Medicaid plans are not required to cover Wegovy for weight loss or obesity, but some have done so and others are considering adding Wegovy for those uses.
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Medicaid plans are not required to cover Wegovy for weight loss or obesity, but some have done so and others are considering adding Wegovy for those uses.
Scott Olson/Getty Images
Della McCullough has struggled with her weight since she was 11, when she remembers her mother telling her she had “big bones.” Now 53, she says she has tried supplements, diet, exercise and even tried a fruit-only diet at one point. None of them worked.
“I’m still not feeling well,” said McCullough, a semi-retired school bus driver in Colorado. “I’ve been doing nutritional counseling, trauma counseling, meditation, and positive affirmation therapy, but I’m still close to 300 pounds again and I’m sad and unhappy.”
She’s interested in new blockbuster drugs that help people who are overweight or obese.
But last year, she and her husband found themselves on Medicaid for the first time. Colorado’s Medicaid plan doesn’t cover Nordisk’s obesity drug Wegoby, which she wants to try.
Wegovy contains the same active ingredient as Novo Nordisk’s diabetes drug Ozempic, but Wegovy is specifically approved for obesity and weight loss.
Outdated laws complicate Medicaid coverage
Medicaid is not required to cover Wegoby or similar drugs because of a decades-old law that excludes drugs to treat anorexia, weight gain, and weight loss from required coverage.
McCullough is frustrated. “I’m not ashamed of the fact that I’m on state aid, and especially when you have obesity, state aid is not appropriate,” McCullough said.
Robin Feldman Professor at the University of California School of Law in San FranciscoWhen laws were passed to exclude weight-related drugs in the 1990s, everyone believed that diet and exercise were the keys to losing weight and keeping it off, even if the evidence didn’t support it. He said he was thinking. “In that context, being overweight was seen as lacking willpower and dedication.”
State Medicaid programs are not required to cover weight loss drugs, but 16 programs currently do.
Cost is the limiting factor in coverage. Wegovy’s list price is $1,300 or more per month. Even if Medicaid programs typically receive deep discounts, the total expenditures can be large.
Brown University researchers People on Medicaid found to be 27% more likely to be obese compared to those with commercial insurance.
And people can take these drugs for years.
“The state always has to deal with this investment or that investment,” he says. Kate McEvoy, Executive Director, National Association of Medicaid Directors. “There are many other preventive health issues, especially maternal health and child issues. So it’s kind of the current state of affairs for states to look at the relative merits of these investments.”
More Medicaid plans are considering Wegovy
Some states’ Medicaid programs, such as Minnesota, cover Wegovy because they are required to do so under state law. Some places, like Louisiana, don’t feature Wegovy at all and instead feature older weight loss drugs. orlifastis considered to be less effective.
In North Carolina, Cody Kinsley, Secretary of Health and Human Services He says he hopes the Medicaid program will cover Wegovy by this summer.
“We have something like a standard policy process,” he says. “We thoroughly consider the actuarial impact, rebate negotiations, value of adding a drug, etc., but we don’t really look at other drugs because we have to consider all of these things. But for these drugs, the ones that the federal government cuts out, we’re going through that process.”
He said Wigovy is not the most expensive drug covered by North Carolina’s Medicaid program and will not bankrupt the state.
Advocates say policies that exclude weight loss treatments need to change. “Research shows that obesity is a complex chronic disease.” Tracy ZubenyachDirector of Policy Strategy and Partnerships Obesity Countermeasures Coalition, a national nonprofit organization working to expand access to evidence-based treatments for obesity. “The science is clear that obesity is not a result of choice, but is caused by powerful biology,” Zbenyach says.
In Colorado, where McCullough lives, Medicaid doesn’t cover Wegobee’s weight loss.
However, Wigovi recently approved It was offered by the Food and Drug Administration to reduce the risk of cardiovascular death, heart attack, and stroke in people with cardiovascular disease and who are overweight or obese. That means Medicaid is no longer just a weight-loss drug and should cover it for some people.
“In Colorado, Wegobee is currently eligible for Colorado Medicaid coverage when used to reduce the risk of serious cardiovascular events in adults with established cardiovascular disease and who are obese or overweight, per FDA approval.” ,” said Mark Williams, a Colorado state spokesperson. in the field of health policy and finance.
However, Mr. McCullough does not have cardiovascular disease and is not eligible.
She says obese people are treated differently than people with other health conditions. I asked her if she felt it was personal.
“I never thought of that, but being in that situation now, it feels very personal,” she says. “Like, ‘She’s just fat.’ ‘That’s her problem. She’ll do something about it.’ Or, ‘She’s going to have to change something.’ she I will do it” “
She hopes policy will eventually catch up with science.
