“They have a tremendous amount of disease burden,” said Ro, medical director of the University of North Carolina Physicians Network weight management program, which serves patients from marginalized communities at clinics across the state. “All the complications that you could think of.”
But the increasingly popular drug therapy known as GLP-1s could help, she said.
GLP-1 drugs mimic a hormone in the intestinal tract to balance the body’s blood sugar levels. And while GLP-1 drugs such as Ozempic, Wegovy and Zepbound have been around for years to help patients with diabetes, they are growing in popularity to treat patients in need of significant weight loss. That’s because the drugs also send the brain a signal that reduces hunger.
Due to their high list price in the United States — ranging from about $940 to $1,350 a month before insurance, rebates or discounts — many patients can’t afford them.
But now that these drugs are in greater demand from both patients and doctors, state Medicaid programs are grappling with whether to cover them for weight loss, both for reasons of equity and to save on future health expenditures. Some researchers, however, question whether the drugs can help lower costs in the long run.
Last August, North Carolina became the latest state to begin covering some federal Food and Drug Administration-approved GLP-1s for obesity treatment among some populations, joining a dozen other states.
“For me, it wasn’t ever an option not to cover it,” said Kody Kinsley, who just ended his term as secretary of the North Carolina Department of Health and Human Services under former Democratic Gov. Roy Cooper.
“The first big reason was just a sense of doing what is right for folks,” Kinsley told Stateline. He also thinks coverage is the right investment economically, estimating that the North Carolina Medicaid program spends about a billion dollars a year on obesity-related expenses.
He told Stateline that funding drugs that can cut those costs down by even a small percentage is worth it over the long run. He also noted that Medicaid covers other expensive drugs. The department expects the cost of covering GLP-1s to be about $16 million a year under the new policy. By comparison, coverage for Dupixent, a drug commonly used to treat eczema, runs the state about $28 million a year.
“It is my experience that the only time we seem to really get up in arms as a society about the cost of a drug — to the point where we are willing to not cover it — is when it is for some sort of stigmatized disease,” Kinsley told Stateline.
Obesity, he noted, is a recognized medical condition.
Medicaid Spending
Medicaid programs cover some GLP-1 drugs to treat obesity in a dozen other states: California, Delaware, Kansas, Massachusetts, Michigan, Minnesota, Mississippi, New Hampshire, Pennsylvania, Rhode Island, Virginia and Wisconsin.
An annual survey from the health policy research organization KFF recently found that half of the remaining state Medicaid programs are considering covering the drugs, but that the high costs are still prohibitive for most despite federal matches and rebate programs with drug manufacturers.
State officials say health equity — the idea that all groups regardless of background deserve equal access to health care — is one of the main reasons they are considering the coverage, but that they worry higher costs will put pressure on their Medicaid budgets, said KFF senior policy analyst Liz Williams, who co-authored the survey of state Medicaid program directors.
Medicaid spending on GLP-1s for all conditions increased from $597.3 million for about 755,000 prescriptions in 2019 to $3.9 billion for 3.8 million prescriptions in 2023, according to KFF. It’s hard to tell, however, how much of the increase is solely for obesity vs. diabetes, or a combination of both, the study noted.
Some states in KFF’s survey said they are considering whether coverage expansion in the future may reduce long-term Medicaid spending on chronic illnesses such as diabetes and heart disease.
But one researcher, John Cawley, a professor of economics and public policy at Cornell University, and his colleagues found that while obesity “basically doubles a person’s annual health care costs,” the savings associated with public insurance plans covering GLP-1s for just obesity treatment are dependent on the patient’s starting body mass index, or BMI.
A healthy weight is a BMI of up to 25. People who are obese, based on their height and weight, have an amount of fat on their bodies representing a BMI of 30 or higher.
“You shouldn’t expect to see almost any cost savings for somebody whose BMI is around 30 or 31,” Cawley told Stateline. He noted that most significant savings would happen at a starting BMI of around 40, but added that “those savings still may not be great enough to pay for the current list price of these drugs.”
Cawley said there are numerous other reasons to cover the drug, though, such as improving someone’s quality of life.
An ‘Obesogenic Environment’
Ro, the weight management doctor, told Stateline that across North Carolina people in vulnerable communities can be predisposed to developing obesity because they often live within what’s known as an “obesogenic environment” — a combination of physical, economic and social factors that promotes obesity.
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. Many cities in the state aren’t that walkable, leaving many residents with few options for basic exercise.
And some of the state’s most popular foods are high-fat, high-sugar dishes such as pork shoulder slathered in sugary and smoky barbecue sauce, peach cobbler, fried shrimp and fried green tomatoes. North Carolina is the “buckle of the barbecue belt,” Kinsley said.
There, 70 percent of residents are either overweight or obese. Obesity is linked to several comorbidities, such as diabetes and heart failure. The federal Centers for Disease Control and Prevention estimates that 34 percent of North Carolina adults — compared with 40 percent nationally — are obese.
That rate rises across demographic groups. While white North Carolinians experience an obesity rate of 32 percent, Hispanic populations sit at 34 percent, Indigenous North Carolinians are at 38 percent and Black North Carolinians have a rate of 48 percent.
Most Medicaid enrollees in the state are people of color.
In late November, the Biden administration proposed a new rule to require Medicaid and Medicare programs to cover GLP-1s for weight loss. The incoming Trump administration will have to decide whether to approve those changes.
The Biden administration estimates that the change would cost the federal government about $11 billion over the course of 10 years for Medicaid. States would have to pay an estimated $3.8 billion.
While states assess their capacities and the federal government considers its plans, Ro said her patients are getting a better shot at getting healthier by having access to the coverage.
“GLP-1s are not the answer for everybody,” Ro told Stateline. “But If I have a high-risk patient with heart disease, with sleep apnea and advanced liver disease, this could be a lifesaving medication.”
Stateline is part of States Newsroom, a national nonprofit news organization focused on state policy. ©2025 States Newsroom.
