Tracy Frey underwent gastric sleeve surgery in 2015 to help control her weight. She lost 110 pounds, but still weighs about 370. The circulation in her legs has deteriorated significantly, a result of her type 2 diabetes. Frey’s condition could, in a worst-case scenario, lead to the amputation of a limb, blindness, organ damage, and even death. Already, her kidneys are on the brink of failure. Yet today, the 54-year-old high school librarian in McAllen has reason to hope for healthier days ahead.
In June, Frey was among the first in the nation to be prescribed tirzepatide, a diabetes medication approved by the FDA in May and sold under the brand name Mounjaro. Clinical trials of the drug yielded tantalizing results. It did more than just lower blood sugar levels—some patients receiving the highest dosage lost more than 25 pounds over a period of 40 to 52 weeks.
Diabetes comes in two forms. Type 1 is an autoimmune disorder that usually begins in childhood. It compromises the body’s ability to make insulin, which is necessary to regulate the amount of glucose in the blood. Type 2—the far more prevalent form—normally develops later and is strongly associated with obesity and physical inactivity. Mounjaro treats type 2 diabetes.
Some of the most effective medicines for the condition mimic a gut hormone called glucagonlike peptide-1, which spurs the body’s production of insulin. Mounjaro likewise mimics GLP-1, but it also does the work of another gut hormone that stimulates insulin, called glucose-dependent insulinotropic polypeptide, or GIP. Medical researchers can’t say for certain why this combination in Mounjaro appears so effective.
Mounjaro also slows the emptying of the stomach, which puts the brakes on overeating. In June, Eli Lilly published the results of a clinical trial that tested the drug as a treatment for obesity. (It has so far been approved only for diabetes.) The findings, published in the New England Journal of Medicine, showed patients dropping an average of 35 to 52 pounds over 72 weeks, depending on their dosage. These results garnered more attention from news outlets than has the drug’s use in combatting diabetes. “It’s really a double win,” said Thomas Blevins, an Austin endocrinologist who helped oversee some of Mounjaro’s clinical trials.
The drug holds special promise in the Rio Grande Valley, where Frey lives. Roughly a quarter of adults in the Valley live with diabetes, compared with 12.6 percent of Texans and 13 percent of Americans. (Between 90 and 95 percent of those with diabetes in the U.S. have type 2.) And local physicians say there are likely many more Valley residents who have diabetes but are undiagnosed.
At the same time, about half of adults in the Valley’s Cameron, Hidalgo, and Starr counties are obese, compared with roughly 36 percent of Texans and 42 percent of Americans. While this fact partly explains the prevalence of type 2 diabetes in the area, it doesn’t tell the whole story. Why, for example, does type 2 diabetes affect roughly the same percentage of the population in the city of Chennai, in India—half a world away, with a much lower obesity rate? Genetics must play a role, but to what degree remains unclear. “It’s not just one gene,” said Joseph McCormick, a physician and professor of epidemiology at the UTHealth School of Public Health in Brownsville. “We have some clues about which genes, but it varies from one ethnic group to another.”
The prevalence of type 2 diabetes is 60 percent greater among Hispanic adults than among non-Hispanic white adults, according to the Centers for Disease Control and Prevention. Given that statistic, the higher rate of diabetes is unsurprising in heavily Hispanic portions of the state, including the border region of West Texas, the San Antonio area, and the Valley, where at least 90 percent of residents are Hispanic. Yet researchers can’t say why the condition is more common among those who are Hispanic or, for that matter, among Indigenous Americans (96 percent greater prevalence of diabetes, compared with the non-Hispanic white population), Black Americans (64 percent greater), and Asian Americans (28 percent greater). “There’s a lot we don’t know, but it’s probably not all just how much you eat and how much you exercise,” McCormick said.
Mounjaro has outperformed many other diabetes medications in clinical trials in lowering blood sugar levels. But this promise comes with a high price tag that could place it out of reach for many in the Valley. In a state where more than 18 percent of the population is medically uninsured—double the figure nationally—the Valley in particular lacks affordable health care, with about 30 percent of its residents uninsured and at least 24 percent living at or below the poverty line. “People here are poor,” said McCormick, who has coauthored dozens of studies on diabetes in the Valley. “They just don’t have access to these drugs.”
Mounjaro’s retail price is $974.33 for a four-week prescription, compared with roughly $20 per month for metformin, among the most common generic drugs for type 2 diabetes. Frey’s insurer covered nearly the whole cost of her first Mounjaro injections, in June, but she soon faced complications with her coverage. She is attempting to sort those out with the insurer, but fortunately, her doctor informed her about a coupon from Eli Lilly entitling her to buy the drug at $25 per month. Meanwhile, her 55-year-old husband, Ambrosio Maldanado, who also has type 2 diabetes and weighs almost four hundred pounds, hopes his doctor will soon prescribe Mounjaro for him too.
Frey numbers among the fortunate few. McCormick has researched public health in the Valley for two decades, and one of his studies found that “nearly half of those who knew they had diabetes were on inadequate medication,” largely because of drug costs. Many diabetes patients in the Valley access medications at area clinics that serve low-income and uninsured families and can acquire some drugs at a discount. It’s unclear whether those clinics will be able to bring down the price of Mounjaro for their patients as well.
Ultimately, the financial burden of caring for uninsured people with diabetes gets passed on to all of us, through higher insurance premiums and taxes to support publicly funded hospitals and clinics. In Texas, treating complications from diabetes—including both direct and indirect expenses—costs an estimated $26 billion annually, according to the American Diabetes Association. The state’s Medicaid program spent about $163 million in 2019 for diabetes care. Diabetes accounts for $1 of every $4 spent on health care nationwide, with diabetes-related medical expenses and the cost of reduced productivity totaling as much as $327 billion annually, and that figure continues to rise.
Uninsured diabetes patients in the U.S. make 60 percent fewer office visits and use 52 percent fewer medications than their insured counterparts, but they make 168 percent more emergency room visits, which are often expensive for patients and taxpayers alike. A review of ER patients in 2015 found that a quarter of those ages 45 and older were there because of complications arising from diabetes, and a quarter of these patients relied on Medicaid for payment.
While there is no available research yet on the potential financial impact of making a drug such as Mounjaro freely accessible to all, studies have shown, and health-care economists agree, that preventive care is a good investment. For instance, at a retail price of $12,666 per year, Mounjaro isn’t cheap, but spending that amount to help a patient avoid serious kidney damage and the resulting dialysis—for which Medicare pays at least $31,500 annually per patient and $90,000 a year for patients with end stage renal disease—is a bargain. But the U.S. health-care system does not, by and large, emphasize preventive care. “There’s a disconnect between insurance companies, patients, doctors, and big pharmaceutical companies,” said Alejandro Gonzalez Campos, an endocrinologist in Edinburg. “Everyone is looking to avoid paying large sums of money in the short term, when we need to focus on prevention measures” to avoid much higher costs in the long term.
One program in the Valley that’s helping uninsured patients to manage their diabetes is run by UTHealth. Called Salud y Vida, or “Health and Life,” it centers on addressing diet, physical activity, and other lifestyle changes, such as reducing stress and monitoring blood glucose levels. Type 2 diabetes can, after all, be a reversible condition.
One of Salud y Vida’s participants, Martin Rocha, a 59-year-old auto mechanic, was diagnosed with type 2 diabetes in his early thirties. Because he lacked health insurance, he went without medication until his health began deteriorating. A few years ago, Rocha turned to the Hope Family Health Center, a clinic for low-income and uninsured patients in McAllen. The clinic offers medications to its patients that it secures through a national nonprofit, though Mounjaro is not yet among them. “If it wasn’t for the clinic and Salud y Vida,” Rocha said, “I would have been buried months ago.” Even with the care he now receives, Rocha has experienced partial vision loss and had a pair of toes amputated.
Rocha doesn’t have the means to benefit from a cutting-edge drug such as Mounjaro. As for Frey, after a few weeks of taking the drug, she said she had yet to see benefits, though she expected that to change as her dosage increases in the months to come. (Unfortunately, Mounjaro became hard to obtain, so she at least temporarily had to go without it.) For his part, McCormick is frustrated by the stark disparities in access to health care among patients such as Rocha and Frey and by a system that fails to invest in preventive medications that could save taxpayers billions of dollars now spent for dialysis and other expensive diabetes treatments.
Aaron Nelsen is a freelance journalist based in the Rio Grande Valley.
This story appeared in the September 2022 issue of Texas Monthly with the headline “The Price of a Miracle.” An abbreviated version originally published online on June 28, 2022, and has since been updated. Subscribe today.