As healthcare costs continue to rise, many states across the U.S. are increasingly struggling to manage the financial burden associated with popular GLP-1 medications such as Wegovy, Ozempic, and Zepbound. These medications, originally designed to treat diabetes, have gained attention for their effectiveness in promoting weight loss. However, the unexpectedly high costs of these drugs are putting considerable pressure on state Medicaid programs, forcing policymakers to explore potential solutions to alleviate this budgetary strain.

One approach that some state legislators are contemplating involves limiting the eligibility of Medicaid recipients who wish to access these expensive medications for weight loss purposes. For instance, in Pennsylvania, it is predicted that the state's Medicaid program will incur costs of approximately $1.3 billion for GLP-1 drugs by 2025. This figure marks a significant increase from previous expenditures and contributes to forecasts of a multibillion-dollar budget deficit. Consequently, state officials are considering imposing restrictions, such as requiring Medicaid patients to meet specific body-mass index (BMI) benchmarks or to attempt alternative weight-loss strategies—like diet and exercise or less costly medications—before being approved for GLP-1 prescriptions.

Dr. Val Arkoosh, Pennsylvania's Human Services Secretary, acknowledged the growing popularity of these medications during a state House hearing in March. “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,” she stated, highlighting the challenge faced by legislators as they navigate constituent demands and budgetary constraints.

Currently, at least 14 states offer coverage for GLP-1 medications under their Medicaid programs specifically for obesity treatment. According to an analysis by the Associated Press, both Democrats and Republicans in several other states have introduced bills this year aimed at expanding similar coverage. Some of these legislative efforts have stalled, while others remain active, such as a proposal in Arkansas that mandates Medicaid coverage for GLP-1s when prescribed for weight loss. Meanwhile, Iowa lawmakers are advocating for a comprehensive cost-benefit analysis before making any commitments to coverage. On the other hand, states like West Virginia and North Carolina have scrapped programs in 2024 that provided these medications to state employees due to skyrocketing costs.

Jeffrey Beckham, the budget director for Connecticut, expressed concerns regarding the financial implications of continuing Medicaid coverage for these weight-loss drugs. “It is very expensive,” he remarked, noting that many other states are arriving at the same conclusion, as are private insurance carriers.

Data from a November report by KFF, a nonprofit research organization focused on health care issues, shows that overall Medicaid spending on GLP-1 medications surged from $577.3 million in 2019 to a staggering $3.9 billion in 2023. During this same period, the number of prescriptions for these drugs skyrocketed by over 400%. The average annual expenditure per patient for a GLP-1 drug stands at approximately $12,000, according to insights from the Peterson KFF tracker.

A recent poll by AP-NORC indicated that nearly half of Americans either “strongly” or “somewhat” support having Medicare and Medicaid cover weight-loss drugs for individuals suffering from obesity. Conversely, about 20% oppose this idea, with a quarter remaining neutral. Despite this public backing, Medicare does not currently cover GLP-1s, and the Trump administration recently announced plans to discard a proposal from President Biden's administration that sought to integrate these medications into Medicare’s Part D prescription drug coverage. This proposal was projected to be financially burdensome, potentially costing taxpayers up to $35 billion over the next decade.

States currently providing coverage for GLP-1s have begun implementing cost-control measures, such as imposing limits on prescriptions. Proponents argue that if Medicaid patients experience significant weight loss through these medications, their overall health may improve, ultimately reducing long-term healthcare costs. Tracy Zvenyach, of the advocacy group Obesity Action, pointed out that the long-term implications of GLP-1 usage remain unclear, particularly regarding whether patients will need to continue treatment indefinitely. “Someone may have to be on treatment for over the course of their lifetime,” Zvenyach warned, emphasizing the uncertainty surrounding treatment requirements.

According to the U.S. Centers for Disease Control and Prevention (CDC), approximately 40% of American adults are classified as obese, a condition linked to serious health risks including hypertension, Type 2 diabetes, and high cholesterol—all of which elevate the likelihood of severe medical events such as strokes and heart attacks.

Dr. Adam Raphael Rom, a physician affiliated with Greater Philadelphia Health Action, noted that many of his patients utilizing GLP-1 drugs are enrolled in Medicaid, with some individuals without diabetes opting for the prescriptions solely for weight management. He recounted the transformative impact these medications can have on patients' lives. “I had one patient tell me that it’s like, changed her relationship to food,” he shared, noting that some have managed to lose significant amounts of weight—ranging from 20 to as much as 60 pounds.

However, obesity experts caution that results can vary, with estimates suggesting that up to 20% of users may not experience substantial weight loss. A recent survey conducted by KFF involving state Medicaid directors also identified cost and potential side effects as critical concerns regarding GLP-1 drug coverage.

The ongoing debate surrounding Medicaid coverage coincides with escalating Medicaid budgets and fears of dwindling federal funding, as Congressional Republicans contemplate potentially slashing around $880 billion from Medicaid over the coming decade.

Connecticut currently faces a $290 million deficit in its Medicaid fund, prompting Governor Ned Lamont to propose eliminating a requirement instituted in 2023 for Medicaid to cover GLP-1s for severe obesity. Interestingly, the state has never fully adhered to this coverage requirement, citing financial constraints. Starting June 14, 2023, however, Medicaid patients in Connecticut will need to receive a diagnosis of Type 2 diabetes to qualify for coverage of GLP-1 medications. Additionally, Lamont is advocating for the inclusion of two less expensive FDA-approved oral medications for weight loss, alongside nutrition counseling.

Individuals impacted by these changes are voicing their experiences. Sarah Makowicki, a 42-year-old graduate student, shared her struggles with alternative medications that resulted in severe side effects. She is now working on legislation aimed at restoring full GLP-1 coverage for herself and other patients. Another individual, Sara Lamontagne, a transgender woman with disabilities on Medicaid, recounted her personal journey of weight gain after her access to GLP-1 medication was cut off. She lamented, “So, it’s a horrible game to be played, to be going back and forth,” in reference to her unsuccessful attempts to appeal the state’s decision regarding her Ozempic prescription refill.

Makowicki credited GLP-1 drugs and weight-loss surgery with significantly improving her life, stating, “I am a different person from what I was five years ago, not only in my physical space but also mentally.” These personal accounts underscore the larger implications of healthcare policy decisions, particularly as they impact individuals seeking treatment for obesity.

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Haigh reported from Hartford, Connecticut, while Levy reported from Harrisburg, Pennsylvania.