State Pilots and What This Means for MASH and IBD Patients with Obesity

How the CMS Pause on GLP-1 Coverage Shapes Patient Access in the U.S.

In 2025, the debate over coverage of anti-obesity GLP-1 drugs reached a critical point. The U.S. Centers for Medicare and Medicaid Services (CMS) effectively paused efforts to expand reimbursement for medications such as Wegovy® (semaglutide) and Zepbound™ (tirzepatide), citing the need for additional cost and outcomes data. Under current federal law, Medicare Part D excludes weight-loss drugs, even when prescribed for chronic obesity, a condition that affects more than 40% of American adults and drives billions in downstream healthcare spending.

This decision reverberates through the entire health system.

Medicaid programs remain inconsistent: a few states have begun limited pilot initiatives covering GLP-1s for specific populations, while others continue blanket exclusions. Commercial insurers often follow CMS’s lead, leaving patients, especially older adults and those with complex metabolic diseases, without affordable access.

What makes this pause especially consequential is that GLP-1 agonists are no longer viewed solely as “weight-loss” drugs. Recent FDA approvals link them to cardiovascular risk reduction, obstructive sleep apnea, and emerging indications in liver and gastrointestinal disease. Yet the CMS position still categorizes them under aesthetic or elective use.

The tension between fiscal restraint and preventive health is becoming untenable. For clinicians treating obesity-related comorbidities, from diabetes and MASH to inflammatory bowel disease, the inability to prescribe GLP-1s under public insurance isn’t a policy abstraction; it’s a daily clinical frustration. As states pilot coverage models and Congress debates reform, patient outcomes and equity remain at stake.

This material explores the evolving coverage landscape through the eyes of physicians, researchers, and policy experts navigating this uncertain transition.

By Robert F. Kushner, MD – Professor of Medicine, Northwestern University Feinberg School of Medicine

State Pilots and the Fragmented Coverage Landscape

For more than thirty years, I’ve devoted my practice to treating obesity as a chronic, relapsing disease, not a lifestyle failure. I have watched progress unfold from calorie counting and orlistat to the modern era of GLP-1 receptor agonists, which finally allow patients to achieve metabolic and inflammatory control beyond simple weight reduction. Yet in 2025, my greatest challenge isn’t the medicine itself. It’s the insurance system that decides who can access it.

When CMS reaffirmed that Medicare Part D cannot broadly reimburse anti-obesity drugs, it created a ripple effect that fractured the national map of access. Each state began improvising. Some like North Carolina, Massachusetts, West Virginia, and Wisconsin launched Medicaid and state-employee pilot programs to test limited coverage of drugs such as semaglutide and tirzepatide. Others refused coverage outright. These pilots are meant to collect data on costs, adherence, and durability of weight loss, but for patients, they represent a confusing lottery.

In my own clinic, I see this inequity daily. Two women of similar age and BMI, both with metabolic syndrome and early fatty-liver disease, one from Illinois, the other recently moved from North Carolina, receive entirely different care. The first pays out-of-pocket over $1,000 a month; the second qualifies for a state pilot and receives her medication at minimal cost. Both are motivated, both clinically indicated, yet only one benefits.

These programs are, in essence, experiments in preventive health economics. States want to know whether covering GLP-1s reduces downstream costs—fewer hospitalizations, less insulin use, delayed cardiovascular events. But the rules vary. Some pilots restrict therapy to patients with diabetes; others cap treatment at six or twelve months. Ironically, many patients lose coverage precisely when their health begins to improve. Obesity doesn’t vanish in a fiscal quarter.

What frustrates me most is that policy has not caught up with physiology.

These agents are not cosmetic interventions; they are disease-modifying therapies that recalibrate hormonal and inflammatory pathways central to metabolic dysfunction. The science has moved far faster than our reimbursement logic.

The pilots give me cautious optimism. For the first time, state data will quantify the public-health value of treating obesity as a disease. But until CMS updates its position, Americans’ access to these life-changing drugs will remain determined not by medical need—but by their ZIP code.

The Hidden Consequence for MASH Patients

One of the most overlooked effects of CMS’s restrictive coverage policy is how it inadvertently limits access to effective therapies for metabolic liver disease. I see this every week in my obesity and metabolic clinics. Many of my patients don’t simply live with excess weight; they live with the full constellation of metabolic dysfunction—insulin resistance, dyslipidemia, and fatty liver disease that can evolve into metabolic dysfunction-associated steatohepatitis (MASH).

We are witnessing a quiet epidemic of MASH in the United States. It is now one of the leading causes of liver transplantation, closely linked to obesity and type 2 diabetes. For years, we had no pharmacologic therapy, only lifestyle modification, which is effective in theory but difficult to sustain at scale. Then, GLP-1 receptor agonists changed the equation.

Recent data show that drugs such as semaglutide and tirzepatide not only drive weight loss but also reduce hepatic steatosis and inflammation, and in some trials, improve fibrosis scores. They act on the same metabolic pathways that underlie both obesity and liver injury, i.e., insulin signaling, oxidative stress, and lipid metabolism. In my clinic, I’ve seen liver enzyme normalization and radiologic improvement within months in patients who could stay on therapy. But that last phrase – who could stay on therapy – is the crux.

Under the current CMS framework, these medications are not covered for MASH, nor for obesity alone. They are only reimbursed when prescribed for diabetes. That means patients with early liver disease but without hyperglycemia must either pay out of pocket or forgo treatment entirely. The policy draws an artificial boundary that ignores the biology connecting these conditions.

I recall one patient, a 59-year-old man with biopsy-proven MASH and a BMI of 37. His diabetes had gone into remission after bariatric surgery, but his liver fibrosis was progressing. We recommended semaglutide, supported by emerging evidence. His insurer denied coverage because he no longer met diabetes criteria. Six months later, his fibrosis worsened, and he joined a transplant waiting list.

This is the moral paradox of our system: we are denying patients a medication that could prevent organ failure simply because it’s labeled as “weight loss.” If CMS recognized obesity and MASH as interlinked chronic diseases rather than cosmetic concerns, we could prevent this spiral.

Until then, state pilot programs may become the only lifeline for these patients, generating the data we need to prove what every clinician already knows: treating obesity early is liver medicine.

The Overlap with IBD and Systemic Inflammation

The Overlap with IBD and Systemic Inflammation
In the past, obesity and inflammatory bowel disease seemed to occupy opposite ends of the metabolic spectrum, one defined by excess, the other by wasting. But in recent years, the lines have blurred. I now treat many patients who live with both obesity and Crohn’s disease or ulcerative colitis, an intersection that reveals how profoundly inflammation and metabolism are intertwined. The science supports what we observe clinically: obesity is a pro-inflammatory state. Adipose tissue releases cytokines such as TNF-α and IL-6, amplifying the same pathways implicated in intestinal inflammation. In patients with IBD, this background inflammation worsens disease activity, reduces response to biologics, and complicates surgical outcomes. Obesity also changes drug pharmacokinetics: dosing anti-TNF agents, for example, becomes more difficult, sometimes requiring higher or more frequent infusions. In this context, GLP-1 receptor agonists offer something uniquely valuable, they modulate both metabolism and inflammation. While their use in IBD remains exploratory, small studies and mechanistic models suggest GLP-1 agonists may attenuate inflammatory signaling in the gut, promote mucosal healing, and even improve intestinal barrier integrity. In my own experience, several patients with concurrent obesity and IBD who began semaglutide for weight control reported fewer flare symptoms and improved energy levels – observations that merit rigorous study.

Yet here again, CMS’s coverage exclusion blocks access for exactly the population that stands to gain the most. Many IBD patients develop obesity from long-term corticosteroid exposure, reduced activity, and metabolic adaptation to chronic illness. When these patients ask about GLP-1 therapy, I must often tell them it’s not covered unless they also have diabetes or reside in one of the handful of states running pilot programs. The irony is painful: the same medications that could lower systemic inflammation and reduce steroid dependence are classified as cosmetic weight-loss aids under federal policy.

One of my patients, a 42-year-old woman with ulcerative colitis, exemplifies this paradox. Years of steroid treatment stabilized her disease but led to severe obesity and hypertension. She was eager to try a GLP-1 drug after reading about its metabolic and anti-inflammatory effects. Despite my documentation of medical necessity, her insurer denied coverage because “obesity” was not a reimbursable diagnosis under her Medicaid plan. She could not afford to pay privately, and within months, she was back on prednisone for another flare. Cases like hers remind me that CMS’s stance is more than a fiscal decision; it’s a clinical barrier that fragments care. For patients at the crossroads of metabolic and inflammatory disease, separating “obesity treatment” from “IBD management” no longer makes biological sense.

Until our reimbursement structures reflect that reality, we will continue treating inflammation in pieces, while leaving the underlying metabolic fire untouched.

Policy Outlook and Realistic Solutions

When policymakers talk about the cost of GLP-1 drugs, they often focus on the sticker price. And it’s true, at more than $1,000 per month, these medications are expensive. But what’s missing from the conversation is the cost of inaction. Every untreated case of obesity compounds the future burden of diabetes, heart disease, and liver failure. In public health economics, we call this “deferred spending,” and it’s one of the most costly forms of denial.

From my perspective, a balanced solution begins with targeted expansion of coverage, not unrestricted access.

CMS could start by approving GLP-1 reimbursement for patients with specific obesity-related conditions like cardiovascular disease, obstructive sleep apnea, or MASH, where outcomes data already justify benefit. This would align with the FDA’s recent expanded indications for semaglutide and tirzepatide, and it would allow policymakers to gather real-world data on cost-effectiveness before scaling further. We can also learn from the state pilots. If early data show reductions in hospitalizations, insulin use, or liver transplants, those savings should be quantified and reinvested into coverage. Obesity treatment is preventive medicine, but our insurance frameworks were built for acute illness, not chronic metabolic care. CMS needs a reimbursement category that reflects the long-term trajectory of obesity, rather than lumping GLP-1s under “cosmetic” exclusions written decades ago.

Another solution lies in value-based contracting. If drug manufacturers and public insurers can tie payment to measurable outcomes, such as sustained weight loss, HbA1c reduction, or reduced medication burden, coverage can expand responsibly. That model already exists for cardiovascular and oncology therapies; obesity medicine should not be an exception.

Finally, the conversation must shift from cost to equity. Right now, wealth determines access. My patients with private insurance or employer plans can afford to stay on treatment; my Medicare and Medicaid patients cannot. This discrepancy perpetuates the very health disparities our healthcare system claims to be addressing.

The next phase of the CMS review process will test whether federal health policy is ready to acknowledge obesity as the disease that drives nearly every other. Until it does, clinicians like me will continue to fight not just biology—but bureaucracy.