This piece was made available for publication in the Tega Cay Sun after first appearing in the South Carolina Gazette.
Dr. Sarah Ro, a weight management specialist, has seen hundreds of patients in her three decades in practice. Many of them are Medicaid recipients and have turned into yo-yo dieters who struggle to lose weight that is negatively impacting their health despite their best attempts to alter their eating patterns and lives.
According to Ro, medical director of the University of North Carolina Physicians Network weight management program, which treats patients from underserved neighborhoods at clinics around the state, they have a significant illness burden. Any and any complications that come to mind.
However, she suggested that the increasingly common medication therapy known as GLP-1s might be beneficial.
GLP-1 medications control the body’s blood sugar levels by imitating a hormone in the intestines. Furthermore, although GLP-1 medications like Ozempic, Wegovy, and Zepbound have long been used to treat diabetes, they are also becoming more and more well-liked for treating individuals who need to lose a lot of weight. This is due to the fact that the medications also transmit a signal to the brain that decreases appetite.
Many patients cannot afford them because of their expensive list price in the US, which ranges from roughly $940 to $1,350 per month before insurance, rebates, or reductions. (Although Ozempic is popular, it is not a federally approved medication for weight loss; nonetheless, identical medications at other dosages are approved for the treatment of obesity.)
In light of the increased demand for these medications from both physicians and patients, state Medicaid programs are debating whether to cover them for weight loss in order to promote equity and reduce future medical costs.
However, other academics doubt that the medications will ultimately contribute to cost reduction.
In August of last year, North Carolina started to cover some GLP-1s that were approved by the federal Food and Drug Administration for the treatment of obesity in specific groups.
On November 1, South Carolina followed. However, coverage requires prior authorization.
Patients must engage in nutritional counseling, have a body mass index above the obesity threshold, and have associated health issues in order for Medicaid to cover the medications. Additionally, the South Carolina Department of Health and Human Services states that their physician must certify that they are increasing their physical activity.
Spokesman Jeff Leieritz told the SC Daily Gazette that the agency’s larger anti-obesity campaign, which also includes expanded coverage of nutritional counseling, includes coverage of GLP-1 medications.
According to him, the organization estimates that the state will spend $3.3 million a year on the twin initiative of medications and therapy.
GLP-1s are covered for the treatment of obesity in at least 12 other states.
Kody Kinsley, who recently concluded his tenure as secretary of the North Carolina Department of Health and Human Services under former Democratic Governor Roy Cooper, stated, “For me, it was never an option not to cover it.”
Kinsley told Stateline that the first major factor was simply a sense of doing what is right for others. Because he estimates that the North Carolina Medicaid program spends roughly $1 billion annually on costs associated with obesity, he also believes that coverage is the best economic investment.
“Funding medications that can reduce those costs by even a small percentage is worth it in the long run,” he told Stateline. He added that some costly medications are covered by Medicaid. According to the department, the new policy will cost roughly $16 million annually to cover GLP-1s.
In contrast, North Carolina spends over $28 million year on coverage for the medication Dupixent, which is frequently used to treat eczema.
According to my observations, the only instances in which we as a culture seem to become so outraged about a drug’s price that we are prepared to forgo paying for it are when it is prescribed for a sickness that is stigmatized, Kinsley told Stateline.
He pointed out that obesity is an acknowledged medical problem.
In a dozen other states—California, Delaware, Kansas, Massachusetts, Michigan, Minnesota, Mississippi, New Hampshire, Pennsylvania, Rhode Island, Virginia, and Wisconsin—GLP-1 medications are covered by Medicaid programs to treat obesity.
Despite federal matches and rebate programs with medication makers, the high costs remain prohibitive for the majority, according to a November analysis from the health policy research group KFF. Half of the remaining state Medicaid programs are considering covering the drugs.
KFF senior policy analyst Liz Williams, who co-authored the survey of state Medicaid program directors, stated that state officials are considering the coverage primarily for health equity—the belief that all groups, regardless of background, should have equal access to health care—but they are concerned that higher costs will strain their Medicaid budgets.
According to KFF, Medicaid spent $3.9 billion for 3.8 million prescriptions of GLP-1s for all diseases in 2023, up from $597.3 million for roughly 755,000 prescriptions in 2019.
However, the study pointed out that it’s difficult to determine how much of the increase is due to diabetes, obesity, or a mix of the two.
According to certain states surveyed by KFF, they are thinking about whether future coverage expansions could lower Medicaid’s long-term costs for chronic conditions like diabetes and heart disease.
Although obesity essentially doubles a person’s annual health care costs, one researcher, John Cawley, a professor of economics and public policy at Cornell University, and his colleagues discovered that the savings from public insurance plans that cover GLP-1s for the treatment of obesity alone depend on the patient’s body mass index, or BMI.
A BMI of up to 25 is considered healthy weight. Obese people have a body mass index (BMI) of 30 or over, which is determined by their height and weight.
For someone whose BMI is around 30 or 31, you shouldn’t anticipate seeing nearly any cost reductions, Cawley told Stateline.
Although he pointed out that the most savings would occur at a beginning BMI of about 40, he also mentioned that the savings might not be sufficient to cover the current list price of these medications.
However, Cawley noted that there are many additional justifications for paying for the medication, including enhancing a person’s quality of life.
An setting that promotes obesity
“People in vulnerable communities across North Carolina can be predisposed to developing obesity because they often live within what is known as an obesogenic environment – a combination of physical, economic, and social factors that promote obesity,” Ro, the weight management doctor, told Stateline.
In addition to eating unhealthy foods, residents also struggle to lose weight because of generational genetics, a lack of healthy grocery stores, hectic schedules from several professions, and a lack of childcare. Many residents have limited choices for basic exercise because many of the state’s cities are not very walkable.
High-fat, high-sugar delicacies like peach cobbler, fried shrimp, fried green tomatoes, and pork shoulder covered in syrupy, smokey barbecue sauce are also among the most popular cuisine in the state. According to Kinsley, North Carolina is the barbecue belt’s buckle.
Seventy percent of the population there is obese or overweight. Numerous comorbidities, including diabetes and heart disease, are associated with obesity. According to the federal Centers for Disease Control and Prevention, 34% of adults in North Carolina are obese, compared to 40% nationwide.
All demographic groups saw an increase in that rate. Obesity rates among North Carolinians are as follows: 32% for white people, 34% for Hispanic people, 38% for Indigenous people, and 48% for Black people.
People of color make up the majority of Medicaid enrollees in the state.
The CDC’s 2023 data, which is the most recent available, shows that South Carolina has a higher obesity rate than its northern neighbors, at 36% of all adults.
The Biden administration put forth a new rule in late November that would mandate that GLP-1s for weight loss be covered by Medicaid and Medicare programs. Whether or if those adjustments are approved will be up to the incoming Trump administration.
According to the Biden administration, the adjustment would cost the federal government roughly $11 billion over a ten-year period for Medicaid. An estimated $3.8 billion would need to be paid by the states.
However, the medications themselves have risks.
Wegovy’s website lists nausea, vomiting, diarrhea, and dizziness as common side effects. Possible serious side effects include low blood sugar (hypoglycemia), pancreatitis, kidney failure, and thyroid tumors.
(While Ozempic, whichlists the same possible side effects, is the most known GLP-1 drug, it s not FDA approved for weight loss generally, which is acommon misconception.It s approved only for patients with Type 2 diabetes. Wegovy, however, is among GLP-1s approved for obesity treatment.)
While states assess their capacities and the federal government considers its plans, Ro said her patients are getting a better shot at getting healthier by having access to the coverage.
GLP-1s are not the answer for everybody, Ro told Stateline. But If I have a high-risk patient with heart disease, with sleep apnea and advanced liver disease, this could be a lifesaving medication.