State board drops coverage of weight loss drugs

GROUP INSURANCE COMMISSION

State House News Service

State health plan overseers voted Thursday to eliminate coverage for GLP-1 drugs for obesity, capping off months of torn decision-making over how to tamp down surging health care costs while maintaining care access for members.

Valerie Sullivan, chair of the Group Insurance Commission board, voted in favor of the change "with a heavy heart."

"This is a very challenging budget year for our state, and our responsibility as commissioners is to focus both on the taxpayers and our fiduciary responsibility to budget, along with our members and our constituents," Sullivan said Thursday morning.

Ten commissioners voted to nix GLP-1 drug coverage for weight loss, aligning with a benefit change already embraced by commercial insurers and the Massachusetts Interlocal Insurance Association. Seven commissioners voted against the benefit change, warning it could exacerbate health disparities and ultimately lead to higher costs if members' chronic conditions worsen.

Some 22,000 GIC members currently take GLP-1 drugs for weight loss, at a total cost of $46 million, said Margaret Anshutz, the agency's director of health policy and analytics.

With one dissenting vote, commissioners separately agreed to move forward with their meeting and not tackle other plan design changes that staff had recommended, including raising copays and deductibles. The board earlier this month tabled a vote on all the proposed changes.

The GIC provides insurance for more than 460,000 public employees and retirees, and the agency is poised to receive a $300 million funding infusion to ensure it can continue to pay claims after April. Soaring costs tied to GLP-1 drugs have strained the agency's budget, prompting the Healey administration's request that the GIC find roughly $120 million in savings.

In a letter Monday, Gov. Maura Healey urged the GIC board to no longer consider benefit plan changes that could shift more costs onto state workers. But Healey urged commissioners to "seriously consider" the recommendation to scrap coverage for GLP-1 drugs for weight loss.

"I want to reiterate the governor's commitment that the work won't stop here," Dana Sullivan, the board's designee from the Executive Office for Administration and Finance, said. "While we make this near-term change, the health care affordability working group will focus on what I know the commission really wants to address: the underlying drivers of growing health care costs."

Commissioner Jane Edmonds, who wanted the GIC to maintain coverage for GLP-1 drugs, said the board was making "not just money decisions" - but choices that would directly impact people's health.

"This would be, to my knowledge, the first time the commission would be eliminating a proven, evidence-based kind of offering that's making a difference to our members," Edmonds said.

Board Vice Chair Bobbi Kaplan said she could not vote "in good conscience" to eliminate GLP-1 coverage.

"Everything points to the disparate impact and what will happen long term," Kaplan said. "This is a short-term fix, if you will, that is going to increase costs exponentially over the next few years when we see the actual impact that removing these GLP-1 medications for weight loss show us."

Kaplan said high-income individuals will still be able to afford GLP-1 drugs, warning the "inequity" of the GIC's decision would "speak volumes to our members who are on it."

In a statement Wednesday, Sam Sharp of the University Staff Association at UMass Amherst explained the personal toll of the looming GIC vote.

"After losing well over 100 pounds with the aid of GLP-1 medications, the state of Massachusetts wants to take away what is a lifetime drug and condemn me back to immobility and isolation," Sharp said in a statement circulated by the Massachusetts Teachers Association. "This is so much worse than never giving them to me in the first place because they gave me three years of hope and progress."

Some commissioners said the GIC could flex its market power by dropping coverage for GLP-1 drugs, arguing the huge decline in demand could force drug manufacturers to drop prices. Additional pressure might come from MassHealth, which could also stop covering GLP-1 drugs in fiscal 2027. The scenario could create a pathway for the GIC to eventually resume covering GLP-1 drugs, commissioners said.

"I would be the first one to say that if we eliminate this drug and that cost-benefit analysis changes, we need to get this right back in," said Commissioner Darren Ambler, who has regularly argued the current cost-benefit analysis for GLP-1 drugs "is still not there."

But other board members voiced skepticism that coverage could be reinstated in the future.

"Once a benefit is eliminated, getting a benefit back into the budget is next to impossible, right?" Commissioner Melissa Murphy-Rodrigues said. "Because other things fill that gap."

GIC Executive Director Matt Veno said officials must still figure out what happens to thousands of members who are currently prescribed GLP-1 drugs.

"I think we all acknowledge that this would be substantially disruptive to those members who are on these drugs today to treat obesity," Veno said.

The GIC in January rolled out a new program with Vida Health to manage GLP-1 drugs in a bid to save costs, and Veno said the contract may need to be restructured. Vida could provide an "off-ramp" for members, such as developing new treatment plans and connecting them with other weight-loss drugs that are "decidedly less effective," Veno said.

Some members taking GLP-1 drugs to treat multiple conditions would not be affected by Thursday's GIC vote.

"If we have an individual who is obese and diabetic, or obese and has sleep apnea, or is obese and has a cardiac condition, some subset of our members currently on GLP-1s will migrate to the same drug for a different covered service," Veno said. "And we have accounted for those dynamics as best as we can in our savings projections."