COLUMBUS, Miss. — April Hines has battled together 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 was, and I’ve been ready to return to church,” she stated.
Hines, 46, credit her weight reduction to Trulicity, a part of a brand new class of pricy 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 individuals 12 and older. Solely 13 states cowl the medicine for Medicaid enrollees for weight problems, and Mississippi’s Medicaid program usually has a few 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 docs 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, based on a report to the state’s Medicaid Drug Utilization Assessment Board.
“It’s a bit unhappy to have so many individuals on the market not benefiting,” stated William Rosenblatt, a household physician in Columbus who treats Hines. “These medicine get to the foundation explanation for so many well being circumstances.”
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 huge tax-and-spending invoice President Donald Trump signed into legislation in July. The Congressional Finances Workplace estimated that the legislation would scale back Medicaid spending by about $911 billion over a decade.
“The legislation goes to create pretty intense strain on states to not broaden advantages,” stated Michael Kolber, a associate within the well being consulting agency Manatt. Which may be very true for these medicine, which regularly price round $1,000 a month and could possibly be utilized by a big share of Medicaid recipients, he stated.
GLP-1s, which have been used for years to deal with Kind 2 diabetes, have gained widespread consideration as a approach to reduce weight and cut back obesity-related circumstances and their long-term prices.
However states could stay reluctant to supply the costly medicine for weight problems, as a result of Medicaid recipients steadily churn on and off the protection as their earnings adjustments. And since the medicine’ well being advantages could take years to materialize — comparable to averting a future coronary heart assault — the long-term monetary benefits might 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 protection of the medicine this month, citing their excessive price.
Protection for the load loss medicine presents a dilemma for the Trump administration, which has recognized as priorities attacking power well being circumstances and lowering federal spending. Well being and Human Companies 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 deal with 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 Publish 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. Requested for touch upon the report, Facilities for Medicare & Medicaid Companies spokesman Alexx Pons informed KFF Well being Information that every one choices undergo a cost-benefit overview.
In the meantime, the Trump administration has included the GLP-1 medicine Ozempic, Wegovy, and Rybelsus on its checklist of 15 medicines that will likely be topic to cost negotiations with pharmaceutical producers below its Medicare Half 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 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 offered to Mississippi’s Medicaid drug overview board reveals that, within the first 15 months the medicine had been coated, solely about 2,900 Medicaid enrollees age 12 or older began therapy. 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 facet 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, based on federal knowledge.
Mississippi Medicaid spokesman Matt Westerfield informed KFF Well being Information that the state spent $12 million within the first 15 months, offering the load 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 might result in price financial savings by lowering illnesses brought on by weight problems.
Westerfield stated that whereas utilization has been under the state’s projections, such therapy choices are as much as sufferers and their docs. He stated the state has been “elevating consciousness” 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 docs have much less incentive to prescribe the medication, as a result of the state doesn’t pay them to counsel sufferers about obligatory dietary adjustments when taking the brand new medicine.
He referred to as the medicine “recreation 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 Drugs research printed in 2021 discovered individuals receiving GLP-1 medicine had been extra more likely to present important, sustained weight reduction in contrast with these getting a placebo.
Different current research have proven the medicine assist individuals with weight problems decrease their hypertension and cut 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 Reasonably priced Care Act to everybody with an earnings below 138% of federal poverty degree, or $21,597 this 12 months.
In Mississippi, Medicaid doesn’t cowl adults with out dependent kids. Dad and mom qualify provided that their earnings is under 22% of the federal poverty degree, or $5,863 for a household of three this 12 months.
The state’s prior authorization course of requires docs to doc to the state that sufferers meet sure weight problems ranges and {that a} therapy plan is in place. Docs should exhibit that enrollees are shedding weight 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 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 or he stated the state’s prior authorization necessities for the drug might discourage major care docs. Many frequent drugs don’t require progress reviews and even prior authorization.
“We have to make sufferers extra conscious that this feature is obtainable 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 simply been superb,” she stated of how the drug drastically reduce her urge for food. “I bear in mind going to Outback with my husband, and we obtained the onion ring appetizer and 16-ounce ribeye and salad with additional ranch dressing. I had some onion rings and began on the salad and realized I couldn’t eat any extra of this.”
