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Category: Health Policy

The Drug Changing Medicine

By EMANUEL SARKEES

The United States is in the middle of what researchers are calling one of the most significant pharmacological developments in modern medicine. GLP-1 receptor agonists, the drug class behind Ozempic and Wegovy, have become able to reduce obesity, lower cardiovascular risk, control blood sugar, and show signals improving areas like addiction and dementia. It is backed by large scale clinical trials and is actively reshaping how physicians think about chronic disease management. The accessibility, however, is not keeping up with the science. The people who will benefit most from GLP-1s are the same people who have no path to receiving them.

This is not a coincidence. It is the outcome of a pricing structure, an insurance system, and a policy environment that have consistently made the same choice, which is to let cost determine who receives care.

What GLP-1s Actually Do

GLP-1s were originally developed to treat Type 2 diabetes. They work by acting similarly to a hormone the gut naturally produces after eating, which signals the brain to reduce appetite, slows digestion, and stabilizes blood sugar levels. The effects have been significant enough that the medical community’s interest has expanded well beyond diabetes management.

A 2023 clinical trial, known as the SELECT trial, found that semaglutide, the active ingredient in Wegovy, reduced the risk of cardiovascular issues like heart attacks and strokes by 20% in patients with obesity who did not have diabetes. That finding alone drew serious attention from cardiologists. Early research is also exploring GLP-1s in alcohol use disorder, sleep apnea, chronic kidney disease, and Alzheimer’s. The amount of potential application is unlike anything seen from a single drug class in recent times.

The Price Problem

The issue is not whether these drugs work. It is whether the system is built to let people use them. Wegovy, the FDA approved version specifically made for weight management, holds a price of around $1,300 per month in the United States without insurance coverage. Ozempic, technically approved for Type 2 diabetes but widely prescribed off label for obesity, runs at a similar cost. As one analysis noted, GLP-1 pricing “increased 442% between 2021 and 2023, creating a market three times larger than cancer spending, with list prices reaching $1,400”. Novo Nordisk and Eli Lilly, the two companies that dominate this market, charge American patients prices that are dramatically higher than what patients pay for the same medications in other countries.

The actual price a patient pays has very little to do with that $1,349 list price and almost everything to do with how they access the drug. With commercial insurance that covers obesity, costs can fall to around $25 a month, though that requires a plan that actually covers weight loss medications and prior authorization that actually gets approved. The Wegovy pill is available directly through NovoCare at $149 per month, the lowest price point ever for an FDA-approved GLP-1 weight loss medication. Zepbound starts at $299 per month through LillyDirect for patients who pay out of pocket. The government’s TrumpRx platform offers GLP-1s at around $350 per month for cash-paying patients who do not have coverage. Compounded versions through telehealth platforms like Ro and Hers run anywhere from $99 to $349 per month, though the FDA is actively restricting that market. And as of July 1, 2026, eligible Medicare beneficiaries can access Wegovy, Zepbound, and Foundayo at a flat $50 per month through the new Medicare GLP-1 Bridge program. That is a 27-times spread between the lowest and highest price for the exact same drug, determined not by what the medicine costs to make, but almost entirely by who you are when you walk up to the pharmacy counter. And for the uninsured, low income patient with no Medicare, no qualifying commercial plan, and no compounding option, none of those prices are on the table at all. 

At $1,300 per month, the annual cost of Wegovy exceeds $15,000. For millions of Americans, that number is not just high, but is completely out of reach. That gap in pricing is not accidental. In countries where governments negotiate drug prices directly, the same medication costs a fraction of what Americans pay. The United States remains one of the only developed nations that does not regulate pharmaceutical pricing at the federal level, and patients suffer the difference.

Insurance coverage for GLP-1s follows a path that is both frustrating and familiar.

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The price of Ozempic is a meaningless phrase

By JOHN SAMARAS

Ask what Ozempic costs. The honest answer runs from $25 a month to $1,100 a month, and every number in that range is real, published, and defensible. A phrase that covers a forty-four-fold spread is not a price. It is a fog, and patients make four-figure annual decisions inside it.

I run GLP Chart, an independent GLP-1 price index. The index shows that “the price of Ozempic” fails as a concept for three stacked reasons. The molecule sells in five forms under four names. Each form sells through different channels at different prices. And the advertised price rarely survives to month four.

One molecule, five forms

Ozempic is semaglutide, branded for type 2 diabetes. The same molecule is Wegovy when approved for weight loss, sold as a weekly pen and, since 2026, a daily pill. It is Rybelsus in the older oral form. And 503A compounding pharmacies still sell it as compounded semaglutide where the rules allow, though the FDA’s compounding restrictions and the manufacturer lawsuits thinned that market through 2025 and 2026.

When someone says “Ozempic price,” they almost always mean “what will semaglutide cost me.” Those are different questions with different answers.

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Value Is in the Eye of the Beholder

By KIM BELLARD

The most (unintentionally) amusing story I read this week was Tim Higgin’s Wall Street Journal article Alex Karp Is Saying What Every Angry CEO Is Thinking About AI. Dr. Karp (yes, he has a Ph.D.), co-founder and CEO of Palantir Technologies, is upset about how AI companies are using relationships with their business customers to harvest data and business insights from those customers. “Something has gone completely wrong,” he fumed.

Now, this is Palantir, mind you; it may not have invented surveillance capitalism but it might have perfected it. It has become essential to government and large corporations across the world. Most of us are aware of how tech companies like Meta or Google give us “free” services that exist primarily to collect more data on us, which they then use to target ads to us, but Palantir’s data collection and analysis operate at a level we often don’t recognize.  But make no mistake; it is using our data, and not necessarily in our best interests.

Mr. Higgins quotes former White House AI czar David Sacks in support of Dr. Karp’s concerns:

Anthropic has launched Claude Science, Claude Security, Claude Legal, and of course Claude Code—each expanding into categories previously served by companies building on top of their models. The pattern is consistent: Watch where value is being created, then move in directly. Dominate the model layer, then use that position to capture the most lucrative verticals.

So it is delicious irony that Dr. Karp and others are finding themselves at the wrong end of the power inequality with their data.

I find myself thinking about healthcare when I think above this new wave of data collectors/ synthesizers. It seems pretty clear that the AI companies aren’t going anywhere, and are expected to reshape most industries, including healthcare. Lots has been written about AI’s use in healthcare, including by me. It is both inevitable and, in many cases, desirable. Now this issue of AI’s insatiable appetite for data makes me wonder if we’re looking at things wrong.

I’ve worked in healthcare for longer than I care to admit, and at no point did people not complain that healthcare in general, and health insurance in particular, was too expensive. And yet, costs have kept rising. We’re closing in on $6 trillion in U.S. healthcare expenditures. No matter what kind of health insurance you have – large employer, small employer, ACA Marketplace, Medicare Advantage, even Medicare Supplements for traditional Medicare – your premiums (and/or out-of-pocket costs) are likely going up at rates we haven’t seen in years.

Two well known facts about rising costs are, one, that it is not so much we’re using too many services as it is that Americans pay way higher prices for healthcare than in most countries, and, two, that a relatively small percentage of people account for the vast majority of healthcare spending. The latter has an insidious effect on health insurance premiums, as people with fewer expenses are less likely to have or keep health insurance, making premiums for the remaining people higher. Nobody wants to pay for the people who use a lot of health care, but they want other people to help pay if they end up being one of those people. It’s a conundrum.

Now, optimists hope that AI can do a better job of identifying all the wasted, unnecessary, or inappropriate care we use – estimated as much as one-third – and help make administration more efficient; current levels are estimated as 15-30% of spending. Good goals, both of them, and it is entirely plausible that AI can help with both. But it would still remain that sick people are the “problem” with our health care spending and health insurance premiums, and I want to propose a different way of looking at them.

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Future of AI and Telehealth in primary care — Panel discussion

A couple of months back I hosted a conversation about my favorite topics, primary care and how telehealth and AI are changing it. The panel was Timm Schneider — Co-Founder & COO, Third Way Health, Jamie Reddick — COO, Graybill Medical Group & Erin Parks, Ph.D. — Co-Founder, Equip. The panel was at a tech heavy conference called TechCon Global in San Diego. Sadly the weather stopped us getting Matt Siegler from Akido Labs. We got into it about tech. incentives, specialty care and the role of AI in access and patient support–Matthew Holt

A ridiculously stupid letter from a health insurer

By MATTHEW HOLT

It’s hard to imagine but I may now be in possession of the stupidest letter I’ve ever received from an American health insurance company–-and I’m the guy who got five identical letters on one day from Blue Shield of California telling me that they had changed my primary care doctor when I had initiated the change.

A little backstory.  As those you’ve been following along with my various telenovelas may remember that last year I was diagnosed with a failing heart valve.  I also have a failing left knee due mostly to snowboarding into a tree 24 years ago.

I was attempting to put off doing anything about the heart valve for as long as possible because it sounds painful and unpleasant, and I was hoping that I could go ahead with a knee replacement so that my snowboarding can continue apace. My doctors are at UC San Francisco and they agreed that I should have the knee replacement on July 6th, assuming that my heart valve had not got much worse. On June 16th I went into UCSF for a bunch of knee replacement pre-workup and they also checked my heart.

However, my new insurance company, thanks to my wife’s new job, is Cigna. Those of you in California may know that Cigna was having a big dispute with the University of California Health system and that its contract with them was due to expire on June the 30th of this year. Why a health plan and a big provider organization have contracts that expire in the middle of the year when the employers and people who use the health plan network buy them on an annual basis starting in January I don’t know –  and it’s ridiculously stupid. But let’s not get distracted cause I’m not talking about that here!

Because of the fact that they’d be out of network, the ortho team made the obvious suggestion that I move the knee replacement a little earlier, In fact it was planned for June the 22nd. This did not upset me too much as you may have seen that some corrupt Italians have organized a soccer tournament that would give me plenty of games on TV to be entertained by while I was lying around recovering.

Sadly one of the pretests I had on June 16th was an echocardiogram that indicated that my heart valve was in even worse shape than it had been earlier in the year.  After quite a lot of back and forth between the cardiac team, the knee team and the anesthesia team, everyone agreed to put off the knee surgery until we figured out my heart.

Meanwhile sometime late on Thursday the 25th or early on Friday the 26th of June, UC Health and Cigna stepped back from the brink and came to an agreement that will continue the UC system being in Cigna’s network.

Which all brings me to July 6th when I received a letter from Cigna

This is the one that contains more stupidity per square inch than any other communication I’ve had from an insurance company.

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AI and Professional Nursing: On a Collision Course

By JEFF GOLDSMITH

In his wonderful and pragmatic new book, A Giant Leap, Dr. Robert Wachter cautions his professional colleagues that simply confiscating potential administrative and clinical staffing savings created by AI could foster a whirlwind of negative consequences for healthcare enterprises.

Nowhere is the explosive potential for reaction to AI incursions into care delivery greater than in nursing, hospitals’ largest single professional expense category. Hospitals employ more than 1.8 million Registered Nurses (RNs) and another 400 thousand non-RN nursing personnel. RNs alone are more than 30% of the hospital salaried workforce, and more than 40% of overall staff costs.

Nursing productivity is a central issue in overall hospital performance, and a key intervening variable both in clinical quality and patient satisfaction. So the capacity of AI to improve nursing productivity will be a core issue in determining AI’s effect on overall hospital operating performance.

There is clearly room for improvement. Studies have shown that nurses spend only 25-30% of their work hours in direct patient care activities. AI’s potential for alleviating the huge administrative burden damaging nursing productivity might be the biggest benefit AI could provide. AI could materially increase nursing time at the bedside, increasing both patient and nursing satisfaction.

However, AI could also reduce hospitals’ nurse headcount, a factor which could, in turn, reduce nursing union membership, the largest and fastest growing single category of hospital employees’ union membership. Almost 18% of all hospital employed RNs are members of labor unions (AFSCME, AFT Healthcare, National Nurses Union, etc. and their local affiliates). Union dues from nurses represent hundreds of millions in annual income to the unions that represent them.

Nursing unions’ most visible public policy initiative, which appeared first in California twenty years ago, was getting its state legislature to mandate nurse to patient staffing ratios in hospitals. These were designed to compel hospitals to hire more nurses with the intention of improving patient safety. What the ratios actually did was throw more nursing bodies at broken processes and systems. These laws had the important collateral benefit of assuring a “guaranteed income” in union dues from more nurses employed by hospitals subject to these ratios!

Formal (though less comprehensive) mandates for nurse staffing ratios have since spread to Oregon, Massachusetts and New York, with legislation pending in Maine, New Jersey, Pennsylvania. Michigan, Minnesota and Washington State. The research on the intended qualitative benefits of California’s state-mandated ratios confirm the expected benefits to patients, though the studies relied upon correlational analyses vs. states without the ratio mandate, not pre- and post- studies of the ratios’ effects on patient care.

Other studies concluded that the ratios pushed up both RN numbers and compensation vs other job categories as well as damaging hospitals’ operating margins relative to states lacking the mandates. The point-counterpoint of these studies gives one a sense of an issue rapidly becoming politicized.

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THCB Spotlight: Warris Bokhari, Claimable

One of the most interesting follows on Linkedin is Warris Bokhari from Claimable. He’s a British MD, who has had stints not only as a doc in the UK, but also as a health tech and health insurance exec in the US. But now he’s at war with the system, in particular working for patients to overturn denials from insurers using AI. But what exactly is the big picture aim, and how does Warris think that he’s going to fix American health care? We had quite the discussion and we sort of agree, but also don’t. Great discussion and transcript is below the video–Matthew Holt

This was such a great discussion I wanted to publish the transcript. The way I do that is to copy the Youtube generated transcript and drop it into Claude to smooth it over. I then read it and if I think it’s made an error, dip back into the video and listen to what actually happened and make a correction. This is all code therefore for me saying I think this transcript is pretty accurate but it might have a bunch of AI and human generated mistakes.

THCB Spotlight: Warris Bokhari, CEO of Claimable

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How The Patient Rights Revolution Builds on America’s 1776 One

By MICHAEL MILLENSON

It took 129 years for the inalienable rights proclaimed in America’s Declaration of Independence to apply to the rights of patients in relationship to their doctors.

In 1905, an Illinois appellate court ruled in favor of a woman who’d sued her surgeon for performing a hysterectomy without disclosing in advance what procedure he was doing. The court declared in what became one of the foundational principles of informed consent that “under a free government,” all citizens had the right to know what a doctor planned to do to their body before he did it, no matter how “skillful or eminent” the physician.

Today, in the era of artificial intelligence chatbots and data democratization, the lessons of America’s 1776 political revolution continue to be reflected in the push for patient rights.

The most important lesson pertains to power. The American colonists learned from hard experience that those holding power rarely concede it voluntarily. Similarly, every advance in information sharing with patients can be linked to sustained economic or legal pressure.

Just as the British genuinely believed they practiced “benign colonialism,” the surgeon who performed a hysterectomy on 40-year Parmelia Davis to treat her epilepsy not only believed deceiving her was necessary for her health, but might also have cited as support the American Medical Association’s Code of Medical Ethics. Patients, the code then declared, should not allow their own ”crude opinions” to obstruct “prompt” obedience to the doctor.

Although that admonition was subsequently axed, patient rights remained minimal for decades.

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Good News: Teen Pregnancies Hit New Low In the US

By MIKE MAGEE

Last week, policy wonks from the right and the left, finally found a topic they could agree on – Kids are no longer having (as many) kids.

Specifically, teen pregnancies dropped an additional 10% in the US in 2025. This is an acceleration of a trend which began two decades ago. Teen births peaked in America in 1991 with 62 births per 1000 girls/women age 15 to 19. In 2025, the rate was below 12 per 1000, a drop of 80%, with the majority of that (72%) occurring since the 2008 Great Recession.

Obviously, this is “good news” for these young women according to Congressional reports. And most agree the causes are multifactorial, and include gains in health education, declines in sexual activity in youth, access to contraception and the Plan B pill, and expanded economic and professional opportunities for women in society.

But for societies worldwide, leaders look on with angst as the birth rates in their nations have broken through the replacement line, with deaths exceeding births. This “replacement rate” is roughly 2.1 births per woman. The CDC recently reported that without immigration, the 2023 total fertility rate was only 1.6 births per woman (1,616 per 1000 women over a lifetime).

Since 2007, trend lines have pointed decidedly downward. In that year, there were 4,316,233 births in the U.S. In 2025, American women gave birth to only 3,606,400 newborns (a 23%) decline.

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Oceans, Away

By KIM BELLARD

It probably didn’t show up on your calendar, but Monday was World Ocean Day. It’s a day meant to catalyze “collective action for a healthy ocean and a stable climate,” and has been around since 2002 (although the U.N. didn’t officially recognize it until 2008). Its website claims a network of over 2,000 organizations, in 180 countries.

I wish we had more to celebrate.

Many have recognized the irony of humans calling our planet “Earth,” when, in fact, 71% of its surface is covered with water. Even more amazing, oceans account for 99% of the biosphere. We come from the ocean and still owe much of our existence to it.

Unfortunately, these are not good times for oceans, and we’re to blame. The most recent World Ocean Assessment from the U.N. highlights:

  • The ocean matters to everyone, everywhere;
  • The ocean is under intensifying stress;
  • Climate change is transforming conditions;
  • Biodiversity is declining across nearly every marine habitat;
  • Pollution is widespread and increasing;
  • Ocean food systems are threatened.

The report concludes: “The coming decade is decisive: without rapid, coordinated global action, ocean health will continue to decline, threatening climate stability, biodiversity resilience, food security, livelihoods and the wellbeing of billions.”

I think about this in light of last month’s announcement by the National Science Foundation that it was “descoping” the Ocean Observatories Initiative (OOI) Major Facility, beginning next week. That’s a $368 million deep-ocean observation system “that delivers real-time data from more than 900 instruments to address critical science questions regarding the world’s oceans.” Some 900 instruments will be removed, in both the Pacific and Atlantic oceans.

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