The Ozempic Flip-Flop

Photographs by Kristian Thacker

A few years ago, West Virginia, which has the highest obesity rate in the nation, quietly began a small and unusual pilot program that would touch hundreds of lives: It started covering obesity drugs for state employees—even as many other insurers balked at what they considered expensive “vanity” drugs.

The program was, by health measures, a success. Patients shed as much as 120 pounds, their cholesterol dropped, their prediabetes faded, and they cut down on blood-pressure meds. As word began to spread, more patients wanted to join. A school nurse told me her weight loss inspired at least six other teachers and staff to get into the pilot program too.

Then it all came to an abrupt end. In March, the state’s Public Employee Insurance Agency (PEIA) decided it could no longer bear the crushing costs of Wegovy and Zepbound. (These obesity drugs are sometimes better known by the brand names Ozempic and Mounjaro, respectively, which is how they are sold for diabetes.) In the months after, PEIA patients began running out of medication. They rationed their remaining supplies, stretching the weekly injections to 10 days, two weeks, even three weeks. They considered copycat compounded versions. One woman began sharing her diabetic mother’s Ozempic. Those who could no longer get the drugs felt their “food noise,” the constant thoughts about eating that the obesity drugs suppress, return with a vengeance. And they have regained weight.

West Virginia’s pilot program is a microcosm of the dilemma posed by new obesity drugs that are at once effective and shockingly expensive. Patients, doctors, and insurers alike are stuck in an intractable situation. Since the program ended, Laura Davisson, the director of medical weight management at West Virginia University, told me, “there’s a lot of desperation that we’re seeing in our practice.” Her center was one of a handful in the state’s pilot program, which was always small; it enrolled about 1,000 patients at its peak, a tiny fraction of the more than 200,000 West Virginians who rely on PEIA. (About two in five people in West Virginia have obesity.) And these 1,000 patients have since become unwitting subjects in an experiment about what happens when patients are given a life-changing drug—only to have it taken away.

Megan Pigott is what one might call a Wegovy super-responder; she lost 120 pounds, more than a third of her body weight, after starting the drug in 2022. Before that, she had been counting calories since elementary school; she had tried SlimFast shakes, a cabbage-and-green-pepper-soup diet that left her miserable, and an older obesity drug called liraglutide. Nothing worked as well as Wegovy, which WVU prescribed for her as part of a weight-management plan that also included dieting and exercise. The drug is meant to be taken indefinitely, first to help patients lose weight and then to keep it off. Wegovy, Pigott told me, finally gave her hope.

After PEIA cut off coverage, she ran out of Wegovy in July. Half of the weight she lost has already come back. She is now considering a generic version of liraglutide, despite the drug causing vomiting and diarrhea when she previously took it. (Wegovy can cause these side effects, too, but Pigott personally found them milder.) To afford even this cheaper and less effective medication, she plans to drive an hour and half to the nearest Rite Aid, which takes a coupon that reduces the cost to $245 a month. Wegovy’s out-of-pocket price, which is more than double that even with a manufacturer’s coupon, is out of the question. “I felt like a drug seeker,” Pigott told me, going to such lengths for medication to lose weight. She is willing to try because, like other PEIA patients I interviewed, she found that managing her obesity had reversed so much of what ailed her body.

When Cassie Hornbeck Maxwell started Wegovy, she had already been diagnosed with prediabetes, sleep apnea, and polycystic ovarian syndrome, a hormonal disorder that can cause irregular periods—all of which are associated with obesity. “I had given up on myself,” she told me. “I had given up on my health.” With Wegovy, her health problems faded away one by one: Her blood sugar went down, she stopped needing a CPAP machine to sleep, and her periods became regular. Her experience matches growing anecdotal and clinical evidence that obesity drugs can mitigate these associated conditions.

Hilaria Ireland Swisher has cut her use of blood-pressure medication in half. She told me she had cried when she first started on Zepbound, so overwhelmed was she to have—after a lifetime of dieting, dieting, dieting, and regaining the weight anyway—a drug that might finally end her health struggles. Obesity made her everyday life difficult: She used to lose her breath climbing a flight of stairs, and her feet would ache for days after outlet shopping with friends. But the drug-induced weight loss kicked off a virtuous cycle. She can move without pain, so she can be more active and keep healthier habits. Now she goes to the gym twice a week.

This is why patients on PEIA don’t want to lose access to the drugs. Whatever the downsides of the drugs—the long-term side effects are still unknown—patients don’t want to go back. The pilot program has been a bit of a roller coaster for patients, says Bisher Mustafa, a weight-management specialist at Marshall Health, one of the centers in the PEIA pilot program. Davisson at WVU has been advocating for PEIA to keep at least the patients in the pilot program on the drugs. Kicking them off Wegovy and Zepbound now, she argues, would reverse the progress already made: “All that money you just put in, you’re going to throw away.”

Around the country, however, other insurers faced with the same costs as PEIA have been largely unswayed by the argument that covering obesity drugs will ultimately save money, by preventing obesity-related conditions such as diabetes and heart attacks down the line. North Carolina also dropped coverage for state employees earlier this year, and private insurance has been cutting patients off too. Wegovy and Zepbound are still new enough that firm evidence of cost savings is hard to come by. A handful of studies and simulations, though, suggest that any future health savings will still be dwarfed by the cost of the drugs, at least at current prices. A simulation from Wegovy’s manufacturer, Novo Nordisk, for example, found a savings of $85 million over five years for 100,000 patients—but the current list price of Wegovy over that same period would run $8 billion, a huge discrepancy even if insurers do not pay full price

In West Virginia, PEIA says it was struggling with costs: The pilot program for 1,000 patients ran at roughly $15 million a year at its peak. Expanding it to 10,000 patients would require $150 million a year, or 40 percent of the agency’s total prescription-drug budget. “I’ve laid awake at night pretty much since I made the decision,” the agency’s director, Brian Cunningham, said in June. “But I have a fiduciary responsibility, and that’s my No. 1 responsibility.” (PEIA did not respond to The Atlantic’s questions about ending the pilot program.) Shutting down the pilot program puts West Virginia in line with other states: Most never covered the obesity drugs for state employees in the first place. Only about a quarter of Americans, with any sort of insurance, have coverage for these medications, according to Obesity Coverage Nexus.

For the West Virginians who briefly gained and then lost coverage, this talk of numbers can feel rather abstract compared with the change they feel so viscerally in their bodies every day. To insurers, a heart attack averted might be a number in a spreadsheet, but to patients, this is their life. Some have written letters to PEIA and state legislators pleading their case. Angela Young, a retired state employee (who wasn’t part of the pilot but lost coverage when she got on PEIA after a divorce), put it to me most bluntly. She feels the extra weight in the knee she had replaced. She struggles with shortness of breath and heart problems. “I’m assuming,” she said, “this is eventually going to kill me.”

Even a short stint on the obesity drugs, PEIA patients told me, changed their lives in ways beyond the physical. “When you’re an overweight person, it’s like you’re invisible,” Lory Osborn said. “Like you’re less than a person,” Randi Bourne, the school nurse with six co-workers in the pilot program, told me. They had always been aware of the fat-shaming, the willful ignoring, the subtle and not-so-subtle disrespect, but losing weight opened their eyes to just how differently society treated people with obesity. Maxwell felt she had lost part of her identity when she was seen first as “the fat person.” Losing weight finally let her be seen as herself—as Cassie—but would regaining it erase a part of her identity again?  

The drugs also made Maxwell rethink how she thought about herself and about obesity. Like many, she had long considered obesity a problem of self-discipline and motivation. Being on Wegovy and then Zepbound—feeling the food noise disappear with a tweak in brain chemistry—made her see it as a medical condition. Obesity is more complicated than a simple imbalance of the hormone mimicked by these drugs, but doctors do now generally consider it a chronic disease. Maxwell now sees it that way too.

To her, and other patients, that makes PEIA’s decision all the more unjustifiable. “It’s the same thing as giving someone with cancer a cancer drug, or someone with diabetes their insulin,” Swisher said of the obesity drugs. Putting them in a different category, many said, felt like yet another instance of discrimination. Historically, the reluctance of insurance companies to cover obesity medications is born out of a belief that obesity is a personal failing. Medicare is still prohibited by law from covering medications for weight loss; the Biden administration recently proposed a rule to sidestep that law, but the Trump administration would need to approve it.

In the fall, PEIA proposed raising premiums for next year. It even cited the high cost of GLP-1 drugs, the class that includes Wegovy and Zepbound, as a key reason. But PEIA had already canceled the obesity-drugs pilot program. The cost, going forward, would be from funding the drugs prescribed for diabetes. (The pilot program was so small that some 86 percent of the money PEIA had been spending on GLP-1 drugs was still for diabetes treatment. However, about two or three times more people in West Virginia have obesity than diabetes, so expanding the pilot program would make obesity costs much higher.) The agency did not propose eliminating coverage for diabetes.

When Pigott started Wegovy, she was prediabetic. “One of the reasons I took the medicine was to prevent myself from getting diabetes,” she said. And it worked: Her blood-sugar levels went down. Now her premiums are going up, and she still can’t get the drug—not unless, of course, she eventually does develop diabetes. “It doesn’t make sense,” she said. To get help, she would first have to get sicker.

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