GLP-1’s, drugs like Ozempic and Wegovy, cost Connecticut more than $80 million last year. Should Medicaid keep covering them?
WSHU’s Ebong Udoma spoke with CT Mirror’s Katy Golvala to discuss her article, “People call GLP-1s life-changing. CT says it can’t afford them,” as part of the collaborative podcast Long Story Short. Read Katy’s story here.
WSHU: Hi, Katy. You talk about Sarah Makowicki as an example of what's going on with weight loss drugs covered by Medicaid. Could you just tell us a little bit about her and what her experience has been with this?
KG: Yeah, absolutely. So, a few years ago, Sarah was in a lot of pain. She needed a knee replacement, and unfortunately, patients can only qualify for a knee replacement when they have a BMI of 40 or under, and at the time, Sarah's BMI was around 70. So she had to work with her physicians in order to qualify for that knee surgery. So she started out by getting bariatric sleeve surgery, which removes a portion of your stomach. That helped a lot. She lost a lot of weight, but before she reached the weight she needed to be able to get that knee replacement, her weight loss stalled. So, after about a year of not seeing weight loss, her physician recommended that she go on a GLP-1, and she began taking Monjaro.
WSHU: What is a GLP-1?
KG: Yeah, so a GLP-1 is this new class of drugs that we've been hearing about everywhere for the last couple of years. That includes Ozempic and Wegovy, and they work by targeting a hormone in the brain that regulates hunger. So these GLP-1s basically mimic a hormone in the body that controls insulin and blood glucose levels, which can make a patient feel less hungry or feel full for longer. And it really seems like they've taken the world by storm. I feel like we can't go a week without seeing in the news some other benefits that have everything from controlling people's appetite for alcohol to potentially having benefits for Alzheimer's disease. So these drugs are just about the hottest pharmaceuticals to come out, maybe in my lifetime.
WSHU: Now, with the example of Sarah, she was able to get this, and it was very helpful. However, the cost to the insurance company, which pretty much Medicaid covered for her, was about $1,000 a month.
KG: Yeah, these drugs are very expensive. They can cost about $1,000 a month out of pocket for patients who don't have insurance. What we know about their cost to the state is that these GLP-1s are not just for people who are taking them only for obesity; this includes people who are taking them for diabetes, but they cost the state around $85 million in fiscal year 2024, which was an absolutely staggering more than 1/3 of the state's Medicaid pharmaceutical budget. So that is a lot of money, and if you think about the trade-offs, you know that that is money that can't go towards coverage of other prescriptions or other conditions. So it's a really, really complicated issue because the state is thinking about trade-offs, but these drugs also, they're so effective, so it's just a really difficult issue.
WSHU: But what does the law say? Because if these are covered drugs, the state can’t just decide whether it wants to cover a particular drug or not. Doesn't the state have to cover every single drug that has FDA approval?
KG: That's a great question. In general, that is true. However, there are some exceptions and drugs for weight loss are one of those exceptions. So, the state has to cover these drugs if they are being used for an FDA-approved reason, like in the case of Ozempic, which is type 2 diabetes. But since Ozempic is not actually FDA approved for weight loss, it's just widely used for it, Medicaid does not have to cover it.
WSHU: Well, I believe that a couple of years ago, the state legislature stepped into this and tried to clarify the rule to allow the state's Medicaid program to cover some of these drugs.
KG: That's right. So in 2023, the legislature passed a law that said, even though we're not required to cover drugs for weight loss by federal law, we're putting a state law into place that says we are going to cover that Medicaid is going to cover these drugs for weight loss. One of the legislators who was part of writing that bill, Matt Lesser, said the intent was for the administration to cover GLP-1s. However, DSS never began covering these drugs for weight loss. So there has been a lot of back and forth on this. And basically where the administration has landed is that that law passed in 2023 required them to cover weight loss drugs in general, it does not specify that they had to cover GLP-1s. So they are now making moves to comply with the state law. They just filed for permission to cover two weight loss drugs that are not GLP-1s. A lot of advocates say, you know, these drugs are much older and much less effective. Why is Medicaid not covering the drugs that we know really work for patients?
WSHU: Well, at the same time, Connecticut's Medicaid program is facing a deficit of $290 million. So, is there more money coming from the state legislature to fill that hole?
KG: Yeah, that's a great question. There is no money currently in Governor Lamont's budget proposal to, you know, cover the cost of these drugs. In fact, he wants to eliminate GLP-1 coverage by Medicaid officially. And, you know, the Medicaid program isn't just facing issues of its own. We've been hearing for months about the potential federal cuts. This is just another piece of the puzzle that complicates this issue further; the state Medicaid program is certainly not in a financially stable place.
WSHU: So, is this being discussed by the state legislature right now, and are there any solutions in the works?
KG: Yeah, so the legislators who originally passed this law in 2023 are seeking to pass a law, again, that specifies coverage of GLP-1S for people who have a BMI of 35 or higher, and it would also guarantee continued coverage if those people were to lose weight fall below that BMI, as long as a doctor says, hey, if, if this person were to go off of this drug, they would likely regain the weight. So that is what state legislators are trying to do at the same time that the governor is trying to officially repeal the coverage of GLP-1S. So it'll certainly be interesting to see what happens.
WSHU: And hovering over all of this is the federal cuts to Medicaid that are being considered right now.
KG: Yeah, exactly. I don't envy the position that state officials and legislators are in when they're trying to figure out a state budget at a time when there's so much uncertainty about how federal decisions are going to play into that budget. So this is, for so many reasons, a very complicated issue to think about, which I think makes it very interesting.
