Medicaid plans aren’t required to cover Wegovy for weight loss and obesity, but some do and others are considering adding it for those uses.
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Medicaid plans aren’t required to cover Wegovy for weight loss and obesity, but some do and others are considering adding it for those uses.
Scott Olson/Getty Images
Della McCullough has struggled with her weight since the age of 11, when she remembers her mother telling her she had a “big frame”. Now 53, she says she’s tried supplements, diet and exercise — even an all-fruit diet once. None of them worked.
“Still, I’m not doing well,” says McCullough, a semi-retired school bus driver in Colorado. “I’ve been through nutrition counseling, trauma counseling, meditation, positive affirmation therapy, and I still weigh almost 300 pounds and I’m sad and unhappy.”
She is interested in new blockbuster drugs that help overweight and obese people.
But she and her husband found themselves on Medicaid for the first time last year. Colorado’s Medicaid plan won’t cover Wegovy for her, an obesity drug made by Novo Nordisk that she would like to try.
Wegovy contains the same active ingredient as Novo Nordisk’s Ozempic, a diabetes medication, but Wegovy is specifically approved for the treatment of obesity and weight loss.
Old law complicates Medicaid coverage
Medicaid is not required to cover Wegovy and similar drugs because of a decades-old law excluding from required coverage drugs that treat anorexia, weight gain and weight loss.
McCullough is frustrated. “I’m not ashamed to be on state assistance and I can say that the assistance they provide is not adequate, especially if you have obesity,” McCullough said.
Robin Feldman, a professor at the University of California Law School in San Francisco, says that when the law banning weight-related drugs was passed in the 1990s, everyone thought diet and exercise were the key to lose weight and keep it off – even if the evidence doesn’t support it. “In this context, being overweight was seen as a lack of willpower and dedication.”
Although state Medicaid programs are not required to cover weight-loss drugs, 16 currently do.
Cost is a factor limiting coverage. Wegovy’s list price is over $1,300 per month. Even if Medicaid programs receive a significant discount, which is usually the case, total spending could be significant.
Brown University researchers found that people with Medicaid are 27 percent more likely to have obesity than people with commercial insurance.
And people can take these medications for years.
“States still have to deal with, you know, this investment or that investment,” says Kate McEvoy, executive director of the National Association of Medicaid Visitors. “There are many other preventative health issues, particularly around maternal health and child-related issues. And so looking at the relative merits of these investments is sort of where states are right now.”
Other Medicaid Plans Consider Wegovy
Some state Medicaid programs, like Minnesota’s, cover Wegovy because they are required to do so by state law. Others, like Louisiana’s, don’t cover Wegovy at all but cover an older weight-loss drug, Orlistat, considered less effective.
In North Carolina, Kody Kinsley, the state’s secretary of Health and Human Services, hopes the Medicaid program will cover Wegovy by this summer.
“We have sort of a standard political process,” he says. “We look at the actuarial impacts, the negotiation of rebates, the value of adding drugs, which we don’t really look at for other drugs, because they have to be covered. But for these, because of this federal exclusion, we follow this process.
He says Wegovy would not be the most expensive drug covered by North Carolina’s Medicaid program and would not put him out of business.
Advocates say policies that exclude treatments intended to help people lose weight need to change. “Research shows us that obesity is a complex, chronic disease,” says Tracy Zvenyach, director of policy strategy and alliances at the Obesity Action Coalition, a national nonprofit trying to expand access. to evidence-based treatments for obesity. “The science clearly shows that obesity is driven by powerful biology, not by choice,” says Zvenyach.
In Colorado, where McCullough lives, Medicaid does not cover Wegovy for weight loss.
However, Wegovy was recently approved by the Food and Drug Administration to reduce the risk of cardiovascular death, heart attack, and stroke in people who have cardiovascular disease and are overweight or obese. That means Medicaid would be required to cover it for some people, since it’s no longer just a weight-loss drug.
“In Colorado, Wegovy is currently covered by Colorado Medicaid when used to reduce the risk of major cardiovascular events in adults with established cardiovascular disease and obesity or overweight, as approved by the FDA” , said Marc Williams, spokesperson for the Colorado department. health care policy and financing.
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 ask him if this seems personal to me.
“You know, I never would have thought that, but now that I’m in this situation, it feels very personal,” she says. “Like, ‘She’s just fat,’ you know? ‘That’s her problem. She’ll find a solution.’ Or ‘She’ll have to change anything She do.’ “
She hopes that politicians will eventually catch up with science.
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