This month, North Carolina did something enthusiastically that most states have been reluctant to try: It started covering new obesity medicines like Wegovy for its poorest residents as part of its Medicaid program.

For Kody Kinsley, the state’s health and human services secretary, the choice was easy. Those poor residents are disproportionately affected by obesity and its related diseases. “From a base-line justice perspective,” he said, “why are we even talking about it?”

The reason many people are talking about it is the price tag. Expensive drugs are nothing new in the U.S. health system, but these are an unprecedented type of blockbuster because so many people could benefit: More than a third of American adults meet the clinical definition of obesity. The combination of high prices and high demand is forcing every insurer, public and private, to make tough decisions.

Just this spring, the North Carolina state employees’ health plan dropped coverage of the same class of drugs, citing unsustainable costs, ending coverage for nearly 25,000 people who were taking them.

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That means the civil-service administrators who will be helping the state’s poorest residents get access to Wegovy and its siblings have lost their own employer coverage for the very same drugs.

The costs of the drugs, known as GLP-1 agonists, can add up quickly. Novo Nordisk’s Wegovy and Eli Lilly’s Zepbound — the two GLP-1 drugs that have been approved specifically for weight loss — each come with a sticker price over $1,200 a month, and need to be taken long-term for sustained effect. (Ozempic has the same active ingredient as Wegovy, but has been approved for diabetes.)

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