Episode 130: Clinical Conversations: Access, Coverage & Health Equity in 2026[

Uh, it is...

And welcome to the podcast.

Uh, this is a very, uh, difficult topic.

Uh, it's, it's, uh, such challenges that healthcare providers face in trying to provide obesity care, and the scenario I provided, I think, is, is sort of a typical example of some of the challenges that we're facing.

So how are payer policies across the Medicare, Medicaid, and commercial insurance evolving in 2026, and what's driving the recent shifts in coverage for anti-obesity medications?

Yeah.

I would say, um, the first thing to note, which many of us know now but some may not, is with Medicare we now have the Medicare Bridge, uh, GLP-1 program, which is a demonstration program that's expanding the coverage of GLP-1 medications for patients with Medicare Part D who, uh, meet the qualifications.

Um, we're excited about this program because it is new and it is increasing access.

And although it is not perfect, it is a first step.

Um, as far as Medicaid goes, um, we have some states that cover, and even with coverage there i- there are limitations there, um, and barriers that are still there.

And then among commercial payers, um, majority do not cover obesity management medications.

So we have a ways to go when it comes to increasing the equitable access of high quality obesity care.

Yeah.

And, and-

And Shelley, do you, do you see that these guidelines are, uh, actually moving the needle of coverage in, in, uh, coverage decisions?

So I would say we've definitely come a long way because now we've gone from, you know, understanding that obesity is a chronic disease, that it needs to be treated, that access to care is important, to what does that look like in, uh, today's society? And so, um, sometimes I do feel s- um, that with the guidelines that are there, that, es- especially with some of the commercial payers and even with, um, Medicare, they may not necessarily be, um, allowing access to, uh, the way the guidelines are.

For example, when we talk about, um, uh, having medications for p- persons with a BMI of 27 plus a weight related comorbidity or a BMI of 30 and above, sometimes what I'm seeing in my practice is that these commercial payers would be like, "No, you have to have a BMI of 30 with a comorbidity or a BMI of 35 and above without a comorbidity for us to cover." So they're taking some of the guidelines, but not completely all of the guidelines, um, which is actually having more barriers to, um, patients who really do need it.

Mm.

Yeah.

It's frustrating when, you know, each insurance company kinda makes up its own rules which are not evidence-based, right?

Absolutely.

Yeah.