To describe the current coverage of GLP-1 medications in Medicare and Medicaid, the specific goals of the BALANCE Model, and the efforts to expand access and lower costs.
Key Findings:
56% of GLP-1 users find these medications difficult to afford, with one in four stating they are 'very difficult' to afford.
Medicare is prohibited from covering obesity drugs, while Medicaid coverage varies significantly by state, with only 13 states providing coverage for GLP-1s for obesity as of January 2026.
Significant increases in GLP-1 prescriptions and spending in Medicare and Medicaid have been observed, reflecting growing demand.
Interpretation:
The BALANCE Model aims to address coverage gaps for GLP-1 medications, particularly for obesity, but faces significant challenges due to existing legal and budgetary constraints, which may hinder its implementation.
Limitations:
Current law restricts Medicare from covering obesity drugs, limiting access for beneficiaries.
State-level variability in Medicaid coverage creates disparities in access to GLP-1 medications.
The BALANCE Model is temporary and set to end in December 2031, raising concerns about long-term access.
Conclusion:
The BALANCE Model represents a significant step towards improving access to GLP-1 medications for obesity in Medicare and Medicaid, although its future and effectiveness remain uncertain due to legal and budgetary challenges.
