Leadership1 distinct publisher3 min readPublished
The BALANCE model offers Medicaid agencies most-favored-nation prices on obesity drugs if they also run fitness coaching and nutrition counselling, and one state budget office has so far judged that worth taking.
The Board Room · Leadership desk
Compiled by The Board RoomSomething wrong?How this is made
A Medicaid director looking at BALANCE is being asked to fund a long-dated return out of a single-year appropriation. Forbes columnist Joshua Cohen puts enrollee churn near the centre of the refusals: recipients cycle out of the program before the long-term benefits of sustained weight loss would accrue to Medicaid [16], while demand for the drug class is high and off-label use is a live possibility [15]. Most-favored-nation benchmarking changes the unit price without changing who eventually banks the savings or how long they take to arrive [3].
Twenty-six sellers have now pledged these prices against one publicly confirmed buyer [18], and that ratio shows where the administration's leverage actually reaches. A manufacturer signing an MFN pledge concedes a price on volume that only materialises if a payer buys. A state signing BALANCE takes on a spending line plus a delivery obligation, because the model pairs the discounted drugs with physical fitness coaching and nutrition counselling [2]. The discount is federal to grant; the decision to spend sits with the states, which is the link in the chain the pledges do not bind.
A count of one could look early rather than final, since voluntary pilots often fill slowly. But the calendar cuts against that reading: the President's promise of better GLP-1 access in Medicaid dates to late last year [17], and the Medicare Part D half of the same model has already been rescheduled rather than merely slow to fill [6]. It is also worth noting that two of the recent coverage withdrawals were from state employee health plans rather than Medicaid [14], which suggests the resistance tracks the cost curve of the drug class rather than the rules of any one program.
Indiana's specific negotiated terms remain undisclosed, as does the current roster of states that have joined the GENEROUS model since the participation deadline moved [10]. Cohen's own view is that GENEROUS will probably not meet resistance on the same scale, while calling it a big unknown [21]. There is a structural reason to agree: GENEROUS applies an international-price rebate drug by drug where it beats a state's existing supplemental rate [9], which lowers a bill the state already pays, whereas BALANCE asks a state to start paying one that some have just stopped paying [13].
GENEROUS is scheduled for January 2027, and the delayed Part D tranche now points at 2028 [8], so the Medicaid side has to demonstrate the model roughly a year before the Medicare side tries again [19]. The usable input for anyone forecasting either program this quarter is one confirmed state and an undisclosed roster, which means volume assumptions in a 2027 model are assumptions rather than findings.
Ranked by verification strength, evidence, and original report placement.
The only definite participant in the BALANCE voluntary Medicaid demonstration project is the state of Indiana, and only Indiana has publicly signed on.
BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) is a voluntary model offering state Medicaid agencies lower negotiated prices on certain GLP-1 receptor agonists for obesity, pairing those lower prices with physical fitness coaching and nutrition counselling.
According to the Trump administration, the lower BALANCE prices are based on prices paid in other developed countries, a benchmarking approach known as most favored nation pricing.
According to Politico, most states have said they will not participate in BALANCE.
The BALANCE model was originally intended for both Medicaid and Medicare Part D recipients.
The Medicare Part D portion of the BALANCE model has been delayed until 2028 owing to insufficient participation from payers.
Distinct publishers with included, body-backed reporting in this cluster.
forbes.com
1 article · September 1, 2026
Follow any of these and your For You feed starts watching them — no settings page required.
invest
Another $96M of USD1 walks into the exchange that already holds most of it1 distinct publisher
leadership
Cuba has 2.6 times America's doctors per capita. The grid took the health system anyway.1 distinct publisher
product
A semiconductor tariff would land on the same devices the memory crunch already repriced1 distinct publisher
leadership
NIH's plan to hide peer-review scores swaps a contestable number for a 25-point band1 distinct publisher
Evidence-backed comparisons of source perspectives and observed adoption signals. Read the methodology
Which Builder, Operator, and Investor concerns the observed source mix emphasized—not a truth score.
Evidence, demonstrated adoption, hype gap, incentives, and confidence are assessed independently, each on its own current evidence. How these are measured.
One column carrying borrowed counts
Every fact here — the lone Indiana signature, the 2028 Part D slip, the extended GENEROUS deadline, the manufacturer tally — reaches a reader through one Forbes column, and the two counts the argument leans on hardest are other outlets' work: Politico for 'most states' refusing, STAT News for the nine smaller manufacturers. Cohen is precise about what he does not know, which counts in his favour, but the net prices at the centre of the story are undisclosed and no participant, refuser or federal official is quoted anywhere.
One state, one signature
Adoption is the story. A federal model open to fifty Medicaid agencies has one publicly confirmed taker; the Medicare half could not find enough payers and moved to 2028; the sibling GENEROUS pilot needed its deadline pushed and has no named participants. The only sign of movement anywhere is in the opposite direction, with California, North Carolina and West Virginia narrowing GLP-1 coverage rather than widening it.
The promise outran the sign-ups
Measured against the pledge of better Medicaid access to weight-loss drugs, delivered 'in part through' BALANCE, what exists is one state, a delayed Medicare tranche and a narrowing set of state benefits. The overstatement belongs to the policy announcements, not to this reporting: Cohen's column is the deflationary account, and the twenty-six-to-one gap between manufacturer pledges and state participants is the cleanest measure of how much of this program is still press release.
Cheap to promise, costly to accept
The structure explains the standoff better than any motive does. Manufacturers get credit for signing voluntary most-favored-nation pledges whose prices are never published and whose volume they do not control, so the pledge costs little. States are asked to give up prior authorization and step edits in exchange, converting a per-prescription discount into an open-ended budget line at exactly the moment last year's Medicaid financing restrictions tighten their own funding tools. Cohen has a columnist's stake in the contrarian read, and no manufacturer or agency is here to argue the other side.
Direction firm, details thin
That uptake is poor is hard to doubt — delayed tranches and extended deadlines are the kind of fact that does not flatter anyone. What a reader cannot rely on is the causal story: the budget-strain and churn arguments arrive without a single utilization figure or enrollment series, and the GENEROUS forecast is hedged into a shrug by its own author. Trust the count of one; treat the reasons as informed conjecture.