Angela Fitch was in her early 40s when she got bad news. A physician herself, Fitch had gone in for a physical exam expecting a clean bill of health. But this time her blood pressure was high and her doctor suspected sleep apnea. Stress, long work hours and pregnancy had contributed to steady weight gain, and now she was realizing the health impacts. 

Fitch thought of her patients with obesity — their struggles to lose weight and to manage associated ailments. She wondered if her fate would be that of her dad’s — a serious, but non-fatal heart attack at age 50. 

Obesity affects 40 percent of American adults. It reduces life expectancy and quality of life, and contributes to chronic illnesses, including heart disease, diabetes and at least 13 types of cancer. For most of modern history, no safe, effective medical therapy existed. A seismic shift occurred with the arrival of powerful anti-obesity medicines. But such therapy is out of reach for millions of Americans due to high prices and insurance coverage exclusions. That needs to change. 

In 2013, the American Medical Association recognized obesity as a disease, not simply a consequence of personal choices. Advocates for this change hoped it would improve medical care and insurance coverage and reduce the stigma of obesity. But 12 years later, those promises remain largely unfulfilled.

Fitch, now chief medical officer at knownwell, a tech-enabled healthcare services company that provides “empathetic, weight-inclusive medical care,” drew from her training to improve her health. She prioritized lifestyle interventions — cutting calories, strength-training, workouts on the Peloton. She tried Weight Watchers and Jenny Craig. She experimented with the keto diet and protein shakes. It worked — she lost about 5 percent of her body weight. But it wasn’t enough. 

Fitch’s story is familiar to millions of Americans. The difficulty of losing weight — and keeping it off — has led to a flourishing diet industry. Sales of weight-loss programs and products reached nearly $90 billion in 2023, according to a Marketdata report.  

Meanwhile, the health costs of obesity have skyrocketed, accounting for nearly $173 billion annually in recent years, according to the Centers for Disease Control and Prevention. Other estimates, incorporating indirect costs like lost productivity, absenteeism and premature mortality, are much higher. 

Game-changer medications — at a cost 

Approved by the Food and Drug Administration to treat obesity in 2021 and 2023, respectively, new medications like semaglutide (marketed as Ozempic and Wegovy) and tirzepatide (Zepbound and Mounjaro) work by slowing food transit through the stomach, reducing appetite and helping the body control blood sugar levels. Their growing popularity is justified: the medicines can reduce total body weight by 10 to 20 percent — sometimes more — and have additional benefits, including improved control of diabetes, heart failure, fatty liver disease and sleep apnea. 

Fitch herself turned to anti-obesity medicines when lifestyle changes weren’t enough. She’ll keep renewing her prescription. “I’ve been on medication for the past 12 years pretty much consistently, and every time I try to go off, I gain [the weight] back,” she said. 

The need for indefinite use of the drugs is problematic because of the high price tag. According to an analysis published in the Journal of the American Medical Association Open Forum in April, covering the newer anti-obesity medications under Medicare could cost taxpayers nearly $66 billion over the next decade. Even after accounting for savings from improved health outcomes, net spending would still rise by a projected $47.7 billion. 

Hence the reluctance by insurers to pay. While these medicines may be covered for related indications like diabetes, they are excluded by more than half of employer insurance plans in the United States, most state Medicaid programs, and Medicare Part D for obesity management — a legacy from the era before obesity was recognized as a disease. 

For patients paying out-of-pocket, the monthly costs — often over $1,000 — can be an enormous burden. In my practice, some patients stop the medicines due to high prices, only to regain the lost weight. Others turn to unregulated compounding pharmacies for cheaper versions, which may be unsafe or less effective. Even when patients have insurance coverage for weight-loss therapies, high deductibles and prior authorization requirements can limit access. 

“The moral injury in this space as a clinician is so bad because you have treatment [to offer patients] … and they can’t get coverage,” Fitch said. 

Such high costs are not inevitable. Semaglutide, for example, can be manufactured for less than $5 a month. And in other countries, the medicines can be purchased at a fraction of what people are paying in the United States. 

While most other high-income countries negotiate prices before drugs become available, “the U.S. allows pharmaceutical companies to set the prices for the drugs they manufacture however high they want when they enter the market,” said Dr. Reshma Ramachandran, a Connecticut-based physician and co-director of the Yale Collaboration for Regulatory Rigor, Integrity, and Transparency.

Federal efforts to expand access

As recently reported by the Washington Post, the Trump administration has announced a five-year “experiment” to allow state Medicaid programs and Medicare Part D plans to choose to cover the newer medications for weight management. Given anticipated federal funding cuts to Medicaid, however, the plan’s fate is uncertain.  

Legislation pending in Congress — the Treat and Reduce Obesity Act — would eliminate discriminatory rules that bar anti-obesity medications from the same coverage afforded treatments of other chronic diseases. It has received rare bipartisan support. But its impact would depend on whether the government can negotiate lower drug prices — a crucial element missing from the proposal. 

The act “fails to address the reason why there are coverage restrictions in the first place, which is that pharmaceutical companies like Novo Nordisk and Eli Lilly refuse to lower the prices for these treatments,” Ramachandran said.

The costs of the most effective anti-obesity medicines are coming down, even without special price negotiations. Other drugs are being developed that could increase competition, reducing prices. On August 26, Lilly announced promising clinical trial data for orforglipron, a new oral medicine similar to injectable semaglutide, and said it will seek FDA approval later this year.  But the path to affordability could be shortened with dedicated federal efforts to address cost concerns now.

Often underfunded and undervalued by insurers, lifestyle medicine programs — focusing on diet, physical activity, sleep, stress management, avoidance of unhealthy substances, and social connection — also are essential to any obesity treatment plan. According to Dr. Jonathan Bonnet, an obesity and lifestyle medicine physician and clinical associate professor (affiliated) at Stanford University School of Medicine, patients on anti-obesity medicines achieve greater weight loss and health with lifestyle changes. “I’m concerned that we are missing a huge opportunity to reap those benefits by focusing primarily on drugs instead of overall health and wellbeing,” he said.  

Comprehensive care needed

To support equitable access to the full spectrum of obesity treatment options, a multi-pronged approach is needed. This includes destigmatizing the condition, controlling medication costs, accepting the need for long-term treatment and expanding access to lifestyle interventions.

Policymakers have explored options like bulk purchasing, strengthening the ability of the Centers for Medicare & Medicaid Services to negotiate drug prices, adjusting patent and regulatory frameworks to facilitate entry of generic drugs into the market, and even government manufacturing to lower costs. All deserve consideration. 

We now have safe, effective medications that can change lives, and lifestyle interventions to reduce obesity and other chronic diseases. We need to ensure widespread access to both.

Lisa Doggett  is a columnist for Public Health Watch. Doggett is a family and lifestyle medicine physician at the Multiple Sclerosis and Neuroimmunology Center of UT Health Austin, the clinical practice of Dell Medical School at the University of Texas at Austin. She is also senior medical director of Sagility and author of the memoir, Up the Down Escalator: Medicine, Motherhood, and Multiple Sclerosis. The views expressed in her columns do not necessarily reflect the official policies or positions of Public Health Watch, UT Health Austin or Sagility.