Who Gets the Drug? Reimbursement, the Market and the Allocation of GLP-1 Agonists in Japan and China

Imagine a world where a new medicine exists that can help people lose weight, but getting it depends less on how much you need it and more on who is holding the gate. This is the reality of modern healthcare, where a drug's journey from a laboratory to a patient's hand is blocked by a series of checkpoints. These checkpoints are not just medical tests; they are rules set by insurance companies, government agencies, and professional societies. Each checkpoint asks a different question: Is this a real disease? Does the patient have a specific medical record? Can the patient afford to pay? The result is that the people who end up with the medicine are often not the ones the rules were written to help. Instead, the medicine flows to those who can navigate the system or pay for it privately, creating a split between who is officially eligible and who actually receives the treatment.

This dynamic is playing out clearly in two major Asian nations, Japan and China, where the same powerful weight-loss drugs are available but reach very different groups of people. Researchers examined how these two countries handle the allocation of GLP-1 agonists, a class of medicines that includes well-known brands like Wegovy and Mounjaro. Both nations recognize obesity as a medical condition. Both have approved these drugs for treating it. Yet, the path to getting the drug is a maze of different rules. In Japan, the government pays for the drug only if a patient meets a strict set of conditions, including a long history of failed dieting and a specific list of other health problems. In China, the government refuses to pay for weight loss at all, viewing it as a lifestyle choice rather than a medical necessity. Despite these different starting points, the outcome is surprisingly similar: in both countries, the people who actually get the drugs through official channels are a tiny fraction of those who need them, while a much larger group of people buys the drugs privately, often at high prices.

The story begins with the drug itself. In Japan, the government decided to cover the cost of these injections, but only under very tight conditions. To qualify, a patient must be treated at a specific, accredited hospital that employs a full-time dietitian. The patient must prove they have tried to lose weight through diet and exercise for at least six months at that same hospital without success. They must also have a body mass index of at least 27 along with other health issues like high blood pressure, or a body mass index of 35 on its own. Even then, the treatment is capped at 68 weeks. These rules were designed to ensure the drug is used only by those who truly need it and have shown they are willing to put in the work. However, the result of these strict gates is that fewer than one in a hundred of the six million people who technically qualify are actually being treated. Only about 1,200 hospitals in the entire country meet the requirements to prescribe the drug under insurance.

While the official channel remains narrow, a wide market has opened up just outside the gate. Because Japanese law allows doctors to prescribe these drugs for weight loss if the patient pays out of pocket, many people are turning to private clinics and online services. Here, the rules are different. A person does not need to prove they tried and failed at dieting, nor do they need to visit a specific type of hospital. They simply need to pay. Reports show that many of these private prescriptions are for women of average weight who want to slim down for cosmetic reasons, not for the severe medical conditions the insurance rules target. In fact, a version of the drug licensed for diabetes has become the fourth best-selling medicine in Japan, largely because it is being used off-label for weight loss by people paying full price. The government has tried to stop this by warning doctors and manufacturers, but the market continues to grow, serving a population that is the exact opposite of the one the insurance rules were meant to help.

China presents a different picture but leads to a similar conclusion. In China, the government has explicitly stated that weight loss is not a valid reason for public insurance coverage. The health ministry recognizes obesity as a disease and has ordered hospitals to open weight management clinics, but the national insurance fund will not pay for the drugs used there. The rules for reimbursement are based on the purpose of the drug: if it is for diabetes, it is covered; if it is for weight loss, it is not. This means there is no official gate for weight loss patients to pass through. Instead, the entire market for these drugs operates outside the public system. When the weight-loss version of the drug was launched, it was sold in pharmacies and on delivery apps. Within a year, competition drove the price down significantly, making it accessible to a specific demographic: young, urban, well-paid women.

In China, the proof required to get the drug is minimal. A person can often buy it online with a simple prescription, sometimes without the doctor even verifying the details. The government focuses its energy on preventing fraud, ensuring that people do not use their diabetes insurance to buy weight-loss drugs, but it does not control who buys the drug with their own money. The result is that the drug reaches a massive number of people who are not covered by insurance. The market fills the gap left by the state, selling the medicine to those who can afford it. The people getting the drug are not the ones with the most severe medical needs, but rather those with the most disposable income and the desire to lose weight.

When researchers compared these two systems, they found that the rules set by the payers do not determine who gets the drug; they only determine who gets it at the collective expense of the public. The rules act as a filter, deciding who is "deserving" enough to be paid for by society. In Japan, the filter is a record of effort and failure. In China, the filter is a simple refusal to pay for the purpose at all. But in both cases, the people who are filtered out do not disappear. They go to the market. The market operates on a different principle: the ability to pay. This creates a situation where the drug is available to two different groups of people. One group is small, medically complex, and documented in detail. The other group is large, often younger and female, and defined by their financial capacity.

The study suggests that this split is not an accident or a failure of administration, but a structural feature of how these medicines are distributed. The government sets the rules for the public share, deciding how much of the demand it will meet. The market then picks up the rest. The stricter the rules for the public share, the larger the market share becomes. In Japan, the strict rules created a large private market. In China, the total exclusion created a market that serves everyone who can pay. The people who are left out of the system are not necessarily those who need the drug the most. In fact, the people who need it the most—those with severe health problems but little money—are often the ones who cannot pass the gate for public funding and cannot afford the price at the market counter.

This pattern is not unique to Japan and China. Similar dynamics are seen in other countries where access to these drugs is limited by queues, strict eligibility criteria, or high costs. In every case, the official rules define a small group of eligible patients, while the market serves a much larger group of willing buyers. The researchers argue that the question of "who gets the drug" cannot be answered by looking at the disease classification or the insurance rules alone. It requires looking at the entire system, including the price and the sales channels. The drug is effectively partitioned into two parts: a small, rationed portion for those who meet the state's proof, and a large, saleable portion for those who can pay.

The implications of this finding are significant for how we think about healthcare and fairness. It shows that recognizing a disease as real does not guarantee that people with that disease will get treatment. It also shows that the people who end up with the treatment are often determined by factors unrelated to their medical need, such as their income or their ability to navigate a complex system. The state decides who gets the drug for free, but the market decides who gets the drug at all. As these drugs become more common and prices potentially drop with new competitors, the balance between the gate and the market will shift, but the fundamental division will likely remain. The people who need the medicine most may still be the ones who cannot reach it, while those with the means to pay will continue to find a way to get it.