CHARLESTON, S.C. — When Web page Campbell’s physician beneficial that she attempt an injectable prescription drug known as Wegovy to drop extra pounds earlier than scheduling bariatric surgical procedure, she readily agreed.
“I’ve struggled with my weight for therefore lengthy,” stated Campbell, 40, a single mom of two. “I am not against attempting something.”
In early April, about 4 weeks after she’d began taking Wegovy, Campbell stated she hadn’t skilled any uncomfortable side effects, equivalent to nausea or bowel irritation. However she would not use a scale at house, so she stated she did not know whether or not she’d misplaced any weight since her most up-to-date medical appointment earlier this 12 months, when she weighed 314 kilos. Nonetheless, she was assured about reaching weight reduction.
“It will work as a result of I am placing within the work. I am altering my consuming habits. I am exercising,” stated Campbell, a transport supervisor at a Michaels retailer. “I am not going to second-guess myself.”
Andrew J. Whitaker for KFF Well being Information
Wegovy belongs to an expensive class of medicine known 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 extra 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 medicine. However the medicines stay out of attain for tens of millions 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 had been protecting GLP-1s for the remedy of weight problems for Medicaid beneficiaries as of August 2024. South Carolina turned 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, stated she was not conscious of some 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 stated.
“Because the finances debate, federally, is creating, that will affect how states are occupied with this,” Williams stated.
The federal authorities will not be serving to anytime quickly, both. Medicare covers GLP-1s to deal with diabetes and another well being circumstances, 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 will have allowed an estimated 7.4 million folks lined by Medicare and Medicaid to entry GLP-1s for weight reduction. In the meantime, the Meals and Drug Administration 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 out a federal mandate.
Living proof: 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 stipulations for GLP-1 protection.
Beneath a type of necessities, Medicaid beneficiaries who want to entry these medicine to drop extra pounds should attest to “elevated train exercise,” stated 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 did not drop extra pounds after receiving diet counseling and occurring a 1,200-calorie-a day food regimen, stated Kenneth Mitchell, one in every of Campbell’s medical doctors and the medical director for bariatric surgical procedure and weight problems drugs at Roper St. Francis Healthcare.
Campbell’s Wegovy prescription was accepted for six months, Mitchell stated. 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 diet counseling.
“It is not simply, ‘Ship a prescription in and so they cowl it.’ It is reasonably arduous,” Mitchell stated. “Not lots of of us are going to do that.”
Mitchell stated South Carolina Medicaid’s choice to cowl these medicine 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, because the approval course of is so rigorous and the associated fee excessive. “The issue is the medicines are so costly,” Mitchell stated.
Novo Nordisk, which manufactures Wegovy, introduced in March that it was chopping the month-to-month value 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 price greater than $1,000 per affected person per 30 days, Mitchell stated, and many individuals might want to take them for the remainder of their lives to keep up weight reduction.
“That may be a large price ticket that somebody has to foot the invoice for,” Mitchell stated.
That is the explanation the North Carolina State Well being Plan Board of Trustees voted final 12 months to finish protection of GLP-1s for state workers, after then-North Carolina Treasurer Dale Folwell’s workplace estimated in 2023 that the medicine had been projected to price the State Well being Plan $1 billion over the subsequent six years. The choice got here just a few months after a separate North Carolina company introduced it will begin protecting these medicine for Medicaid beneficiaries. North Carolina Medicaid has estimated it should spend $16 million a 12 months 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 price $10 million a 12 months. 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. did not rule out the likelihood that Medicare and Medicaid may cowl GLP-1s for weight problems remedy sooner or later as prices come down.
They’re “extraordinary medicine” and “we’ll cut back the associated fee,” Kennedy advised CBS Information in early April. He stated 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 extra pounds. “That’s the framework that we’re now debating.”
In the meantime, public well being specialists have applauded South Carolina Medicaid’s choice to cowl GLP-1s. But the brand new profit will not assist the overwhelming majority of the 1.5 million adults in South Carolina who’re categorised as overweight, in accordance with knowledge 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 Energetic Dwelling,” 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, is not meant to put out an overarching method for decreasing weight problems in South Carolina, Traxler stated. As a substitute, it promotes bodily exercise in colleges, diet, 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 uncomfortable side effects, Traxler stated.
“Actually, I feel, there’s a have to carry all of it collectively,” she stated.
Campbell, for one, is taking the excellent method. On prime of injecting Wegovy as soon as weekly, she stated, she is prioritizing protein consumption and transferring her physique. She additionally underwent weight reduction surgical procedure in late April.
“Weight reduction is my largest aim,” stated Campbell, who expressed appreciation for Medicaid’s protection of Wegovy. “It is yet one more factor that is going to assist me get to my aim.”
KFF Well being Information is a nationwide newsroom that produces in-depth journalism about well being points and is likely one of the core working packages at KFF — the impartial supply for well being coverage analysis, polling, and journalism.
