Trump will not power Medicaid to cowl GLP-1s for weight problems. Just a few states are doing it anyway.

CHARLESTON, S.C. — When Web page Campbell’s physician beneficial that she attempt an injectable prescription drug known as Wegovy to shed 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, similar to nausea or bowel irritation. However she does not use a scale at dwelling, 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 attaining 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.”

Wegovy belongs to an expensive class of medication known as GLP-1s (quick 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 weight in myriad different methods.

Campbell gained entry to Wegovy via South Carolina Medicaid’s resolution in late 2024 to cowl these weight reduction medication. However the medicines 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 revealed 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 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 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 stated.

“Because the price range debate, federally, is growing, that will affect how states are enthusiastic about 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 introduced it is not going to finalize a rule proposed by the Biden administration that might have allowed an estimated 7.4 million individuals lined by Medicare and Medicaid to entry GLP-1s for weight reduction. In the meantime, the Meals and Drug Administration is poised to power cheaper, 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 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.

Below a kind of necessities, Medicaid beneficiaries who want to entry these medication to shed 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 shed weight after receiving diet counseling and happening a 1,200-calorie-a day weight loss plan, stated Kenneth Mitchell, considered one 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 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 diet counseling.

“It is not simply, ‘Ship a prescription in they usually cowl it.’ It is moderately arduous,” Mitchell stated. “Not a variety of of us are going to do that.”

Mitchell stated South Carolina Medicaid’s resolution to cowl these medication 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 slicing the month-to-month worth for the drug from $650 to $499 for cash-paying prospects. The worth that medical health insurance plans and beneficiaries pay for these medication 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 could 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 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 will begin masking these medication 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 individuals enrolled in North Carolina Medicaid, anticipates spending much less. Leieritz estimated GLP-1s and diet 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 might 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 likelihood that Medicare and Medicaid may cowl GLP-1s for weight problems therapy sooner or later as prices come down.

They’re “extraordinary medication” and “we’ll cut back the fee,” Kennedy informed CBS Information in early April. He stated he would love GLP-1s to finally be made out there to Medicare and Medicaid sufferers who’re looking for weight problems therapy after they’ve tried different methods to shed weight. “That’s 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 will not assist the overwhelming majority of the 1.5 million adults in South Carolina who’re categorised as overweight, in response to 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 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 function they may 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, diet, and the enlargement 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 threat, expense, and uncomfortable side effects, Traxler stated.

“Definitely, I believe, there’s a must 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 transferring her physique. She additionally underwent weight reduction surgical procedure in late April. 

“Weight reduction is my greatest objective,” stated Campbell, who expressed appreciation for Medicaid’s protection of Wegovy. “It is another factor that is going to assist me get to my objective.”

KFF Well being Information is a nationwide newsroom that produces in-depth journalism about well being points and is without doubt one of the core working applications at KFF — the impartial supply for well being coverage analysis, polling, and journalism.