When Page Campbell’s physician advisable she strive an injectable prescription drug referred to as Wegovy to drop extra pounds earlier than scheduling bariatric surgical procedure, she readily agreed.
In early April, about 4 weeks after she’d began taking Wegovy, Campbell mentioned she hadn’t skilled any unwanted side effects, equivalent to nausea or bowel irritation. But she would not use a scale at dwelling, she mentioned, so she did not know whether or not she’d misplaced any weight since her most up-to-date medical appointment earlier this yr, when she weighed 314 kilos. Still, she was assured about attaining weight reduction.
“It’s going to work as a result of I’m placing within the work. I’m altering my consuming habits. I’m exercising,” mentioned Campbell, a delivery supervisor at a Michaels retailer. “I’m not going to second-guess myself.”
Wegovy belongs to a dear class of medication referred to as GLP-1s (quick for glucagon-like peptide-1 agonists) which have upended the therapy of weight problems in recent times, providing hope to sufferers who’ve tried and did not drop extra pounds in myriad different methods.
Campbell gained entry to Wegovy by way of South Carolina Medicaid’s determination in late 2024 to cowl these weight reduction medication. But the drugs stay out of attain for thousands and thousands of sufferers throughout the nation who may gain advantage from them, as a result of many private and non-private well being insurers have deemed the medication too costly.
A report revealed in November by KFF, a well being info nonprofit that features KFF Health News, discovered solely 13 states have been masking GLP-1s for the therapy of weight problems for Medicaid beneficiaries as of August. South Carolina grew to become the 14th in November.
Liz Williams, one of many report’s authors and a senior coverage supervisor for the Program on Medicaid and the Uninsured at KFF, mentioned she was not conscious of some other state Medicaid packages becoming a member of the record since then. Looking forward, the remaining states could also be reluctant so as to add a brand new, costly drug profit whereas they brace for potential federal cuts coming from Congress, she mentioned.
“As the funds debate, federally, is growing, which will affect how states are interested by this,” Williams mentioned.
The federal authorities will not be serving to anytime quickly, both. Medicare covers GLP-1s to deal with diabetes and another well being situations, together with obstructive sleep apnea and heart problems, however not weight problems. In early April, the Trump administration introduced it won’t finalize a rule proposed by the Biden administration that may have allowed an estimated 7.4 million folks coated by Medicare and Medicaid to entry GLP-1s for weight reduction. Meanwhile, the FDA is poised to drive cheaper, compounded variations of those medication off the market.
And the barrier to entry stays excessive, even for Medicaid sufferers in these few states which have agreed to cowl the medication with out a federal mandate.
Case in level: In South Carolina, the place greater than one-third of all adults, and almost half of the African American inhabitants, qualify as overweight, the state Medicaid company estimates only one,300 beneficiaries will meet the stringent stipulations for GLP-1 protection.
Under a kind of necessities, Medicaid beneficiaries who want to entry these medication to drop extra pounds should attest to “elevated train exercise,” mentioned Jeff Leieritz, a spokesperson for the South Carolina Department of Health and Human Services.
Campbell, who’s insured by Medicaid, was granted protection for Wegovy based mostly on her physique mass index. First, although, she was required to submit six months’ price of documentation proving that she’d tried and did not drop extra pounds after receiving diet counseling and happening a 1,200-calorie-a day food regimen, mentioned Kenneth Mitchell, certainly one of Campbell’s docs and the medical director for bariatric surgical procedure and weight problems drugs at Roper St. Francis Healthcare.
Campbell’s Wegovy prescription was authorized for six months, Mitchell mentioned. When that authorization expires, Campbell and her well being care staff might want to submit extra documentation, together with proof that she has misplaced a minimum of 5% of her physique weight and has saved up with diet counseling.
“It’s not simply, ‘Send a prescription in they usually cowl it.’ It’s slightly arduous,” Mitchell mentioned. “Not quite a lot of of us are going to do that.”
Mitchell mentioned South Carolina Medicaid’s determination to cowl these medication was met with pleasure amongst these working in his medical specialty. But he wasn’t stunned that the state anticipates comparatively few folks will entry this profit yearly, because the approval course of is so rigorous and the fee excessive. “The drawback is the medicines are so costly,” Mitchell mentioned.
Novo Nordisk, which manufactures Wegovy, introduced in March that it was slicing the month-to-month worth for the drug from $650 to $499 for cash-paying prospects. The worth that medical health insurance plans and beneficiaries pay for these medication varies, however some GLP-1s value greater than $1,000 per affected person per thirty days, Mitchell mentioned, and many individuals might want to take them for the remainder of their lives to take care of weight reduction.
“That is an amazing price ticket that somebody has to foot the invoice for,” Mitchell mentioned.
That’s the rationale California Gov. Gavin Newsom on May 14 proposed eliminating Medicaid protection of GLP-1s for weight reduction beginning Jan. 1, to avoid wasting an estimated $680 million a yr by 2028.
And the North Carolina State Health Plan Board of Trustees voted final yr to finish protection of GLP-1s for state workers, after then-North Carolina Treasurer Dale Folwell’s workplace estimated in 2023 that the medication have been projected to value the State Health Plan $1 billion over the subsequent six years. The determination got here only some months after a separate North Carolina company introduced it might begin masking these medication for Medicaid beneficiaries. North Carolina Medicaid has estimated it should spend $16 million a yr on GLP-1s.
South Carolina Medicaid, which insures fewer than half the variety of folks enrolled in North Carolina Medicaid, anticipates spending much less. Leieritz estimated GLP-1s and diet counseling provided to Medicaid beneficiaries in South Carolina will value $10 million a yr. State funding will cowl $3.3 million of the expense; the rest shall be paid for by matching Medicaid funds from the federal authorities.
In a latest interview, Health and Human Services Secretary Robert F. Kennedy Jr. did not rule out the chance that Medicare and Medicaid would possibly cowl GLP-1s for weight problems therapy sooner or later as prices come down.
They’re “extraordinary medication” and “we’ll scale back the fee,” Kennedy advised CBS News in early April. He mentioned he would really like GLP-1s to finally be made obtainable to Medicare and Medicaid sufferers who’re looking for weight problems therapy after they’ve tried different methods to drop extra pounds. “That is the framework that we’re now debating.”
Meanwhile, public well being specialists have applauded South Carolina Medicaid’s determination to cowl GLP-1s. Yet the brand new profit will not assist the overwhelming majority of the 1.5 million adults in South Carolina who’re labeled as overweight, in response to knowledge revealed by the South Carolina Department of Public Health.
“We nonetheless have some work to do,” acknowledged Brannon Traxler, the general public well being division’s chief medical officer.
But the state’s new “Action Plan for Healthy Eating and Active Living,” written by a coalition of teams in South Carolina, together with the Department of Public Health, makes no point out of GLP-1s or the position they could play in decreasing weight problems charges within the state.
The motion plan, underwritten by a $1.5 million federal grant, is not meant to put out an overarching method for decreasing weight problems in South Carolina, Traxler mentioned. Instead, it promotes bodily exercise in faculties, diet, and the enlargement of out of doors strolling trails, amongst different methods. A extra complete weight problems plan would possibly deal with the advantages of surgical intervention and GLP-1s, however these additionally carry danger, expense, and unwanted side effects, Traxler mentioned.
“Certainly, I believe, there’s a must deliver all of it collectively,” she mentioned.
Campbell, for one, is taking the excellent method. On high of injecting Wegovy as soon as weekly, she mentioned, she is prioritizing protein consumption and shifting her physique. She additionally underwent weight reduction surgical procedure in late April.
“Weight loss is my largest objective,” mentioned Campbell, who expressed appreciation for Medicaid’s protection of Wegovy. “It’s yet another factor that is going to assist me get to my objective.”
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