CHARLESTON, S.C. — When Web page Campbell’s physician beneficial she strive an injectable prescription drug referred to as Wegovy to drop some weight earlier than scheduling bariatric surgical procedure, she readily agreed.
“I’ve struggled with my weight for therefore lengthy,” mentioned Campbell, 40, a single mom of two. “I’m not against attempting something.”
In early April, about 4 weeks after she’d began taking Wegovy, Campbell mentioned she hadn’t skilled any unwanted side effects, reminiscent of nausea or bowel irritation. However she doesn’t use a scale at residence, she mentioned, so 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 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 medicine referred to as GLP-1s (brief for glucagon-like peptide-1 agonists) which have upended the remedy of weight problems in recent times, providing hope to sufferers who’ve tried and did not drop some weight in myriad different methods.
Campbell gained entry to Wegovy by South Carolina Medicaid’s choice in late 2024 to cowl these weight reduction medicine. However the drugs stay out of attain for thousands and thousands of sufferers throughout the nation who may benefit from them, as a result of many private and non-private well being insurers have deemed the medicine too costly.
A report revealed in November by KFF, a well being info nonprofit that features KFF Well being Information, discovered solely 13 states have been protecting GLP-1s for the remedy 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 every other state Medicaid packages becoming a member of the record since then. Trying 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.
“Because the price range debate, federally, is creating, that will affect how states are eager about this,” Williams mentioned.
The federal authorities received’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 may have allowed an estimated 7.4 million folks lined by Medicare and Medicaid to entry GLP-1s for weight reduction. In the meantime, the FDA is poised to drive cheaper, compounded variations of those medicine off the market.
And the barrier to entry stays excessive, even for Medicaid sufferers in these few states which have agreed to cowl the medicine with no federal mandate.
Working example: 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 just one,300 beneficiaries will meet the stringent conditions for GLP-1 protection.
Underneath a kind of necessities, Medicaid beneficiaries who want to entry these medicine to drop some weight should attest to “elevated train exercise,” 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 primarily based 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 some weight after receiving vitamin counseling and happening a 1,200-calorie-a day weight-reduction plan, mentioned Kenneth Mitchell, one in all Campbell’s medical doctors and the medical director for bariatric surgical procedure and weight problems medication 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 stored up with vitamin counseling.
“It’s not simply, ‘Ship a prescription in they usually cowl it.’ It’s relatively arduous,” Mitchell mentioned. “Not a whole lot of people are going to do that.”
Mitchell mentioned South Carolina Medicaid’s choice to cowl these medicine was met with pleasure amongst these working in his medical specialty. However he wasn’t shocked that the state anticipates comparatively few folks will entry this profit yearly, because the approval course of is so rigorous and the price excessive. “The issue 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 clients. The worth that medical health insurance plans and beneficiaries pay for these medicine 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 may be a large price ticket that somebody has to foot the invoice for,” Mitchell mentioned.
That’s the explanation California Gov. Gavin Newsom on Might 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 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 medicine have been projected to value 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 protecting these medicine for Medicaid beneficiaries. North Carolina Medicaid has estimated it’s going to 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 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 can 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 would possibly cowl GLP-1s for weight problems remedy sooner or later as prices come down.
They’re “extraordinary medicine” and “we’re going to scale back the price,” Kennedy instructed CBS Information in early April. He mentioned he would really like GLP-1s to finally be made obtainable to Medicare and Medicaid sufferers who’re in search of weight problems remedy after they’ve tried different methods to drop some weight. “That’s the framework that we’re now debating.”
In the meantime, public well being consultants have applauded South Carolina Medicaid’s choice to cowl GLP-1s. But the brand new profit received’t assist the overwhelming majority of the 1.5 million adults in South Carolina who’re labeled as overweight, in line with information revealed by the South Carolina Division of Public Well being.
“We nonetheless have some work to do,” acknowledged Brannon Traxler, the general public well being division’s chief medical officer.
However the state’s new “Motion Plan for Wholesome Consuming and Lively Residing,” 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 position they may play in decreasing 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 strategy for decreasing weight problems in South Carolina, Traxler mentioned. As a substitute, it promotes bodily exercise in colleges, vitamin, and the enlargement of out of doors strolling trails, amongst different methods. A extra complete weight problems plan would possibly handle the advantages of surgical intervention and GLP-1s, however these additionally carry danger, expense, and unwanted side effects, Traxler mentioned.
“Definitely, I feel, there’s a must carry all of it collectively,” she mentioned.
Campbell, for one, is taking the great strategy. 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 reduction is my greatest objective,” mentioned Campbell, who expressed appreciation for Medicaid’s protection of Wegovy. “It’s yet one more factor that’s going to assist me get to my objective.”
