CHARLESTON, S.C. — When Web page Campbell’s physician really helpful that she strive an injectable prescription drug known as Wegovy to shed some pounds earlier than scheduling bariatric surgical procedure, she readily agreed.
“I’ve struggled with my weight for so long,” mentioned Campbell, 40, a single mom of two. “I’m not opposed to trying anything.”
In early April, about 4 weeks after she’d began taking Wegovy, Campbell mentioned she hadn’t skilled any unwanted effects, equivalent to nausea or bowel irritation. However she doesn’t use a scale at dwelling, so she mentioned she didn’t 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. Nonetheless, she was assured about reaching weight reduction.
“It’s going to work because I’m putting in the work. I’m changing my eating habits. I’m exercising,” mentioned Campbell, a delivery supervisor at a Michaels retailer. “I’m not going to second-guess myself.”
Web page Campbell, of Charleston, South Carolina, underwent weight reduction surgical procedure in April. Campbell additionally injects a GLP-1 prescription treatment weekly for the therapy of weight problems, along with prioritizing protein consumption and bodily motion.
Wegovy belongs to an expensive class of medication known as GLP-1s (brief for glucagon-like peptide-1 agonists) which have upended the therapy of weight problems lately, providing hope to sufferers who’ve tried and didn’t shed some pounds in myriad different methods.
Campbell gained entry to Wegovy by means of South Carolina Medicaid’s choice in late 2024 to cowl these weight reduction medication. However the medicines stay out of attain for tens of millions 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.
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 another state Medicaid applications becoming a member of the listing since then. Wanting 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 budget debate, federally, is developing, that may impact how states are thinking about this,” Williams mentioned.
The federal authorities gained’t 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 is not going to finalize a rule proposed by the Biden administration that might have allowed an estimated 7.4 million folks coated by Medicare and Medicaid to entry GLP-1s for weight reduction. In the meantime, the Meals and Drug Administration is poised to drive inexpensive, 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 and not using a federal mandate.
Living proof: In South Carolina, the place greater than one-third of all adults, and practically 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.
Underneath a type of necessities, Medicaid beneficiaries who want to entry these medication to shed some pounds should attest to “increased exercise activity,” mentioned Jeff Leieritz, a spokesperson for the South Carolina Division of Well being and Human Providers.
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’ value of documentation proving that she’d tried and didn’t shed some pounds after receiving vitamin counseling and occurring a 1,200-calorie-a day weight loss program, mentioned Kenneth Mitchell, considered 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 accredited for six months, Mitchell mentioned. When that authorization expires, Campbell and her well being care group might want to submit extra documentation, together with proof that she has misplaced no less than 5% of her physique weight and has saved up with vitamin counseling.
“It’s not just, ‘Send a prescription in and they cover it.’ It’s rather arduous,” Mitchell mentioned. “Not a lot of folks are going to do this.”
Mitchell mentioned South Carolina Medicaid’s choice to cowl these medication was met with pleasure amongst these working in his medical specialty. However he wasn’t stunned that the state anticipates comparatively few folks will entry this profit yearly, for the reason that approval course of is so rigorous and the associated fee excessive. “The problem is the medicines are so expensive,” Mitchell mentioned.
Novo Nordisk, which manufactures Wegovy, introduced in March that it was chopping the month-to-month worth for the drug from $650 to $499 for cash-paying prospects. The value that medical insurance plans and beneficiaries pay for these medication varies, however some GLP-1s price greater than $1,000 per affected person monthly, Mitchell mentioned, and many individuals might want to take them for the remainder of their lives to take care of weight reduction.
“That is a tremendous price tag that someone has to foot the bill for,” Mitchell mentioned.
That’s the rationale the North Carolina State Well being Plan Board of Trustees voted final yr to finish protection of GLP-1s for state staff, after then-North Carolina Treasurer Dale Folwell’s workplace estimated in 2023 that the medication had been projected to price the State Well being Plan $1 billion over the following six years. The choice got here just a few months after a separate North Carolina company introduced it could 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 vitamin counseling supplied to Medicaid beneficiaries in South Carolina will price $10 million a yr. State funding will cowl $3.3 million of the expense; the rest might be paid for by matching Medicaid funds from the federal authorities.
In a latest interview, Well being and Human Providers Secretary Robert F. Kennedy Jr. didn’t rule out the chance that Medicare and Medicaid may cowl GLP-1s for weight problems therapy sooner or later as prices come down.
In the meantime, public well being specialists have applauded South Carolina Medicaid’s choice to cowl GLP-1s. But the brand new profit gained’t assist the overwhelming majority of the 1.5 million adults in South Carolina who’re categorized as overweight, in keeping with knowledge printed by the South Carolina Division of Public Well being.
“We still have some work to do,” acknowledged Brannon Traxler, the general public well being division’s chief medical officer.
However the state’s new “Action Plan for Healthy Eating and Active Living,” written by a coalition of teams in South Carolina, together with the Division of Public Well being, makes no point out of GLP-1s or the function they could play in reducing weight problems charges within the state.
The motion plan, underwritten by a $1.5 million federal grant, isn’t meant to put out an overarching method for reducing weight problems in South Carolina, Traxler mentioned. As an alternative, it promotes bodily exercise in faculties, vitamin, and the growth of outside strolling trails, amongst different methods. A extra complete weight problems plan may tackle the advantages of surgical intervention and GLP-1s, however these additionally carry danger, expense, and unwanted effects, Traxler mentioned.
“Certainly, I think, there is a need to bring it all together,” she mentioned.
Campbell, for one, is taking the excellent method. On prime 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 biggest goal,” mentioned Campbell, who expressed appreciation for Medicaid’s protection of Wegovy. “It’s one more thing that’s going to help me get to my goal.”
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