Sixteen state Medicaid programs covered GLP-1 medications for obesity as recently as October 2025. Since then, four have dropped coverage entirely.
That's the backdrop against which Cleveland Clinic researchers Hamlet Gasoyan, DS, and Michael B. Rothberg, MD, assess the CMS BALANCE model in a JAMA Viewpoint published April 2, 2026. Their argument is measured but pointed: this program represents a genuine policy shift — one that recognizes obesity as a disease, not a lifestyle choice or moral failing — but its success hinges on voluntary participation from the very stakeholders with the most reason to hesitate.
The model, announced in December 2025, would have CMS negotiate standardized pricing and coverage terms for GLP-1 and GLP-1/GIP receptor agonist medications on behalf of Medicare Part D plans and state Medicaid programs, with a short-term bridge program opening access to Part D beneficiaries in July 2026 at a $50 monthly co-pay.
The underappreciated argument here isn't about the drugs — it's about discontinuation. The authors point to US Department of Veteran Affairs data suggesting that when financial barriers are removed, adherence can approach levels seen in phase 3 trials. In their analysis, discontinuation is driven more often by cost or insurance-related issues than by adverse effects. The BALANCE model directly targets that dynamic.
The friction is structural. States are facing Medicaid budget pressure tied in part to federal Medicaid cuts in the 2025 reconciliation law, and Part D plans may balk if high enrollment outweighs savings from lower negotiated prices on other indications. As the authors write, “getting states and Medicare Part D plans to participate will be essential for the program to succeed.” That’s not guaranteed — and without robust participation, standardized access remains theoretical.
The clinical and institutional takeaway is clear: advocacy matters here. Gasoyan and Rothberg explicitly urge “state Medicaid programs and Medicare Part D plans to participate in the BALANCE model” — a rare, direct call to institutional action in a peer-reviewed Viewpoint. Clinicians treating Medicare and Medicaid patients with obesity should understand what’s coming in 2026 and what it would take for their patient populations to actually benefit.
Disclosures are printed in the published Viewpoint.
Source: JAMA
