Don Thompson
SACRAMENTO, Calif. — Many low-income Californians prescribed wildly fashionable weight reduction medicine misplaced their protection for the medicines at first of the brand new 12 months.
Health officers are recommending weight loss program and train as alternate options to closely marketed weight reduction medicine like Wegovy and Zepbound, recommendation consultants say is unrealistic.
“Of course he tried eating well and everything, but now with the medications, it’s better — a 100% change,” mentioned Wilmer Cardenas of Santa Clara, who mentioned his husband misplaced about 100 kilos over about two years utilizing GLP-1s coated by Medi-Cal, California’s model of Medicaid.
California joined a number of different states in proscribing an possibility they are saying is now not reasonably priced as they confront hovering pharmaceutical prices and steep Medicaid cuts below the Trump administration, amongst other financial pressures. Despite negotiated worth reductions introduced in November that the White House said would make the medicine obtainable at a “dramatically lower cost to taxpayers” and allow Medicaid to cowl them, states are going forward with the cuts, which suppliers say could undermine sufferers’ well being.
“It will be quite negative for our patients” as a result of knowledge reveals folks usually regain weight after stopping the medicine, mentioned Diana Thiara, medical director of the University of California-San Francisco Weight Management Program.
While California, New Hampshire, Pennsylvania, and South Carolina stopped masking grownup GLP-1 prescriptions for weight problems on Jan. 1, they proceed to cowl the medicine for different well being points, corresponding to Type 2 diabetes, heart problems, and power kidney illness.
Michigan, Rhode Island, and Wisconsin are planning or contemplating restrictions, in keeping with KFF’s most recent survey.
That reverses a pattern that noticed 16 states masking the medicines for weight problems as of Oct. 1. Interest in offering the protection “appears to be waning,” the survey discovered, possible as a result of medicine’ price and different state price range pressures. North Carolina pulled again GLP-1 protection in October, however Gov. Josh Stein reinstated it in December, bowing to courtroom orders regardless of a lingering price range shortfall.
Catherine Ferguson, vice chairman of federal advocacy for the American Diabetes Association and its affiliated Obesity Association, mentioned it’s not clear how states will regulate to the White House plan to decrease the price of a number of of the preferred GLP-1s via TrumpRx, an internet portal for discounted prescribed drugs. The worth of Wegovy, for instance, will probably be $350 monthly for shoppers, versus the present record worth of practically $1,350, and Medicare and Medicaid applications can pay $245, in keeping with the plan.
“Many states are facing budgetary challenges, such as deficits, and are working to address the impacts of the changes to Medicaid and SNAP,” Ferguson wrote, referring to the Supplemental Nutrition Assistance Program. “As more details become available for the Administration’s agreements, we will see how state Medicaid responds.”
The Department of Health and Human Services referred inquiries to the White House, which didn’t reply to requests for touch upon states’ termination of Medicaid protection for the burden loss medicine.
California projected its prices to cowl GLP-1s for weight reduction would have greater than quadrupled over 4 years to nearly $800 million annually if it didn’t finish Medi-Cal protection for that use. Medi-Cal has coated weight reduction medicine since 2006, however use of GLP-1s soared solely in recent times. By 2024, greater than 645,000 prescriptions had been coated by Medi-Cal throughout all makes use of of the medicines. The California Department of Health Care Services couldn’t readily present a breakdown of whether or not the medicine had been for weight reduction or different situations.
When requested whether or not the state would rethink its plans in mild of the introduced worth cuts, Department of Finance spokesperson H.D. Palmer mentioned it had no plans to take action. California’s reduce is written into the state’s budget law.
California officers wouldn’t say how a lot it may save below the TrumpRx plan, citing federal and state restrictions on disclosing rebate info.
Health suppliers don’t anticipate the Trump administration’s negotiated worth cuts to make a lot distinction to shoppers, as a result of pharmaceutical firms already provide some reductions.
“The out-of-pocket costs will still be very cost-prohibitive for most, especially individuals with Medicaid insurance,” Thiara mentioned.
New Hampshire is among the many different states that ended their protection Jan. 1. Officials with the New Hampshire Department of Health and Human Services didn’t reply to requests for remark.
About 1 in 8 adults are actually taking a GLP-1 drug for weight problems, illness, or each, up 6 proportion factors from May 2024, in keeping with KFF poll results launched in November. Over half of customers mentioned their GLP-1s had been tough to afford, and lots of who had stopped the remedy cited the associated fee.
Public and personal payers have been attempting to wean patients off to save lots of prices. California well being officers mentioned Medi-Cal members and their well being care suppliers should consider “other treatment options that can support weight loss, such as diet changes, increased activity or exercise, and counseling.” That echoes recommendation from the New Hampshire Medicaid program.
California Department of Health Care Services spokesperson Tessa Outhyse mentioned in an electronic mail that the official recommendation to attempt these different approaches now “is not meant to dismiss any past efforts, but to encourage Medi-Cal members to take a renewed, proactive, and medically supported approach with their healthcare provider that may appropriately include these additional options.”
But that could be unrealistic, mentioned Kurt Hong, founding director of the Center for Clinical Nutrition at Keck School of Medicine of the University of Southern California.
“We definitely want patients to do their part with the diet and exercise, but unfortunately, and from a practical standpoint, that itself frequently is not enough,” Hong mentioned, including that often by the point sufferers see medical doctors they’ve already failed at reaching outcomes via these means.
Hong understands why Medicaid applications, in addition to personal suppliers, need to reduce on masking the medicine, which may price thousands of dollars per affected person per 12 months. However, they’ll produce twice the burden loss because the medicines usually used beforehand, he mentioned.
A faculty of medical thought helps sufferers’ steadily ending their use, however Hong mentioned weight problems is usually thought of a power situation that requires indefinite remedy.
“Once they reach their target weight, a lot of people will try to see whether or not they can wean off,” Hong mentioned. “We do see a lot of patients — when they try to get off, unfortunately, then the weight comes back.”
Medi-Cal members below age 21 remain covered for functions together with weight reduction, California officers mentioned, citing a federal requirement.
Medi-Cal members are in a position to maintain their GLP-1 protection if they’ll display it’s medically crucial for functions apart from weight reduction, the division mentioned. Members who’re denied protection can search a listening to, the division mentioned in a letter to members.
Members will nonetheless be capable to pay for the prescriptions out-of-pocket and could possibly use numerous reductions to decrease prices. Another possibility is new tablets to deal with weight problems, which will probably be cheaper than their injectable counterparts. The FDA approved a tablet model of Wegovy on Dec. 22, which is able to possible run $149 monthly for the bottom dosage, and related weight reduction tablets are anticipated to be obtainable within the first half of the 12 months.
While Cardenas mentioned his husband, Jeffer Jimenez, 37, makes use of GLP-1s primarily for weight reduction, Jimenez’s prescription is for his diabetes, so the couple hoped to proceed receiving protection via Medi-Cal.
“He tried a thousand medications, pills, natural teas, exercise program, but it doesn’t work like the injections,” Cardenas mentioned. “You need both.”
