“We’re not looking forward to it,” shared Martinez from Chelsea. “We really don’t want to revert back to how things were before.”
Individuals facing loss of healthcare coverage are left with limited choices, as described by their physicians. They could skip medications altogether, which typically leads to substantial weight gain in a matter of months, switch to cheaper yet less effective options, or pay out of pocket.
For those relying on Medicaid, like Martinez, paying out of pocket simply isn’t feasible. While prices for GLP-1 medications, such as Ozempic and Wegovy, have decreased since their inception, they still generally cost several hundred dollars monthly, according to Dr. Florencia Halperin, an endocrinologist and chief medical officer at Form Health, which specializes in weight management.
Martinez is exploring alternative medications, though these options may come with side effects, including elevated blood pressure, an issue that GLP-1s helped her manage.
The FDA greenlit Wegovy, the first GLP-1 intended solely for weight loss, in 2021, and prescriptions for this drug class have surged, quadruply increasing over the last five years. The outcomes are impressive, with many patients shedding 15 to 20 percent of their body weight, similar to the results from bariatric surgery. However, the high costs have led some insurance companies to cease coverage. Up until last Friday, MassHealth was among only 13 states’ Medicaid programs that did, according to KFF.
Many doctors classify obesity as a serious health condition that poses risks for various life-threatening diseases, including cancers, heart disease, diabetes, and liver issues. Weight loss through GLP-1s can also relieve or eliminate conditions like arthritis, joint pain, or hypertension.
The recent Medicaid coverage cut, however, raises concerns among physicians about making these medications available primarily to the affluent.
Interestingly, while MassHealth is halting coverage for weight loss drugs, Medicare is expanding its access. The federal program for seniors began a pilot program on Wednesday that covers certain GLP-1s for Medicare Part D beneficiaries.
MassHealth officials state they have limited options following last year’s federal reforms aimed at reducing enrollment and funding costs for the state.
“We are starting to see the real effects of those cuts at the state level,” said Stacey Nee, a MassHealth spokesperson. “Our proposed changes to GLP-1 coverage for weight loss are intended to control expenses, align us with other states, and preserve access to care as much as we can.”
By dropping GLP-1s for weight loss, the state expects to save around $15 million. However, MassHealth will still cover these medications if they are prescribed for diabetes or other medical conditions, or if they are used in conjunction with severe sleep apnea, metabolic liver disease, or heart disease to lower the chance of a heart attack or stroke.
Martinez, who stands at five feet seven inches, previously found it challenging to maintain a weight below 200 pounds.
“It was so frustrating, no matter how hard I tried—counting calories, staying active, exercising—nothing worked,” she recalled.
After having her son Kevin in April 2023, her weight climbed to 230 pounds. It was the persistently high blood pressure that led Dr. Richard Siegel from Tufts to prescribe Wegovy in 2024, and then shift her to Zepbound.
Currently, she weighs about 150 pounds.
“This medication has been the best thing for me,” she said.
Her blood pressure normalized and remained stable, even with the stress of parenting two children, working for a catering company, and caring for her father during his cancer treatments.
“I feel healthy,” she explained. “I have more energy.”
Siegel, co-director of Tufts Medical Center’s Diabetes and Lipid Center, mentioned that he has been discussing alternative, cheaper medications with patients under Medicaid for weeks. Some have even contemplated getting second jobs just to afford their prescriptions. Others might resort to out-of-pocket payments, opting for lower dosages or less frequent injections, which would ultimately be less effective.
Recently, he noted his pharmacy team was busy trying to get authorizations from both MassHealth and Medicare as their policies on GLP-1s shift. Patients with co-existing conditions eligible for GLP-1s tend to be older, meaning many younger patients will be left without coverage.
“Patients feel like the ground has been pulled from under them,” he said.
This particularly affects roughly 2,500 children in Massachusetts on GLP-1s solely for weight loss, with pediatricians warning that they might experience renewed anxiety, depression, and bullying tied to being overweight. Additionally, there’s the risk of developing serious, lifelong health issues related to obesity, said Dr. Jason Zhang from Boston Children’s Hospital.
“We fear any improvements in their condition will disappear,” he added.
For those under 21, MassHealth will still cover GLP-1s if deemed medically necessary, but this guideline raises concerns among pediatricians.
“I’m unsure how strict they’ll be about what qualifies as necessary,” expressed Dr. Benjamin Weintraub, a pediatrician in Watertown, noting that around 15 to 20 percent of his patients depend on Medicaid.
A spokesperson from MassHealth indicated they will assess medical necessity on a case-by-case basis.
Eric-Paul Olsson, a psychiatric nurse practitioner serving patients in Newton, Northampton, and Marshfield, emphasized how crucial GLP-1s have been for those grappling with weight gain from antipsychotic medications.
“People are scared there will be a return of weight gain,” he said. “Some just started to regain control over their lives.”
Despite her hectic routine as a parent, caregiver, and employee, Martinez manages to hit the gym every day at 6 a.m.
She remains hopeful that by staying active and eating well—perhaps even using a more affordable medication—she can hold onto the substantial weight loss she achieved.
“The anxiety is present,” she admitted. “But I’m trying to remain optimistic.”
