By SUSAN HAIGH and MARC LEVY, Associated Press
States increasingly struggling to cover the rising cost of popular GLP-1 drugs like Wegovy, Ozempic and Zepbound are searching for ways to get out from under the budgetary squeeze that took them by surprise.
One solution some policymakers may try is restricting the number of people on Medicaid who can use the pricey diabetes drugs for weight-loss purposes.
Pennsylvania’s Medicaid coverage of the drugs is expected to cost $1.3 billion in 2025 — up from a fraction of that several years ago — and is contributing to projections of a multibillion-dollar budget deficit. The state is thinking about requiring Medicaid patients who want to use GLP-1s for weight loss to meet a certain number on the body-mass index or try diet and exercise programs or less expensive medications first.
“It is a medication that’s gotten a lot of hype and a lot of press, and has become very popular in its use and it is wildly expensive,” Dr. Val Arkoosh, Pennsylvania’s human services secretary, told a state House hearing in March.
At least 14 states already cover the cost of GLP-1 medications for obesity treatment for patients on Medicaid, the federal health care program for people with low incomes. Democrats and Republicans in at least a half-dozen other states floated bills this year to require the same coverage, according to an Associated Press analysis using the bill-tracking software Plural.
Some bills have stalled while others remain alive, including a proposal in Arkansas requiring GLP-1s to be covered under Medicaid when prescribed specifically for weight loss. Iowa lawmakers are thinking about ordering a cost-benefit analysis before making the commitment. Already, West Virginia and North Carolina ended programs in 2024 that provided coverage for state employees, citing cost concerns.
“It is very expensive,” said Jeffrey Beckham, the state budget director in Connecticut, where Medicaid coverage of the drugs for weight loss may be scrapped entirely. “Other states are coming to that conclusion, as well as some private carriers.”
Overall Medicaid spending on GLP-1 drugs — before partial rebates from drug manufacturers — jumped from $577.3 million in 2019 to $3.9 billion in 2023, according to a November report from KFF, a nonprofit that researches health care issues. The number of prescriptions for the drugs increased by more than 400% during that same time period. The average annual cost per patient for a GLP-1 drug is $12,000, according to a Peterson-KFF tracker.
About half of Americans “strongly” or “somewhat” favor having Medicare and Medicaid cover weight-loss drugs for people who have obesity, a recent AP-NORC poll showed, with about 2 in 10 opposed the idea and about one-quarter with a neutral view.
But Medicare does not cover GLP-1s, and the Trump administration said Friday that wouldn’t put into place a proposed rule by presidential predecessor Joe Biden to cover the medications under Medicare’s Part D prescription drug coverage. Biden’s proposal was expensive: It would have included coverage for all state- and federally funded Medicaid programs, costing taxpayers as much as $35 billion over next decade.
States that do provide coverage have tried to manage costs by putting prescribing limits on the GLP-1s. There’s also some evidence that if Medicaid patients lose weight with the drugs, they’ll be healthier and less expensive to cover, said Tracy Zvenyach of Obesity Action, an advocacy group that urges states to provide coverage.
Zvenyach also stressed how it’s unclear whether patients will need to regularly take these drugs for the rest of their lives — a key cost concern raised by public officials. “Someone may have to be on treatment for over the course of their lifetime,” she said. “But we don’t know exactly what that regimen would look like.”
About 40% of adults in the U.S. have obesity, according to the U.S. Centers for Disease Control and Prevention. Obesity can cause hypertension, Type 2 diabetes and high cholesterol, which lead to greater risks of things like stroke and heart attacks.
Dr. Adam Raphael Rom, a physician at Greater Philadelphia Health Action, a network of health centers in the city, said most of his patients who take GLP-1s are covered by Medicaid and some are non-diabetics who use it for weight loss.
“I had one patient tell me that it’s like, changed her relationship to food,” Rom said. “I’ve had patients lose like 20, 40, 60 pounds.”
But obesity experts have told The Associated Press that as many as 1 in 5 people may not lose the amount of weight that others have seen come off. And in a recent survey of state Medicaid directors conducted by KFF, a health policy research organization, they said cost and potential side effects are among their concerns.
The debate over coverage coincides with rising Medicaid budgets and the prospect of losing federal funding — with congressional Republicans considering siphoning as much as $880 billion from Medicaid over the next decade.
Connecticut is facing a $290 million Medicaid account deficit, and Democratic Gov. Ned Lamont proposed doing away with a 2023 requirement that Medicaid cover GLP-1s for severe obesity, though the state has never fully abided by the law due to the cost.
Starting June 14, though, state Medicaid patients will be required to have a Type 2 diabetes diagnosis to get the drugs covered. Lamont also is pushing for the state to cover two less expensive oral medications approved by the FDA for weight loss, as well as nutrition counseling.
Sarah Makowicki, 42, tried the other medications and said she suffered serious side effects. The graduate student and statehouse intern is working on a bill that would restore the full GLP-1 coverage for her and others.
Sara Lamontagne, a transgender woman with a disability who is on Medicaid, said she regained weight when her coverage for GLP-1 medication was cut off in the past. She said she went from 260 pounds to over 300, heavier than she had ever been.
“So, it’s a horrible game to be played, to be going back and and forth,” said Lamontagne, whose attempts to appeal the state’s recent denial of her Ozempic prescription refill have been unsuccessful.
Makowicki said GLP-1 drugs combined with weight-loss surgery helped her change her life: She’s had knee-replacement surgery and lost over 200 pounds.
“I am a different person from what I was five years ago,” Makowicki said. “Not only in my physical space, but also mentally.”
Haigh reported from Hartford, Connecticut. Levy reported from Harrisburg, Pennsylvania.
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Source: Paradise Post
