Russell Wooten of Hendersonville, North Carolina, has spent much of his life battling obesity, often carrying 260 pounds on his 6-foot-3 frame. He repeatedly starved himself to lose weight and then gained it back by eating comfort foods. During the cycle he felt “depressed and disturbed”.
In February 2023, Wooten began taking Wegovy, one of a class of drugs called GLP-1s. These medications have long been used to balance blood sugar levels for patients with type 2 diabetes and cardiovascular disease.
Wegovy helped Wooten, an administrator at a local public school, lose 40 pounds. But his joy was short-lived: The North Carolina State Health Plan for Teachers and Other Public Employees last April stopped covering the weight-loss drug. The list price for Wegovy is over $1,300 per month – far more than Wooten can afford on his $45,000 salary.
“It worked for me. I trained. “I felt better than I had in a very long time,” said Wooten, 54.” It’s like someone giving you a Ferrari and then taking it away. “
The exploding popularity of weight loss drugs is quickly becoming a government budget concern. When deciding whether to cover the medication, policymakers must choose between the long-term benefits of reducing obesity among public employees and their families – which could reduce spending on chronic disease treatment – and the short-term costs.
Separately, 13 state Medicaid programs, including North Carolina, have chosen to cover GLP-1 for obesity. However, Medicaid is jointly funded by the federal government and states, and drug manufacturers must offer these programs significant discounts in exchange for coverage of their products. The insurance plans that cover public employees must cover most of the costs themselves.
About a dozen states Last year, legislation that would have added GLP-1 weight loss medication coverage to state health plans, Medicaid or policies on Affordable Care Act marketplaces considered. Most failed or did not progress. West Virginia, like North Carolina, had treated drugs for state employees but stopped. However, the move impacted far fewer people because its initiative was a restricted pilot program.
Meanwhile, Illinois approved coverage for its public employees last year, and Connecticut officials say they will continue to cover the drugs they started in 2023 despite the high price tag.
“North Carolina is wrong because when employees are healthy, they are more productive,” said Connecticut Comptroller Sean Scanlon, a Democrat.
Costs and benefits
Dr. Nicholas Pennings, chair of family medicine at Campbell University in Buies Creek, North Carolina, saw many patients on the state’s employee health plan lose it after their GLP-1 coverage ended. That’s because obesity is a chronic condition that can be caused by genetics, emotional dependency and lack of access to hearty foods, Pennings said.
In North Carolina, where 70% of residents are overweight or obese, foods like barbecue pork and peach cobbler Part of the local culture. Pennings said he has patients, including the children of state employees, who were doing well on GLP-1 but are now heading toward developing diabetes.
It worked for me. I trained. I felt better than I had in a very long time.
– Russell Wooten, a public servant in North Carolina
The North Carolina State Health Plan, which covers nearly 750,000 employees, retirees and their dependents %. With various rebates and rebates, the health plan was expected to spend $170 million on the drugs in 2024.
The state health plan spends a total of about $4.13 billion annually to insure people who work for state agencies, universities, community colleges and local school systems. Of that total, taxpayers contributed dollars Cover about 84% and employee bonuses cover the rest.
In the long term, coverage of weight loss medications may lead to lower spending on chronic diseases linked to obesity, such as diabetes, heart disease and certain types of cancer, researchers say. But Dale Folwell, the former Republican state treasurer of North Carolina who was in office when the plan phased out the drugs, said it was an investment the state couldn’t afford.
“The whole issue about weight loss drugs and their cost came at 300 miles an hour like a Top Fuel dragster,” Folwell said. “It’s not emotional, it’s not political, it’s mathematical.”
Currently the state health plan has a deficit of $507 million. Pharmacy benefit managers, the intermediaries in the drug supply chain, are supposed to exploit their bargaining power to negotiate lower drug prices, and Folwell said the state’s PBM secured discounts on the weight-loss drugs. But they weren’t enough.
Brad Briner, who replaced Folwell as treasurer earlier this month, said the state has reduced costs by limiting coverage to the most risk-managed patients, but the state’s current contract with its PBM would not allow that. He hopes the state’s next PBM contract will allow for more flexibility and that the state will restart the medication for at least some patients next year.
In the meantime, he said, covering coverage is the right decision.
“We need to balance the books before we add GLP-1s back,” said Briner, also a Republican.
Like North Carolina, more than 70% of West Virginia residents are overweight or obese. The state’s Public Employees Insurance Agency, which oversees the state’s health plan, ended the compact pilot program, which covered about 1,100 participants, in March 2024 due to concerns about costs and supply.
The agency said in an email that the program costs $1.3 million per month. If it had expanded coverage to all potential eligible members, about 70,000 people, the projected annual cost would be more than $1 billion per year.
Dr. Laura Davisson, director of the Medical Weight Management Program at West Virginia University, one of the obesity treatment pilot program sites, wrote in an email to Stateline that her patients experienced an average weight loss of 15%, which is “three times so.” much weight like lifestyle only programs. “
“The challenge is that the benefits of treating obesity, such as:
Stay the course
In Illinois, Democratic Gov. JB Pritzker pushed to consider weight-control drugs for public employees. The Pritzker administration estimates this will cost the state $210 million in the first year, but some economists say the cost will likely be as much than three times higher.
In Connecticut, the cost of public employee weight loss drug coverage ranges from $7.7 million in 2020 to An estimated $40 million last year. The Connecticut State Health Plan has approximately 270,000 beneficiaries.
In an attempt to control costs, the state in 2023 required patients seeking a GLP-1 prescription for weight loss to enroll first A telemedicine program to facilitate them make lifestyle changes instead of using the medication.
Scanlon, the state comptroller, said the program has reduced GLP-1 exploit but enrollment is increasing. Now the state is looking for its next solution, he said.
“Our North Star has always continued reporting for people who want to get the help they need and deserve,” he said.
One thing Scanlon isn’t counting on, he said, is the price of the GLP-1 drugs, which are about to come down.
“Trying to convince the makers of these drugs to make them cheaper is like me trying to convince my 2-year-old and 5-year-old not to eat candy in a candy store,” Scanlon said.
