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The out-of-pocket costs associated with treating obesity and secondary conditions, such as cardiovascular disease (CVD), can be prohibitive.¹ When patients cannot afford these treatments, they often resort to cost-related prescription drug rationing.² Glucagon-like peptide-1 receptor agonists (GLP-1RAs) offer benefits in treating both obesity and CVD,³ but given their high prices,⁴ patients struggling with cost-related prescription rationing will be unable to access new therapies. Understanding prevalence of cost-related prescription drug rationing among people with obesity can inform expectations about adopting these medications.

We analyzed 2020 to 2022 data from the National Health Interview Survey, a nationally representative cross-sectional survey of US households (eMethods in Supplement 1). We included adults who were not pregnant, did not have diabetes, used at least 1 prescription medication, and answered all 3 prescription drug rationing questions. Cost-related prescription rationing was defined as any self-reported skipping, taking less, or delaying filling a medication to save money. Prevalence of rationing was calculated in people with and without obesity and within subgroups defined by age, sex, race and ethnicity (self-reported), income, health insurance coverage, CVD, and cancer for adults with obesity. Because obesity and cost-related drug rationing vary by race and ethnicity, this variable was analyzed (eMethods and eTable 1 in Supplement 1). The Yale University Institutional Review Board approved this cross-sectional study and waived informed consent because it was not considered human participant research. We followed the reporting guideline.

Statistical comparisons were made using χ² tests. We calculated estimated probabilities from a multivariable logistic regression model of cost-related prescription rationing for people with obesity within subgroups defined by sociodemographic and clinical characteristics (eTable 2 in Supplement 1). All analyses used survey weights to account for the complex survey design used to ascertain nationally representative estimates. Analysis was performed using Stata, version 18 (StataCorp LLC). Two-sided P < .05 was considered significant.

The analytical sample comprised 51 720 adults (mean [SD] age, 51.2 [19.1] years; 30 230 females [58.4%]; 5040 Hispanic [9.7%]; 46 680 other ethnicities [90.3%]; 323 American Indian or Alaska Native [0.6%]; 2288 Asian [4.4%]; 5015 Black [9.7%]; 41 380 White [80.0%]; 1041 individuals [2.0%] of other races; and 1673 with missing data [3.2%]), representing 138 603 574 US adults. Of those, 16 768 adults (mean [SD] age, 50.1 [16.6 years]; 55.8% female; 1677 [10.0%] with self-reported CVD) or 33.9% (95% CI, 33.2%-34.5%) had obesity, representing 46 921 106 US adults.

Prevalence of cost-related prescription drug rationing among adults with vs without obesity was 8.3% (95% CI, 7.7%-8.8%) vs 5.9% (95% CI, 5.6%-6.2%; P < .001). Individuals with obesity and CVD had higher prevalence of rationing than those without CVD (10.3% [95% CI, 8.8%-12.0%] vs 8.0% [95% CI, 7.5%-8.6%]; P = .005). Prevalence of rationing was also higher among patients with obesity who were younger, female, had lower income levels, and were uninsured (Table 1). In fully adjusted analyses, age 18 to 44 years, female sex, lower income, lack of health insurance coverage, and CVD were associated with higher estimated probability of rationing among individuals with obesity (Table 2). The adjusted estimated probability of cost-related prescription drug rationing was 7.4% (95% CI, 5.5%-9.3%) for those with CVD and 4.4% (95% CI, 3.6%-5.3%) for those without CVD.

Patients with obesity, particularly those with CVD, were more likely to engage in cost-related prescription drug rationing, suggesting difficulties affording their medications. Given that few insurance providers cover GLP-1RA for obesity,⁵ cost-related prescription drug rationing could be exacerbated if patients were prescribed GLP-1RAs at their current prices (over $1000 per month).⁴ Moreover, high prices of GLP-1RAs may worsen health disparities because Black and Hispanic individuals with obesity have a higher prevalence of prescription drug rationing compared with White and non-Hispanic individuals.

Study limitations include inability to assess which medications adults were prescribed and whether adults were already prescribed GLP-1RA for treating obesity, although use for indications other than diabetes was minimal until late 2022.⁶ Respondent answers to survey questions are subject to recall bias, and weight and height were self-reported.

Accepted for Publication: July 11, 2024.

Published: November 5, 2024. doi:10.1001/jamanetworkopen.2024.33000

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2024 Chen AS et al. ÌÇÐÄvlog Open.

Corresponding Author: Alissa S. Chen, MD, MPH, Yale School of Medicine, 333 Cedar St, New Haven, CT 06510 (alissa.chen@yale.edu).

Author Contributions: Dr Chen had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Chen, Lipska.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Chen.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Chen, Borden, Canavan.

Administrative, technical, or material support: Oladele.

Supervision: Lipska.

Conflict of Interest Disclosures: Dr Ross reported receiving grants from the Food and Drug Administration, Johnson & Johnson, Medical Device Innovation Consortium, Agency for Healthcare Research and Quality, National Institutes of Health or National Heart, Lung, and Blood Institute, and Arnold Ventures outside the submitted work. Dr Ross was an expert witness at the request of Relator's attorneys, the Greene Law Firm, in a qui tam suit alleging violations of the False Claims Act and Anti-Kickback Statute against Biogen Inc, which was settled in September 2022. Dr Oladele reported receiving grants from the National Institutes of Health during the conduct of the study. Dr Lipska reported receiving personal fees from UpToDate to write and edit content and other fees from Centers for Medicare and Medicaid Services Support to develop and evaluate publicly reported quality measures outside the submitted work. No other disclosures were reported.

Funding/Support: Dr Chen was funded by grant T32 AG019134 from the National Institute on Aging outside the submitted work. Dr Chen was funded as a Yale National Clinician Scholar.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2.