By Shalina Chatlani, Stateline.org
The Trump administration this month scrapped a Biden-era proposal that might have required state Medicaid packages and allowed federal Medicare to pay for some GLP-1s for weight problems therapy. As a substitute, state Medicaid packages will retain the selection of whether or not to cowl the high-priced drugs for his or her residents.
The medication, which have traditionally been prescribed to diabetic sufferers, additionally assist sufferers shed weight and have grown in recognition amongst medical doctors and sufferers. However they’re usually too costly for most individuals to afford with out insurance coverage.
Whereas medical doctors and affected person advocates say these medication are important to serving to sufferers scuffling with weight problems and might get monetary savings in the long term by decreasing comorbidities corresponding to coronary heart illness, others say the drugs are simply too costly for many states to afford. Greater than a dozen state Medicaid packages have opted to cowl GLP-1s for weight problems therapy, and the proposed Biden rule would have requested all states to determine methods to pay for them. However now, advocates concern these medication could proceed to be out of attain for a lot of.
“It’s unfortunate that they’re excluding a whole class of medications that seem to have a tremendous number of health benefits to patients,” Dr. Nicholas Pennings, chair of household drugs at Campbell College in Buies Creek, North Carolina, stated in an interview.
GLP-1s, which stand for glucagon-like peptide-1, are a category of medicine that stability blood sugar ranges. They’ve lengthy been prescribed to sufferers with Kind 2 diabetes. However for the reason that medication additionally curb starvation alerts, medical doctors could prescribe these medication — together with common manufacturers Wegovy and Ozempic — to assist sufferers shed weight.
Medicaid is a joint federal-state funded program that largely serves individuals with decrease incomes underneath the age of 65 or who’ve a incapacity. The federal Medicare program focuses totally on individuals above the age of 65, regardless of their revenue.
How and whether or not to cowl costly therapies and medicines is usually a vital deliberation for state Medicaid administrators. In North Carolina, the place 70% of individuals wrestle with being chubby or overweight, officers opted to start masking the medication for weight reduction final 12 months. That protection has been a sport changer, stated Pennings, who continues to deal with Medicaid sufferers.
“They are expensive, but there’s a lot of other medications that are expensive too. Why is it that obesity medications and diabetes medications are being selected out?” Pennings stated. “I think that’s just part of the inherent bias towards the treatment of people with obesity, feeling like it’s cheating or not necessary.”
The listing worth for Wegovy is round $1,300 per 30 days, and for Ozempic, round $1,000. Even so, the skyrocketing recognition of those medication has prompted not less than 14 state Medicaid departments to start masking these medication to deal with weight problems up to now decade.
Along with North Carolina, these states embody California, Delaware, Kansas, Massachusetts, Michigan, Minnesota, Mississippi, New Hampshire, Pennsylvania, Rhode Island, South Carolina, Virginia and Wisconsin.
An annual survey of Medicaid administrators from well being coverage analysis group KFF just lately discovered that half of the 47 responding states not already masking the medication have been contemplating doing so.
In January, the Nationwide Affiliation of Medicaid Administrators instructed the federal Facilities for Medicare & Medicaid Companies that state Medicaid departments had “significant concerns over the fiscal impacts” of the Biden proposal to require protection of GLP-1s, and “strongly recommend that CMS maintain the current state option to cover or not cover anti-obesity medications.”
However others say masking the medication will yield long-term financial savings.
John Cawley, a professor of economics and public coverage at Cornell College who has studied the financial impacts of weight problems, has discovered that weight problems primarily doubles an individual’s annual well being care prices as a result of comorbidities corresponding to coronary heart illness, fatty liver illness and kidney illness.
He’s discovered that weight reduction amongst these with excessive weight problems, with a BMI of 40 or larger, can yield substantial reductions in medical care prices.
Cawley added that state Medicaid packages “have a lot of flexibility” in guaranteeing prices don’t get uncontrolled, by, for instance, masking a newly obtainable generic model of GLP-1s, requiring prior authorization, and asking sufferers to attempt behavioral packages earlier than getting a prescription.
North Carolina’s Medicaid division started masking GLP-1s for weight problems in August. The state has been capable of afford GLP-1 protection by negotiating rebates, or reductions, with drug producers, and by getting the federal authorities to cowl some prices. Division leaders assume decreasing weight problems will save the state cash in the long term, stated Jay Ludlam, deputy secretary for North Carolina Medicaid.
He stated that one of many advantages of Medicaid is that “we get to choose, as a state, where we want to make kind of those extra investments or not.” He added that masking the drugs might be doubtlessly financially possible for different states.
“Each program is different and has its own pressures. It would be welcome to be able to come together with other states to be able to negotiate broader deals,” Ludlam stated. “If North Carolina is able to get a good deal, I don’t know why other states wouldn’t be able to participate in that.”
In 2023, Connecticut enacted a legislation requiring Medicaid to cowl weight problems therapy companies. This system started masking GLP-1s for weight reduction, however prices have been vital sufficient that the state instructed suppliers this 12 months that it’s now specializing in different weight problems therapies as an alternative.
Sean Scanlon, the Connecticut comptroller, stated that not masking GLP-1s is “shortsighted, bad policy.” The state well being plan, which takes care of lecturers and different state staff, has been masking the medication for weight reduction since 2023. The plan controls prices by solely prescribing GLP-1s after sufferers undergo some on-line weight-loss counseling, stated Scanlon.
“The most fiscally conservative thing we can do is give people tools that will save the taxpayers money in the long run,” he stated in an interview. “And GLP-1 drugs are one of the best tools that we have to ensure that the taxpayers are not going to pay more money for the health care of hundreds of millions of people in the long run.”
It’s unclear whether or not the federal authorities will reverse course. Previously, Well being and Human Companies Secretary Robert F. Kennedy Jr. has really helpful “three good meals a day” and behavioral adjustments reasonably than weight-loss treatment.
However this month, Kennedy instructed CBS Information he’s contemplating a regulatory framework to have Medicare and Medicaid cowl these “extraordinary drugs” sooner or later, as soon as their price goes down.
“Ideally, over the long-term, we’d like to see those drugs available for people after they try other interventions,” Kennedy stated.
Stateline reporter Shalina Chatlani will be reached at schatlani@stateline.org.
©2025 States Newsroom. Go to at stateline.org. Distributed by Tribune Content material Company, LLC.
Initially Revealed:
