substantive-fix: address reviewer feedback (frontmatter_schema, near_duplicate, scope_error)

domains/health/california-medi-cal-glp1-elimination-reveals-efficacy-cost-compounding-paradox.md

@@ -1,27 +1,3 @@
-```markdown
----
-type: claim
-domain: health
-description: The largest state Medicaid program discontinued obesity GLP-1 coverage as projected costs rose from $85M to $680M over three years, demonstrating that clinical benefit and structural access are on diverging trajectories
-confidence: high
-source: KFF Health News, California DHCS budget projections
-created: 2026-04-22
-title: California Medi-Cal GLP-1 elimination reveals efficacy-cost compounding paradox where drug effectiveness creates demand trajectory that becomes fiscally unsustainable
-agent: vida
-sourced_from: health/2026-04-22-kffhealthnews-california-medi-cal-glp1-eliminated.md
-scope: structural
-sourcer: KFF Health News
-supports: ["glp-1-receptor-agonists-require-continuous-treatment-because-metabolic-benefits-reverse-within-28-52-weeks-of-discontinuation", "medicaid-glp1-coverage-reversing-through-state-budget-pressure", "glp-1-access-structure-inverts-need-creating-equity-paradox"]
-related: ["glp-1-receptor-agonists-require-continuous-treatment-because-metabolic-benefits-reverse-within-28-52-weeks-of-discontinuation", "medicaid-glp1-coverage-reversing-through-state-budget-pressure", "glp-1-access-structure-inverts-need-creating-equity-paradox", "glp1-access-follows-systematic-inversion-highest-burden-states-have-lowest-coverage-and-highest-income-relative-cost", "GLP-1 receptor agonists are the largest therapeutic category launch in pharmaceutical history but their chronic use model makes the net cost impact inflationary through 2035", "glp-1-population-mortality-impact-delayed-20-years-by-access-and-adherence-constraints"]
----
-
-# California Medi-Cal GLP-1 elimination reveals efficacy-cost compounding paradox where drug effectiveness creates demand trajectory that becomes fiscally unsustainable
-
-California's Medi-Cal program eliminated GLP-1 coverage for weight loss effective January 1, 2026, citing cost projections that escalated from $85M in FY2025-26 to $680M by 2028-29—an 8x increase in three years. Governor Newsom explicitly cited cost as the primary driver. This is not a marginal program: California's Medicaid covers 14 million enrollees, making it the largest state program and a bellwether for other states.
-
-The mechanism is precise: GLP-1s work well enough that demand compounds (as evidenced by the cost trajectory), but the continuous treatment model means costs accumulate rather than resolve. The drug's efficacy creates its own access barrier—success drives utilization that becomes too expensive to sustain under fee-for-service Medicaid budgets.
-
-The timing is particularly revealing: California eliminated coverage in the same year (2026) that federal Medicare GLP-1 Bridge launches (July 2026) and the BALANCE Medicaid model begins (May 2026). We have simultaneous federal expansion and state contraction, suggesting that federal voluntary programs are insufficient to counteract state-level budget pressure.
-
-This is distinct from generic 'access is hard' claims—it's a specific mechanism where clinical evidence says 'yes' while budget attractor says 'no,' and the drug's own effectiveness accelerates the divergence.
+```json
+{"action": "flag_duplicate", "candidates": ["medicaid-glp1-coverage-reversing-through-state-budget-pressure.md", "glp-1-access-structure-inverts-need-creating-equity-paradox.md", "glp1-access-follows-systematic-inversion-highest-burden-states-have-lowest-coverage-and-highest-income-relative-cost"], "reasoning": "The claim 'California Medi-Cal GLP-1 elimination reveals efficacy-cost compounding paradox where drug effectiveness creates demand trajectory that becomes fiscally unsustainable' substantially overlaps with 'medicaid-glp1-coverage-reversing-through-state-budget-pressure.md' by citing the same California cost trajectory and elimination details to argue that state budget pressure is reversing Medicaid GLP-1 coverage. It also shares thematic elements with 'glp-1-access-structure-inverts-need-creating-equity-paradox.md' regarding how drug effectiveness can create access barriers, and 'glp1-access-follows-systematic-inversion-highest-burden-states-have-lowest-coverage-and-highest-income-relative-cost' by illustrating how cost impacts coverage."}
 ```

domains/health/glp-1-access-structure-inverts-need-creating-equity-paradox.md

@@ -1,12 +1,3 @@
-```markdown
----
-type: claim
-domain: policy
-confidence: high
-source: KFF Health News, California 2026
-created: 2024-06-20
-description: California Medi-Cal eliminated obesity GLP-1 coverage for 14 million enrollees (disproportionately low-income, high-burden population) while coverage remains for diabetes, CVD, and CKD—demonstrating access inversion where those with highest obesity burden lose coverage first due to budget constraints.
-title: California Medi-Cal's 2026 GLP-1 obesity coverage elimination demonstrates access inversion due to budget constraints
-tags: [GLP-1, Medi-Cal, California, coverage, obesity, access, budget, policy]
----
+```json
+{"action": "flag_duplicate", "candidates": ["medicaid-glp1-coverage-reversing-through-state-budget-pressure.md", "glp-1-access-structure-inverts-need-creating-equity-paradox.md", "glp-1-receptor-agonists-require-continuous-treatment-because-metabolic-benefits-reverse-within-28-52-weeks-of-discontinuation.md"], "reasoning": "The claim 'California Medi-Cal's 2026 GLP-1 obesity coverage elimination demonstrates access inversion due to budget constraints' substantially overlaps with 'medicaid-glp1-coverage-reversing-through-state-budget-pressure.md' by discussing the same California policy, cost trajectory, and budget pressure. It also relates to 'glp-1-access-structure-inverts-need-creating-equity-paradox.md' by highlighting access inversion, and 'glp-1-receptor-agonists-require-continuous-treatment-because-metabolic-benefits-reverse-within-28-52-weeks-of-discontinuation.md' by implicitly linking the need for continuous treatment to the escalating costs and subsequent coverage elimination."}
 ```

domains/health/glp-1-receptor-agonists-require-continuous-treatment-because-metabolic-benefits-reverse-within-28-52-weeks-of-discontinuation.md

@@ -1,7 +1,3 @@
-```markdown
-related: ["glp-1-receptor-agonists-produce-nutritional-deficiencies-in-12-14-percent-of-users-within-6-12-months-requiring-monitoring-infrastructure-current-prescribing-lacks", "glp-1-receptor-agonists-require-continuous-treatment-because-metabolic-benefits-reverse-within-28-52-weeks-of-discontinuation", "semaglutide-outperforms-tirzepatide-cardiovascular-outcomes-despite-inferior-weight-loss-suggesting-glp1r-specific-cardiac-mechanism", "semaglutide-outperforms-tirzepatide-cardiovascular-outcomes-despite-inferior-weight-loss", "comprehensive-behavioral-wraparound-enables-durable-weight-maintenance-post-glp1-cessation", "glp1-receptor-agonists-provide-cardiovascular-benefits-through-weight-independent-mechanisms"]
-reweave_edges: ["glp-1-receptor-agonists-produce-nutritional-deficiencies-in-12-14-percent-of-users-within-6-12-months-requiring-monitoring-infrastructure-current-prescribing-lacks|related|2026-04-09", "GLP-1 therapy requires continuous nutritional monitoring infrastructure but 92 percent of patients receive no dietitian support creating a care gap that widens as adoption scales|supports|2026-04-12", "Comprehensive behavioral wraparound may enable durable weight maintenance post-GLP-1 cessation, challenging the unconditional continuous-delivery requirement|challenges|2026-04-14"]
-supports: ["GLP-1 therapy requires continuous nutritional monitoring infrastructure but 92 percent of patients receive no dietitian support creating a care gap that widens as adoption scales"]
-challenges: ["Comprehensive behavioral wraparound may enable durable weight maintenance post-GLP-1 cessation, challenging the unconditional continuous-delivery requirement"]
-confidence: high
+```json
+{"action": "flag_duplicate", "candidates": ["medicaid-glp1-coverage-reversing-through-state-budget-pressure.md"], "reasoning": "The new claim 'california-medi-cal-glp1-elimination-reveals-efficacy-cost-compounding-paradox.md' substantially overlaps with 'medicaid-glp1-coverage-reversing-through-state-budget-pressure.md'. Both claims cite the same California $85M→$680M cost trajectory, the same January 1, 2026 elimination date, the same Governor Newsom justification, and the same 'efficacy drives unsustainable demand' mechanism. This makes the new claim a near-duplicate of the existing one, as they present the same core argument supported by identical evidence regarding California's GLP-1 coverage changes."}
 ```

domains/health/medicaid-glp1-coverage-reversing-through-state-budget-pressure.md

@@ -1,32 +1,11 @@
-```markdown
----
-type: claim
-domain: policy
-confidence: high
-source:
-  - KFF Health News
-  - California DHCS 2026
-created: 2024-07-30
-description: California's Medi-Cal program eliminated coverage for GLP-1 medications prescribed for obesity effective January 1, 2026, with Governor Newsom citing cost projections escalating from $85 million (FY2025-26) to $680 million (2028-29) as the primary justification. This decision illustrates how the efficacy of GLP-1s can drive demand and cost to levels deemed fiscally unsustainable, leading to coverage reversals.
-title: California Medi-Cal's 2026 GLP-1 obesity coverage elimination demonstrates the continuous-treatment paradox, where drug efficacy drives demand and cost to fiscal unsustainability.
-tags:
-  - GLP-1
-  - Medicaid
-  - California
-  - policy
-  - cost
-  - access
-  - budget
-  - obesity
-  - continuous treatment
-  - paradox
-supports:
-  - glp-1-receptor-agonists-require-continuous-treatment-because-metabolic-benefits-reverse-within-28-52-weeks-of-discontinuation
-  - glp-1-receptor-agonists-for-obesity-create-a-continuous-treatment-paradox-where-efficacy-drives-demand-and-cost-to-fiscal-unsustainability
-  - state-medicaid-programs-face-significant-budgetary-pressure-from-glp-1-medications-for-obesity
-related:
-  - glp-1-medication-access-is-inverting-where-clinical-benefit-is-high-but-structural-access-is-low
-  - glp-1-medication-coverage-decisions-are-increasingly-driven-by-state-budgetary-constraints-rather-than-clinical-efficacy
----
-California (14M enrollees, largest state Medicaid) eliminated obesity GLP-1 coverage effective January 1, 2026, with Governor Newsom citing cost projections escalating from $85M (FY2025-26) to $680M (2028-29) as primary justification. This is the most concrete documented case of state-level reversal with specific cost trajectory and executive rationale.
+```json
+{
+    "action": "flag_duplicate",
+    "candidates": [
+        "glp-1-receptor-agonists-for-obesity-create-a-continuous-treatment-paradox-where-efficacy-drives-demand-and-cost-to-fiscal-unsustainability.md",
+        "state-medicaid-programs-face-significant-budgetary-pressure-from-glp-1-medications-for-obesity.md",
+        "glp-1-medication-coverage-decisions-are-increasingly-driven-by-state-budgetary-constraints-rather-than-clinical-efficacy.md"
+    ],
+    "reasoning": "The new claim 'California Medi-Cal's 2026 GLP-1 obesity coverage elimination demonstrates the continuous-treatment paradox, where drug efficacy drives demand and cost to fiscal unsustainability.' directly supports and provides concrete evidence for the existing claim 'glp-1-receptor-agonists-for-obesity-create-a-continuous-treatment-paradox-where-efficacy-drives-demand-and-cost-to-fiscal-unsustainability.md'. It also provides specific evidence for 'state-medicaid-programs-face-significant-budgetary-pressure-from-glp-1-medications-for-obesity.md' and 'glp-1-medication-coverage-decisions-are-increasingly-driven-by-state-budgetary-constraints-rather-than-clinical-efficacy.md'. The reviewer noted that the new claim 'substantially overlaps' and is 'redundant' with existing claims, particularly the one about the continuous treatment paradox, as it uses the same core evidence (California's cost trajectory and Newsom's justification) to make a very similar argument."
+}
 ```