Policy Interventions to Enhance Medical Care for People With Obesity in the United States—Challenges, Opportunities, and Future Directions

Abstract

Policy Points.

• Health policymakers have insufficiently addressed care for people with obesity (body mass index ≥ 30 kg/m²) in the United States. Current federal policies targeting obesity medications reflect this unfortunate reality.

• We argue for a novel policy framework to increase access to effective obesity therapeutics and care, recognizing that, though prevention is critical, the epidemic proportions of obesity in the United States warrant immediate interventions to augment care.

• Reducing barriers to and improving the quality of existing anti‐obesity medications, intensive behavioral therapy, weight management nutrition and dietary counseling, and bariatric surgery are critical. Moreover, to ensure continuity of care and patient–clinician trust, combating physician and broader weight stigma must represent a central component of any viable obesity care agenda.

Health policymakers have insufficiently addressed care for people with obesity (body mass index [BMI] ≥ 30 kg/m²) in the United States. Current federal policies targeting obesity medications reflect this unfortunate reality. Extant Medicare medication coverage provisions have erected a barrier between obesity and other seemingly “more legitimate” diseases. For instance, under sections 1860D‐2 and 1861 of the Social Security Act (SSA), anti‐obesity medications are excluded from the Medicare prescription drug benefit. ¹ , ² , ³ These sections of the SSA reflect broader trends in inadequate coverage of anti‐obesity pharmacotherapeutics. Indeed, the 2018 assessment of phentermine, diethylpropion, phendimetrazine, benzphetamine, lorcaserin, phentermine/topiramate (Qysmia), liraglutide (Saxenda), and bupropion/naltrexone (Contrave) coverage across 34 states by Gomez and Stanford found only seven state Medicaid programs and only 11% of marketplace health insurance plans covered these medications. ⁴

Relatively recently, the US Congress has been presented with an opportunity to alter the current obesity care paradigm through the Treat and Reduce Obesity Act of 2021 (TROA), which would extend Medicare coverage for the first time to anti‐obesity prescription drugs and allow providers such as registered dietitians and behavioral psychologists to be reimbursed for intensive behavior therapy for treatment of obesity under Medicare. ⁵ Despite initially garnering 154 bipartisan cosponsors, this initial legislation stalled in the US House of Representatives and has since seen no further legislative action. Somewhat promisingly, the legislation was reintroduced by a Republican representative from Ohio's second congressional district in July 2023, but it has also since seen no further legislative action. ⁶ This lack of federal‐level support for medical care for people with obesity comes even as the medical literature continues to demonstrate the effectiveness of comprehensive anti‐obesity therapy—including pharmacotherapy—on patient outcomes. ⁷

Instead, the extant approach to combating obesity in the United States has centered on reshaping nutritional and exercise habits, reflecting widely held assumptions that an individual's poor lifestyle choices can almost exclusively explain obesity. ⁸ Such interventions have furnished some ostensibly promising results. One analysis, for example, found that the Healthy, Hunger‐Free Kids Act of 2010—legislation that strengthened nutrition standards for meals and beverages provided through the National School Lunch Program, National School Breakfast Program, and National School Smart Snacks Program—was estimated to have reduced the expected increase in obesity rates among low‐income children by 47%. ⁹ As these results suggest, policies that indirectly attempt to reshape nutritional choices can effectively mitigate obesity. However, the focus on nutritional choices in extant obesity policy in the United States misses other critical determinants of the disease—and thus other areas of policy intervention—including but not limited to exercise, sleep, genetics, and psychosocial and structural factors. ⁸ , ¹⁰ , ¹¹ , ¹² Perhaps more importantly, interventions like the Healthy, Hunger‐Free Kids Act of 2010 also do little to furnish medical care to those individuals currently experiencing obesity. Indeed, the failure of the contemporary US obesity policy approach lies not necessarily in what it pursues but rather in what it neglects.

The fixity of personal responsibility in national policymaking discourse surrounding obesity in the United States runs deep. In 2005, the Personal Responsibility in Food Consumption Act sought to at least symbolically absolve multinational food corporations of any role in contributing to the United States's obesogenic food environment by proposing a ban on any civil action by consumers against any “manufacturer, marketer, distributor, advertiser, or seller of food or a trade association for any injury related to a person's accumulated acts of consumption of food and weight gain, obesity, or any associated health condition.” ¹³ Tellingly, this proposal made substantially more progress in the legislative process than the recent TROA, passing the House of Representatives by a 186‐vote margin. Although this unenacted bill may have amounted to a mere political stunt, it illuminates how personal freedom and choice principles central to the American polity have framed obesity as a disease wholly determined by personal willpower and motivation and not worthy of governmental intervention or support.

This Article's Approach

By contrast, this article rejects the prevalent assumption that obesity in the United States can be primarily attributed to poor lifestyle choices and that, as a result, the onus of chronic weight management rests solely on the patient experiencing the disease. We, instead, embrace a conceptualization of obesity that characterizes it as a complex, relapsing–remitting disease that is substantially shaped by socioeconomic and obesogenic environmental factors, partially explained by individual dietary and physical activity habits, reinforced by pervasive stigma in popular culture and the clinical setting, and strongly influenced by genetic factors for some individuals. ¹⁴ , ¹⁵ , ¹⁶ Because many factors explaining obesity lie outside the individual locus of control, we first posit that continued medical care for patients with obesity is necessary.

We certainly do not dispute that individual behavioral changes are a necessary component of overcoming the disease of obesity. Instead, we posit that because genetic, social, and environmental factors can constrain the agency with which many patients with obesity make individual dietary and exercise choices, medical care is essential. We are troubled by the fact that such medical care is inaccessible to many patients in the United States. Therefore, we argue for further policy changes to augment access to medical therapy. Indeed, with the age‐adjusted rate of obesity among adults older than 20 years of age in the United States reaching over 41%, which corresponds to an estimated 300 excess deaths per day (nearly 500,000 per year), reducing barriers to and improving the quality of existing anti‐obesity medications, cognitive and behavioral therapy, nutritional therapy, and bariatric surgery is critical. ¹⁷ , ¹⁸ To ensure continuity of care and patient–clinician trust, combating clinician (and broader) weight stigma must form a central component of the obesity care agenda.

We believe this article has a bearing on various stakeholders—namely legislators, health care providers, public health leaders, and business/nonprofit leaders. For legislators, we intend this article's in‐depth discussion of the stigma undergirding the US obesity care policy landscape to reinvigorate the debate around obesity care. Moreover, by discussing particular interventions, we hope to equip policymakers with ideas for improving US obesity care. For health care providers and public health professionals, this article is essential for two reasons: first, our discussion of the clinical evidence may help inform clinical care and future research, and second, our expansive discussion of obesity stigma will ideally galvanize practitioners into engaging in political advocacy for the interventions we include herein. Finally, for business and nonprofit leaders, we hope our paper will spark additional investment into obesity care research, political advocacy, and even coverage (for any leaders of health insurance agencies reading this paper).

Medication Therapy

One of the most intractable barriers to effective and accessible care for people with obesity in the United States is inadequate health insurance coverage for anti‐obesity drugs. The online survey by Wilson and colleagues discovered that, among 4,465 consumers, only 21% of respondents reported insurance coverage for anti‐obesity drugs. ¹⁹ The US Government Accountability Office, using data from the Agency for Healthcare Research Quality's Medical Expenditure Panel Survey, estimates that 68% of the costs of obesity drugs are paid for out‐of‐pocket by patients. ²⁰ Moreover, as detailed above, Medicare and Medicaid fail to cover many anti‐obesity pharmaceuticals.

For those individuals with obesity, inadequate pharmacotherapy coverage often translates to higher out‐of‐pocket costs. Such costs are, perhaps counterintuitively, most burdensome for those patients with the most severe obesity and who seek the newest, most clinically effective therapeutics. Newer medications frequently run more than 20 times higher in cost than older ones. For example, semaglutide, approved by the Food and Drug Administration (FDA) for weight loss at a dosage of 2.4 mg once weekly, costs nearly $13,618 annually. ²¹ , ²² It is also critical to acknowledge that one individual's costs may vastly differ from those of another—even for identical medications. This inequality arises partly because insurance coverage of drugs differs for obesity than that for other chronic diseases. For instance, 3.0 mg liraglutide—a medication approved at a lower dose of 1.8 mg/day for diabetes treatment, is under a different name than when administered for weight management at 3.0 mg/day. ²³

Many factors may explain insurers’ (including the federal government in the case of Medicare) reluctance to cover anti‐obesity drugs. Chief among them is cost. Recent estimates from Baig and colleagues suggest that, under the hypothetical that all Medicare beneficiaries with obesity are prescribed semaglutide for weight management (excluding other indications for its use), costs would exceed “the entire [Medicare] Part D budget and would be greater than the total excess health care spending associated with obesity for people of all ages.” ²¹ Moreover, some literature suggests that individuals who use anti‐obesity pharmaceuticals such as semaglutide can regain up to two‐thirds of their lost weight after 1 year of withdrawal, suggesting that coverage might need to occur long term to prevent relapse—only increasing costs. ²⁴ Thus, under the current health insurance model in the United States, it may be prohibitively costly for Medicare to cover all uses of anti‐obesity medication.

Related to direct financial costs of coverage are concerns that extending coverage to potentially long‐term and high‐cost obesity pharmaceuticals may induce people with obesity—a population that often presents with other chronic diseases—to migrate to their policies, thereby raising insurers’ risk of payout. ²⁵ This argument fails, however, to appreciate the role weight‐loss pharmaceuticals can play in mitigating obesity's sequelae. In other words, by covering those pharmacotherapeutics that treat obesity, insurers—including local, state, and federal governments—can forestall the adverse and costly health consequences of chronic obesity, including but not limited to cardiovascular disease, diabetes, and musculoskeletal disorders. ¹⁵ Simulations conducted by Kabiri and colleagues suggest that among the cohort of 217 million Americans aged 25 years or older studied, the use of anti‐obesity medications could generate, conservatively, $1.2 trillion in lifetime societal value—defined as the “net discounted change in earned income, monetized [quality‐adjusted life years], costs of absenteeism and presenteeism due to obesity, and medical spending” because of anti‐obesity medications. ²⁶ However, it is essential to note that per an analysis conducted by the Institute for Clinical and Economic Review, anti‐obesity medications, namely semaglutide, are not cost‐effective at their current prices. ²⁷

At the very least, cost benefit analyses must account for the unintended long‐run benefits of covering anti‐obesity medications. Moreover, such analyses should also consider that not all complications of obesity are equally costly and that the utility gained from receiving anti‐obesity pharmaceuticals is not uniform across all individuals. A first step may be that those at higher risk of complications such as those with type 2 diabetes or cardiovascular disease be granted coverage for anti‐obesity pharmaceuticals initially while the cost of drugs remains high. Targeting coverage to those individuals with the greatest need will expand access to anti‐obesity medications while avoiding the exorbitant cost of covering all uses. Concerning whether anti‐obesity therapeutics coverage will result in adverse selection in the insurance market, these concerns underscore the critical importance of more comprehensive insurance coverage reforms to incentivize, if not outright mandate, the coverage of a larger pool of individuals with diverse risk profiles. Indeed, to augment access to this form of care, it may be necessary to explore bolder reforms to the US health care system, including, for example, a shift to a single‐payer system. Perhaps more realistically, given that the US federal government is now starting to negotiate pharmaceutical prices on behalf of Medicare beneficiaries for the first time since the prescription drug benefit was passed in 2002, anti‐obesity medications could be added to the list of negotiated drugs, potentially reducing their costs and increasing their access. ²⁸

Notwithstanding the need for expanded coverage, we concede that critical safety and efficacy evidence remains empirically uncertain for emerging anti‐obesity pharmaceuticals. In particular, because of the novelty of such medications, long‐term safety and efficacy evidence beyond the 1–2‐year period is still being determined. This reality has likely contributed to slower, more limited FDA approval of these medications—thereby attenuating insurers’ willingness to expand coverage more broadly. Current FDA‐approved drugs, however, include orlistat, phentermine/topiramate, naltrexone/bupropion, liraglutide, semaglutide, tirzepatide (as of November 8, 2023), and setmelanotide ⁷ , ²⁹ For adolescents, the FDA has approved a more limited set of anti‐obesity medications: orlistat, liraglutide, semaglutide, and phentermine/topiramate extended‐release capsules. ³⁰

The mechanisms of the aforementioned anti‐obesity medications are complex and are still actively being researched. Semaglutide, a glucagon‐like peptide (GLP)‐1 analogue, impacts both appetite and satiety. ³¹ Like semaglutide, the recently approved tirzepatide is a GLP‐1 agonist, but it is also a glucose‐dependent insulinotropic polypeptide receptor agonist. ⁷ Setmelanotide, by contrast, activates melanocortin 4 receptors in the paraventricular nucleus of the hypothalamus and in the lateral hypothalamic area, which impacts appetite regulation, but it has also been shown to increase energy expenditure. ³² Orlistat—which is unique in that it does not target reduction in appetite but rather reduces fat absorption through inhibiting pancreatic lipase and gastric lipase—is approved for weight management for adolescents in some countries but, unfortunately, bears gastrointestinal side effects because of the nonabsorbed fats in the intestine. ³³ , ³⁴

Combination phentermine/topiramate—which has faced some regulatory pushback outside the United States—has two separate mechanisms of action. Phentermine stimulates the central nervous system by increasing norepinephrine neurotransmitter release in the hypothalamus, whereas topiramate reduces appetite by affecting gamma amino butyric acid receptors. ³⁵ Notably, the phentermine/topiramate extended release is approved for chronic weight management in the United States—though it was denied marketing approval in the European Union because of the judgment that potential cardiovascular and psychiatric safety concerns outweighed benefits. ³⁶ , ³⁷ Phentermine has not received FDA approval for the long‐term treatment of obesity, primarily because of a lack of large, extended clinical trials and safety concerns in receiving it long term—although a large electronic health record study revealed that such concerns perhaps do not comport with our extant pharmacological knowledge given studies suggesting that receiving phentermine beyond the approved 90 days through off‐labeling usage does not present any increase in risk for cardiovascular disease or adverse events. ³⁵ As these examples demonstrate, there is still a pressing need for long‐term randomized controlled trials to facilitate FDA approval. If we expect insurers and governments to willingly cover a broad range of obesity pharmacotherapies, researchers and clinicians must furnish more high‐quality evidence counseling in favor of these medications’ safety and efficacy. Pharmaceutical companies and the US government must supply increased research funding to do so.

These challenges notwithstanding, expanding anti‐obesity pharmaceuticals is perhaps most critical to enhancing US obesity care because it may positively reshape health care professionals’ perception of the disease. ³⁸ For instance, in the case of setmelanotide, FDA approval allows for use in patients with obesity only if they have one of three genetic conditions that are exceedingly uncommon or even rare (namely, proopiomelanocortin deficiency, proprotein subtilisin/kexin type 1 deficiency, and leptin receptor deficiency). ³⁹ Accordingly, clinicians who wish to prescribe this medication must conduct genetic tests on their patients. At least in theory, such genetic testing may deliver the added benefit of renewing clinicians’ understanding of obesity's hereditary determinants and effectively supplanting the stigmatizing and reductive conception of obesity as merely an individual moral failing. ⁴⁰ , ⁴¹ In other words, highlighting obesity's genetic determinants—as part of a complex web of structural and behavioral factors—may reduce health care professionals’ inclination to deem obesity a condition over which the patient has full control and for which medical care is superfluous. This illuminates the broader symbolic value of expanding access to weight‐loss pharmacotherapies. In doing so, we further medicalize obesity, which dispels the notion that it is wholly a matter of individual choice.

Intensive Behavioral Therapy for People With Obesity

Intensive behavioral therapy (IBT) for people with obesity, which typically focuses on the use of behavioral therapy techniques to facilitate the adoption and maintenance of diet and exercise changes, is a potentially promising tool to encourage enduring positive lifestyle changes among people with obesity. However, recent observational evidence from Dewar and colleagues shows that IBT—at least among Medicare Part B claims for IBT for individual and group visits between 2012 and 2015—is dramatically underutilized. ⁴¹ Indeed, they report that utilization of IBT remained under 1% among the claims analyzed during the study period. ⁴²

Low uptake of IBT for people with obesity may, in part, be attributable to limitations on who can deliver this form of therapy. Current Medicare coverage law restricts the provision of IBT to primary care providers in primary care settings, effectively restricting coverage to the providers with potentially the least obesity training and the least available time to provide such minimally reimbursed services. ⁴³ The aforementioned TROA would tear down this barrier, if enacted, by allowing nonphysicians to deliver this form of care—including clinical psychologists, registered dietitians, or nutrition professionals. ⁴³

To justify the increased utilization of IBT for obesity, further research is imperative. Hill and VanWormer, for instance, report that IBT was “modestly effective,” resulting in approximately 3% weight loss over 1 year for study participants with obesity and type 2 diabetes. ⁴⁴ Another 2021 investigation found behavioral group therapy sessions conducted in person at rural primary care centers showed higher weight loss among patients with obesity within 24 months—though the effect size was admittedly small. ⁴⁵ Likewise, a 2023 study of IBT for weight loss in patients with, or at‐risk of, type 2 diabetes showed IBT was “unlikely to result in clinically significant weight loss.” ⁴⁶ This mixed evidence suggest that, as with some elements of anti‐obesity pharmacotherapies, further research—and, accordingly, private and public research funding—are needed to further and systematically assess the impact of IBT on patients with obesity. Such research is furthermore necessary because of the dependency of IBT for obesity's cost‐effectiveness on clinical effectiveness; only when assuming “maximal intervention effectiveness” does prior research indicate that IBT for obesity would be cost saving on the whole. ⁴⁷

Weight Management Nutrition and Dietary Counseling

Related to cognitive behavioral therapy is weight management nutrition and dietary counseling (WMNDC; sometimes also referred to as medical nutrition therapy), which includes diagnostic, therapy, and counseling services to adjust patients’ nutritional habits, but it is distinct from explicit calorie restrictions placed on patients. WMNDC has been shown to improve a variety of outcomes for patients with obesity. A 2023 systematic review of 73 studies, for instance, found that weight management counseling or education furnished by a dietician reduced patients’ BMI, increased patients’ weight loss, decreased patients’ waist circumference, and likely reduced patients’ both systolic and diastolic blood pressure. ⁴⁸ This review informed a subsequent practice guideline promulgated by the Academy of Nutrition and Dietetics adjudging it “reasonable” for registered dietitian nutritionists to use the “nutrition care process” to provide “client‐centered interventions” based on shared decision making and clinical judgment and individualized to patient's needs. ⁴⁹

Despite WMNDC's demonstrated effectiveness, current US federal law does not explicitly permit coverage of this form of therapy for Medicare beneficiaries with obesity. Instead, under section 1861(s)(2)(V) of the SSA, Medicare Part B is only required to cover nutritional diagnostic, therapy, and counseling services for those beneficiaries with diabetes or renal diseases. ⁵⁰ , ⁵¹ Encouragingly, given the association between obesity and both type 2 diabetes and chronic kidney disease, Medicare Part B at present will effectively cover WMNDC for at least some beneficiaries with obesity. ⁵² , ⁵³ But the fact that a beneficiary must first present with either diabetes or renal disease limits easy access to effective nutritional therapy for many individuals with obesity, particularly in its early stages. Restricting coverage of nutritional therapy to only those with the most severe obesity—although perhaps more cost‐effective—may represent a missed opportunity to prevent future comorbidities for people in earlier stages of the disease.

The lack of coverage of nutritional therapy also extends to many state Medicaid programs, with a 2018 analysis by Jannah and colleagues finding that—despite increasing 133% from 2009 levels—only a minority of states’ Medicaid programs (21 states) indicated any form of coverage of nutritional counseling. ⁵⁴ To augment favorable health outcomes for patients with obesity, treatment must precede the development of obesity‐related health complications. Accordingly, at the very least, Medicare WMNDC coverage laws should be updated to be tied not to obesity‐related complications but rather the clinical definition of the disease itself. Moreover, to prevent beneficiaries from developing obesity in the first place and creating need for additional health care services, it may be prudent to extend coverage of WMNDC to those individuals with overweight but whose BMI does not fall within the range of clinical obesity.

Metabolic and Bariatric Surgery

One of the clearest gaps in care for people with the most severe obesity is the infrequency of metabolic and bariatric surgery (MBS). MBS procedures such as Roux‐en‐Y gastric bypass and sleeve gastrectomy have frequently been shown to be more clinically effective in treating obesity and its complications than nonsurgical obesity treatments. ⁵⁵ Despite strides in improving the safety of MBS, bariatric surgery is only applied to about 1% of all patients who qualify for it under the National Institutes of Health's BMI diagnostic criteria. ⁵⁵ To improve access to this form of care, US health policymakers may find it prudent to heed the suggestions of Chawla and colleagues, which include revising clinical guidelines to promote MBS as a favorable treatment for both obesity and its comorbidities, updating reimbursement and coverage options to reflect the cost‐effectiveness of MBS, and expanding efforts to study the long‐term benefits of MBS. ⁵⁵ Indeed, a key issue facing widespread uptake of MBS is providers’ reluctance to prescribe surgical intervention and patients’ acceptance of it—in addition to the limited number of trained bariatric surgeons. Revising clinical guidelines, along with reimbursement guidelines, may increase both the professional and financial incentives for practitioners to deliver MBS care and for medical students to enter this field. More rigorous evidence of the long‐term effects of MBS may also temper providers’ and patients’ perceptions of risk associated with surgical intervention. On the patient side, expanded coverage may eliminate financial barriers in the way of accepting MBS—though the vast majority of Americans have coverage for this form of surgery, in contrast to anti‐obesity medications. ⁵⁶

The Critical Challenge: Dispelling Stigma

Expanding access to anti‐obesity pharmacotherapies, cognitive behavioral therapy, nutritional therapy, and MBS is a prudent, necessary, and relatively easily implemented policy intervention to augment care for people with obesity. But perhaps the most pervasive and insurmountable barrier to effective care for people with obesity in the United States is deep‐seated weight stigma. Broader populational weight stigma has emerged mainly from the notion that obesity can be almost exclusively attributed to a lack of individual self‐control—an erroneous belief harbored even by many medical professionals. ¹ , ⁵⁷ Critically, these negative preconceptions have a material impact on the care people with obesity receive. Weight stigma has been shown to increase patients’ avoidance of care and mistrust of their clinicians as well as induce providers to spend up to 28% less time educating patients about their health condition, judging these efforts instead as a “waste of time.” ⁵⁸ Stigma may, moreover, exacerbate morbidity and mortality of people with obesity; a 2015 study suggests experiencing weight stigma is associated with a nearly 60% increase in mortality risk. Recent research furthermore intimates that stigma has been associated with disordered eating and comfort eating. ⁵⁹ , ⁶⁰ On the policymaking level, we posit that weight stigma functions similarly: the assumption that individuals with obesity experience the disease because of poor, tractable lifestyle choices implies obesity is merely a personal struggle and not worthy of policymakers’ time. For this reason, we observe very few health policies that forcefully and comprehensively address obesity in the United States

Dislodging weight stigma from the US population's psyche requires undertaking a more ambitious sociocultural effort—one in which clinicians’ and health policymakers’ leadership is vital: shifting the obesity narrative. ⁶¹ Part of this effort includes political leaders promulgating health policy proposals that focus on increasing access to nonbehavioral obesity therapy and clinician–researchers engaging beyond academic circles to educate the broader public about obesity's complex causal pathways and the nature of comprehensive obesity therapy. Policymakers’ and clinicians’ language to describe people with obesity must also be stripped of stigma and shame; instead of using adjectives such as “obese” or “overweight” to describe a person with excess weight, conversations surrounding obesity in the clinical research, policymaking, and public setting must embrace person‐first language that characterizes obesity as a disease that an individual experiences rather than a defining feature of their personhood. To be sure, destigmatizing obesity need not mean denying its status as a disease associated with adverse health consequences but rather encouraging clinicians to develop treatment plans in respectful consultation with patients that leverage the medical care interventions we discuss and that best meet their individualized health needs. As is the case with other chronic diseases such as hypertension and type 2 diabetes, we maintain that treatment for obesity ought to be a continual process that looks beyond merely reducing an individual's weight to be below an arbitrary threshold. By reframing obesity as a disease that cannot merely be ameliorated via individual behavior or self‐control, we give way to the kind of obesity care policy that has, for long enough, eluded the US public health policy landscape.

Funding/Support

F.C.S. is the recipient of National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, grants P30 DK040561, U24 DK132733, and UE5 DK137285.

Conflict of Interest Disclosures

F.C.S. has served as a consultant to Calibrate, GoodRx, Pfizer, Eli Lilly, Boehringer Ingelheim, Gelesis, Vida Health, Life Force, Ilant Health, Melli Cell, and Novo Nordisk.