Joanna Bailey, a family physician and obesity specialist, doesn’t want to tell her patients that they can’t take Wegovy, but she has gotten used to it.

Around a quarter of the people she sees in her small clinic in Wyoming County would benefit from the weight-loss medications, which also include Ozempic, Zepbound and Mounjaro, she says. The drugs have helped some of them lose 15 to 20 percent of their weight. But most people in the area she serves don’t have insurance that covers the cost, and virtually no one can afford sticker prices of $1,000 to $1,400 a month.

“Even my richest patients can’t afford it,” Dr. Bailey said. She then mentioned something that many doctors in West Virginia — among the poorest states in the country, with the highest prevalence of obesity, at 41 percent — say: “We’ve separated between the haves and the have-nots.”

Such disparities sharpened in March when West Virginia’s Public Employees Insurance Agency, which pays most of the cost of prescription drugs for more than 75,000 teachers, municipal workers and other public employees and their families, canceled a pilot program to cover weight-loss drugs.

Some private insurers help pay for medications to treat obesity, but most Medicaid programs do so only to manage diabetes, and Medicare covers Wegovy and Zepbound only when they are prescribed for heart problems.

Over the past year, states have been trying, amid rising demand, to determine how far to extend coverage for public employees. Connecticut is on track to spend more than $35 million this year through a limited weight-loss coverage initiative. In January, North Carolina announced that it would stop paying for weight-loss medications after forking out $100 million for them in 2023 — 10 percent of its spending on prescription drugs.

The problem is not isolated to public programs. Blue Cross Blue Shield of Michigan, the state’s largest insurer, paid $350 million for the new classes of obesity and diabetes drugs in 2023, a fifth of its prescription drug spending, and earlier this month it announced that it would remove coverage of the medications from most commercial plans.

West Virginia’s program for public employees was limited to a little over 1,000 people, but at its peak — despite rebates from manufacturers — it cost around $1.3 million a month, according to Brian Cunningham, the agency’s director. Mr. Cunningham said that if it were expanded as intended to include 10,000 people, the program could end up costing $150 million a year, more than 40 percent of its current spending on prescription drugs, leading to severe premium hikes.

“I’ve laid awake at night pretty much since I made the decision,” he said. “But I have a fiduciary responsibility, and that’s my No. 1 responsibility.”

To Dr. Bailey, however, and to other obesity doctors in the state, the decision was maddening. She said it showed a lack of understanding that obesity is medically classified as a “complex disease,” in the same category as depression and diabetes.

Laura Davisson, the director of the weight management program at the West Virginia University Health System, found that in her clinic, patients taking obesity medications lost 15 percent more weight than those who relied solely on diet and exercise. Local legislators have jurisdiction over drug coverage in state programs like Medicaid, and Dr. Davisson has been lobbying in recent months to maintain the public employee insurance agency’s pilot program and expand coverage more broadly for weight-loss medications but has not made much progress. So far the issue hasn’t resonated politically: Leading elected officials in the state have remained largely silent.

“Pretty much everyone is the same,” she said. “They say: ‘I’d love to treat obesity. I’d love to help people. It’s just too expensive.’ But you can’t not treat cancer because it’s too expensive. Why can you do that with obesity?”

Christina Morgan, a professor of political science at West Virginia University, began taking Zepbound in December as part of the state’s obesity drug pilot program. By March, she had lost 30 pounds. Her blood pressure dropped, as did her blood sugar. When she heard about the program’s cancellation, she was despondent.

“I’ll be honest,” she said. “I can’t afford this out of pocket. It’s just not feasible.”

Her physician warned her about regaining weight and canvassed her options before the coverage for her drugs ends, in July. They were slim. “She said, ‘Listen — I don’t want you to be diabetic, but if you are, you’re eligible for this medicine,’” Dr. Morgan said. “It’s mind boggling. They’d rather you get sicker to take this medicine.”

In some regards, doctors, patients, health advocacy groups and pharmaceutical companies are aligned against employers and government health insurance programs in the battle over access to weight-loss medications.

Novo Nordisk, which sells Ozempic and Wegovy, and Eli Lilly, which sells Zepbound and Mounjaro, are top donors to America’s largest obesity advocacy groups and are well represented at medical conferences. Most manufacturers mention the stigma around weight on their websites and present their products as ways to change, as Novo Nordisk puts it, “how the world sees, prevents and treats obesity.” And, over the past few years, they have been able to do so, to some extent.

Although Novo Nordisk and Eli Lilly promote coupons to patients with commercial insurance and give large rebates to employers and government programs that cover the drugs, Mr. Cunningham said that the cost was still staggering for the health care system and for most patients in West Virginia and that declarations of social justice could ring hollow from two corporations that, combined, are valued above $1 trillion. F

Levi Hall, a pharmacist at Rhonda’s Pineville Pharmacy in Wyoming County, often turns away patients who come to him with prescriptions for the medications, because of either supply shortages or exorbitant prices. “It’s like that Geico commercial, where the guy has a dollar bill on a string, and he keeps pulling it away when you get close,” Mr. Hall said. “You just can’t get it.”

Mr. Cunningham said he also worried about possible long-term side effects of the drugs that are not yet known, and he noted that West Virginia had good reason not to trust big pharmaceutical companies. The state was at the center of the nation’s opioid epidemic, with the highest rate of opioid overdoses and prescribed pain pills in America. That began in the mid-1990s when Purdue Pharma marketed OxyContin to areas with high disability rates to treat a silent “epidemic of pain.”

“The drug manufacturers have spun a tale, and been very effective at creating a coalition of do-gooder nonprofits, and putting pressure on physicians to prescribe this,” Mr. Cunningham said, referring to obesity medications.

Mollie Cecil, an obesity doctor from Lewis County, W.Va., acknowledged such skepticism and said her patients sometimes voiced their own mistrust of the big pharmaceutical companies. But she contended that drugs like Ozempic and Wegovy were categorically different from prescription opioids like OxyContin: They have been on the market for nearly two decades, are highly effective and are not addictive. And, she added: “Obesity isn’t a silent epidemic. It’s a very real epidemic.”

She continued: “So I would question if someone has an issue with anti-obesity medications in a way that they don’t with other disease states. Why do they doubt obesity best practices and guidelines because of industry involvement, but they don’t question other areas of medicine with the same involvement?”

Especially in West Virginia, Dr. Cecil said — where healthy food can be expensive and difficult to obtain and eating habits are passed down through generations, often leading to greater risks of obesity, diabetes, fatty liver disease and stroke — there is a dire need for the medications.

“These are really effective treatments, and they can make a difference in people’s lives here,” she said. “But they may as well have never been created.”