Russell Wooten, a custodian from Hendersonville, North Carolina, has struggled with obesity for most of his life, often weighing 260 pounds on his 6-foot-3 frame. His attempts to lose weight through starvation followed by binge eating comfort foods led to a cycle that left him feeling “depressed and distraught.”
In February 2023, Wooten started taking Wegovy, a weight-loss medication from the GLP-1 class. Initially used for managing Type 2 diabetes and cardiovascular conditions, these drugs also curb hunger and help with weight loss. The medication allowed Wooten to shed 40 pounds. But his success was short-lived. In April 2023, North Carolina’s State Health Plan for public employees, including teachers, stopped covering the drug for weight loss. At more than $1,300 a month, Wooten cannot afford the medication on his $45,000 salary.
“It was working for me. I was exercising. I felt better than I had in a very long time,” said Wooten. “It’s like somebody giving you a Ferrari and then taking it away.”
The increasing use of weight-loss drugs has sparked a debate over state budgets. Policymakers are weighing the long-term benefits of reducing obesity-related diseases, which could lower healthcare costs, against the short-term expenses of providing coverage for these expensive medications.
Thirteen state Medicaid programs, including North Carolina’s, now cover GLP-1s for obesity. However, Medicaid benefits from substantial federal rebates, while state-run health plans for public employees bear the full cost. In 2023, 13 states proposed bills to expand coverage of GLP-1 medications, but most failed. West Virginia, like North Carolina, had covered the drugs for public employees but ended its program due to costs, although it had affected fewer people.
Illinois, on the other hand, approved coverage for public employees, and Connecticut continues covering the drug, despite the high cost. Connecticut’s Comptroller Sean Scanlon believes supporting employee health leads to increased productivity. “When employees are healthy, they’re more productive,” he said.
The debate is further complicated by the challenges of addressing obesity as a chronic condition, often influenced by genetics, emotional factors, and limited access to healthy food. Dr. Nicholas Pennings, a family medicine chair at Campbell University in Buies Creek, North Carolina, noted that many patients lost the weight they gained on GLP-1s once coverage ended.
In North Carolina, 70% of residents are overweight or obese, with local foods contributing to the state’s health challenges. Pennings shared that many patients, including children of state employees, had improved while on GLP-1s but are now at risk of developing diabetes. In 2023, 23,215 beneficiaries of the North Carolina State Health Plan were using the drug, up from just 2,795 in 2021, an increase of 731%. The health plan was projected to spend $170 million on the medication in 2024.
The North Carolina State Health Plan covers nearly 750,000 individuals and has an annual budget of about $4.13 billion. While the long-term benefits of obesity treatment could lower healthcare spending, former state treasurer Dale Folwell said the state couldn’t afford the upfront costs. “The whole issue about weight-loss drugs and their cost came at us like a top fuel dragster at 300 miles an hour,” Folwell said.
The health plan has a $507 million deficit, and pharmacy benefit managers (PBMs) have been unable to secure enough rebates to make the drugs affordable. Brad Briner, the current state treasurer, said the state considered limiting coverage to high-risk patients, but its PBM contract doesn’t allow it. Briner hopes the next PBM contract will offer more flexibility, allowing some patients to resume coverage in 2024.
West Virginia, where more than 70% of residents are overweight or obese, ended its pilot program for GLP-1 coverage in March 2024. The program, which covered around 1,100 enrollees, cost $1.3 million per month. If expanded, the program’s cost would exceed $1 billion annually. Dr. Laura Davisson, who led the program at West Virginia University, said her patients experienced an average weight loss of 15%, which is three times more than what lifestyle programs achieve. However, the benefits of treating obesity may not be apparent for years.
In Illinois, Democratic Governor JB Pritzker has pushed to cover weight-loss drugs for public employees. The state estimates the program will cost $210 million in the first year, but economists believe the cost could be three times higher. Similarly, Connecticut’s coverage costs rose from $7.7 million in 2020 to an estimated $40 million in 2023. The state’s health plan covers around 270,000 individuals. To control costs, Connecticut now requires patients seeking GLP-1 prescriptions to first enroll in a telehealth program that focuses on lifestyle changes.
Despite the challenges, Scanlon remains committed to providing access to weight-loss medications. “Our North Star has always been continuing coverage for people who want to get the help that they need and that they deserve,” he said. He added that he doesn’t expect the price of GLP-1 drugs to decrease anytime soon. “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 want to eat candy in a candy store,” Scanlon joked.
