The Rise of GLP-1s and Their Impact on Medicaid Coverage
April Hines, a 46-year-old from Mississippi, has spent much of her life battling obesity. However, in recent years, she has made significant progress, shedding over 200 pounds and improving her overall health. Her journey is largely attributed to Trulicity, a drug belonging to a new class of weight loss medications known as GLP-1s. These drugs have become a focal point for many individuals struggling with obesity, especially those covered by Medicaid.
Mississippi's Medicaid program took a bold step in 2023 by including GLP-1s in its coverage for individuals aged 12 and older. This decision was notable because only 13 states cover these drugs for Medicaid recipients, and Mississippi’s Medicaid program typically offers limited benefits. Despite this, the uptake of these medications has been slower than expected, with just 2% of eligible adults receiving a prescription by December 2024.
Challenges in Accessing GLP-1s
The slow adoption of GLP-1s in Mississippi has been influenced by several factors. National drug shortages, a complex prior authorization process, and a lack of marketing have all contributed to the low usage rate. William Rosenblatt, a family doctor in Columbus who treats Hines, expressed disappointment that so few people are benefiting from these drugs. He emphasized that GLP-1s address the root causes of many health issues, making them a valuable tool in managing chronic conditions.
However, the future of GLP-1s in Medicaid coverage is uncertain. Federal funding cuts, stemming from a recent tax-and-spending bill signed by President Donald Trump, could lead to reduced coverage. The Congressional Budget Office estimates that the law will cut Medicaid spending by $911 billion over a decade. This financial pressure may force states to reconsider expanding benefits, particularly for costly medications like GLP-1s, which can cost around $1,000 per month.
The Cost-Benefit Dilemma
Despite their high cost, GLP-1s have shown promise in treating obesity and related health conditions. These drugs, originally developed for Type 2 diabetes, have gained attention for their effectiveness in weight loss and reducing obesity-related complications. However, states remain hesitant to expand coverage due to the long-term nature of the health benefits. For example, the reduction in heart attacks or strokes may not be evident for years, and the financial benefits might accrue to other insurers rather than Medicaid itself.
North Carolina recently dropped its coverage of GLP-1s, citing their high cost. This decision highlights the challenges states face in balancing the immediate costs of these drugs with potential long-term savings. The Trump administration has also faced criticism for its stance on GLP-1s, with Health and Human Services Secretary Robert F. Kennedy Jr. downplaying their necessity and emphasizing diet and exercise instead.
Federal Policy Shifts
In contrast, the Biden administration proposed covering weight loss drugs under Medicare and Medicaid to combat obesity as a public health crisis. However, the Trump administration revoked this proposal, stating that the programs would not cover GLP-1 drugs for weight loss. Despite this, there have been rumors of a potential five-year pilot program for Medicare and Medicaid to cover these drugs, although no details have been released.
The Trump administration has also included GLP-1 drugs such as Ozempic, Wegovy, and Rybelsus on its list of medicines subject to price negotiations under Medicare Part D. The results of these negotiations are expected this fall, potentially impacting the affordability of these drugs for patients.
Limited Coverage and Patient Experiences
Most private insurers do not cover GLP-1s for weight loss, making them unaffordable for many patients. In Mississippi, the first 15 months of coverage saw only about 2,900 Medicaid enrollees starting treatment. Nearly 90% of these patients were female, and many had comorbidities such as high blood pressure and high cholesterol.
The analysis also revealed that most users lived in the southern, central, or northern parts of Mississippi, rather than the Mississippi Delta, where obesity rates are highest. About 40% of adults in Mississippi are obese, placing the state just one percentage point behind West Virginia.
Medicaid's Perspective
Mississippi Medicaid spokesman Matt Westerfield noted that the state spent $12 million in the first 15 months, providing the drugs to 2,200 adult members. While utilization has been below projections, Westerfield emphasized that treatment decisions are up to patients and their doctors. The state has been working to raise awareness among healthcare providers, but further efforts are needed.
Rosenblatt, who works for Baptist Medical Group, highlighted the importance of these drugs in his practice. He has seen patients lose significant weight and reduce their need for other medications. However, he pointed out that the state does not pay doctors to counsel patients on necessary dietary changes when prescribing GLP-1s, which may discourage some physicians from using them.
Future Outlook
Despite the challenges, the potential benefits of GLP-1s remain clear. A study published in the New England Journal of Medicine found that participants receiving GLP-1 drugs experienced more significant and sustained weight loss compared to those on a placebo. Other studies have shown that these drugs can help lower high blood pressure and reduce the risk of heart attacks or strokes.
As the debate over Medicaid coverage continues, the impact of GLP-1s on public health remains a critical issue. With ongoing policy shifts and financial constraints, the future of these medications in Medicaid coverage remains uncertain, but their potential to improve lives cannot be overlooked.