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Access to Wegovy limited in Medicaid programs : Shots - Health News New
medications like Wegovy are changing the way people lose weight and manage
obesity, but many Medicaid beneficiaries can't get them.


SHOTS

Health News From NPR
 * Your Health
 * Treatments & Tests
 * Health Inc.
 * Policy-ish
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POLICY-ISH


DECADES-OLD LAW LIMITS ACCESS TO WEGOVY FOR MEDICAID BENEFICIARIES

May 8, 202411:38 AM ET

By 

Sydney Lupkin

DECADES-OLD LAW LIMITS ACCESS TO WEGOVY FOR MEDICAID BENEFICIARIES

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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 hide caption

toggle caption
Scott Olson/Getty Images


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 been struggling with her weight since she was 11, when she
remembers her mother telling her she was "big boned." 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 semiretired school bus driver in
Colorado. "I have done nutrition counseling, trauma counseling, meditation,
positive affirmation therapy, and still I am almost 300 pounds again and sad and
unhappy."

She is interested in new blockbuster drugs that help people with overweight and
obesity.

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 medicine
made by Novo Nordisk that she'd like to try.

Sponsor Message



Wegovy contains the same active ingredient as Novo Nordisk's Ozempic, a diabetes
drug, but Wegovy is specifically approved for obesity and weight loss.


SHOTS - HEALTH NEWS


WEGOVY WORKS. BUT HERE'S WHAT HAPPENS IF YOU CAN'T AFFORD TO KEEP TAKING THE
DRUG


AN OLD LAW COMPLICATES MEDICAID COVERAGE

Medicaid doesn't have to cover Wegovy and drugs like it because of a decades-old
law excluding medicines that treat anorexia, weight gain and weight loss from
required coverage.

McCullough is frustrated. "I'm not ashamed of the fact that I am on state
assistance, and I can say that what assistance they provide is not adequate,
especially if you do have obesity," McCullough says.

Enlarge this image

"I have done nutrition counseling, trauma counseling, meditation, positive
affirmation therapy, and still I am almost 300 pounds again and sad and
unhappy," says Della McCullough, a semiretired school bus driver in Colorado.
Della McCullough hide caption

toggle caption
Della McCullough


"I have done nutrition counseling, trauma counseling, meditation, positive
affirmation therapy, and still I am almost 300 pounds again and sad and
unhappy," says Della McCullough, a semiretired school bus driver in Colorado.

Della McCullough

Robin Feldman, a professor at the University of California Law in San Francisco,
says when the law excluding weight-related drugs was passed in the 1990s,
everyone thought diet and exercise were the key to losing weight and keeping it
off — even though the evidence doesn't support that. "So in that context, being
overweight was viewed as lacking willpower and dedication."

While state Medicaid programs don't have to cover weight loss drugs, 16 do right
now.

Cost is a factor limiting coverage. Wegovy's list price is more than $1,300
dollars a month. Even if Medicaid programs get a big discount, which they
typically do, the total spending could be significant.

Researchers at Brown University found that people on Medicaid are 27% more
likely to have obesity compared with people who have commercial insurance.



And people may take these drugs for years.

"States are always having to grapple with, you know, this investment or that
investment," says Kate McEvoy, executive director of the National Association of
Medicaid Directors. "There are a lot of other preventive health issues, notably
around maternal health, issues for children. And so examining the relative
merits of those investments is kind of where states are right now."


MORE MEDICAID PLANS ARE CONSIDERING WEGOVY

Some state Medicaid programs, like Minnesota's, cover Wegovy because they're
required to under state law. Others, like Louisiana's, don't cover Wegovy at all
but cover an old weight loss drug, Orlistat, which is considered less effective.

In North Carolina, Kody Kinsley, the state's Secretary of Health and Human
Services says he hopes the Medicaid program will cover Wegovy by this summer.

"We have a kind of a standard policy process," he says. "We go through to
consider the actuarial impacts, the negotiation of rebates, the value of adding
the drugs, all of which we don't really go through for any other drug because
they're required to be covered. But for these, because of that federal carve
out, we are going through that process."

He says Wegovy would not be the most expensive drug North Carolina's Medicaid
program covers and won't bankrupt it.

Advocates say policies that exclude treatments 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 organization that is trying to expand access to
evidence-based treatments for obesity. "The science is clear that obesity is
driven by powerful biology, not by choice," Zvenyach says.

In Colorado, where McCullough lives, Medicaid doesn't cover Wegovy for weight
loss.

However, Wegovy was recently approved by the Food and Drug Administration to
reduce risk of cardiovascular death, heart attack and stroke for people with
cardiovascular disease and who are overweight or obese. That means Medicaid
would be required to cover it for some people since it's not just a weight loss
drug anymore.



"In Colorado, Wegovy is currently covered by Colorado Medicaid when it's used to
reduce the risk of major cardiovascular events in adults with established
cardiovascular disease and either obesity or overweight as approved by the FDA,"
says Marc Williams, a spokesman for the Colorado Department of Health Care
Policy and Financing.

But McCullough doesn't have cardiovascular disease and wouldn't qualify.

She says people with obesity are treated differently from people with other
health conditions. I ask her if that felt personal.

"You know, I never would have thought that, but now that I'm in that situation,
it does feel very personal," she says. "Like, 'She's just fat,' you know? 'It's
her problem. She'll figure something out.' Or 'She'll need to change whatever
she does.' "

She hopes the policies eventually catch up to the science.

 * obesity
 * Medicaid
 * obesity treatments
 * Wegovy

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