Illinois Gov. J.B. Pritzker’s office pushed to expand coverage of high-priced weight-loss drugs for state government’s workforce, a quiet maneuver which could cost Illinois taxpayers hundreds of millions of dollars starting this summer.
These boutique weight-loss drugs have been championed by former NBA star Charles Barkley, comedian Amy Schumer and others because of how they trigger dramatic changes in a person’s waistline. The results can be akin to bariatric surgery but at a prohibitive cost — in some cases, more than $16,000 a year.
In making highly sought-after injectable medications like Wegovy, Mounjaro and Ozempic available to eligible enrollees in the state’s group health insurance program, Pritzker’s administration is seeking an estimated $210 million to fund the first full year of broadened coverage, starting July 1.
That’s when all health insurance carriers involved in the state health program have to cover those drugs for state workers, legislators, judges and their dependents.
Pritzker’s administration says access to the medication will yield important health benefits for those who take advantage of the benefit and would equitably give access to the medication across the state’s insurance plans.
But one economist who has studied the cost impact of this new class of drugs told WBEZ the state’s yearly outlay could cost as much as three times the state’s estimate, depending on the number of people who access the program.
That Illinois may soon experience such sticker shock is classic Springfield — as in, always read the fine print.
In an 899-page budget bill approved the final day of the spring legislative session last May, a four-sentence provision codified for the first time that carriers in the state program “shall provide coverage for all types of injectable medicines prescribed on-label or off-label to improve glucose or weight loss for use by adults diagnosed or previously diagnosed with prediabetes, gestational diabetes, or obesity.”
But who gave the go-ahead to include those four sentences in the bill, adding what could be hundreds of millions of dollars of coverage costs, is difficult to say.
During floor debate, its sponsors in the Democratic-led General Assembly did not disclose that the measure was in the budget-implementation bill. In turn, that meant no discussion about what the seemingly innocuous add-on might really cost.
The bill breezed by lawmakers in both parties, even those specializing in state budget matters.
Multiple legislators learned about the initiative for the first time after being reached by WBEZ.
“Dropping a bill out of the air on the last day of session with something in it that nobody knows about and then blowing the doors off the budget, that is insanity,” said state Sen. Chapin Rose, R-Mahomet, ranking Republican on the Senate Appropriations Committee.
Rose, who voted against the budget measure last May, was one of those lawmakers unaware of the provision and its nine-figure cost a full 11 months after the fact.
“This is a flat-out indictment of a process where bills are voted on with thousands of pages dropped as they’re being voted on, within an hour of being voted on, within a couple hours of being voted on, and nobody voting for them even knows what’s in them,” Rose said.
Despite concern, coverage quietly pushed through
This class of drugs, known as GLP-1 receptor agonists, have enabled overweight people to reduce their weight by more than 20% over 36 months, one national study has shown. The drugs suppress appetite by moderating the effects of dopamine and changing how sugar is processed by the body.
“By adding coverage for injectable weight loss medications to state health insurance plans, more people will have a chance to eliminate long-term health problems,” said Cathy Kwiatkowski, a spokeswoman for the state Department of Central Management Services, which administers the state health insurance program.
She said those on the state health program with pre-diabetes, gestational diabetes or obesity are eligible for the drugs if “deemed medically appropriate by the physician.” Enrollees also are required under the law “to participate in their health plan’s lifestyle management program,” Kwiatkowski said.
“Taking into account projected utilization and the law that was passed by the legislature, CMS made a budget request for up to $210M for this expansion,” she said.
Last year’s legislation did not apply to the 3.9 million low-income and disabled Illinoisans enrolled in Medicaid, a population that generally struggles with obesity at higher levels than the overall population. Nationally, Medicaid and CHIP recipients reported a 38% obesity rate — substantially more than the 29% obesity rate reported among Illinois’ 12.8 million residents.
State retirees enrolled in Medicare Advantage plans through the state group plan also were not made eligible for coverage.
Leading up to last spring’s budget vote, the governor was silent about the provision to expand coverage of injectable weight-loss medications to state health insurance participants. He didn’t bring it up during his February 2023 budget address. And after signing the state budget last June, there also was no mention of the expansion.
Within Pritzker’s office, the idea to expand coverage of these drugs appears to have originated with the governor’s chief of staff, Anne Caprara, who is the first to mention the idea in emails obtained from the governor’s office by WBEZ under the state Freedom of Information Act.
Records show on Feb. 1, 2023, Caprara emailed several key staffers in the governor’s office to convene a meeting “for a discussion about state health insurance coverage (as well as other health insurance plans) of drugs like Ozempic, wegovy (sic) and mounjaro (sic).” She made a point in the note to say she wanted the group, “because of time constraints,” to meet “AFTER the budget rollout mid-month” by Pritzker.
There’s no record in the documents turned over by Pritzker’s office of any involvement by the governor himself in the decision to expand coverage of the drugs ahead of signing the budget last June or in the legislative strategy making it state law.
There also is no record in the emails of involvement by state government’s largest employee union, AFSCME Council 31, which represents roughly 35,000 state workers.
Ahead of the measure’s legislative passage, the emails showed there was recognition internally within the governor’s office about the initiative’s expensive cost.
Aides to Pritzker, including Caprara, were included in a May 5, 2023, email from the cabinet secretary whose agency manages the state health insurance program. CMS director Raven DeVaughn assessed “cost implications” of covering injectable weight-loss drugs.
But in records provided to WBEZ, the Pritzker administration blacked out what DeVaughn said to the group. The administration redacted and, in an unclear number of times, withheld documents, saying they were draft records or recommendations, or pertained to personal privacy involving information that is “highly personal or objectionable to a reasonable person.”
In another instance, Pritzker’s budget director, Alexis Sturm, appeared to question why the measure would be inserted into the budget implementation bill at all.
“That had been flagged as potentially having a pretty high cost,” she wrote two days before final passage of the bill to a Senate Democratic staffer and other key aides within the offices of the governor and House Speaker Emanuel “Chris” Welch, D-Hillside.
“We don’t need this in the BIMP right now,” Sturm told the group, describing a familiar legislative acronym for a traditional piece of the state budget package known as the budget-implementation bill.
But it went into that bill anyway.
'Equity' is the aim
Pritzker spokeswoman Jordan Abudayyeh said the administration’s aim with the initiative was to achieve “equity” among all nine different health insurance plans offered by the state to its employees. She said two insurance carriers were not covering the drugs.
Abudayyeh said her boss, Caprara, took an interest in the idea after seeing a media report that outlined the difficulty a government worker in another state was having obtaining the injectable weight-loss drugs. Abudayyeh said Caprara wanted to be sure the state workforce here “wouldn’t face the same challenges in obtaining these medications.”
“As the governor’s chief of staff, it is her job to identify problems and fix them — that’s what she did in this situation,” Abudayyeh said.
There is no record within 350 pages of emails turned over to WBEZ by the governor’s office and the governor’s budget office of anyone last spring discussing the need to achieve equity among all state group health insurance plans.
When asked whether the governor was aware of the expansion of coverage and its costs, Abudayyeh responded in email:
“The governor was made aware of the disparities in state worker health plans during session and was made aware of the language in the BIMP when he reviewed the BIMP with his team before signing it into law.”
The administration’s $210 million ask to expand coverage of injectable weight-loss drugs is part of a major projected escalation in health care costs associated with the state health insurance program. It’s expected to have nearly $3.8 billion in total expenses in the fiscal year that begins in July.
Coverage of such drugs is driving up costs for some states across the country. Last month, a report by the Commission on Government Forecasting & Accountability, the non-partisan fiscal research arm of the legislature, cited coverage of the weight-loss drugs as one driver of a nearly 17% increase in state group health insurance liabilities for the upcoming state fiscal year. That’s the steepest rise in expenses in eight years, the report said.
The CGFA report also showed that in 2024, prescription drug prices for the state health program were expected to be up by about 36%. That is more than triple the national increase in drug prices of nearly 10% — and now, this new drug initiative could be piled on top of those costs.
Abudayyeh stressed that the $210 million estimate for the injectable weight-loss drugs may not fully materialize.
“Because these medications are new, that number is an estimate, and it is possible this ends up costing less, depending on uptake,” she said, using a term to describe how many enrollees may actually wind up using the medication. “But we must budget for the high end of the estimates to ensure the budget remains in balance.”
Still, at least one expert says that cost could get much higher.
Much higher cost estimates
Nationally, these high-priced drugs are not fully paying for themselves through lessened costs for obesity-related maladies.
One group of researchers recently warned in a New York Times piece that the drugs could be government budget-busters and pose “an enormous risk to America’s taxpayers.” The authors included a former director of the National Economic Council, chairman of the economics department at Massachusetts Institute of Technology, and a former staff economist at the Council of Economic Advisers in the White House.
If injectable weight-loss drugs remain at current pricing levels, they predicted the cost of making them available to all obese Americans could top $1 trillion annually. That would eclipse the $800 billion they estimate in annual savings from having fewer cases of diabetes and other obesity-related illnesses.
Reached by WBEZ, one of the co-authors of that piece looked at Illinois’ potential costs and savings associated with making the injectable weight-loss drugs available to state health insurance program enrollees.
The net cost to Illinois in mandating coverage of the drugs for those in the state health insurance program could range between $300 million and more than $461 million if half of the eligible individuals on the state program that are estimated to be obese partake in coverage, said Cummings, who helped research economic policy in the White House under Democratic President Joe Biden.
To come up with those numbers, Cummings said he took into account the number of enrollees in the state health program, the state’s average obesity rate, the average cost of injectable weight-loss drugs and the health-related benefits resulting from the drugs.
At the upper range, Cummings said the state could have to spend as much as $590 million, and those expenditures would then be offset by slightly more than $129 million in health-related savings.
Cummings said if the costs for the drugs far exceed any health-related savings — and if pharmaceutical companies won’t lower prices — the Pritzker administration could face difficult decisions.
“Do you force people to pay more in their premiums? Do you issue new bonds to finance this? Do you have to raise taxes? Or do you tell people who are on it, sorry you’ve got to get off it now and you’re going to gain your weight back,” he said. “There are a lot of invidious choices if we can’t figure out collectively as a government and as policymakers…a way to get the cost of this drug down.”
Abudayyeh dismissed Cummings’ calculations when told of them.
“You’ll have to forgive us for not taking seriously back of the napkin cost analysis from someone who does not know the particulars of the state insurance plans,” she said.
As more becomes known about the cost-benefit scenario associated with this class of drugs, one other state — North Carolina — was forced to pull the plug in April on its insurance coverage of injectable weight-loss drugs for its government workers. The state faced a possible $170 million bill for the drugs had it not ended its program.
Legislative transparency in question
Roughly four weeks remain before Illinois lawmakers are scheduled to end their spring session.
Facing an unexpected cost for the enhancement, legislators will have to decide whether to follow North Carolina’s lead and scale back the drug coverage that Springfield Democrats authorized last year. Abudayyeh said that is not an option the administration is considering.
Or, they’ll have to decide whether to go along with the Pritzker administration’s request for money to fund the new drug — a cost, by comparison, that is almost exactly equivalent to what education advocates are seeking to pay for free breakfasts and lunches to any Illinois student who wants it. (Last year, the legislature authorized that school initiative but didn’t appropriate the money for it.)
Veteran state Rep. Fred Crespo, D-Hoffman Estates, isn’t sure what lawmakers will do about the funding request for injectable weight-loss drug coverage, but he’s frustrated that he had to learn about the mandate from a news reporter.
And this is a lawmaker who knows a thing or two about state budgeting.
“Something like this just illustrates how dangerous it is to put things in the BIMP bill of this magnitude,” Crespo said. “To my knowledge, it was never vetted. It was never discussed.”
Crespo chairs one of five budget-writing committees in the Illinois House. Earlier this month, the head of CMS testified in front of Crespo’s panel about the projected jump in state health care spending but didn’t mention specifically that injectable weight-loss drugs were now an apparent funding priority.
After 18 years in Springfield, Crespo has often seen the hiding of expensive or controversial items in sprawling budget-implementation bills. A couple of months ago, he set out to shine some sunlight on the process.
In February, Crespo introduced legislation requiring that any expensive new add-ons to end-of-session budget implementation bills go to House and Senate appropriations committees at least two business days before being heard.
“I just wonder how many other things are in that BIMP that we don’t know about,” Crespo said.
Abudayyeh, however, offered little sympathy to Crespo, Rose and possibly others who had no idea that the weight-loss expansion was in the bill.
“Perhaps the better question is why lawmakers who are on budget writing committees don’t know what is in the publicly available bills they are voting on and then signed into law,” she said.
Crespo’s bill, meanwhile, is showing few signs of legislative life. Asked if there had been any movement or signs of support from Springfield’s powers-that-be on his bid for more transparency, Crespo responded dryly, “Take a guess.”
In other words, no.
