on these drugs. That will be for everybody. Some payers we are seeing or some plans have made the decision, they don't want to pass those costs on to all of their insureds, so they've declined to cover them. So big, big financial implications.

But obesity is also a financial strain on healthcare systems, given what we know about obesity as a disease and the health risks that it poses. So from that perspective, there is the chance that these drugs that seem to work really, really well for weight loss actually do end up alleviating the burden of obesity on the system over time. That hasn't happened yet. We are not seeing that happen right now, but we may see that in the long term if we can get the policies. So it's a wait and see on the broader policy impacts, it could go a lot of different ways, and I don't think we have enough data to note either way.

Katie:

Well, I want to get into that argument a little bit about making the drugs more accessible and the cost of access versus the cost savings, because I think that in a lot of ways it does kind of rely on that assumption that being fat is a dangerous condition. And that by, if you eliminate obesity, you will then save a bunch of money on all these expensive health side effects. But when I think about these health insurers and the decisions that they're making and the fact that they are solely in business to make money, it's kind of leading me to this question where I'm like, well, if that were true, and these insurers have thousands of people crunching the numbers for them, the data scientists, the actuaries, the unlimited health data practically over outcomes and patients and what have you, if they are not reaching that conclusion, if they don't see it that way and they're not keen on approving it widely, I guess it makes me wonder is there some question or recognition behind the scenes that maybe the relationship between health and weight is not as straightforward on its own, at least economically as we've been led to believe.

And so I'm curious if these insurers widely believe or operate under the assumption that they will save a bunch of money if fewer people are obese, wouldn't that prompt them to want to cover it more? I'm just curious what you make of those coverage decisions in light of those various stances because they seem a little at odds to me.

Shannon:

No, and I totally understand that, and to a certain extent they are. But I think there's a few factors that come into play here, and I would say with the GLP-1 agonists in particular is the thing that changes that paradigm potentially is simply the phenomenal cost of these drugs. If we were paying the same for these drugs that they're paying in the UK or in Germany, which we all know is substantially less, we might not be having this discussion about coverage for these drugs, but you are looking at a thousand dollars a month or so, or probably $1,000 to $1,600 a month per patient for these drugs, that's a massive increase in drug spending for payers. So I think you've got that really impacts kind of that paradigm of value, like the cost, the benefit analysis that we have going on here. I think payers have for a long time not covered any anti-obesity medications.

Even some of the predecessors that were much cheaper and probably because they didn't actually necessarily work all that well. Most payers will cover bariatric surgery, they will cover behavioral counseling for lifestyle modification interventions. But I don't think previous to these drugs, we've seen a lot of things have the efficacy that we would like to see.

And I think we are consistently fighting still against a little bit of this idea of stigma about obesity that the medical community is at least long recognized, is not just because you don't have willpower. Clinical obesity is a disease with many physiological components that contribute to it, and it's not always eat less and you can manage this. But I think there's been a prevailing perception that the people that are abuse and suffer just suffer from a willpower issue or they don't want to exercise. We know that's not really true, but I think policy also has not completely caught up with that.

But obesity is a disease is much more complicated than that, and we know that there are elements of disease that are physiological in nature that make that not just as easy as a willpower issue. So yeah, we're fighting an uphill battle, I think against this continued stigma around obesity and weight loss, but at the end of the day, it's a cost consideration. Everybody's bottom line in this business right now, what are you willing to pay to lessen the risks? What costs you more? And right now, I don't think they are convinced that it's cheaper to pay for the drugs 10 years from now, we might be in a different situation.

Katie:

It's very fascinating. It's a really fascinating analysis and challenge.

Shannon:

One of the interesting things too, and I hate saying this, but it's kind of true and it comes with a compounding issue, is that part of the reasons that I didn't mention that it's bad policy to a certain extent is I will never defend a pharmaceutical company on price. It's just not something I can get on board with. But I don't think any of us can deny that pharmaceutical companies play an indispensable role, literally not live as healthy and as long as we live without pharmaceutical interventions, and many cases—

Katie:

Modern medicine is great.

Shannon:

But I don't think people quite understand how many billions of dollars go into pharmaceutical research and development. It is not a cheap proposition whatsoever, and if we do want companies to continue to engage in drug development, they do have to be incentivized to do so at a certain level because the health insurers like the compounding pharmacies, they're a business at the end of the day, however much we don't like it, if you allow a company or pharmacy to come in and start knocking off a brand new drug with some ease, what do you do then to the incentives for manufacturers to continue to engage in drug development, which is so critically important to me, that's a big problem, and that's coming from somebody that will rarely defend a pharma company.

Katie:

Sure. Yeah. And I mean, I'm curious with your role, to what extent is that funding provided by the companies themselves and how much of it is provided by say, the federal government? Because my understanding was that the federal government also helps to fund necessary R&D, but I'm not sure if we're talking like a 90/10 thing or like a 50/50. I'm sure it varies, but what's your impression of that?

Shannon:

I couldn't really tell you that there's some consistent split in how that works, but the federal research component really comes in what you would term more like basic research and development versus the more complex true drug development like R&D that the pharmaceutical companies do. I would, that probably varies pretty widely depending on what drug that you're talking about. The federal research dollars absolutely play a role in how we ultimately get from nothing to something, but I just couldn't tell you with a lot of certainty exactly how that ultimately breaks down and where it's in different places. So the transparency about cost and pricing is not necessarily something that the pharmaceutical companies are—

Katie:

It’s not being rioritized. Okay. Yeah. Well, I mean it wouldn't really behoove them to be shouting that from the rooftops. If it's like a lot of the money that's going into r and d is public funding, then the privatization of the profits that follow isn't a very good look. It's a less defensible position, I would say.

Shannon:

Yeah, that is a conversation a lot of people have been having for a very long time with. Oh, so I'm not onto something new here.

Katie:

Darn.

Shannon:

No, unfortunately. Unfortunately not.

Katie:

Well, it was a pleasure to speak with you. Thank you for joining today.

After we hung up, I started thinking about what would drive me to mail order chemicals from a potentially unknown source with which to inject myself. And at first it seemed really risky, but maybe the best way to think about the demand at scale for this, because obviously there's a lot of demand, is as evidence of how hard it is to be fat in our culture and how much someone might be willing to withstand or risk for a chance to be thinner. It's like the Economist said, “It's economically rational to want to be as thin as possible.” That is less an indictment of compounding pharmacies, producing semaglutide dupes and more an indictment of the culture that surrounds them.

But on that last question that Shannon and I talked about, if you are responsible for running a health system, you're engaged in a constant cost-benefit economic analysis.

How do you deliver the best long-term health outcomes most efficiently and with the lowest costs? Medicare does not cover Wegovy for weight loss and few state Medicaid programs do, and as we know, this drug is expensive. According to New York Times reporting, sales data from the pharmaceutical companies indicate that the insurance companies are paying much lower prices for these drugs than consumers who are buying them directly. Wegovy's net price or the average price that Novo Nordisk is most often receiving for it is around $700 per month. It's $300 for Ozempic and $215 for Mounjaro. But for the individual consumer without insurance or those with insurance whose coverage won't cover the GLP-1s, and so they must pay out of pocket, per GoodRx, Wegovy's price is $1,350 per month, $995 for Ozempic and up to $1200 for Mounjaro. Roughly half of people who reported taking a GLP-1 said they had difficulty affording the medication.

And while part of what we're going to talk about more next week with Dr. Gordon is that weight is not the best proxy to emphasize for health outcomes. Those who are making large scale policy choices for health systems about what will or will not be subsidized are trying to understand if the health benefits of these drugs are worth the expense of increasing access to them. And I realize this calculation sounds pretty cold and harsh, but again, it's interesting to me from the standpoint of assumptions that fatness itself is an expensive and dangerous condition.

One study that was included in the New York Times reporting found that obesity is associated with $1,861 in excess health costs per person per year. And if you take that analysis at face value saving $1,800 a year in annual health costs cannot economically justify a public investment of even the lower insurance company pricing end of these drugs.

According to the Congressional Budget Office's calculations, the cost savings claims are relatively uncompelling. So please excuse the boring government vernacular: “Cost and savings per user weight loss is associated with reductions in health-related spending per user that are less than the estimated federal costs per user of covering these medications throughout the 2026-2034 period per user. The average direct federal cost to provide the medication would be roughly $5,600 in 2026, decreasing to $4,300 in 2034. And average offsetting federal savings would be around $50 in 2026, reaching $650 in 2034.”

In other words, by next year, you would save around $50 bucks in public health costs for every $5,600 spent on increasing access to weight loss medications. By 2034, they would expect that same equation to be $650 in savings for every $4,300 spent. Though one expert I spoke with said that the data used in these calculations on what sort of savings you could expect is somewhat limited.

Maybe this is because as Tressie McMillan Cottom writes in the New York Times, your access to these drugs can in practice be more highly correlated with how much money you have than your physical health and needs. She describes her socioeconomic status as a person who has access to concierge medicine: “I was overweight before I entered the concierge medical office, but being overweight was incongruent with a person who could afford concierge medicine. My doctor assumed I would want to be thin in many ways. She was providing exactly the service I didn't realize I was paying for acculturating me to the expectations of the right body for my station. Minimizing weight stigma was a health service, even if my health indicators did not require intervention”

She wrote about how despite being technically overweight her A1C, the measure of average blood sugar levels over the past months was normal, bordering on low. Even her metabolic health markers were great, but her outward appearance did not match her health report card. She wrote, “I switched doctors when I realized one of us was rooting for me to be sicker so I could afford to be skinnier in her defense. That is exactly the equation that GLP-1 drugs present to the millions of Americans who need health insurance to afford them.”

So what does this mean as she writes, much like Casey, the listener whose question sparked this episode for now, cash-strapped American consumers are left to contend with a society in which the price of being fat is so high that there will always be a rational reason to pay an exorbitant amount to be thin.

One such cash strapped American, we'll call her. Judy reached out to me after I posted about doing this episode. Judy told me she's 47 and about 10 years ago she was diagnosed with pre-diabetic insulin resistance.

Her grandmother and her father were both diabetic and at an endocrinologist appointment in 2019, she was offered a new medication Ozempic. She was told it would help with insulin regulation and many of her symptoms, and it did immensely. Her blood sugar levels returned to normal. Her hunger levels returned to their pre-diagnosis state, and at the time her insurance covered it. But about a year and a half ago, she says they stopped.

Judy wrote, “My claim appeal was of course denied. The cost of Ozempic then was right around a thousand dollars per month. I work as a flight attendant and I cannot afford it. I have many feelings around privilege and Ozempic and fairness of this predicament that I found myself in. The solution I found for myself was procuring it on layovers in other countries, though it's not available for non-residents in many places. For example, Italy, which is my regular route, I was able to buy it in Spain at the time, but not anymore for only 136 euro. And the pharmacist was apologizing for the high cost for non-residents. My recent purchase was in London for 300 pounds. It's upsetting to see the price difference between the US and these other countries. I'm lucky that I'm able to get it because of my job, but it's still a constant stress in my life because I can't always get the work trips where I was previously successful buying Ozempic. Or often when I go back, it's not available anymore to non-residents or they're out. I often run out and have to do half doses or skip weeks of treatment.”

The severity of these issues of inequality in access reached a high point during the shortages of 2023 when people with type two diabetes found it all but impossible to get the drugs they needed to stay alive. As Shannon noted, once the implications for cosmetic weight loss became clear, anyone with disposable income could purchase it and the manufacturers couldn't keep up. This illustrates how for some people access is their primary issue. For others, it's something else.

Lili, you wrote a three-part series in Jenny Magazine about your experience taking and then getting off Mounjaro, and in part one, you talked about your experience deciding to take the drug you wrote. I sat in my doctor's office discussing what to do about the weight I'd gained over the past two years. Despite my virtuous eating and intense daily exercise, I was ready for the answer to be a prescription. I also felt guilty that I hoped the answer would be a prescription. Why guilty?

Lili:

Yeah, it's a good question. I think in our society as a whole, there's a lot of guilt around weight and there's a moral, it feels like a moral bankruptcy. If you've gained weight, it means you're failing somehow. You're eating too much or you're not exercising enough and feeling like, well, I'm doing those things correctly. I'm eating half of the calories that I should be eating as a normal person on any given day, and I am averaging five to eight miles of walking a day plus, oh, I live in New York City. So it's not difficult, but it's not normal. So having that kind of physical activity and virtuous eating felt like I shouldn't be gaining weight.

And if I need a drug, that means I'm doing something wrong. We take drugs to fix something. There's none of this guilt around taking insulin or what other kind of life sustaining drugs that people take with modern pharmacology. But for some reason there is such guilt around weight, and I think it's because our society has created this kind of ideal. The idea of a BMI index in general, it tells you, you are supposed to weigh this thing based on your height and your gender, and if you're not, you are bad.

Katie:

So you begin taking it, you get on the drug. What was that like?

Lili:

It felt too easy to get it from my doctor for one. So I felt like I just won some kind of secret prize that he had pulled it out of his refrigerator in his office. There was no prescription. A drug rep had given him samples and he had it in his office.

And so I'm in my mid forties and at the time, and because I'm suddenly responsible about my health, I'm going to an annual physical. And the year before, we had discussed the weight gain and he had offered, and he's like, well do these things over the next year and we'll talk about it again. So I did. And when the discussion came up again, I did not expect him to be like, oh, sit tight and walk into the other room and pull up his little mini fridge and pull out a box of medicine that is a thousand dollars a pop. It felt exciting and illicit and also a bit scary.

Katie:

It strikes me that your experience was one of kind of illicit thrill at how easy it was to get it, because so much of the conversation around these drugs right now is about access and the lack of access and how hard they are to get. And so I was very struck by that in your piece and in your story once you go on it, how did it feel in your daily life when you first start taking it and you sort of noticed the inner monologue is changing a little bit. What was that process like?

Lili:

I was laid off when I got it, so I had health insurance, but I knew that this thousand dollars prescription wasn't something I was going to be able to sustain if it worked for me. And I said to my doctor. I'm not sure if the insurance I have, we'll cover it. And he said, well, we'll get to that. We'll cross that bridge when we to it. If you don't have it, I might be able to get you some more. So there is an interesting access question there. And so it was a surprise too, but once I started taking it, I held onto it for I think about a week in my refrigerator before I got up the nerve to take it. I am an anxious person by nature. Taking medicine makes me anxious. So this felt like it was going to be a big deal and I kind of needed to work up my nerve to do it.

I had planned it for, I want to take it on a, I think it was a Saturday morning, I share custody with my kids and my kids were going to be away and I didn't want to be sick and have them around. So I waited until they were at their dad's for the weekend and I took it and I immediately got this kind of metallic taste in my mouth, which freaked my anxious brain out and dove down a bunch of Reddit subreddit rabbit holes to see if that was normal or not.

Katie:

I’m glad that that's a universal experience.

Lili:

Oh, absolutely, absolutely. And interestingly, it was where I found the most information because the generic drug information only shares the really big dangerous warning signs if you're vomiting, call your doctor kind of thing. But these other small side effects aren't really elaborated on at all. So I felt that kind of metallic taste and I had to distract myself from that.

So I picked up an apple and I was going to go out for a walk, which is something that I do on weekends. I'll do like a five mile walk when it's beautiful weather out. It was a perfect day to do it, and it was such an odd sensation that a lot of people described the food noise going away, which eventually happened. But what happened first was food felt disgusting. It was a very strange sensation to be eating an apple, and it was beginning of fall, farmer's market apple, like a honey crisp that I knew should have tasted amazing.

There was an immediate change that felt like it had happened, and this wasn't like I injected it in five minutes later. This felt like this was probably over the course of the next couple of hours, but it was as soon as those next few hours where it felt wrong to have food in my mouth. It was so bizarre.

Katie:

I was so drawn to your narration of this experience. I thought you captured some of these visceral feelings and reactions and sensations so powerfully. And something that you talked about that I hadn't really seen elsewhere, because I've read a lot of personal accounts of this to produce this episode, is that a lot of people talk about this sense of fullness or satiety. I just don't think about food or I'm not hungry. But you also mentioned in your piece that you had been in calorie deficit states for years and intensely exercising and nothing was happening.

But then once you started this medication that you even noticed your heart rate during exercise was spiking more, which gave me the impression as a reader of it almost communicated like this isn't just about physically restricting the body from eating something more physiologically powerful is changing inside the body.

Lili:

That's what it felt like to me too. When I talked to my doctor about it, he talked about like, oh, it works on yes, suppressing your appetite and yes, insulin sensitization and those things are true. He's like, but it works in your brain in such a way that it changes XYZ, and I'm not a doctor, so I won't be able to explain it as well as he did, but that's what it felt like. It a full body experience. I did intermittent fasting for five plus years before this. That's peddled as a healthy way of eating and living, and it's probably really not. My ex-husband and I did it at the same time and on his body, he immediately lost 20 pounds and it took a significant time for my body to change at all. So it wasn't just calorie restriction. I know the intake was different.

And it felt to me like if my heart rate is going up to a level that it feels like it should, and I am using air quotes here while I'm exercising, maybe it wasn't doing it right before. Maybe I have a slow metabolism, maybe my resting heart rate, which has always been fairly low. Maybe it's supposed to be higher. Maybe this drug is fixing all of the things that have been causing me to kind of just slowly pile on weight because my body's just sluggish, for lack of a better word, my heart rate, my metabolism, the weight that I digest, food, everything it felt like had been turned on.

Katie:

It was interesting too because you are pretty forthright in part one about you were excited, you were pumped. You're like, hell yeah, this is working. I can feel it working. But then by part two, your initial excitement is beginning to curl. Why?

Lili:

I am a really analytical person by nature and an overthinker, so might call it, but I knew that it's not healthy to only be able to eat. And because I've done these years and years of intermittent fasting, you become really aware of calorie counts.

So I know that an egg is like 78 calories, and if I cannot finish a 78 calorie egg, those are my two meals, like half an egg and then a half an egg for lunch. That's starvation. That's not healthy. That's not everybody's reaction to the drug. But that was mine and it started to feel like it could be dangerous.

Katie:

And we will get to that and a whole lot more in next week's episode.

Our show is a production of Morning Brew and is produced by Henah Velez and me, Katie Gatti Tassin with our audio engineering and sound design from Nick Torres. Devin Emery is our chief content officer, and additional fact checking comes from Scott Wilson.