West Virginia faces a significant challenge with obesity rates ranking among the highest in the nation. This has led to increased attention on the potential of weight loss drugs, particularly GLP-1 receptor agonists, to address this health crisis. However, the high cost of these medications and varying insurance coverage policies have created barriers to access for many residents. This article explores the complexities surrounding WV Medicaid's coverage of weight loss drugs, examining the perspectives of patients, healthcare providers, insurers, and policymakers.
The Promise of Weight Loss Drugs
GLP-1 drugs, such as Ozempic, Wegovy, and Zepbound, mimic a hormone in the intestinal tract to balance the body’s blood sugar levels. While initially developed for treating type 2 diabetes, these drugs have demonstrated significant effectiveness in promoting weight loss. Dr. Bisher Mustafa, a Marshall Health physician, emphasizes that these medications are "very successful" at helping people lose weight. He highlights the "astonishing" data and notes that these medications represent the most significant advancement in weight loss treatment since the 1950s, offering a sound, metabolic approach.
For individuals like Lory Osborn, these drugs have been life-changing. Osborn, an administrative assistant at West Virginia University, lost 75 pounds (over a quarter of her body weight) using Wegovy and reported feeling healthier than she had since graduating high school. Similarly, Plante, of South Charleston, reported feeling more active as he lost weight. “This has helped me reverse those trends,” Plante said. “And, I think that’s worthwhile." Swisher, another West Virginian, echoed this sentiment, stating, "I have so much more energy and a lot more confidence." She now has the energy to enjoy activities like camping and hiking.
Barriers to Access: Cost and Coverage Limitations
Despite the potential benefits, access to these drugs is often limited by their high cost and inconsistent insurance coverage. Dr. Bisher Mustafa notes that coverage has been a "very big problem, especially in West Virginia," with insurance companies initially covering the drugs and then backing off due to the cost.
The cost of these medications can be prohibitive for many individuals without insurance coverage. Some patients have had to pay the cost of a mortgage payment to get a dose. This financial burden forces many to exhaust other weight loss plans before seeking medical help.
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West Virginia's Public Employees Insurance Agency (PEIA) paused a pilot program that covered weight loss drugs due to the high cost. PEIA Director Brian Cunningham said GLP-1s cost the program around $53 million last fiscal year, which is about 20% of what PEIA spends on drugs. The cost of the GLP-1s was cited as a reason for 14% premium hikes for state employees, as well as a 16% increase for county employees and a 12% bump in costs for retirees. This decision has left patients like Osborn scrambling and feeling "weight-based discrimination."
Ashley Peggs, a Kanawha County teacher who doesn't use GLP-1 drugs, expressed frustration that the plan was spending so much on the medicines when she was denied coverage for a spinal procedure. Michael Kimball, who takes the drug for diabetes, worries about the potential consequences of losing access to the medication.
Medicaid Coverage Policies: A Patchwork Approach
Medicaid programs, which serve a significant portion of West Virginia's population, play a crucial role in determining access to weight loss drugs. According to the Department of Human Services, Medicaid covers an estimated 250,000 adults in West Virginia.
Under the Medicaid Drug Rebate Program, state Medicaid programs must cover nearly all of a participating manufacturer’s Food and Drug Administration (FDA)-approved drugs for medically accepted indications. However, weight-loss drugs are included in a small group of drugs that can be excluded from coverage. While all state Medicaid programs cover the drugs for Type 2 diabetes, only 13 provide some form of coverage to treat obesity.
West Virginia's proposed program would have been open to Medicaid recipients with a body mass index of at least 35 and at least one of the following comorbidities - hypertension, metabolic-associated fatty liver disease, obstructive sleep apnea, coronary heart disease or type 2 diabetes.
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The Federal Role: Proposed Expansion and Potential Opposition
Recognizing the importance of addressing obesity, the Biden administration has proposed a new rule that would require Medicaid and Medicare programs to cover GLP-1s for weight loss. The Biden administration estimates that the change would cost the federal government about $11 billion over the course of 10 years for Medicaid.
Gov. Jim Justice said he supports expanding the weight loss drugs to access for all.
However, this proposal faces potential challenges. The proposed change is expected to cost the federal government $25 billion for Medicare and $11 billion for Medicaid over the next decade. Whitney Wetzel, a spokeswoman for the West Virginia Department of Human Services, pointed West Virginia Watch to a fiscal note for legislation that would have created a supervised weight loss program for the state’s Medicaid recipients.
The Need for a Comprehensive Approach
Experts emphasize that weight loss drugs are not a magic bullet and should be part of a comprehensive approach that includes lifestyle changes, such as diet and exercise. Dr. Bisher Mustafa stresses that "people have to take their medicine but at the same time, change their lifestyle together." This includes consulting with dieticians, engaging in physical activity, and sometimes talking to psychologists about stress eating or emotional eating or boredom eating.
Dr. Laura Davisson emphasizes the importance of responsible prescribing practices, including counseling on diet, exercise, and side effect management. She also highlights the need for ongoing support and monitoring to ensure the long-term success of treatment.
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Long-Term Implications: Cost Savings and Health Equity
Proponents of expanded coverage argue that the long-term savings associated with reduced obesity-related health conditions could outweigh the initial costs of providing these medications. Gov. Jim Justice believes that "losing weight, we’re going to provide cutting costs for hospitalization, like for heart disease, for strokes, for many other obesity related diseases." He also anticipates reduced costs for amputations, renal failure, and dialysis.
Expanding access to weight loss drugs could also address health equity concerns, as obesity disproportionately affects marginalized communities. Residents struggle with losing weight not only due to a diet of unhealthy foods, but also because of generational genetics, a dearth of grocery stores with healthy foods, and busy schedules with multiple jobs and a lack of child care. Dr. Sarah Ro, medical director of the University of North Carolina Physicians Network weight management program, emphasizes that her patients from marginalized communities have a "tremendous amount of disease burden."