Trump Offered State Medicaid Programs Lower Prices On Weight-loss Drugs. Most Are Rejecting The Deal. 

President Donald Trump’s pledge to make new but pricey weight-loss drugs widely available for low-income Americans isn't panning out as planned.

Trump promised last year that obese Americans on Medicaid would soon gain access to drugs known as GLP-1s, like Wegovy and Zepbound, if the states where they live signed on with his administration to negotiate prices directly with manufacturers.

Nine months later, Medicaid patients’ access to the drugs has shrunk. Only Indiana has publicly signed on with the administration. Some states have stopped covering the medications for Medicaid patients who need them for weight loss. Others are considering ending coverage. Most states told POLITICO they will not participate.

States opting out of coverage — including Maine, New Mexico and Oklahoma — cited budget constraints and concerns about the long-term financial sustainability of Trump’s model. That comes as they’ve watched other states spend hundreds of millions more than they expected on the medications. California’s Medicaid program stopped covering GLP-1s for weight loss at the start of this year after projecting costs of the medications would nearly quadruple to $800 million by 2028-29.

“We also want to make sure that we can afford it the first time, afford it upfront, so that we're not in situations like other states who have had to contract or withdraw entirely their GLP-1 coverage,” said Louisiana Medicaid Director Seth Gold.

Halting access can have devastating effects on Medicaid patients, some of whom have lost hundreds of pounds on the medications and vastly improved their health.

States’ reluctance to participate in Trump’s program illustrates Medicaid’s limits in covering expensive drugs, especially with looming cuts to the program from last year’s One Big Beautiful Bill Act. States with tight budgets are struggling more than ever with the enormous costs of the GLP-1 medications. They aren’t willing to pay for them even considering that the drugs could reduce long-term health costs by preventing the onset of chronic diseases linked to obesity.

States are required to cover GLP-1s for such diseases, such as diabetes and heart disease, but not for weight loss alone. Medicaid spending on the medications already grew from $1 billion in 2019 to almost $9 billion in 2024, and interest in the drugs would be massive if state Medicaid programs covered them for weight loss. Nearly 40 percent of patients with obesity might qualify. Seventy million people rely on the program for their health insurance.

Late last year, Trump said his historic drug pricing deals would help people who need the drugs for weight loss gain access for little to no money.

Many Americans were paying more than $1,000 per month for weight-loss drugs, Trump said in the Oval Office in November: "That ends starting today."

His cut-rate pricing would arrive mid-year, Trump promised.

Direct negotiations between the federal Centers for Medicare and Medicaid Services and the drugmakers would “expand access and lower prices for obesity GLP-1 medication without passing the bill to taxpayers,” CMS Administrator Mehmet Oz said earlier this year when announcing the model.

"We've got to throw everything we've got at empowering individuals to take control of their health."

Indiana plans to begin offering the drugs by the start of next year. Seven states — Arizona, Georgia, Michigan, Montana, Ohio, Tennessee and Virginia — told POLITICO they're still deciding whether to participate.

Twenty-nine state Medicaid programs said they will not participate in the Trump administration payment model, with many citing costs and budgetary pressures. Five of those states already cover GLP-1s for obesity with varying restrictions.

The remaining 14 states did not respond to requests for comment. CMS declined to provide a list of participating states.

“Information on all future model developments and next steps will be shared as it becomes available,” a CMS spokesperson said. “CMS remains focused on working with partners across the health care system to improve access to care, support better health outcomes, and ensure program sustainability over the long term.”

Twelve states currently provide Medicaid coverage of the weight-loss drugs. Over the past year, five states — California, Massachusetts, New Hampshire, Pennsylvania and South Carolina — ended coverage, citing high costs and budgetary strains. Rhode Island will end coverage in October.

In the majority of states that don’t cover GLP-1s, Medicaid enrollees can pay out-of-pocket through the president’s drug-discount platform, TrumpRx. But the discounted prices — around $350 a month on average — are still unaffordable for most low-income Americans.

In Louisiana, Gold said he wants to make weight-loss drugs accessible to the nearly 40 percent of Louisianans who need them, but doesn't want to follow in the footsteps of states that have given patients access to the drugs, only to later take it away. The Trump model “just was not something that we could readily be able to make work,” he said.

The coverage struggle

States have long wrestled with whether to cover anti-obesity drugs for Medicaid patients. Coverage is optional for states, as a decades-old federal law excludes weight-loss medications from mandatory coverage in both Medicaid and Medicare.

Over the past few years, the rising popularity of GLP-1s to treat obesity has prompted a handful of states to voluntarily pay for the medications, hoping to recoup the high up-front cost by reducing rates of costly diseases like diabetes, heart disease and other chronic conditions associated with obesity. Drugmakers — including Eli Lilly and Novo Nordisk, which are both participating in the Trump administration model — have encouraged Medicaid and other insurers to cover their medications for that reason.

States are offered a price point of $245 per monthly dose of Novo Nordisk’s Wegovy under the Trump administration model, the company told POLITICO. The actual cost to states is likely lower when federal match rates and drugmaker rebates are taken into account, they noted.

Indiana has said it will pay $85.16 of the $245 monthly cost per person.

“Wegovy in particular is a great option for patients because of the proven clinical benefit of reduced cardiovascular events and improved liver health,” Novo Nordisk's spokesperson said. “Those are huge cost drivers in the health care system, in Medicare and Medicaid, and reduced rates of obesity and [cardiovascular] and liver health events would go a long way in reducing program costs.”

Eli Lilly, which makes Zepbound, is urging states to look at the long-term picture despite the initial budget impact, a spokesperson told POLITICO.

But the leap to pay for the medications now to potentially reduce long-term spending is not one all states are able to take.

Florida’s Medicaid program, which evaluated the model and opted not to apply, said participating would “require new, non-budgeted spending and legislative appropriation.” In Oregon, participating would “require significant additional investment” from the legislature, according to Kristen Lambert, spokesperson for the state Medicaid program.

Hawaii’s and Vermont’s Medicaid agencies also said the model would be too costly. North Dakota opted out because state lawmakers rejected a plan to require coverage of anti-obesity medications during the state’s last legislative session. New Mexico carefully considered the model, but said it’s “not currently feasible,” citing the “major Medicaid changes and financial pressures” created by the One Big Beautiful Bill Act.

In New Jersey and Kentucky, state laws prohibit Medicaid programs from covering weight-loss drugs.

“This is public dollars, and the state is the purchaser, so they have to be a little bit more mindful of it,” said Johanna Butler, director of health care costs at The National Academy for State Health Policy, a nonpartisan organization for state policymakers. “It's not always clear when and where the savings will accrue, which can make the case for coverage more challenging.”

‘Wait-and-see’

Michigan, which already covers GLP-1s through Medicaid, said it applied to participate and is meeting with CMS later this month. If the state and CMS agree, the state would expand its coverage to people with moderate to severe obesity and to those who need the medication for weight loss and have certain comorbidities, like high blood pressure or Type 2 diabetes, effective Jan. 1, said Lynn Sutfin, a spokesperson for the Michigan Department of Health and Human Services. The state currently requires a patient to have the most severe classification of obesity to qualify.

Virginia and Tennessee, which also cover GLP-1s, said they are still evaluating whether to participate.

But some states, including Minnesota and Missouri, that cover the medications said they are not participating in the Trump administration model. Butler said states may be better able to control costs by negotiating coverage terms and prices directly with drugmakers.

“They might know or think that their current net pricing is better than what's been negotiated,” she said. “They might also want to keep that kind of autonomy to be able to negotiate their own coverage terms rather than doing that through CMS.”

Trump’s model would require states to adopt standardized coverage criteria, including a 35 or higher body-mass index. That index compares height to weight. A 5’10” person would need to weigh 244 pounds to qualify. CMS would need to approve any variations or more restrictive coverage. The model also offers participants lifestyle support programs like nutrition and fitness counseling.

Some states — like Delaware and Kansas — cover GLP-1s for weight loss with much stricter limits, helping them manage cost and utilization. Those states did not return requests for comment on whether they’re participating in the model.

For Louisiana, which hopes to eventually cover GLP-1s for Medicaid patients with obesity, setting coverage limits to control costs is paramount, said Gold. And though the state isn’t participating in the model, he’s hopeful the federal government’s approach to directly negotiating prices will open the door for more states to negotiate with pharmaceutical companies and put downward pressure on prices.

“Manufacturers are now more aggressive in wanting to be covered by Medicaid programs, and they're working more with states,” he said. “Just because we aren't participating ... doesn't mean that our eventual coverage of GLP-1s wouldn't be the result of their work there.”

But for now, it’s likely most states will take a “wait-and-see” approach, keeping a careful eye on Indiana to see how its Medicaid budget fares as federal cuts take effect, said Butler of The National Academy for State Health Policy.

“States are wanting to see how the next year to three years plays out on the budget front before making any sort of dramatic moves that could impact state spending.”