---
type: musing
domain: health
session: 22
date: 2026-04-12
status: active
---

# Research Session 22 — GLP-1 + Vulnerable Populations: Is the Compounding Failure Being Offset?

## Research Question

Is there a direct study of micronutrient outcomes in food-insecure GLP-1 users, and are state or federal programs compensating for SNAP cuts to Medicaid GLP-1 beneficiaries — or is the "compounding failure" thesis from Sessions 20–21 confirmed with no offsetting mechanisms?

**Why this question now:**
Session 21 found that GLP-1 users require continuous delivery infrastructure, that 22% develop nutritional deficiencies within 12 months, that 92% receive no dietitian visit, and that the OMA/ASN/ACLM/Obesity Society joint advisory explicitly recommends SNAP enrollment support as part of GLP-1 therapy — issued during OBBBA's $186B SNAP cuts. The double-jeopardy inference was structurally confirmed but not directly studied. Session 21 flagged this as a research gap.

**Note:** Tweet file was empty this session — no curated sources. All research is from original web searches.

## Belief Targeted for Disconfirmation

**Belief 1: Healthspan is civilization's binding constraint, and we are systematically failing at it in ways that compound.**

### Disconfirmation Target

**Specific falsification criterion for the compounding failure thesis:**
If state-level Medicaid GLP-1 coverage is being maintained or expanded to offset federal SNAP cuts, or if food banks / community health organizations are systematically providing micronutrient supplementation for GLP-1 users, the "systematic dismantling of access infrastructure" claim weakens. The failure would be real but compensated — which is a fundamentally different structural picture than "compounding unaddressed."

Additionally: if a direct study of food-insecure GLP-1 users shows micronutrient deficiency rates similar to the general GLP-1 population (not elevated), the double-jeopardy inference may be overstated.

**What I expect to find:** State-level coverage is inconsistent and fragile — likely to find some states expanding while others cut. Food banks and CHWs are not systematically providing GLP-1 nutritional monitoring. The direct study doesn't exist. The compounding failure thesis will hold.

**What would genuinely disconfirm:** A coordinated federal or multi-state initiative that is actively offsetting SNAP cuts with targeted food assistance for Medicaid GLP-1 users, at scale. I expect NOT to find this.

## Secondary Thread: Never-Skilling Detection Programs

Also targeting **Belief 5: Clinical AI creates novel safety risks (de-skilling, automation bias)**

**Disconfirmation target:** If medical schools are now implementing systematic pre-AI competency baseline assessments and "AI-off drill" protocols at scale, the "structurally invisible" and "detection-resistant" characterization of never-skilling weakens. The risk is real but being addressed.

## What I Searched For

**Primary thread:**
- Direct studies of micronutrient deficiency in Medicaid/food-insecure GLP-1 users (2025-2026)
- State-level Medicaid GLP-1 coverage policies post-OBBBA
- Federal or state programs addressing GLP-1 nutritional monitoring for low-income patients
- SNAP + GLP-1 policy intersection: any coordinated response to double-jeopardy risk
- GLP-1 adherence in Medicaid vs. commercial insurance populations

**Secondary thread:**
- Medical school AI competency baseline assessment programs 2025-2026
- "Never-skilling" detection protocols in clinical training
- Health system "AI-off drill" implementation data
- Clinical AI safety mitigation programs at scale

## Key Findings

### 1. DISCONFIRMATION TEST RESULT: Compounding failure thesis CONFIRMED — no operational offset

**The disconfirmation question:** Are state or federal programs compensating for SNAP cuts and state Medicaid GLP-1 coverage retreats?

**Answer: No — the net direction in 2026 is more access lost, not less.**

State coverage retreat (documented):
- 16 states covered GLP-1 obesity treatment in Medicaid in 2025 → 13 states in January 2026 (net -3 in 12 months)
- 4 states eliminated coverage effective January 1, 2026: California, New Hampshire, Pennsylvania, South Carolina
- Michigan: restricted to BMI ≥40 with strict prior authorization (vs. FDA-approved ≥30 threshold)
- Primary reason across all ideologically diverse states: COST — this is a structural fiscal problem, not ideological

The BALANCE model is NOT an offsetting mechanism in 2026:
- Voluntary for states, manufacturers, and Part D plans — no entity required to join
- Medicaid launch: rolling May–December 2026; Medicare Part D: January 2027
- No participating state list published as of April 2026
- States that cut coverage would need to voluntarily opt back in — not automatic
- Medicare Bridge (July–December 2026): explicitly excludes Low-Income Subsidy beneficiaries from cost-sharing protections — $50/month copay for the poorest Medicare patients

USPSTF pathway (potential future offset, uncertain):
- USPSTF has a B recommendation for intensive behavioral therapy for weight loss, NOT GLP-1 medications
- Draft recommendation developing for weight-loss interventions (could include pharmacotherapy)
- If finalized with A/B rating: would mandate coverage under ACA without cost sharing
- This is a future mechanism in development — no timeline, not yet operational

**California cut is the most revealing datum:** California is the most health-access-progressive state. If California is cutting GLP-1 obesity coverage, this is a structural cost-sustainability problem that ideological commitment cannot overcome.

### 2. Adherence Problem: Even With Coverage, Most Patients Don't Achieve Durable Benefit

**The compounding failure is deeper than coverage:**
- Commercially insured patients (BEST coverage): 36% (Wegovy) to 47% (Ozempic) adhering at 1 year
- Two-year adherence: only 14.3% still on therapy (April 2025 data presentation, n=16M+)
- GLP-1 benefits revert within 1-2 years of cessation (established in Sessions 20-21)
- Therefore: 85.7% of commercially insured GLP-1 users are not achieving durable metabolic benefit

Lower-income groups show HIGHER discontinuation rates than commercial average. Medicaid prior authorization: 70% of Medicaid PA policies more restrictive than FDA criteria.

**The arithmetic of the full gap:**
(GLP-1 continuous delivery required for effect) × (14.3% two-year adherence even in commercial coverage) × (Medicaid PA more restrictive than FDA) × (state coverage cuts) × (SNAP cuts reducing nutritional foundation) = compounding failure at every layer

Complicating factor: low adherence in the best-coverage population means the problem isn't ONLY financial. Behavioral/pharmacological adherence challenges (GI side effects, injection fatigue, cost burden even with coverage) compound the access problem.

### 3. Micronutrient Deficiency: Now Systematic Evidence (n=480,825), Near-Universal Vitamin D Failure

Urbina 2026 narrative review (6 studies, n=480,825):
- Iron: 64% consuming below EAR; 26-30% lower ferritin vs. SGLT2 comparators
- Calcium: 72% consuming below RDA
- Protein: 58% not meeting targets (1.2-1.6 g/kg/day)
- Vitamin D: only 1.4% meeting DRI — 98.6% are NOT meeting dietary vitamin D needs
- Authors: "common consequence, not rare adverse effect"

The 92% dietitian gap remains unchanged. Multi-society advisory exists; protocol adoption lags at scale.

No direct study of food-insecure GLP-1 users found — research gap confirmed. The double-jeopardy (GLP-1 micronutrient deficit + food insecurity baseline deficit + SNAP cuts) remains structural inference, not direct measurement.

### 4. HFpEF + GLP-1: Genuine Divergence Between Meta-Analysis (27% Benefit) and ACC Caution

**Meta-analysis (6 studies, 5 RCTs + 1 cohort, n=4,043):** 27% reduction in all-cause mortality + HF hospitalization (HR 0.73; CI 0.60–0.90)
**Real-world claims data (national, 2018–2024):** 42–58% risk reduction for semaglutide/tirzepatide vs. sitagliptin
**ACC characterization:** "Insufficient evidence to confidently conclude mortality/hospitalization benefit"

This is a genuine divergence in the KB — two defensible interpretations of the same evidence body:
- ACC: secondary endpoints across underpowered trials shouldn't be pooled for confident conclusions
- Meta-analysis: pooling secondary endpoints = sufficient to show statistically significant benefit

What would resolve it: a dedicated HFpEF outcomes RCT powered for mortality/hospitalization as PRIMARY endpoint.

### 5. Never-Skilling / Clinical AI: Mainstream Acknowledgment Without Solution at Scale

The Lancet editorial "Preserving clinical skills in the age of AI assistance" (2025) confirms:
- Deskilling is documented (colonoscopy ADR: 28% → 22% after 3 months of AI use)
- Three-pathway taxonomy (deskilling, mis-skilling, never-skilling) now in mainstream medicine
- No health system is running systematic "AI-off drills" or pre-AI baseline competency assessments at scale
- JMIR 2026 pre-post intervention study: "informed AI use" training improved clinical decision-making scores 56.9% → 77.6% — but this is an intervention study, not scale deployment

The never-skilling detection problem remains unsolved: you cannot lose what you never had, and no institution is measuring pre-AI baseline competency prospectively before AI exposure.

## Follow-up Directions

### Active Threads (continue next session)

- **Continuous-treatment model claim: READY TO EXTRACT.** Three independent confirming sources now available (GLP-1 rebound from Session 20, food-as-medicine reversion from Session 17, antidepressant relapse from Session 21). The pharmacological/dietary (continuous delivery required) vs. behavioral/cognitive (skill-based partial durability) distinction is fully documented. Target file: `domains/health/pharmacological-dietary-interventions-require-continuous-delivery-behavioral-cognitive-provide-skill-based-durability.md`

- **GLP-1 HFpEF divergence file: READY TO WRITE.** Session 21 identified it, this session confirmed the evidence. Create `domains/health/divergence-glp1-hfpef-mortality-benefit-vs-guideline-caution.md`. Links: meta-analysis (27% benefit), ACC statement (insufficient evidence), sarcopenic obesity paradox archive, weight-independent cardiac mechanism. "What would resolve this" = dedicated HFpEF outcomes RCT with mortality as primary endpoint.

- **USPSTF GLP-1 pathway:** USPSTF is developing draft recommendations on weight-loss interventions. If they expand the B recommendation to include pharmacotherapy, this would mandate coverage under ACA — the most significant potential offset to the access collapse. Monitor for publication of the draft. Search: "USPSTF weight loss interventions draft recommendation statement 2026 pharmacotherapy GLP-1"

- **Never-skilling: prospective detection search update.** The Lancet editorial (August 2025) raised the alarm; the JMIR 2026 study showed training improves AI-use skills. Search for any medical school running prospective pre-AI competency baselines before AI exposure in clinical training. This is the detection gap — absence of evidence remains the finding.

### Dead Ends (don't re-run these)

- **Direct study of food-insecure GLP-1 users + micronutrient deficiency:** Does not exist. Confirmed absence after 4 separate search attempts. Note for KB: this is a documented research gap — structural inference (GLP-1 deficiency risk + food insecurity + SNAP cuts) is the best available evidence.
- **State participation in BALANCE model:** No published list as of April 2026. State notification deadline is July 31, 2026. Don't search for this again until after August 2026.
- **GLP-1 penetration rate in HFpEF patients:** No dataset provides this. Research-scale only (~1,876 trial patients vs. ~2.2M theoretically eligible). Not searchable with better results.

### Branching Points (one finding opened multiple directions)

- **GLP-1 adherence complication:** 14.3% two-year adherence in commercial insurance means the problem is NOT only financial access — it's behavioral/pharmacological adherence even with coverage. Direction A: investigate what behavioral support programs improve adherence (the Danish digital + GLP-1 half-dose study from Session 20 is relevant); Direction B: investigate whether the 85.7% non-adherent population shows metabolic rebound and what the population-level effect of poor adherence means for healthcare cost projections. Direction A is more actionable — what works.

- **USPSTF A/B rating pathway:** Direction A — monitor for the draft recommendation (future session, check after August 2026); Direction B — investigate whether anyone has filed a formal USPSTF petition specifically for GLP-1 pharmacotherapy inclusion. Direction A is passive (monitoring); Direction B is active research. Pursue Direction B if session capacity allows.

- **GLP-1 access equity framing:** Two frames are emerging: (1) "structural fiscal problem that ideology can't overcome" (California datum); (2) "access inversion — highest burden populations have least access" (Medicaid coverage optional precisely for highest-prevalence population). These are complementary claims for the same phenomenon. Both should be extracted, framing A for the cost-sustainability argument, framing B for the structural inequity argument.

