COLUMBUS, Miss. — April Hines has battled along with her weight since she was a teen.
However up to now couple of years, she’s fallen from 600 kilos to 385, and her blood strain and blood sugar ranges are down, too. “I’m not as fatigued as I used to be, and I’ve been able to go back to church,” she stated.
Hines, 46, credit her weight reduction to Trulicity, a part of a brand new class of pricey weight reduction medicine often called GLP-1s, and her Medicaid protection for it. “It’s a blessing,” she stated.
In a state the place the weight problems charge ranks among the many highest within the nation, many well being suppliers had been thrilled when Mississippi Medicaid in 2023 started overlaying GLP-1s for folks 12 and older. Solely 13 states cowl the medicine for Medicaid enrollees for weight problems, and Mississippi’s Medicaid program sometimes has a number of the sparsest advantages and strictest eligibility guidelines.
Hines is one in every of comparatively few enrollees to have used the brand new Medicaid profit, which weight reduction medical doctors within the state say has been hindered by nationwide drug shortages, the state’s prior authorization course of for the medicine, and a scarcity of selling. Simply 2% of adults on Mississippi Medicaid who meet the weight-related standards had been prescribed a GLP-1 as of December 2024, in response to a report to the state’s Medicaid Drug Utilization Assessment Board.
“It’s a little sad to have so many people out there not benefiting,” stated William Rosenblatt, a household physician in Columbus who treats Hines. “These drugs get to the root cause of so many health conditions.”
Already-scarce Medicaid protection of the extremely touted weight reduction medicine might develop into extra restricted, with federal Medicaid funding cuts anticipated within the wake of the large tax-and-spending invoice President Donald Trump signed into regulation in July. The Congressional Funds Workplace estimated that the regulation would scale back Medicaid spending by about $911 billion over a decade.
“The law is going to create fairly intense pressure on states not to expand benefits,” stated Michael Kolber, a accomplice within the well being consulting agency Manatt. Which may be very true for these medicine, which frequently price round $1,000 a month and may very well be utilized by a big proportion of Medicaid recipients, he stated.
GLP-1s, which have been used for years to deal with Sort 2 diabetes, have gained widespread consideration as a option to shed weight and scale back obesity-related circumstances and their long-term prices.
However states might stay reluctant to supply the costly medicine for weight problems, as a result of Medicaid recipients continuously churn on and off the protection as their earnings modifications. And since the medicine’ well being advantages might take years to materialize — similar to averting a future coronary heart assault — the long-term monetary benefits might accrue to different insurers.
Even forward of the federal cuts, which is able to largely take impact in 2027, states are already feeling the pinch. North Carolina’s Medicaid program dropped its protection of the medicine this month, citing their excessive price.
Protection for the burden loss medicine presents a dilemma for the Trump administration, which has recognized as priorities attacking power well being circumstances and decreasing federal spending. Well being and Human Providers Secretary Robert F. Kennedy Jr. has downplayed the necessity for the medicine and stated extra emphasis ought to be positioned on consuming higher and exercising extra.
In 2024, the Biden administration proposed that Medicare and Medicaid cowl weight reduction medicine to assist sort out weight problems as a public well being disaster. In April, the Trump administration revoked the Biden-era proposal, saying the applications wouldn’t cowl GLP-1 medicine for weight reduction.
However in August, The Washington Submit reported the Trump administration was contemplating a five-year pilot program for Medicare and Medicaid to cowl the medicine in spite of everything. No particulars have been launched. Requested for touch upon the report, Facilities for Medicare & Medicaid Providers spokesman Alexx Pons advised KFF Well being Information that every one choices undergo a cost-benefit assessment.
In the meantime, the Trump administration has included the GLP-1 medicine Ozempic, Wegovy, and Rybelsus on its listing of 15 medicines that shall be topic to cost negotiations with pharmaceutical producers below its Medicare Half D program, a system created in the course of the Biden administration amid opposition from Republicans. The outcomes of these negotiations are anticipated to be introduced this fall.
Most non-public insurers don’t cowl GLP-1s for weight reduction, which might make the medicine unaffordable for these paying out of pocket.
Additional evaluation supplied to Mississippi’s Medicaid drug assessment board reveals that, within the first 15 months the medicine had been lined, solely about 2,900 Medicaid enrollees age 12 or older began remedy. Almost 90% of them had been feminine, and lots of had hypertension and excessive ldl cholesterol.
The evaluation additionally discovered most enrollees utilizing the medicine lived within the southern, central, or northern components of Mississippi — not alongside the Mississippi Delta on the western aspect of the state, the place weight problems charges are highest, at practically 50%.
About 40% of adults in Mississippi are overweight, only one proportion level behind top-ranked West Virginia, in response to federal knowledge.
Mississippi Medicaid spokesman Matt Westerfield advised KFF Well being Information that the state spent $12 million within the first 15 months, offering the burden loss medicine to 2,200 grownup members. He stated the state permitted the brand new medicine on the logic that treating weight problems would enhance enrollees’ well being and ultimately might result in price financial savings by decreasing ailments brought on by weight problems.
Westerfield stated that whereas utilization has been beneath the state’s projections, such remedy choices are as much as sufferers and their medical doctors. He stated the state has been “raising awareness” of the medicine amongst well being care suppliers, however he declined to remark additional.
Rosenblatt, who works for Baptist Medical Group, half of a giant regional well being system, stated some medical doctors have much less incentive to prescribe the drugs, as a result of the state doesn’t pay them to counsel sufferers about essential dietary modifications when taking the brand new medicine.
He referred to as the medicine “game changers,” including that he has seen sufferers lose 50 kilos or extra inside a number of months of beginning the medicine and now not want drugs for diabetes or different circumstances.
A New England Journal of Medication examine printed in 2021 discovered individuals receiving GLP-1 medicine had been extra more likely to present vital, sustained weight reduction in contrast with these getting a placebo.
Different latest research have proven the medicine assist folks with weight problems decrease their hypertension and scale back their odds of coronary heart assaults or strokes.
Mississippi is one in every of 10 states that haven’t expanded Medicaid eligibility below the 2010 Inexpensive Care Act to everybody with an earnings below 138% of federal poverty stage, or $21,597 this 12 months.
In Mississippi, Medicaid doesn’t cowl adults with out dependent kids. Mother and father qualify provided that their earnings is beneath 22% of the federal poverty stage, or $5,863 for a household of three this 12 months.
The state’s prior authorization course of requires medical doctors to doc to the state that sufferers meet sure weight problems ranges and {that a} remedy plan is in place. Medical doctors should exhibit that enrollees are losing a few pounds each six months to resume their prescription.
On the Hattiesburg Clinic — a big, multi-specialty group with a location in Hattiesburg, Mississippi — Virginia Crawford, a doctor who focuses on weight problems, stated she was stunned so few sufferers are getting the medicine. A 12 months in the past, there have been shortages of the medicine that would have curtailed physicians prescribing them. And she or he stated the state’s prior authorization necessities for the drug might discourage major care medical doctors. Many widespread drugs don’t require progress stories and even prior authorization.
“We need to make patients more aware that this option is available for them,” she stated.
Lauren Scott, 40, of Laurel, Mississippi, stated that with the assistance of Medicaid protection, she misplaced practically 100 kilos taking Wegovy.
“It’s just been amazing,” she stated of how the drug drastically minimize her urge for food. “I remember going to Outback with my husband, and we got the onion ring appetizer and 16-ounce ribeye and salad with extra ranch dressing. I had some onion rings and started on the salad and realized I could not eat any more of this.”
