Coverage Gaps and Challenges Ahead for Obesity Drugs

In a video interview with Pharma Commerce, Hyung Heon Kim, CEO of MetaVia, describes how the current US payer ecosystem, including commercial insurers and Medicaid, exhibits a divided approach when it comes to supporting access to obesity medications. Coverage largely depends on whether obesity is accompanied by additional health complications. He explains that there are essentially two categories of patients: those who are obese without any complications and those who are overweight or obese with related conditions, such as type 2 diabetes or Metabolic Dysfunction-associated Steatohepatitis (MASH).

For patients who fall into the second category—those with complications—insurance coverage is typically available. This is because obesity-linked conditions like type 2 diabetes are recognized as serious health issues that require treatment. Payers are prepared to provide coverage in these cases, acknowledging the need for medical interventions that go beyond lifestyle changes alone.

However, for individuals who are obese but otherwise healthy, coverage remains limited. Kim highlights that the current administration does not fully recognize obesity as a disease on its own, instead viewing it as a condition that can be managed through lifestyle interventions, such as diet and exercise. This perspective means that insurance companies are less inclined to cover obesity medications for patients who do not have related health complications.

Kim suggests that this approach overlooks the broader benefits of proactive obesity treatment, which can prevent complications before they arise. While insurers and Medicaid seem prepared to handle cases with associated conditions, they are not yet structured to provide long-term affordability and access for individuals seeking preventive care solely for obesity. In essence, the payer ecosystem is ready for treatments tied to co-morbidities but lacks readiness and policy alignment for covering obesity medications in otherwise healthy patients.

He also comments on how dual-action metabolic therapies address clinical or tolerability gaps observed in first-generation GLP-1s; alternative reimbursement or value-based contracting models that could be feasible in the short term, given CMS’ decision not to finalize coverage for obesity medications in 2026; market dynamics or stakeholder misalignments that need to be resolved for next-generation weight-loss drugs to reach scale without overburdening payers (from a commercialization standpoint); and much more.

A transcript of his conversation with PC can be found below.

PC: As utilization of obesity medications has surged in recent years, how prepared is the current US payer ecosystem—including commercial insurers and Medicaid—to support broader access and long-term affordability for these therapies?

Kim: You have to group it into two different buckets. Bucket number one is just obese people without any complications. Then, you have another bucket. Typically for overweight, you accompany other complications, like type 2 diabetes, MASH [or Metabolic Dysfunction-associated Steatohepatitis], and it goes on. When you look at the current insurance payers, when you have type 2 diabetes due to obesity, then your medication is actually covered.

With people who are overweight or obese with other complications, I think everyone's ready for it. It's just that if you're obese and very healthy—I don't know how that works—but if that is the case, then it's just like us. The companies don't really cover it. Under the current administration, I think they're saying that obesity is not a disease, you have to eat less and exercise. I think you have to look at it from a different angle. If you're looking at just obese, but healthy, I don't think anyone's really ready for it. Other complications, yes, everyone's ready for it.