In clinical medicine, we evaluate treatments by one standard: does the evidence support their use? For GLP-1 receptor agonists, the answer is unambiguous. The landmark SELECT trial, published in the New England Journal of Medicine, enrolled 17,604 patients with established cardiovascular disease and obesity but no diabetes. Patients on semaglutide experienced a 20% reduction in major adverse cardiovascular events and a 73% reduction in new-onset diabetes compared to placebo. These are the kind of numbers that, in any other context, would trigger immediate calls to expand access.

Medicare, the federal insurance program covering 67 million Americans, covers GLP-1 drugs for Type 2 diabetes and cardiovascular disease. For obesity alone, coverage has historically been barred under a 2003 statutory provision excluding drugs labeled for weight loss from Part D plans. The result is medically absurd. A patient with established heart disease and obesity gets coverage. A patient with obesity and prediabetes, carrying every measurable risk factor for both conditions, does not.

The cost of these medications without insurance reinforces the inequity. Wegovy lists at approximately $1,350 per month in 2026. Ozempic approaches $1,000. KFF polling found 56% of GLP-1 users described these drugs as difficult to afford, including one in four calling them “very difficult.”

This results in roughly 40% of GLP-1 prescriptions going unfilled between 2018 and 2022. The burden, however, does not fall equally. Black and Hispanic patients, who face disproportionately high rates of Type 2 diabetes and obesity, are significantly less likely to fill GLP-1 prescriptions than their White counterparts. For patients with obesity alone, out-of-pocket costs ran nearly twice as high as those for patients with diabetes. Insurance coverage, or its absence, directly determines whether a written prescription becomes a filled one.

The argument against expanding access centers on cost. The Congressional Budget Office estimated extending Medicare coverage to obesity treatment would increase federal spending by $35.5 billion from 2026 to 2034. A 2025 analysis in JAMA Health Forum modeled the 10-year fiscal impact of extended Medicare GLP-1 coverage. Gross drug costs came to $65.9 billion, but projected health care savings from reduced obesity-related comorbidities reached $18.2 billion, producing a net cost of $47.7 billion. Critics cite this net figure as disqualifying, ignoring the opposite side of the ledger. Untreated cardiovascular disease, end-stage kidney disease, and preventable hospitalizations carry significant costs over time. The question is not whether to spend money. The question is when and on what.

CMS moved toward partial reform in December 2025 when it announced the Medicare GLP-1 Bridge, a demonstration program set to begin in July 2026 offering time-limited coverage to eligible Part D beneficiaries. The program is temporary and leaves the underlying statutory barrier untouched.

The Medicaid picture is equally troubling. As of January 2026, only 13 states covered GLP-1 medications for obesity through their Medicaid programs, down from 16 the previous year. This opt-in structure guarantees access tracks state politics rather than patient need. No clinical rationale justifies this variation. It is purely political.

The BALANCE Model was announced by CMS in December 2025 as a direct response to the Medicaid access gap. It offered state Medicaid agencies a voluntary path to expanded GLP-1 coverage, with CMS negotiating drug prices on behalf of participating states, removing administrative burden. A state that opts out is making a political decision, and its Medicaid population will bear that cost.

The Medicare side of BALANCE collapsed before it launched. CMS required at least 80% of Part D plan sponsors to participate for the program to proceed. The April 20, 2026 deadline passed. Insurers refused to commit because they could not model how many patients would use the drugs. CMS has since paused the Medicare BALANCE model indefinitely and extended the Medicare GLP-1 Bridge program through 2027 as a stopgap. That outcome is its own indictment. A federal program designed to expand access to a clinically proven drug failed not because the evidence was weak or because the price was wrong, but because private insurers declined to absorb the uncertainty. 

Congress still has a direct path forward. The Treat and Reduce Obesity Act, advanced out of the House Ways and Means Committee in June 2024, would extend Medicare Part D coverage to obesity treatment through statute, removing the reliance on voluntary insurer participation entirely.

From a clinical standpoint, the evidence does not support the current framework. The minority communities that face the highest risk of cardiometabolic conditions are the least likely to get access under current policy. 

The drug works. Private insurers have now demonstrated they will not voluntarily close the access gap. The question before Congress is whether it will.

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