CHARLESTON, S.C. — When Web page Campbell’s physician really helpful she strive an injectable prescription drug referred to as Wegovy to shed some pounds earlier than scheduling bariatric surgical procedure, she readily agreed.
“I’ve struggled with my weight for thus lengthy,” mentioned Campbell, 40, a single mom of two. “I’m not against making an attempt something.”
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. 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 transport supervisor at a Michaels retailer. “I’m not going to second-guess myself.”
Wegovy belongs to an expensive class of medication referred to 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 did not 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 medicine. However 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 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 overlaying 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 applications becoming a member of the checklist 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.
“Because the price range debate, federally, is growing, that will affect how states are serious 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 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 inexpensive, 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 practically half of the African American inhabitants, qualify as overweight, the state Medicaid company estimates only 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 shed some pounds should attest to “elevated train exercise,” mentioned Jeff Leieritz, a spokesperson for the South Carolina Division of Well being and Human Companies.
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 shed some pounds after receiving vitamin counseling and occurring a 1,200-calorie-a day food regimen, 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 permitted for six months, Mitchell mentioned. When that authorization expires, Campbell and her well being care workforce might want to submit extra documentation, together with proof that she has misplaced not less than 5% of her physique weight and has saved up with vitamin counseling.
“It’s not simply, ‘Ship a prescription in and so they cowl it.’ It’s quite arduous,” Mitchell mentioned. “Not a number 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 stunned 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 chopping the month-to-month worth for the drug from $650 to $499 for cash-paying clients. The value that medical insurance plans and beneficiaries pay for these medicine 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 keep up weight reduction.
“That could be a large price ticket that somebody has to foot the invoice for,” Mitchell mentioned.
That’s the rationale California Gov. Gavin Newsom on Could 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 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 only some months after a separate North Carolina company introduced it will begin overlaying these medicine for Medicaid beneficiaries. North Carolina Medicaid has estimated it is 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 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 shall be paid for by matching Medicaid funds from the federal authorities.
In a current interview, Well being and Human Companies Secretary Robert F. Kennedy Jr. didn’t rule out the likelihood that Medicare and Medicaid may cowl GLP-1s for weight problems therapy sooner or later as prices come down.
They’re “extraordinary medicine” and “we’re going to scale back the price,” Kennedy advised CBS Information in early April. He mentioned he would really like GLP-1s to ultimately be made obtainable to Medicare and Medicaid sufferers who’re searching for weight problems therapy after they’ve tried different methods to shed some 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 gained’t assist the overwhelming majority of the 1.5 million adults in South Carolina who’re categorised as overweight, in response to 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 Energetic 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 method 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 may handle the advantages of surgical intervention and GLP-1s, however these additionally carry danger, expense, and unwanted side effects, Traxler mentioned.
“Definitely, I believe, there’s a must carry all of it collectively,” she mentioned.
Campbell, for one, is taking the great 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 reduction is my greatest purpose,” 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 purpose.”
