Real headlines and “wealth consultants” helped weave an unseemly portrait of wealth in America.
Note: This article contains spoilers for several episodes from all four seasons of Succession.
Early in Succession’s first season, professional simp Tom Wambsgans told his punching-bag-slash-protegé Greg Hirsch that he’ll show him how to be rich, as if it’s a skill to practice and absorb. They’re outsiders — Tom (Matthew Macfadyen) married into the Roy family, while Greg (Nicholas Braun) is a mere cousin, initially prodded into the Roys’ business not by ambition but by his mother. He had only recently wormed his way into the family’s affairs. They’re in awe of the glittering world of billionaires almost within their grasp, with little idea of the misery and humiliation in store.
Over the past four seasons, Succession, which airs its final episode on HBO on Sunday, May 28, has shown its audience not only how to be rich but the way extreme wealth and power can be a pestilence that subtly rots everything it touches.
Without moralizing, Succession carefully built its case over the years, charting the slow unraveling of the Roy family as it chased ever-higher heights of power. The show was a Shakespearean tragedy, a car wreck that gained a huge, rubber-necking audience: The Roys, the magnates pulling the strings at media conglomerate Waystar-Royco, ate, dressed, and lived well, but they were not well. They and their social circle existed in a walled garden, surrounded by an underclass of household servants, bodyguards, drivers, and assistants who oiled the machine of their elegant lifestyle. But their fear of losing even a scrap of power further isolated them even from the people they claimed to love. Their riches didn’t just make them powerful or self-absorbed — they made them paranoid. Far from being satisfied with their lot in life, they hunched over in a defensive position, beset with gnawing anxiety over all the precious things others were jealously trying to take from them.
Succession’s portrayal of the secluded halls of power was deeply cynical, and its allure at times was purely voyeuristic, but it’s hard to deny the show’s realism. Succession’s world — its aesthetics and plotlines, its characters’ grand motivations and little tics — mirrored real-life billionaires and the circles they run in. Under showrunner Jesse Armstrong, the show employed a squad of wealth consultants to ensure the accuracy of the writing on the nitty-gritty of the media business (like whether it’s possible that a CEO of a large conglomerate could hide significant debt from shareholders) and how the wealthy behave (they never wear coats because they’re always transported directly from one destination to another). They wear Patek Philippe watches, which can run well north of $100,000, casually take helicopter rides out of New York to throw around a baseball, relish eating illegal avian delicacies, and have no idea what a gallon of milk costs. Many popular TV shows have portrayed the lives of the wealthy as glitzy and glamorous, but few have so deftly used the real symbols and language of wealth to tell a story of greed and abuse of power that’s also a microcosm of a society suffering under the weight of an increasingly unequal, undemocratic economic landscape.
On Succession, as in real life, rich people have easily, and often catastrophically, meddled in politics and society. It showed us how easily the wealthy misapprehend the magnitude of their power, using it to force obedience and invade the lives of others while never contemplating whether it came with obligation. They used the potent combination of wealth and influence to avoid the consequences of scandal and regulation whenever convenient, and frittered away hundreds of millions on vanity art projects and political campaigns, even to sway narratives about presidential elections. In one episode in season 3, the Roys attended an exclusive political conference where a group of rich donors and business leaders hand-pick the next Republican presidential nominee after the current president has announced he’s not running again, in part because he’s so beaten down by attacks against him by ATN — the Roys’ news network. Logan Roy (Brian Cox), the family’s malignant patriarch, favored whoever was most beneficial to his business interests.
Such private gatherings are where real billionaires also whisper their political desires, throwing their considerable cash behind one candidate or another. Political mega-donors like Peter Thiel, Ken Griffin, Mike Bloomberg, and George Soros (and formerly Sam Bankman-Fried) have undeniably helped shape which politicians make it onto the ballot and what pro-industry, anti-regulation policies these candidates support. The amount of “dark money” in politics — political spending where the donor isn’t disclosed — continues to soar, exceeding $1 billion in the 2020 federal elections. The ultra-rich, being as well-connected as they are, involve themselves not only in elections but in heated political issues and even weigh in on White House policy. Billionaires pour their money into politicians and social causes for a variety of stated reasons, but their interference leads to basically one result: Their power grows, and often, so does their net worth.
The Roys’ most obvious inspiration were the Murdochs, who own a global media empire that includes right-wing network Fox News (though the show also contains dribbles of the Redstones, the media family behind Paramount Global, and others). ATN was Fox’s fictional twin, as was underscored in this season’s election episode when the network spread disinformation and a narrative of anti-establishment distrust that helps Jeryd Mencken, the show’s caricature of Donald Trump, become president. The core drama of the show — a bitter struggle between siblings to take over the company their father built — was drawn from the real succession fight among the Murdoch children, particularly Elisabeth, Lachlan, and James Murdoch. This feud of two brothers and a sister was dramatized across Succession’s four seasons: The Roys constantly scrabbled to move up the ranks, or at least to not tumble from them. Not despite their wealth but because of it, defensiveness was their default state of being.
Even in the small details, Succession was injected with references and homages to the Murdochs and others — Logan Roy’s idea of buying up a raft of local TV stations in season one was a page out of a Murdoch playbook. Logan stood on boxes of paper to give a speech to ATN employees in an early season four episode, just as Murdoch reportedly did for a speech in the Wall Street Journal newsroom. Logan Roy’s direct line to the US president, however, feels tame compared to Rupert Murdoch’s coziness with world leaders.
But for all their wealth and power, Succession argued, the Roys were never a happy family. Logan, who set the tone for the rest of the family’s moods and behaviors, flew into a rage at any hint that he was being insulted — and was always grinding his teeth at the unease that someone, somewhere, might not be giving him his due respect. (Think: Elon Musk, a frequently impulsive, blustering tech billionaire, who has increasingly spouted off on his perceived persecution in the media, despite his history of doing or saying things that affect his company, shareholders, and the public at large.)
Logan Roy was a billionaire who founded a giant media conglomerate; one would think his self-evident accomplishments would be enough to appease his ego. Yet Logan was petty, thin-skinned, and reactive to every slight. He delayed announcing a Waystar successor — just as Rupert Murdoch, now 92 years old, has — because he could never bear the thought of giving up power. Instead, he spent his last years viciously fighting off any perceived threat to his throne.
It’s hard not to see the parallels, too, between Waystar’s cruise line sexual harassment coverup and Rupert Murdoch’s biggest scandal: His newspapers had been hacking the phones of politicians and celebrities, including those of the British royal family. Under parliamentary testimony, Murdoch’s son James admitted that he’d received an email about the phone hacking after initially denying he had been aware of it. Did Rupert know? In the end, other senior members of the paper took the fall, some being arrested, one senior editor serving a prison sentence, and many other staff resigning or being fired. Murdoch’s company also paid an undisclosed amount in damages — but no one in the family was personally punished beyond financial and reputational damage.
In a eulogy for Logan in the penultimate episode of the series, Ewan (James Cromwell) spoke of the meagerness his brother brought out in others. He had a stinginess of spirit befitting someone forced to aggressively defend his scarce resources — not someone with billions in assets. Not someone whose son cruelly dangled the prospect of a million-dollar reward to a groundskeeper’s young child at a family baseball game in the show’s first episode.
Such unkindness was the least of the damage the Roys wreaked on the less-privileged people around them, whose suffering they barely even register. Kendall (Jeremy Strong) accidentally killed a cater-waiter while high and on a reckless pursuit for more drugs; an ATN employee shot himself at work because he couldn’t bear the workplace harassment he faced; the cruise scandal revealed that in incidents involving violence or abuse against workers at Waystar, the victims were labeled “No Real Person Involved” — as in, not high enough in the ranks to merit much of a response. Later, when Waystar came under scrutiny for their cruise misdeeds, Shiv (Sarah Snook) manipulated a sexual harassment victim into silence. They carelessly left a trail of casualties in their wake, brushing the destruction aside as collateral damage for their all-important need for more power, and for their father’s praise. Perhaps it’s not surprising that Armstrong included a nod to Ghislane Maxwell in the show, invoking a figure who has become a notorious example of powerful men and women abusing vulnerable people.
Yet, in a real sense, the Roys saw themselves as mistreated and maligned. Connor (Alan Ruck), the eldest son, was a libertarian who frequently railed against taxation. His family reins him in not because they disagreed with his stance but because it lacked subtlety. Quietly reducing their taxes was what they hired accountants and financial advisers for. (During Logan’s wake this season, Waystar CFO Karl Muller, played by David Rasche, unironically opined that burning the Gauguin paintings Logan kept in a Swiss vault would be ideal for avoiding taxes and collecting insurance money.)
The Roys’ particular brand of meagerness has been well-documented in real life. The actual billionaires of US society pay incredibly little in taxes compared to the average middle- and low-income American. A ProPublica analysis of billionaires’ tax records in 2021 showed that the 25 richest Americans paid a tax rate of about 3.4 percent, while the median American household paid about 14 percent of their annual wages in federal taxes. Billionaires often argue that tax breaks for them benefit everyone, freeing up capital that can be reallocated to charitable causes, to their innovative companies, to creating jobs. Succession gave us the sense that the truth is far more avaricious.
In The Wealth Hoarders, author Chuck Collins — director of the program on Inequality and the Common Good at the Institute for Policy Studies, as well as the heir to the Oscar Mayer fortune — offers an insider’s view of the mentality of high-net-worth individuals, who consider it sacrilege not to hold onto their wealth. Give away the interest generated from your assets, sure, but to chip away at the principal is “class suicide,” as one rich person suggested to Collins. The wealth management industry — sometimes called the wealth defense industry — has ballooned in the past few decades, consisting of an army of professionals paid hefty sums to ensure that the Roys of the world never have to give too much away, whether it’s by using obscure tax loopholes or taking advantage of trusts and tax havens.
Armstrong’s subtle messaging about the Roys’ vague discontent isn’t some moralistic fable about wealth; the uber-rich often report being perplexingly dissatisfied and uneasy about their financial state. Having “enough” money tends to be relative. Millionaires worry about being able to retire. A famous 2011 Boston College survey of extremely rich American households — whose average net worth was $78 million — revealed that multi-millionaires generally aren’t content with their fortunes, with one respondent saying he wouldn’t feel secure until he had $1 billion. Psychologist Robert A. Kenny, who helped create the survey, told the Atlantic, “Sometimes I think that the only people in this country who worry more about money than the poor are the very wealthy.” One wealth adviser told the New York Times in a 2017 article about the anxieties of the ultra-rich: “They never do feel they have enough. It takes some coaxing to get them to spend money.”
Ewan gave his grandson Greg some trenchant wisdom in the first season, before he’d begun to be corrupted by his association with the Roys. “One of the symptoms of an approaching nervous breakdown is the belief that one’s work is ever so important,” Ewan said, quoting the philosopher Bertrand Russell. That’s been the essence of the entire show: a wealthy family teetering on the edge of a nervous breakdown. As the show comes to a close, it’s closer to the precipice than ever.
Jonathan Glazer’s new film dismantles simple cliches about the banality of evil.
The Zone of Interest, Jonathan Glazer’s first film in 10 years, is ostensibly based on a book: Martin Amis’s stomach-churning 2014 novel of the same name. But understanding the movie’s formal and thematic genius requires looking at it differently: as a sidelong horror-film adaptation of Hannah Arendt’s 1963 Eichmann in Jerusalem, one that goes way beyond that book’s well-worn idea of the “banality of evil.” That phrase, lifted from Eichmann’s subtitle, furnishes most people’s entire Arendt knowledge base: the idea that evil presents itself not as a devil with horns and a pitchfork, but in seemingly egoless, “mediocre” men like Adolf Eichmann, architect of the Final Solution, who carry out unspeakable atrocities.
That’s not wrong, but it’s much too simple, verging on cliche — ironic, given Arendt’s warnings. In her reporting on Eichmann’s trial, Arendt noted how he spoke only in “stock phrases and self-invented cliches,” the kinds of euphemisms that Arendt said indicated a refusal to think for oneself. In this, Eichmann was a true company man; the Third Reich was notorious for inventing language and speech codes that made following the rules seem inevitable. The Nazi Sprachregelung, or its particular bureaucratic vocabulary, was euphemistic in the extreme. Killing became “dispatching”; forced migration became “resettlement”; the mass murder of the Jews became Eichmann’s “final solution.” When you call what you’re doing to millions of your neighbors “special treatment,” you don’t have to think about what it really is. You might even start to enjoy the challenge of doing it more officially.
This Sprachregelung is all over The Zone of Interest, in part because its characters don’t talk about murder or genocide, but also because Glazer — whose previous film was the brilliantly unsettling Under the Skin — replicates the characters’ internal distance through the movie’s images and sounds. The result is unsettling in the extreme. It takes a few minutes of watching to realize what, precisely, you’re looking at, and the nauseating shock at that moment packs a stronger punch than any horror movie I’ve seen this year. Here is the sunny, flower-filled, orderly front garden, in front of a well-appointed and tidy home in which a large, cheerful family lives. But wait; just beyond the yard is a tall gray cement fence with barbed wire on top, and smokestacks visible in the distance.
On the other side of the garden wall is Auschwitz.
The home is occupied by the notorious extermination camp’s commandant, Rudolf Höss (a real man, played here by Christian Friedel), his wife Hedwig (Sandra Hüller), their large brood of children, and a few servants, at least one of whom seems to be Jewish. The Zone of Interest keeps the Höss family in the foreground. We see them on a picnic, having family dinners, spending time playing in the garden, enjoying their greenhouse and their pool. Hedwig is a nurturing mother and hospitable housekeeper.
While they live out their lives in their happy house, we watch with horror. Smartly, Glazer gives us only the most minimal amount of character background; this is emphatically not a movie where there’s a “good Nazi” to root for. Instead, it shows how the whole Nazi system was designed to ensure that nobody could be good. We’re hearing the Hösses talk about life in the foreground. But there’s an ambient noise in The Zone of Interest, akin to the hum of a white noise machine — except in this case it’s omnipresent, the sound of furnaces in the distance, laced with occasional gunshots and howls. To hear what’s going on in the house, we have to tune them out a little. I hope we can’t.
The characters, however, have. Höss and his colleagues have been deeply formed by the regime in which they’ve made their careers, in which Nazi ideology is encoded in its language and systems. (They speak with awe and obedience of Himmler and of Hitler — and, of course, of Eichmann.) Höss has made a name for himself as an executor of efficient systems: “His particular strength is turning theory into practice,” a letter that a colleague writes about him explains. The practice of killing, that is.
It would be inexcusable and deadly wrong to say that The Zone of Interest is about people living in blissful ignorance about what’s going on just over the garden wall. They know exactly what’s happening; they’ve just, essentially, dissociated. Höss talks about gassing thousands of Jews as if it’s an interesting problem to be solved, but it’s his job. What’s more chilling is that his family knows. Hedwig — who proudly tells her mother she’s been nicknamed the “queen of Auschwitz” — admires a fur coat that arrives in a shipment brought in by a prisoner, trying on the lipstick she finds in the pocket. She warns the Jewish girl who works in the house that she could “have my husband spread your ashes” across the fields. She speaks with her visiting mother about whether a former neighbor of theirs, a Jewish woman her mother cleaned for, is “in there.” There’s a tinge of revenge, the feeling that if she is, she probably deserves it because she was probably plotting Bolshevik nonsense in days gone by.
Perhaps the most telling scene comes when two of the young sons are playing in the backyard. The older locks the younger in the greenhouse — and then makes noises of gassing at him. The only family member who seems unable to ignore the horror of what’s happening is the baby, who screams whenever the ovens light up.
The sound design in The Zone of Interest is so extraordinarily effective that it’s easy to miss what the film is doing on a visual level. The scenes of familial bliss take place in a beautiful garden or a comfortable home, but they’re shot with a severity that belies the setting; this is a world gone flat, a paean to a fascist dream of life properly lived, yet all surfaces and no depths. To live such a life would require a hollowing out, an ability to continually ignore one’s senses — those ovens smell awful, but Hedwig never indicates she can smell them at all — until they more or less cease functioning. The insistent bright ugliness gives way occasionally to something shocking (a few black-and-white segments reversed into photonegative, or a shot of a flower that fades to blood-red), all the better to remind us that none of this is beautiful, and we ought to be horrified.
Introducing her book The Life of the Mind by writing about her Eichmann observations again, Arendt could have been writing about the Hösses. She was “struck by the manifest shallowness” in Eichmann, which made it “impossible to trace the uncontestable evil of his deeds to any deeper level of roots or motives.” In fact, she wrote, while his deeds were monstrous, she saw that “the doer — at least the very effective one now on trial — was quite ordinary, commonplace, and neither demonic nor monstrous.”
What is monstrous is the insistently abstracted language the Hösses and other Nazis use in order to avoid thought, especially contrasted with the wordless screams that Mica Levi has worked into the score. Höss is praised for his advances in “KL practice” (KL standing for Konzentrationslager, or concentration camp); we watch him deep in conversation about circular burn chambers that can more efficiently exterminate. “Burn, cool, unload, reload, continuously!” the designer tells him. We watch rooms full of Nazi commandants applaud news of the beginning of the “mass deportation” of Hungarian Jews, with 25 percent “retained for labor.” Nobody says exactly what they mean.
Arendt wrote that the Nazi Sprachregelung introduced a degree of separation between the users and reality, making the horrors of Hitler’s ideas, as Arendt put it, “somehow palatable.” Another way to say this is that humans are capable of great cruelties and monstrosities, but we’re also creatures of compassion and empathy. To see others as sub-human, worthy of prejudice or slavery or torture or extermination, we need to be coached through some mental gymnastics. We need words that disconnect us from reality, that put a layer of remove between us and them, between action and thought. Between our humanity and what we are capable of.
The effect of watching The Zone of Interest ought, I think, to make us feel a mounting horror — and then, from there, to make us think, an act Arendt was always writing about. In the Life of the Mind introduction, she argued that the antidote to the thoughtless cruelty of the autocratic systems around us might be thinking: “Might the problem of good and evil, our faculty of telling right from wrong, be connected with our faculty of thought?”
Maybe, she wrote. “Could this activity be among the conditions that make men abstain from evildoing or even actually ‘condition’ them against it?” she asks. In other words, could learning to think, to avoid cliched thought and stock phrases, train us out of complacency? Could being shocked and horrified and made profoundly uncomfortable, left without easy language, perpetuate a moral good?
What Glazer does with The Zone of Interest is give the audience just a taste of that shock, and then force us into thinking. He never shows the atrocities outright — not to pique our curiosity but because we do not want to see them. To depict it would be, in its own way, an atrocity. Instead, he adds a visual and aural layer of abstraction in order to let us test ourselves, to see if we are, perhaps, the sort of people willing to be in their place now.
“The dividing line,” Arendt wrote, “between those who want to think, and therefore have to judge by themselves, and those who do not, strikes across all social and cultural or educational differences.” All that seems clear right now, at this point in history, is this question is eternally worth facing.
The Zone of Interest premiered at the Cannes Film Festival in May and will be distributed later in 2024 by A24.
Can the US afford to cover this next generation of weight-loss drugs? Can it afford not to?
A new generation of weight-loss drugs presents an opportunity to improve the health of millions of Americans — and a challenge for the nation’s health care system that will have to figure out how to afford them.
The demand for these drugs is proving to be extraordinary. Last week, Novo Nordisk announced it would temporarily stop advertising Wegovy, a diabetes medication that was approved for weight loss in 2021, to prevent high demand from leading to a shortage. Its sister drug with the same active ingredient, Ozempic, is not approved for weight loss but is in high demand for off-label use. And the market is only expected to grow: Eli Lilly has asked the FDA to approve another diabetes drug, Mounjaro, for use in losing weight.
The public health opportunity could also be significant. One in three US adults, more than 85 million people, are considered obese; another one in three are considered overweight. Obesity is a risk factor for various chronic health conditions — like hypertension, heart disease, diabetes, and so on — that are among the most common causes of death in the United States, and the treatments for these diseases are costly. Medical costs associated with obesity exceed $250 billion annually, according to the Institute for Clinical and Economic Review (ICER).
If these drugs can help people shed weight, and early indications are they’re very effective in doing that, that should help them avert those chronic conditions too. And indeed, preliminary research findings suggest Wegovy improves patients’ heart health, which could help to avoid costlier medical problems down the road. The new treatments have the added advantage of relative ease of use, compared to other obesity treatments like gastric bypass surgery. You can take an injection once a week instead of going under the knife. (Although, unlike a one-time surgery, you may need to take those injections in perpetuity.)
The American health care system has seen blockbuster drugs — treatments that are wildly profitable for pharmaceutical companies — before. But this is a special case: drugs that are meant to be taken over the long term to address conditions that affect more than half of the US population.
Not everyone who is obese or overweight is unhealthy, or interested in losing weight, and doctors likely won’t think the medication is appropriate for everyone. Even so, the potential number of people eligible is big enough that, even if the vast majority never fill a prescription, the weight-loss drugs could quickly become among the most common drugs in America, and the most expensive for insurers to cover. ICER estimated if just 0.1 percent of the potential patient population for Wegovy were to receive a prescription, the cost would be significant enough to drive up premiums for private plans.
But the US health system isn’t built to help a vast population take advantage of a very expensive drug, even one with these potential long-term benefits. And that raises questions about whether patients who might benefit and are interested will even be able to afford them.
Having health insurance doesn’t mean your plan will cover every drug on the market. Insurers make decisions, based on both clinical benefit and cost, about whether to cover different drugs, what restrictions to place on that coverage, and how much patients have to pay for them out of pocket. So far, drugs like Wegovy and Ozempic are usually excluded from people’s insurance coverage. Medicare and Medicaid generally do not include weight-loss drugs. Employer health plans, which cover half of the country’s population, typically don’t cover weight-loss drugs either, and are demanding documentation from patients and doctors to justify a Wegovy or Ozempic prescription.
In other words, we have new treatments that address one of the most pressing health crises in the country — and yet our health system seems to be actively discouraging their use. What gives?
Why health insurers typically aren’t covering Wegovy and Ozempic right now
Wegovy, Ozempic, and their peers are ushering in a new era of obesity treatment. Historically, being overweight or obese has been characterized as largely a personal failure and the result of poor lifestyle choices. But most of the medical community already treats weight issues as a biological problem, with behavior as just one component. The public has gradually been coming around to the same view.
The ability to take an injection once a week and see significant weight loss is another step toward treating obesity like any other disease, with the potential to improve health and prevent serious and costly medical conditions later in life. According to ICER, the patients in the clinical trials that evaluated Wegovy as a weight-loss treatment saw about a 15 percent reduction in weight after one year compared to people in the placebo arm of the trials.
That amount of weight loss can result in meaningful health benefits. According to the Centers for Disease Control and Prevention, even a 5-10 percent reduction in body weight can lead to improved blood pressure, cholesterol, and blood sugar. A small Mayo Clinic study estimated that patients saw a reduction in their likelihood of a heart attack or stroke after taking Wegovy for a year.
Those improvements should let people live longer and save the health system money. According to the Peterson-KFF Health System Tracker, people enrolled in large employer health plans who are diagnosed with obesity have significantly higher annual health care costs compared to people who are not: about $12,600 versus $4,700 in 2021.
But those benefits can only be realized for most people if their insurer covers the drug. Wegovy currently has a list price between $800 and $1,000 a month, or between $10,000 and $12,000 a year.
Even in the age of the Affordable Care Act, insurers still have a lot of leeway in deciding which prescription drugs to cover. According to the Wall Street Journal, less than half of large firms (those with more than 5,000 employees) cover weight-loss drugs under their health plan. For smaller shops, the share is even lower, less than 20 percent. Medicaid and Medicare, which insure about 35 percent of the population combined, don’t cover them either, even though obese patients are more likely to be covered by those programs.
Right now, employer health plans are pushing back against the high demand they are seeing for these treatments. Experts say that they don’t expect those attitudes to change until the prices come down or cheaper alternatives come onto the market.
“Until there are, coverage that’s offered through an employer’s health insurance plan may be limited to individuals who are in extreme need of these drugs,” Jennifer Chang, an expert at the Society for Human Resource Management, told me, “versus just as a means of losing weight.”
David Dillon, a health actuary at Lewis & Ellis, explained how this might look in practice. When doctors prescribe Wegovy for weight loss and patients submit their claim, insurers may ask the doctor for information from annual well visits or blood labs that indicate the person is at risk of developing diabetes. The Wall Street Journal reported that patients are already receiving that kind of request from their health insurer, and some are having their claims denied.
Most health insurers do cover gastric bypass surgery, which could in theory be more cost-effective because it’s a one-and-done procedure rather than a prolonged medication regimen. But they also require patients and doctors to meet a long list of criteria before covering that version of obesity treatment.
Medicare, meanwhile, is actually prohibited by law from covering weight-loss drugs under the legislation passed in 2003 that created its prescription drug benefit. Legislation has been proposed in the past to eliminate that exclusion, and drug makers are pushing again for lawmakers to repeal it with these new obesity drugs coming onto the market. Coverage of those drugs could impose significant costs to the program (as much as $27 billion every year) but could also potentially yield long-term cost savings.
Why employer health plans might not invest in people’s long-term health
This is one of the ways in which the US health system’s reliance on employer-sponsored insurance fails us. Most working-age adults are covered by the company that employs them. The priority for the company’s health plan is to try to keep costs as low as possible in the short term, to avert premium increases.
“We have a much more mobile workforce now. Not many folks are staying 20 to 30 years in the same role,” Chang said. “Those long-term benefits might not be a part of their thinking because they are thinking short-term, immediate results versus the long game.”
That’s because in the modern economy, employment is often a short-term proposition. The average tenure for a job in the United States these days is about four years.
“Because people often switch jobs and health insurers, there isn’t always an incentive to pay upfront for a drug that may generate health benefits and cost reductions in the future,” said Larry Levitt, executive vice president at the health policy think tank KFF.
Compounding that problem is that these weight-loss drugs currently appear to be overpriced compared to their value, even if that value is real. Based on ICER’s assessment of Wegovy’s long-term health benefits, the drug provides a value commensurate to between $7,500 and $9,800 per year. But the medicine’s list price is currently above $17,000 and, even when accounting for rebates paid by drug makers to health plans, the average annual cost is still higher (about $13,000) than its expected value.
One thing experts are watching is whether, in the future, the federal government determines weight-loss drugs should be classified as preventive medicine. Health plans are required to cover certain preventive services recommended by expert panels under the ACA. (That is, if the preventive medicine provision survives an ongoing legal challenge.) This would make it easier for patients to access the drugs — and much, much more costly for insurers.
That is the health system the United States has built. Drug makers that patent a novel treatment are given a monopoly and broad discretion to set whatever prices they want for their products. Insurers have some leverage to bring those prices down in negotiations, but they will also resort to restricting coverage to moderate their costs. And because employer plans can expect to cover a given patient for only a few years, they are incentivized to keep costs low in the short term without paying much mind to the potential for long-term savings by averting chronic health problems.
It is a situation driven by the peculiar structure of US health care. A breakthrough weight-loss treatment is going to present a cost challenge to other developed countries, where obesity rates have been rising for years, too. But those countries don’t face the same cost pressures.
In the UK, for example, a month’s supply of Wegovy costs about $100 instead of more than $1,000 — a reflection of the National Health Service’s assessment of the value it will provide. Novo Nordisk also knows it can drive a harder bargain in the US with its more laissez-faire market, reducing the need to try to extract as much revenue as possible from Britain. And the UK has adopted prescription criteria for all patients based on that assessment, with the drug prioritized for people who have specific health conditions, such as high blood pressure, diabetes or prediabetes, heart disease, and even sleep apnea.
So there will be some limits on coverage for weight-loss drugs and experts in the UK do expect some frustration among patients as a result. But that country is making a holistic assessment of the value these drugs can provide and setting costs and access accordingly.
In the US, meanwhile, your ability to take Wegovy or Ozempic or whatever comes next depends on the whims of your employer’s health plan — with little consideration for how it may affect your long-term health.