Phil Galewitz, KFF Health News
COLUMBUS, Miss. — April Hines has battled together with her weight since she was an adolescent.
But previously 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 high-priced weight reduction medicine often known as GLP-1s, and her Medicaid protection for it. “It’s a blessing,” she stated.
In a state the place the weight problems fee ranks among the many highest within the nation, many well being suppliers had been thrilled when Mississippi Medicaid in 2023 started masking GLP-1s for individuals 12 and older. Only 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 certainly one 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 promoting. Just 2% of adults on Mississippi Medicaid who meet the weight-related standards had been prescribed a GLP-1 as of December 2024, in keeping with a report to the state’s Medicaid Drug Utilization Review 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 may turn into extra restricted, with federal Medicaid funding cuts anticipated within the wake of the huge tax-and-spending invoice President Donald Trump signed into legislation in July. The Congressional Budget Office estimated that the legislation would cut 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 companion within the well being consulting agency Manatt. That could also be very true for these medicine, which frequently price round $1,000 a month and might be utilized by a big share of Medicaid recipients, he stated.
GLP-1s, which have been used for years to deal with Type 2 diabetes, have gained widespread consideration as a method to drop some pounds and cut back obesity-related circumstances and their long-term prices.
But states might stay reluctant to supply the costly medicine for weight problems, as a result of Medicaid recipients often churn on and off the protection as their revenue modifications. And as a result of the medicine’ well being advantages might take years to materialize — similar to averting a future coronary heart assault — the long-term monetary benefits may accrue to different insurers.
Even forward of the federal cuts, which can largely take impact in 2027, states are already feeling the pinch. North Carolina’s Medicaid program dropped its coverage of the medicine this month, citing their excessive price.
Coverage 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. Health and Human Services Secretary Robert F. Kennedy Jr. has downplayed the need for the medicine and stated extra emphasis must 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.
But in August, The Washington Post reported the Trump administration was contemplating a five-year pilot program for Medicare and Medicaid to cowl the medicine in any case. No particulars have been launched. Asked for touch upon the report, Centers for Medicare & Medicaid Services spokesman Alexx Pons advised KFF Health News that every one choices undergo a cost-benefit evaluate.
Meanwhile, the Trump administration has included the GLP-1 medicine Ozempic, Wegovy, and Rybelsus on its checklist of 15 medicines that can be topic to cost negotiations with pharmaceutical producers underneath its Medicare Part D program, a system created through the Biden administration amid opposition from Republicans. The outcomes of these negotiations are anticipated to be introduced this fall.
Most personal insurers don’t cowl GLP-1s for weight reduction, which may make the medicine unaffordable for these paying out of pocket.
Further analysis provided to Mississippi’s Medicaid drug evaluate board exhibits that, within the first 15 months the medicine had been lined, solely about 2,900 Medicaid enrollees age 12 or older began remedy. Nearly 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 elements of Mississippi — not alongside the Mississippi Delta on the western aspect of the state, the place weight problems charges are highest, at almost 50%.
About 40% of adults in Mississippi are overweight, only one share level behind top-ranked West Virginia, in keeping with federal knowledge.
Mississippi Medicaid spokesman Matt Westerfield advised KFF Health News 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 accredited the brand new medicine on the logic that treating weight problems would enhance enrollees’ well being and finally may result in price financial savings by decreasing illnesses attributable to 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 vital 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 couple of months of beginning the medicine and not want drugs for diabetes or different circumstances.
A New England Journal of Medicine study printed in 2021 discovered contributors receiving GLP-1 medicine had been extra more likely to present important, sustained weight reduction in contrast with these getting a placebo.
Other current research have proven the medicine assist individuals with weight problems decrease their high blood pressure and cut back their odds of heart attacks or strokes.
Mississippi is certainly one of 10 states that haven’t expanded Medicaid eligibility underneath the 2010 Affordable Care Act to everybody with an revenue underneath 138% of federal poverty stage, or $21,597 this 12 months.
In Mississippi, Medicaid doesn’t cowl adults with out dependent kids. Parents qualify provided that their revenue 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. Doctors should reveal that enrollees are reducing weight each six months to resume their prescription.
At 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 shocked 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 stated the state’s prior authorization necessities for the drug may discourage major care medical doctors. Many frequent drugs don’t require progress experiences 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 almost 100 kilos taking Wegovy.
“It’s just been amazing,” she stated of how the drug drastically lower 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.”