Colorado legislators push obesity prevention bill, governor's approval is uncertain

To address Colorado's growing obesity crisis, lawmakers are pushing a bill that would require insurance companies to cover treatments associated with weight-loss efforts. Gov. Jared Polis has not been a fan of this mandate in the past, a potential roadblock if the bill survives the House and Senate.

Senate Bill 054, also known as the Diabetes Prevention and Obesity Treatment Act, would require insurance providers to cover obesity and pre-diabetes treatments, including behavioral and lifestyle therapy, bariatric surgery, and weight loss medications. 

"Of all the bills that I've done, this is by far the most personal," said sponsor Sen. Dafna Michaelson Jenet, D- Commerce City. Michaelson Jenet has been working on reducing accessibility barriers to obesity treatment since she first took office in the House. Still, she said the issue has become critical to her in the last year.

Michaelson Jenet said she has been struggling with her weight for over 10 years and was told by her doctor that her A1C levels were so high the next time she came in for a checkup, she would most likely be considered diabetic. After being prescribed the weight loss medication Wegovy, she lost 65 pounds, and her A1C was back in the normal range within three months. While she could access Wegovy through the state-provided insurance network, she said many uninsured and underinsured individuals are less fortunate.

"I have access, but many, many people who need access to anti-obesity medications do not have access because of cost and insurance coverage," she said. "Today, I want to fix that for some people. We can't fix it for everyone, but we can fix it for some people and start the movement."

Several of the bill's proponents objected to the financial impact outlined in the fiscal note, which estimated costs to the state upwards of $500 million over three years.

Dr. Rebecca Andrick, an obesity medicine specialist, said the fiscal note was created assuming patients would only be using the most expensive brands of weight loss medication when many patients opt for more affordable alternatives. She also noted that the fiscal note doesn't account for the potential cost savings from the bill's passage, including reduced expenses associated with medical conditions commonly linked to obesity, such as heart disease and diabetes.

Representatives from the insurance industry advocated for eliminating a coverage mandate on weight loss medications, citing potential premium increases for policyholders. Brendan Arnold of the Colorado Association of Health Plans noted that the average wholesale cost for a weight loss medication like Wegovy is about $46,000 per person. Should the bill be enacted, he said policyholders can expect a monthly premium increase ranging from $18 to $24.

Arnold cautioned that premiums could still climb by $9 to $18 per month even if the bill restricts coverage eligibility.

"While we appreciate efforts to narrow the bill to mitigate the cost impacts, these drugs have such a cost that it is not possible to completely mitigate the ramifications," he said. 

The actuarial analysis and fiscal note surprised even the bill's sponsors. Sen. Ginal said the fiscal note was "nowhere near reality" regarding weight loss medication usage rates. She referenced data from Michigan, Kansas, and Delaware, where Medicaid patients' utilization of anti-obesity medication was reported at 1.5%, 1.8%, and .99%, respectively, far lower than the fiscal note predicts.

"You'd think the sky was falling by the way that fiscal note is," Ginal said. "But we've had HIV drugs and we started complaining that they were too high. We've had Hep-C drugs that we were going to go broke on, but they've helped so many people get well and live lives, and isn't that what we want for people, whether they have HIV, Hep-C, or obesity?"

The bill passed through the Senate Health and Human Services Committee on a 5-3 party-line vote. Two Republicans, Sens. Jim Smallwood of Sedalia and Janice Rich of Grand Junction, said they liked the concept but voiced apprehension about the cost.

According to the bill's actuarial analysis, the estimated costs to individual, small group, and large group insurers over five years would be about $27.7 million, $28.3 million, and $83.9 million, respectively.

Sen. Julie Gonzales, D- Denver, who was substituting on the committee, alluded to the Governor's hesitancy to sign insurance mandates into law, saying, "If our dear Governor wants to advance a healthy state, a state where every Coloradan can thrive, I want to see him sign this bill into law."

When asked for a statement on SB 054, the governor's office told Colorado Politics: “Governor Polis is focused on saving Coloradans money on health care and building on Colorado’s nation-leading work like reinsurance, the Colorado Option and reducing prescription drug costs. The Governor’s Office is concerned about mandates that would increase health care costs and will monitor this bill as it moves through the legislative process.”

Fellow sponsor Sen. Joann Ginal, D-Fort Collins, explained that the American Medical Association classifies obesity as a chronic disease and that it can decrease a person's life expectancy by up to 20 years. She said weight loss medications such as Wegovy fall under the category of glucagon-like peptide, or GLP-1, drugs, which act as insulin agonists to prolong feelings of fullness by slowing food movement from the stomach to the small intestine.

Ginal explained that in order to receive a prescription for weight loss medication, a patient typically needs to have elevated A1C levels and a body mass index of around 30. She acknowledged concerns that these medications can be expensive, but contended that as more and more similar medications become available, prices will decrease over time.

"We have heard about, 'well, we can't possibly afford to help folks with because we're going to break the bank', and examples I'm going to give are HIV drugs," she said. "They're very costly. Medicaid and CHIP cover this drug, and we basically wiped out HIV because of it."

The bill's supporters say it will improve accessibility to life-changing treatments for Coloradans living with obesity. Dr. Jamie Moore, a pediatric nutrition and obesity physician, highlighted the harmful health impacts obesity can have on children. She said that without proper treatment, 80% of obese children will remain obese into adulthood, with associated conditions such as diabetes posing more significant challenges to manage compared to adults.

"We see this bill as an investment in our children that's expected to yield significant long-term cost savings with high public health impact and critical improvements in health care," Moore said. 

Christine Fallabel from the American Diabetes Association said the bill would particularly benefit communities of color and low-income individuals, who are disproportionately affected by diabetes and obesity. She said nearly 90% of all /Type 2 diabetics are overweight or obese. "We have an opportunity to improve the lives of people in Colorado and we need to seize on it," Fallabel said. 

Other opponents of the bill were not as concerned about the financial ramifications of the bill but of the potential harm it could cause to obese patients. 

McKenna Ganz of the Eating Disorder Foundation and the Colorado Alliance for Size Equity said weight loss medication is commonly recommended to obese patients with eating disorders, which can be detrimental to their mental health. Ganz argued that the bill should include language to protect patients from being mandated to use weight loss medication before they can pursue other treatments, a concept known as stepped care.

"We are concerned about enabling a coercive system that pushes people into disordered behaviors," she said. "We believe that it's very important for individuals to have access to health care that they decide on with their physicians, however without editing, this bill could potentially be used to discriminate against people in larger bodies by pushing them to weight loss interventions rather than appropriate patient-tailored health care."

Ragen Chastain of the Fat Legal Advocacy, Rights, and Education Project raised objections to the bill's inclusion of the American Association of Pediatrics' guidelines on childhood obesity, which she said are controversial within the medical community. Chastain also said the association receives funding from pharmaceutical companies whose drugs they recommend and worried that the bill's passage could lead to an increase in "stigma, harassment and discrimination against higher-weight people."

Erin Harrop of Mental Health Colorado echoed Chastain's concerns with the pharmaceutical industry profiting from weight loss medications whose long-term effects have not yet been fully studied. She said the longest trial of GLP-1 medications on obese individuals lasted only two years. 

"Like the opioid epidemic, the pharmaceutical industry stands to make huge profits before the long-term studies are even completed as desperate patients and well-meaning providers seek solutions," she said.