Challenges in the American Healthcare System

The American healthcare system is indeed struggling. It’s overly complicated, making it tough for people to access the care and medications they require. A striking 70% of Americans feel that this system has let them down. Frustration and anger about these issues are palpable. It’s becoming increasingly evident that the concept of a cohesive “system” might not even exist.

The emergence of GLP-1 drugs, such as Wegovy and Ozempic, has transformed our understanding of weight loss while revealing the shortcomings in healthcare delivery. Individuals who have battled weight issues for a long time understandably feel annoyed when they find out there are treatments available—yet they can’t access them. I even have three health insurance plans, but none cover my medication costs. For me, paying over $1,000 a month out of pocket for pre-diabetes treatment was a necessary, albeit tough, choice. But that’s simply not feasible for most people.

While these new anti-obesity medications aren’t a cure-all, they effectively address the health complications related to excess weight, including heart and kidney diseases, type 2 diabetes, and some cancers, as well as possibly certain types of dementia.

Obesity is a significant killer, with the health risks associated now damaging lives more than smoking does. Patients struggling with their weight often find themselves ensnared in a labyrinth of complex systems and daunting prices. Even if insurance doesn’t cover these drugs, patients have limited choices: endure financial strain, seek effective treatments, or depend on unregulated combined drugs that may not ensure safety or quality.

The last option carries considerable risk. With drug shortages and rising demand, dubious foreign manufacturers and distributors are offering cheaper alternatives with little regulatory oversight. These products often lack national standards, don’t guarantee quality, and often haven’t undergone rigorous FDA testing. This makes it nearly impossible for consumers to discern between legitimate medications and lower-quality imitations—an enticingly cheap option, but fraught with dangers.

Interestingly, the presence of GLP-1 drugs has prompted pharmaceutical companies to lower their prices due to market pressure. Manufacturers like Lilly and Novonordisk have created online platforms to sell GLP-1 directly to patients, skipping traditional pharmacies. Lilly has also teamed up with telehealth services to connect patients with doctors and dietitians specialized in obesity treatment.

Insurance may cover these medications in some instances, such as for sleep apnea or heart disease, but the criteria set by insurance plans can complicate matters. Employers providing insurance work with pharmacy benefit managers, resulting in many restrictions in an attempt to manage costs effectively.

Some insurers cover GLP-1 for patients at higher risk, like those with a BMI over 40, but many require that patients prove they’ve tried other weight loss methods first. Others enforce lengthy pre-approval processes, akin to those for other expensive drugs.

While these protocols might save some money, they jeopardize the health of countless individuals. One frustrated doctor recently remarked on the irony of insurance companies governing medical practice rather than facilitating healthcare, discussing patients with high BMIs who have no metabolic disorders yet need help.

In response to comments made at a medical conference by CVS Caremark, a pharmacy benefits manager, the shared sentiment is that we are grappling with a tedious system.

Collectively, the medical community, and society as a whole, have failed to acknowledge the biological properties of obesity.

Who exactly decides the appropriate treatment for patients? It’s puzzling why insurance companies seem to rely on different standards than board-certified physicians prescribing medication. Doctors often find themselves trying to navigate diagnoses that will sway insurers to approve treatments. Meanwhile, patients frequently lack a voice in this process.

This dysfunction seems largely rooted in attempts to cut costs, further complicated by the misguided belief that obesity can simply be overcome through sheer will. Our broader community, including medical professionals, often fails to recognize obesity’s biological aspects, contributing to prolonged disability and serious health challenges. The past several decades have seen our bodies decline under the constant temptation of addictive foods. It might be more beneficial to revamp our food environments than to rely solely on medications. However, a shift seems unlikely, and so we endure the consequences of the current healthcare landscape.

Still, the existing system seems incapable of addressing these issues. Drug prices remain excessively high, the FDA has faced significant cuts under the current administration, compromising drug safety assurances. Access to necessary medications has become a steep hurdle, leaving many Americans increasingly frustrated.

At this point, Americans shouldn’t have to worry about whether their insurance coverage is adequate to access the medications that could keep them healthy.

• David A. Kessler MD served as FDA commissioner under Presidents George H.W. Bush and Bill Clinton. He co-led Warp Speed in the Biden administration and was dean of medical schools at Yale University and the University of California, San Francisco. His latest book is Diet, Drugs, and Dopamine: The New Science of Achieving Healthy Weight.