Wegovy and other GLP-1 medications are no longer covered by MediCal to combat obesity. However, if an obese patient develops Type 2 diabetes, cardiovascular disease or sleep apnea, the state will cover the drugs.

On Jan. 1, Medi-Cal quietly stopped covering GLP-1 medications — Wegovy, Zepbound, Saxenda — for adults seeking treatment for obesity. The same drugs remain covered if the same patient develops Type 2 diabetes, cardiovascular disease or sleep apnea. That means California’s Medicaid program will pay for the complications of obesity, but not for treating obesity itself.

At the same time, Medicare announced it would begin expanding GLP-1 coverage, launching demonstration programs that will make these medications available at federally negotiated prices to beneficiaries with obesity and related comorbidities as early as this summer. Drawing on the same body of evidence, the two decisions moved in opposite directions, affecting different populations. The federal program for older and disabled Americans is opening access, while the state program for low-income Californians is closing it.

Before I began studying medicine at UCSF last year, I spent two years as a clinical researcher in one of the country’s highest-volume bariatric endoscopy programs, tracking outcomes for patients navigating exactly these treatment decisions. I don’t have the standing to call this a policy catastrophe. But I do know that the patients California just cut off don’t have good alternatives.

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The Medi-Cal decision is being framed as a budget move. California faces a significant deficit, and GLP-1 medications are expensive; at list price, covering even a fraction of Medi-Cal’s 15 million enrollees would cost billions annually. With the cuts, the state projects $680 million in savings by 2028. But that framing obscures the logic embedded in what the policy retained and what it eliminated.

Medi-Cal will still cover GLP-1 drugs for Type 2 diabetes and for established cardiovascular disease, and obesity is among the leading modifiable risk factors for both. It will, as a result, cover the expensive downstream sequelae of a disease while excluding treatment of the disease itself.

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This is not fiscally or clinically coherent. Every major medical organization classifies obesity as a chronic, multifactorial disease. GLP-1 receptor agonists work because obesity has a neurohormonal architecture at the level of satiety signaling and energy homeostasis. This is not in dispute. What the Medi-Cal cut reveals is the mistaken belief that obesity is a condition people could resolve if they tried harder. That losing weight is more a matter of choice than of biology.

Low-income adults on Medi-Cal, who cannot afford private coverage, are exactly the population for whom alternative weight loss pathways are least accessible. Bariatric surgery is technically covered by Medi-Cal, but only for patients who meet strict body mass index thresholds, can document prior supervised weight loss attempts, complete psychological evaluations and wait through approval timelines that stretch weeks to months at certified facilities.

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For the substantial share of patients who don’t meet surgical criteria, or who can’t navigate that process, GLP-1 medications were filling a gap the system had otherwise left open. Paying out of pocket for Wegovy at the list price runs over $1,000 a month. Manufacturer discount cards exist but require the kind of navigation that is, for many Medi-Cal patients, a barrier in itself. The people who were relying on Medi-Cal coverage for these medications are not people with good backup plans.

At a San Diego conference last year, I presented data from 403 bariatric patients showing that while outcomes were similar across income levels after a year, patients from the lowest socioeconomic areas showed significantly lower weight loss and follow-up rates after three years. The pattern is not that these treatments work less well for lower-income patients. It is that maintaining the gains requires sustained support. Removing pharmacological support from the patients already least likely to maintain that continuity withdraws the margin precisely from those who have the least of it.

On the wards at UCSF, we have seen patients admitted for complications of obesity who have mentioned, almost in passing, that the medication that had been working was no longer covered.

What troubles me — at the beginning of a medical career in a city with one of the largest concentrations of Medi-Cal patients in California — is that the decision to deny GLP-1 medication coverage will result in a higher number of uncontrolled diabetes cases and a rise in cardiovascular events.

Guest opinions in Open Forum and Insight are produced by writers with expertise, personal experience or original insights on a subject of interest to our readers. Their views do not necessarily reflect the opinion of The Chronicle editorial board, which is committed to providing a diversity of ideas to our readership.

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It is worth noting that the California Legislature is debating Senate Bill 535, the Obesity Treatment Parity Act, which would require health insurance plans to cover the full spectrum of obesity interventions: behavioral therapy, bariatric surgery and at least one anti-obesity medication. The Legislature is considering a bill premised on the clinical legitimacy of obesity treatment while having already implemented a cut premised on the opposite.

None of this is to say that GLP-1 medications are without complexity. Long-term data on outcomes, on weight recidivism after discontinuation and on the relationship between pharmacological and structural intervention are still maturing. Cost and the question of how public programs should prioritize competing needs are genuine concerns. The question of coverage should be answered by those considerations, by clinical evidence and comparative effectiveness, not by the outdated views of a disease.

Kate Solpari is a first-year medical student at UCSF. She spent two years as a clinical researcher in gastroenterology and bariatric medicine at Weill Cornell Medicine, where she published work on socioeconomic disparities in bariatric outcomes.

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