CHARLESTON, S.C. — When Web page Campbell’s physician really helpful that she attempt an injectable prescription drug known as Wegovy to lose weight earlier than scheduling bariatric surgical procedure, she readily agreed.
“I’ve struggled with my weight for thus 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, resembling nausea or bowel irritation. However she does not use a scale at residence, 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 should work as a result of I am placing within the work. I am altering my consuming habits. I am exercising,” stated Campbell, a delivery supervisor at a Michaels retailer. “I am not going to second-guess myself.”
Andrew J. Whitaker for KFF Well being News
Wegovy belongs to a dear class of medication known as GLP-1s (quick for glucagon-like peptide-1 agonists) which have upended the remedy of weight problems lately, providing hope to sufferers who’ve tried and did not reduce weight 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 medicine. However the drugs 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 medicine too costly.
A report published in November by KFF, a well being info nonprofit that features KFF Well being News, discovered solely 13 states had been overlaying 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 every other state Medicaid applications becoming a member of the listing 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 price range debate, federally, is creating, that will affect how states are fascinated 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 situations, together with obstructive sleep apnea and heart problems, however not weight problems. In early April, the Trump administration announced it won’t finalize a rule proposed by the Biden administration that might have allowed an estimated 7.4 million individuals coated by Medicare and Medicaid to entry GLP-1s for weight reduction. In the meantime, the Meals and Drug Administration is poised to pressure 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 and not using 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 conditions for GLP-1 protection.
Beneath a type of necessities, Medicaid beneficiaries who want to entry these medicine to reduce weight 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 primarily based 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 reduce weight after receiving vitamin counseling and happening a 1,200-calorie-a day food regimen, stated Kenneth Mitchell, one in all 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 authorised 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 not less than 5% of her physique weight and has saved up with vitamin counseling.
“It isn’t simply, ‘Ship a prescription in they usually cowl it.’ It is slightly arduous,” Mitchell stated. “Not a number of people are going to do that.”
Mitchell stated South Carolina Medicaid’s determination 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 individuals will entry this profit yearly, for the reason that approval course of is so rigorous and the fee excessive. “The issue is the medicines are so costly,” Mitchell stated.
Novo Nordisk, which manufactures Wegovy, introduced in March that it was reducing the month-to-month value for the drug from $650 to $499 for cash-paying clients. The worth that medical insurance plans and beneficiaries pay for these medicine varies, however some GLP-1s value 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 take care of weight reduction.
“That may be a great price ticket that somebody has to foot the invoice for,” Mitchell stated.
That is the rationale the North Carolina State Well being Plan Board of Trustees voted final 12 months to end coverage of GLP-1s for state staff, after then-North Carolina Treasurer Dale Folwell’s workplace estimated in 2023 that the medicine had been projected to value the State Well being Plan $1 billion over the following six years. The choice got here only some months after a separate North Carolina agency announced it could begin overlaying these medicine for Medicaid beneficiaries. North Carolina Medicaid has estimated it can spend $16 million a 12 months on GLP-1s.
South Carolina Medicaid, which insures fewer than half the variety of individuals 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 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 current interview, Well being and Human Providers Secretary Robert F. Kennedy Jr. did not 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’ll cut back the fee,” Kennedy told CBS News in early April. He stated he would really like GLP-1s to finally be made out there to Medicare and Medicaid sufferers who’re looking for weight problems remedy after they’ve tried different methods to reduce weight. “That’s the framework that we’re now debating.”
In the meantime, public well being specialists have applauded South Carolina Medicaid’s determination 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, based on data published 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 function they could play in reducing 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 strategy for reducing weight problems in South Carolina, Traxler stated. As a substitute, it promotes bodily exercise in colleges, vitamin, and the growth of outside 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 uncomfortable side effects, Traxler stated.
“Actually, I feel, there’s a have to convey all of it collectively,” she stated.
Campbell, for one, is taking the great strategy. On high of injecting Wegovy as soon as weekly, she stated, she is prioritizing protein consumption and shifting her physique. She additionally underwent weight reduction surgical procedure in late April.
“Weight reduction is my greatest 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.”
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