State Employee Health Insurance Ends Pilot Program To Treat Obesity, Related Illness

Advocates of a pilot program that covered expensive weight loss medications for West Virginia state employees say the state will end up paying more for obesity-related health problems. In March, the state’s Public Employees Insurance Agency (PEIA) canceled a 1,000-person pilot program that covered the medications due in part to the cost of the medicines.

Now lawmakers and health officials are working behind the scenes to find a solution.

West Virginia is not alone in its struggles with obesity. Before 2013, no state in the U.S. had an adult obesity rate at or above 35 percent. Ten years later, in 2023, data from the Centers for Disease Control (CDC) found that almost half the nation – 23 states including West Virginia – had reached that level, with more than one in three adults, or 35 percent, listed as clinically obese.

However, West Virginia’s obesity problem is more pervasive than in other states. According to 2024 CDC data, 41.6 percent of West Virginian adults are obese. The same report shows 24.8 percent of youth ages 10 to 17 are obese, giving West Virginia a ranking of 51 among the 50 states and D.C.

Searching For Solutions

In recent years, weight loss drugs like Ozempic have become household names. This type of drug is called a GLP-1, which stands for glucagon-like peptide receptor agents. These drugs treat Type 2 diabetes and obesity. Zepbound, Mounjaro and Wegovy are also well-known GLP-1s.

The current list price – which is set by the drug manufacturer before applying insurance or discounts – for Ozempic is $968.52 per month. When prescribed, patients take four doses per month, one dose per week.

According to a New York Times article that spotlighted West Virginia in the nation’s struggle to afford weight loss medication, most Medicaid programs cover these medications to manage diabetes. Medicare covers Wegovy and Zepound when they are prescribed for heart problems.

PEIA director Brian Cunningham told the New York Times in June that West Virginia’s pilot program cost around $1.3 million a month, despite rebates from manufacturers for a little more than 1,000 patients.

The Pilot Program At Work

Laura Davisson is West Virginia University’s (WVU) director of Medical Weight Management, a professor, and associate program director for internal medicine. She said West Virginia’s obesity problem can no longer be ignored.

“Not every single patient is a candidate for surgical treatment, and now we have these medicines that are out there that are fantastic,” Davisson said. “They’re giving really great results. They’re very well tolerated and these are tools that we need to have in our toolbox so that we can give each individual patient the full spectrum of treatment options.”

PEIA started the pilot program in 2019 to assist members with the cost of GLP-1s. PEIA provides health coverage for more than 230,000 public employees and retirees.

“We can have a lot more success if we do this systematically and medically, rather than just continuing, which we’ve done for decades now, of telling people just eat less and exercise more, because we’ve been doing that and it’s not working,” Davisson said.

However, on March 15, 2024, PEIA paused the pilot program due, in part, to the rising cost of GLP-1s. The state honored existing pre-authorizations through June 30th or the term of authorization, whichever was longer.

State officials told MetroNews in August that reasons for pausing the program were “multifaceted,” but included cost, supply shortages, potential side effects and inconclusive results.

“Since they announced canceling the pilot, I have met with them again and given them all the data I could come up with, but from their patients, I’ve shown them data showing that return patients of theirs in the pilot that have come to see us have shown a 15.4 percent decrease in their body mass index,” Davisson said.

Cassie Maxwell is a wife and mom from Morgantown. She has been living with obesity since her late teenage years and says she has experienced a significant amount of stigma around her weight.

“Lots of medical problems that I had were very dismissed,” Maxwell said. “There were lots of false assumptions that my weight was related to willpower, and was just told over and over by numerous doctors, eat less and move more, eat less and move more, and it wasn’t working.”

Maxwell was diagnosed with polycystic ovarian syndrome and insulin resistance. Two and a half years ago, her primary care physician referred her to the medical weight management clinic at WVU.

“I was able to actually get comprehensive evidence-based care for my obesity, which is a chronic health condition, and then I was able to get this comprehensive treatment that included behavioral therapy, it included access to exercise physiologists, access to registered dieticians, and for me, it also included medication,” Maxwell said.

Maxwell said her GLP-1 prescription radically changed her and her family’s lives by allowing her to lose almost 150 pounds.

“The main reason I qualified for the program is because I had reached pre-diabetic numbers, I no longer am in that range,” Maxwell said. “I no longer have high blood pressure. My cholesterol is better than my husband’s, so I’m doing really great cholesterol-wise. My sleep apnea has gone away. All of these things that were that I needed treatment for medically have all improved.”

Maxwell found out she was part of the GLP-1 pilot program when she learned it was ending.

“All of these were things that I needed treatment for medically have all improved, and my insurance is pretty much telling me all of those things need to come back,” Maxwell said. “You even need to get sicker before we’re willing to cover your chronic medical condition, which isn’t fair, because they cover every other chronic medical condition.”

Legislative Efforts To Save The Program

During the 2024 regular legislative session, Del. Kayla Young, D-Kanawha, introduced House Bill 4979 to provide insurance coverage for GLP-1 class medications with a valid prescription after hearing from “dozens” of constituents.

“West Virginia has really high rates of heart disease, and various chronic diseases, many of which are caused by weight, or where weight is at least a factor,” Young said. “I know that we’re spending so much money on taking care of West Virginians and their health concerns, and if this is a medication that can help to get them to a healthy place where they can live longer lives and feel happier and be healthier, I don’t know why we wouldn’t be providing that medication that seems to be working for a very large population of people.”

The bill never moved past the House Committee on Banking and Insurance.

During a special session of the legislature in May of 2024, Del. John Williams, D-Monongalia, introduced another bill in the House in an attempt to save the program, House Bill 116, to require PEIA to reimburse covered persons for GLP-1 agonist medications prescribed by a physician for weight loss.

“This issue is really coming to a head with these individuals losing their coverage,” Williams said. “So I thought that it would have been a failure on my part, on the people I’ve talked to, to not at least try.”

William’s bill never made it past the House Finance Committee.

The Cost Of Care

Davisson and Maxwell agree West Virginia will end up paying for its obesity problem, one way or another.

“It made absolutely no sense to me. If we look at sheer numbers, right, if we just look at the cost of obesity-related health care conditions and know that it is treatable, and to say, ‘No, I’m going to stop covering this, and I’d like to take on all of those additional health care costs.’ Sounds completely ludicrous, but yet here we are,” Maxwell said.

Sen. Tom Takubo, R-Kanawha is the Chair of the Joint Standing Committee on Insurance and PEIA.

“Every year, one of the most difficult things for any business, whether it’s small or large or government, is healthcare cost, and these medications for PEIA had quickly climbed to about $90 million so that completely breaks the bank,” Takubo said.

Takubo acknowledged the effectiveness of the medication and the implications of treating obesity in a state with rates as high as West Virginia’s but says his job as a legislator is to pass a balanced budget.

“We certainly want to keep insurance viable for state employees, and that one class of medication has just gone crazy in terms of cost, and so lot of balls in the air on that one,” Takubo said. “So we’re just trying to work a way through it.”

Takubo says he and his colleagues in the legislature are working “creatively behind the scenes,” speaking with the manufacturers of GLP-1’s.

“There needs to be parameters around qualifying criteria and things like that that have to also be developed,” Takubo said. “But we’re working on all the above.”

Appalachia Health News is a project of West Virginia Public Broadcasting with support from Marshall Health.