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States weigh whether to add coverage for some obesity drugs: NPR

Medicaid is required to cover almost all medications, but Congress specifically excluded those for weight loss. Despite this, 16 states now cover Wegovy. Others are considering it, but it could put a strain on budgets.



JUANA SUMMERS, HOST:

Drugs like Wegovy and Zepbound are revolutionizing the way people lose weight, but many Medicaid recipients don’t have access to them. NPR pharmaceutical correspondent Sydney Lupkin explains how states decide whether to add coverage for these obesity drugs.

SYDNEY LUPKIN, BYLINE: Della McCullough has struggled with her weight since she was 11 years old. That’s when her mother told her she had strong bones. Now 53, she says she’s already tried diet, exercise, supplements and even an all-fruit diet. None of them worked.

DELLA MCCULLOUGH: I’m still not well. I’ve had nutrition counseling, trauma counseling, meditation, positive affirmation therapy, and I still weigh almost 300 pounds, and I’m sad and unhappy.

LUPKIN: McCullough is a semi-retired school bus driver from Colorado. She and her husband found themselves on Medicaid for the first time last year.

MCCULLOUGH: I’m not ashamed of the fact that I’m on state assistance, and I can say that the assistance they provide is not adequate, especially if you have obesity.

LUPKIN: She’s interested in new blockbuster drugs that help overweight and obese people. Wegovy contains the same active ingredient as Ozempic, a diabetes medication, but is specifically approved for weight loss. Medicaid is not required to cover it because of a decades-old law excluding drugs that treat anorexia, weight gain and weight loss. Robin Feldman of the University of California Law School in San Francisco says that at the time, everyone thought diet and exercise were the key to losing weight and keeping it off, even though the evidence current ones do not support it.

ROBIN FELDMAN: So in that context, being overweight was seen as a lack of willpower and dedication.

LUPKIN: Because state Medicaid programs aren’t required to cover weight-loss drugs, only 16 currently do. Kate McEvoy, executive director of the National Association of Medicaid Directors, says it’s often a budget issue.

KATE MCEVOY: States always have to grapple with this or that investment. There are many other preventive health issues, including those related to maternal and child health. And so looking at the relative merits of these investments is sort of where states are right now.

LUPKIN: Wegovy’s list price is over $1,300 per month. Even if Medicaid programs receive a significant cut, total spending could be significant. Studies show that people with Medicaid are more likely to be overweight or obese than people with commercial insurance. And people can take these medications for years. In North Carolina, Kody Kinsley, the state’s secretary of Health and Human Services, hopes the Medicaid program will cover Wegovy by this summer.

KODY KINSLEY: So we have sort of a standard policy process that we follow to consider actuarial impacts, rebate negotiation, the value of adding drugs, which we don’t really follow for any other drug because they ‘must be covered. But for these, because of this federal exclusion, we follow this process.

LUPKIN: In Colorado, where McCullough lives, Medicaid doesn’t cover Wegovy for weight loss. However, the drug was recently approved by the FDA to reduce the risk of serious heart problems in people who are overweight or obese and have cardiovascular disease. That means Medicaid should cover Wegovy for some people, because it’s no longer just a weight-loss drug.

But McCullough does not have cardiovascular disease and would not qualify. She says obese people are treated differently than people with other health conditions. I asked him if this seemed personal to me.

MCCULLOUGH: You know, I never would have thought that, but now that I’m in this situation, it feels very personal. Like, she’s just fat. You know, that’s his problem. She will find a solution, or she will have to change whatever she does.

LUPKIN: She hopes that politicians will eventually catch up with science. Sydney Lupkin, NPR News.

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