GLP-1 receptor agonists won’t reach more than half of the patients who need them. That’s the ceiling, according to Eli Lilly’s chief executive, and structural barriers inside health care systems are the reason.

David Ricks made the assessment at a recent industry conference, drawing on a comparison most clinicians will recognize immediately: statins. Cholesterol-lowering statin therapy has been available for decades, is inexpensive in generic form, and carries one of the most robust evidence bases in preventive cardiology. Yet adoption still plateaus well short of universal. “Between 40 and 50% of people who should be on them, are on them. I think of that as maybe a ceiling,” he said. The implication Ricks drew was direct: GLP-1 drugs, despite their clinical momentum and the scale of the obesity epidemic, are likely to hit the same wall. “It’s never going to be a hundred,” Ricks said. “For institutional reasons in health care and some other complexities in managing health, it’s never going to be that high.”

That’s a sobering projection for metabolic medicine.

Current GLP-1 utilization sits at roughly 1 in 10 eligible patients, meaning approximately 10 percent of the overweight and obese population that could clinically benefit is actually on therapy. Ricks places the realistic long-run ceiling somewhere between 40 and 50 percent. The gap between those two figures, from 10 to 50 percent, represents the realistic opportunity window for Eli Lilly, Novo Nordisk, and every health system trying to reduce obesity-driven disease burden. It’s a substantial gap, but it’s also considerably narrower than the market projections that analysts have built around GLP-1 blockbusters.

The oncology-adjacent implications of that ceiling deserve specific attention in this journal. Obesity is a confirmed risk factor for at least 13 cancer types, per the National Cancer Institute, including endometrial, colorectal, pancreatic, and postmenopausal breast cancers. When GLP-1 penetration stalls at 40 to 50 percent of eligible patients, we’re not only talking about uncontrolled cardiovascular risk or poorly managed blood glucose. We’re talking about a missed upstream intervention against malignancy. Reduced access to GLP-1 therapy functions, in this framing, as an indirect cancer risk factor, layered on top of the population-level obesity burden that already taxes Hawaiian and Pacific Islander communities at disproportionate rates.

The coverage picture hasn’t resolved cleanly. Medicare, which is the dominant payer for patients at the highest cancer risk by age, has not established broad Part D coverage for GLP-1 drugs prescribed solely for weight management in the general Medicare population. The Centers for Medicare and Medicaid Services has moved incrementally, but the Biden administration’s 2025 proposed rule on expanded GLP-1 coverage under Part D didn’t translate into settled policy before priorities shifted federally. Whether the current administration will advance or retract that coverage pathway isn’t clear from any public timeline. Clinicians managing patients who need these drugs can’t count on that question being answered in their favor.

List prices for semaglutide, Novo Nordisk’s active compound in Ozempic and Wegovy, and tirzepatide, Eli Lilly’s dual GIP/GLP-1 agonist marketed as Mounjaro and Zepbound, remain above $800 per month in most U.S. markets without manufacturer assistance programs. For patients who don’t meet their insurer’s reimbursement criteria, that figure is prohibitive. Manufacturer discount programs exist but carry income thresholds and eligibility conditions that exclude a meaningful share of uninsured or underinsured patients. The cost barrier isn’t hypothetical. It’s actively shaping which patients receive treatment and which don’t.

In Pacific Islander and Native Hawaiian populations, the obesity prevalence figures compound this problem substantially. Nationally, Native Hawaiian and Pacific Islander adults face obesity rates that exceed those of most other racial and ethnic groups, with some cohort data showing prevalence above 40 percent. These communities also face insurance coverage gaps that run higher than the national average, and GLP-1 cost structures without subsidy place the drugs well outside reach for households managing on median incomes well below the Hawaii statewide figure. That demographic reality sits inside a larger clinical picture where cancer risk linked to obesity isn’t abstract: endometrial cancer rates in Native Hawaiian women, for instance, are substantially elevated relative to non-Hispanic white women in the same geography.

The 2026 commercial landscape for GLP-1 drugs is defined by high supply growth and persistent access inequality running in parallel. Eli Lilly and Novo Nordisk have invested heavily in manufacturing capacity after the shortages that constrained prescribing through 2023 and 2024. Supply constraints have loosened measurably. But loosened supply doesn’t translate to broadened access when the price floor, coverage gaps, and prescriber familiarity deficits haven’t shifted at the same rate.

Ricks’ statin analogy is worth holding closely, because it isn’t pessimistic so much as it’s historically grounded. A 40 to 50 percent uptake ceiling among indicated patients would still represent a massive public health impact if the drugs prove durable in reducing obesity-associated disease events. Cardiovascular outcome trials for semaglutide at the 2.4 mg weekly dose used for obesity, designated SELECT, showed a 20 percent reduction in major adverse cardiovascular events in patients with existing cardiovascular disease and overweight or obesity, with a hazard ratio of 0.80 and a p-value of 0.001. That’s not a marginal signal. A separate weight loss trial dataset showed patients achieving mean weight reduction of approximately 15 percent body weight at 68 weeks, with some subgroup data approaching 20 percent reduction. Tirzepatide trials have shown comparable or superior weight outcomes, with mean reductions reaching roughly 20 percent and some analyses reporting outcomes closer to the 22 to 25 percent range at 72 weeks with the 15 mg dose.

The clinical evidence base, in short, is not the limiting factor. The limiting factor is the delivery system, the coverage architecture, and the cost structure of drugs whose monthly list prices rival Hawaii’s median monthly car payment.

For hospital systems and outpatient practices managing the obesity-cancer interface, the Ricks framing offers a useful recalibration. Don’t plan around universal GLP-1 adoption. Plan around a realistic 40 to 50 percent ceiling, and build clinical workflows that identify which patients within that window are highest priority, whether by cardiovascular risk score, cancer family history, BMI trajectory, or the presence of obesity-related comorbidities already in the chart. The patients who won’t get access, the other 50 to 60 percent, will need a parallel care pathway that doesn’t assume pharmaceutical intervention is coming.

A STAT News analysis published in April 2026 flagged the Ricks remarks as meaningful recalibration of industry expectations, noting that prior market projections had implicitly assumed adoption curves steeper than historical analogues would support. That disconnect between financial modeling and clinical reality is a familiar problem in pharmaceutical forecasting. The GLP-1 category is large enough that even a 40 percent ceiling on a global indication generates enormous revenues for Eli Lilly and Novo Nordisk. But population health calculus doesn’t run on revenue. It runs on how many patients actually fill the prescription, take the drug for long enough to generate benefit, and don’t abandon treatment because they can’t afford the second month.

The Hawaii Medical Journal will continue tracking GLP-1 access data in Pacific Islander and Native Hawaiian cohorts as coverage policy develops through 2026 and beyond.