As a physician, telling my patients “no” never gets easier. In some cases, I have good reason, such as declining to increase opioids because of the risk of side effects. In other cases, I can only gently tell patients, “The health care system doesn’t want to pay.” In the coming months, I will be saying “no” a lot more often. As of July 1, MassHealth, the state’s Medicaid program, stopped covering GLP-1 drugs prescribed solely for obesity, a decision expected to save the state millions of dollars while affecting around 22,000 patients.
For my patients with physical disabilities, this could not come at a worse time. Budget cuts have already limited access to personal care assistant (PCA) hours. For the worried well with financial means, losing insurance coverage for GLP-1 medications may be an inconvenience. For medically frail patients with severe disabilities, it can become an unnecessary hardship.
Each day seems to bring new evidence of the psychological and medical benefits of GLP-1 medications. But for patients with disabilities, we need a more nuanced model for assessing the risks and benefits of these medications, one that moves beyond simple algorithms and economic formulas.
What the math misses
Consider a 60-year-old patient with a spinal cord injury and obesity who recently lost 15 percent of her body weight while taking a GLP-1 agonist. A health care economist could make a strong case that the medical “return on investment” fails to justify the cost. A 2025 JAMA study did just that. The results are sobering. For a patient with obesity alone, the study estimated that semaglutide would cost the health care system an additional million dollars for each additional quality-adjusted life year gained.
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For patients with obesity and conditions such as diabetes or severe sleep apnea, the calculus shifts because GLP-1 medications may more immediately reduce health care spending on disease complications. As long as drug prices remain high, states will crunch the numbers and direct their limited budgets toward other health care priorities. As of January 2026, only 13 state Medicaid programs covered GLP drugs for obesity treatment.
On a personal level, however, my patients’ loss of access to these medications doesn’t feel like “saving money.” It’s devastating. Since starting the medication, her mood has brightened, and she has begun weaning off her antidepressant. With greater self-esteem and an improved body image, she has started leaving the house to socialize with friends. I returned to the JAMA study to see how the authors accounted for the mental health effects of GLP-1 medications. By linking quality-of-life improvements primarily to reductions in BMI, the analysis may underestimate benefits that patients experience in energy, mobility, pain, sleep quality, and psychological well-being.
Patients at the tail of the bell curve
How much, then, would an additional quality-adjusted life year, or QALY, truly cost for my patient? It’s difficult to say. Many patients in my practice, including those with cognitive limitations, physical impairments, or extreme obesity, do not resemble the “average” patients included in clinical trials. Consider one patient who weighs more than four hundred pounds and has tried nearly every weight-loss therapy. She’s stuck in a recurrent bureaucratic loop. She needs to lose weight to qualify for a knee replacement, but she needs a knee replacement to become active enough to lose weight. She effectively needs to develop diabetes to qualify for a GLP-1 agonist, but by then, she may already have sustained irreversible cardiovascular damage.
Under a simple algorithmic model of care, an additional quality-adjusted life year would simply cost the system too much. But again, this calculation assumes risks and benefits similar to those of more typical patients. For patients with extreme obesity in particular, the calculations become labyrinthine. But as the saying goes, “Absence of evidence is not evidence of absence.” Consider, for example, that many patients with obesity also have heart failure with preserved ejection fraction. Some studies suggest that GLP-1 agonists reduce heart failure hospitalizations in these patients, potentially offsetting some of the drugs’ costs.
As of July 1, the new coverage rules forgo nuance in favor of strict criteria, leaving thousands of clinicians in the untenable position of saying “no” to their patients. One might argue that the prior authorization (PA) process exists for precisely this reason: to justify the use of expensive medications for patients at the tail end of the bell curve. But as any provider can tell you, the additional documentation, time, and bureaucracy consume precious resources that could instead be devoted to improving patients’ lives.
Our most complex patients deserve better: coverage rules that account for clinical complexity, a drug-manufacturing system that values equity over unfettered profit, and, ultimately, the opportunity to continue taking medications that have transformed millions of lives. For the most complex patients at the tail end of the bell curve, the jury is still out on whether coverage will ultimately burden or benefit the health care system financially. Until then, they also deserve a shot.
This essay is cited in the KevinMD record on GLP-1 drugs.
Tom Peteet is a board-certified internal medicine physician, educator, and writer. For nearly a decade, he has practiced at Commonwealth Care Alliance, focusing on home-based care for patients with complex disabilities. He also cares for patients in long-term care facilities and works with InstED, a mobile health program that brings acute care into patients’ homes.
As an adjunct professor at Massachusetts College of Pharmacy and Health Sciences, he directs a year-long pharmacology course for physician assistant students. At Boston University, he has taught more than ten courses through its prison education program and is developing courses in neuroscience and medical anthropology.
His scholarship spans medical ethics, medical education, and health equity, including work on the treatment rights of incarcerated patients, the role of theory and the humanities in medical training, and the intersection of quality improvement and equity in residency. His writing has appeared in the AMA Journal of Ethics, Medical Teacher, and the Journal of Family Medicine, and he authored a 2025 textbook chapter on renal disorders in Pathophysiology in Focus.
His writing explores health care ethics, medical education, and the overlooked paradoxes of human physiology. He writes Against Medical Advice, a Substack on the hidden science of medicine, and is working on a nonfiction book about the strange science of blood pressure. More of his work is available on his personal website.
