COLUMBUS, Miss. — April Hines has battled together with her weight since she was a young person.
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 mentioned.
Hines, 46, credit her weight reduction to Trulicity, a part of a brand new class of pricey weight reduction medicine referred to as GLP-1s, and her Medicaid protection for it. “It’s a blessing,” she mentioned.
In a state the place the weight problems price ranks among the many highest within the nation, many well being suppliers have been thrilled when Mississippi Medicaid in 2023 started overlaying GLP-1s for folks 12 and older. Solely 13 states cowl the medicine for Medicaid enrollees for weight problems, and Mississippi’s Medicaid program sometimes has among 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 medical doctors within the state say has been hindered by nationwide drug shortages, the state’s prior authorization course of for the medicine, and an absence 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, in accordance with 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,” mentioned William Rosenblatt, a household physician in Columbus who treats Hines. “These medicine get to the foundation explanation for so many well being situations.”
Already-scarce Medicaid protection of the extremely touted weight reduction medicine might turn out to be extra restricted, with federal Medicaid funding cuts anticipated within the wake of the huge tax-and-spending invoice President Donald Trump signed into regulation in July. The Congressional Price range Workplace estimated that the regulation would cut back Medicaid spending by about $911 billion over a decade.
“The regulation goes to create pretty intense strain on states to not broaden advantages,” mentioned 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 may very well be utilized by a big proportion of Medicaid recipients, he mentioned.
GLP-1s, which have been used for years to deal with Kind 2 diabetes, have gained widespread consideration as a technique to drop some pounds and cut back obesity-related situations 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 revenue modifications. And since the medicine’ well being advantages could take years to materialize — resembling averting a future coronary heart assault — the long-term monetary benefits might accrue to different insurers.
Even forward of the federal cuts, which is able to 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 burden loss medicine presents a dilemma for the Trump administration, which has recognized as priorities attacking power well being situations and decreasing federal spending. Well being and Human Companies Secretary Robert F. Kennedy Jr. has downplayed the necessity for the medicine and mentioned 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.
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 selections undergo a cost-benefit assessment.
In the meantime, the Trump administration has included the GLP-1 medicine Ozempic, Wegovy, and Rybelsus on its checklist of 15 medicines that shall be topic to cost negotiations with pharmaceutical producers beneath 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 personal insurers don’t cowl GLP-1s for weight reduction, which might make the medicine unaffordable for these paying out of pocket.
Additional evaluation supplied to Mississippi’s Medicaid drug assessment board exhibits that, within the first 15 months the medicine have been lined, solely about 2,900 Medicaid enrollees age 12 or older began remedy. Almost 90% of them have 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 practically 50%.
About 40% of adults in Mississippi are overweight, only one proportion level behind top-ranked West Virginia, in accordance with federal information.
Mississippi Medicaid spokesman Matt Westerfield informed KFF Well being Information that the state spent $12 million within the first 15 months, offering the burden loss medicine to 2,200 grownup members. He mentioned the state permitted the brand new medicine on the logic that treating weight problems would enhance enrollees’ well being and ultimately might result in price financial savings by decreasing ailments brought on by weight problems.
Westerfield mentioned that whereas utilization has been under the state’s projections, such remedy selections are as much as sufferers and their medical doctors. He mentioned 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, mentioned some medical doctors have much less incentive to prescribe the medication, as a result of the state doesn’t pay them to counsel sufferers about crucial dietary modifications when taking the brand new medicine.
He referred to as the medicine “sport changers,” including that he has seen sufferers lose 50 kilos or extra inside just a few months of beginning the medicine and now not want medicines for diabetes or different situations.
A New England Journal of Drugs research printed in 2021 discovered contributors receiving GLP-1 medicine have been extra prone to present vital, sustained weight reduction in contrast with these getting a placebo.
Different current research have proven the medicine assist folks 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 beneath the 2010 Reasonably priced Care Act to everybody with an revenue beneath 138% of federal poverty degree, or $21,597 this yr.
In Mississippi, Medicaid doesn’t cowl adults with out dependent kids. Dad and mom qualify provided that their revenue is under 22% of the federal poverty degree, or $5,863 for a household of three this yr.
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. Medical doctors should reveal 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 makes a speciality of weight problems, mentioned she was shocked so few sufferers are getting the medicine. A yr in the past, there have been shortages of the medicine that would have curtailed physicians prescribing them. And she or he mentioned the state’s prior authorization necessities for the drug might discourage main care medical doctors. Many widespread medicines don’t require progress studies and even prior authorization.
“We have to make sufferers extra conscious that this selection is out there for them,” she mentioned.
Lauren Scott, 40, of Laurel, Mississippi, mentioned that with the assistance of Medicaid protection, she misplaced practically 100 kilos taking Wegovy.
“It’s simply been superb,” she mentioned of how the drug drastically minimize 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.”