CHARLESTON, S.C. — When Web page Campbell’s physician beneficial she attempt an injectable prescription drug referred to as Wegovy to shed pounds earlier than scheduling bariatric surgical procedure, she readily agreed.
“I’ve struggled with my weight for so long,” mentioned Campbell, 40, a single mom of two. “I’m not opposed to trying anything.”
In early April, about 4 weeks after she’d began taking Wegovy, Campbell mentioned she hadn’t skilled any unwanted side effects, corresponding to nausea or bowel irritation. However she doesn’t use a scale at house, 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 12 months, when she weighed 314 kilos. Nonetheless, she was assured about attaining weight reduction.
“It’s going to work because I’m putting in the work. I’m changing my eating habits. I’m exercising,” mentioned Campbell, a transport supervisor at a Michaels retailer. “I’m not going to second-guess myself.”
Wegovy belongs to a dear 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 didn’t shed pounds in myriad different methods.
Campbell gained entry to Wegovy by way of South Carolina Medicaid’s resolution in late 2024 to cowl these weight reduction medication. However the drugs stay out of attain for hundreds of 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 medication too costly.
A report printed in November by KFF, a well being info nonprofit that features KFF Well being Information, discovered solely 13 states had been masking GLP-1s for the therapy of weight problems for Medicaid beneficiaries as of August. 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, mentioned she was not conscious of another 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.
“As the budget debate, federally, is developing, that may impact how states are thinking 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 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 individuals coated by Medicare and Medicaid to entry GLP-1s for weight reduction. In the meantime, the FDA is poised to power inexpensive, compounded variations of those medication off the market.
And the barrier to entry stays excessive, even for Medicaid sufferers in these few states which have agreed to cowl the medication with no 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 only one,300 beneficiaries will meet the stringent stipulations for GLP-1 protection.
Below a type of necessities, Medicaid beneficiaries who want to entry these medication to shed pounds should attest to “increased exercise activity,” 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’ value of documentation proving that she’d tried and didn’t shed pounds after receiving vitamin counseling and occurring a 1,200-calorie-a day weight loss program, mentioned Kenneth Mitchell, one among 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 authorized for six months, Mitchell mentioned. When that authorization expires, Campbell and her well being care crew might want to submit extra documentation, together with proof that she has misplaced at the least 5% of her physique weight and has saved up with vitamin counseling.
“It’s not just, ‘Send a prescription in and they cover it.’ It’s rather arduous,” Mitchell mentioned. “Not a lot of folks are going to do this.”
Mitchell mentioned South Carolina Medicaid’s resolution to cowl these medication was met with pleasure amongst these working in his medical specialty. However he wasn’t shocked 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 problem is the medicines are so expensive,” Mitchell mentioned.
Novo Nordisk, which manufactures Wegovy, introduced in March that it was slicing the month-to-month value for the drug from $650 to $499 for cash-paying prospects. The value that medical insurance plans and beneficiaries pay for these medication varies, however some GLP-1s value 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 is a tremendous price tag that someone has to foot the bill 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 save lots of an estimated $680 million a 12 months by 2028.
And 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 medication had been projected to value 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 might begin masking these medication for Medicaid beneficiaries. North Carolina Medicaid has estimated it’ll 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 supplied 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 latest 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 drugs” and “we’re going to reduce the cost,” Kennedy advised CBS Information in early April. He mentioned he would really like GLP-1s to ultimately be made accessible to Medicare and Medicaid sufferers who’re searching for weight problems therapy after they’ve tried different methods to shed pounds. “That is the framework that we’re now debating.”
In the meantime, public well being consultants have applauded South Carolina Medicaid’s resolution 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 categorized as overweight, based on information printed by the South Carolina Division of Public Well being.
“We still have some work to do,” acknowledged Brannon Traxler, the general public well being division’s chief medical officer.
However the state’s new “Action Plan for Healthy Eating and Active Living,” 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 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 an alternative, it promotes bodily exercise in faculties, vitamin, and the growth of outside 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.
“Certainly, I think, there is a need to bring it all together,” she mentioned.
Campbell, for one, is taking the excellent method. 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 loss is my biggest goal,” mentioned Campbell, who expressed appreciation for Medicaid’s protection of Wegovy. “It’s one more thing that’s going to help me get to my goal.”
