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States consider whether to add coverage for some obesity medicines

JUANA SUMMERS, HOST:

Medications like Wegovy and Zepbound are revolutionizing the way that people lose weight, but many Medicaid beneficiaries don't have access. NPR pharmaceuticals correspondent Sydney Lupkin reports on how states are deciding whether to add coverage for these obesity medicines.

SYDNEY LUPKIN, BYLINE: Della McCullough has been struggling with her weight since she was 11 years old. That's when her mother told her she was big-boned. Now 53, she says she's tried diet and exercise, supplements, even an all-fruit diet once. None of them worked.

DELLA MCCULLOUGH: Still I'm not doing well. I have done nutrition counseling, trauma counseling, meditation, positive affirmation therapy, and still I am almost 300 pounds again and sad and unhappy.

LUPKIN: McCullough is a semiretired school bus driver in 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 am on state assistance, and I can say that what assistance they provide is not adequate, especially if you do have obesity.

LUPKIN: She's interested in new blockbuster drugs that help people who are overweight and obese. Wegovy contains the same active ingredient as Ozempic, a diabetes drug, but is specifically approved for weight loss. Medicaid doesn't have 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 in San Francisco says, at the time, everyone thought diet and exercise were the key to losing weight and keeping it off, even though the current evidence doesn't support that.

ROBIN FELDMAN: So in that context, being overweight was viewed as lacking willpower and dedication.

LUPKIN: Since state Medicaid programs don't have to cover weight loss drugs, only 16 do right now. Kate McEvoy, executive director of the National Association of Medicaid Directors, says it's often a budget issue.

KATE MCEVOY: States are always having to grapple with this investment or that investment. There are a lot of other preventive health issues, notably around maternal health, issues for children. And so examining kind of the relative merits of those investments is kind of where states are right now.

LUPKIN: Wegovy's list price is more than $1,300 a month. Even if Medicaid programs get a big discount, the total spending could be significant. Studies show people on Medicaid are more likely to be overweight or obese compared to people who have commercial insurance. And people may take these drugs for years. In North Carolina, Kody Kinsley, the state secretary of Health and Human Services, says he hopes the Medicaid program will cover Wegovy by this summer.

KODY KINSLEY: So we have a kind of a standard policy process 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 as - because of that federal carve-out, we are going through that 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 risk of serious heart problems for people who are overweight or obese and have cardiovascular disease. That means Medicaid would have to cover Wegovy for some people since it's not just a weight loss drug anymore.

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 asked her if that felt personal.

MCCULLOUGH: You know, I never would have thought that, but now that I'm in that situation, it does feel very personal. 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.

LUPKIN: She hopes the policies eventually catch up with the science. Sydney Lupkin, NPR News. Transcript provided by NPR, Copyright NPR.

NPR transcripts are created on a rush deadline by an NPR contractor. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.

Sydney Lupkin is the pharmaceuticals correspondent for NPR.