Four years ago, I told you the answer was to fix the system from the inside. I want to take that back.

In 2022, I wrote a piece titled "Obesity Care: Past, Present, and Future."

Back then, I argued that the explosion of direct-to-consumer obesity startups was the wrong path — that direct care (or cash-pay services) fragmented treatment, that profit incentives corrupted prescribing, and that the right move was to bring obesity medicine into the existing healthcare system and partner with the stakeholders already inside it. “Our answer is no,” I wrote, about whether B2C was the solution. I believed it.

I was wrong. Not about the disease. About the railways.

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Let me walk back through past, present, and future — and show you where my own thinking broke.

The epidemiology was never the hard part. We have watched this coming for forty years.

Obesity in American adults climbed from roughly 30% at the turn of the millennium to over 42% by 2018. The landmark NEJM projection from Ward and colleagues estimated that by 2030, half of U.S. adults would have obesity^, and nearly one in four would have severe obesity.

And it has never fallen evenly. Obesity tracks a steep socioeconomic gradient — in the latest data, 44.6% of adults with a high-school education or less have obesity, versus 31.6% of those with a bachelor’s degree or more — with the burden landing hardest on lower-income, Black, and Hispanic Americans. The people the disease hits hardest are the same people the payment system serves the worst. Hold onto that. It decides where this story ends.

And it is not a benign condition. In research I helped conduct through the NIH’s All of Us program — one of the largest and most diverse U.S. cohorts ever assembled — obesity carried a steep, graded burden across nearly every organ system, plus a functional toll that almost never enters the coverage debate.

What was harder to explain — what I have spent years trying to explain — is why a disease this prevalent went essentially untreated. The answer is structural, and it starts with a single sentence of law.

When Congress built Medicare Part D in 2003, it carried forward an old exclusion for “agents when used for weight loss” — language written in an era when “diet pills” meant amphetamines and fen-phen. Since the program began, CMS has read that clause to mean that any drug used for weight loss is excluded — full stop — no distinction between treating a person with obesity and a person without it.

So the largest payer in the country was legally barred from covering treatment for one of the most common chronic diseases. Private insurers took their cue from Medicare, as they almost always do. The irony: CMS’s own 2005 rulemaking preamble had said weight-loss agents could be covered for morbid obesity — and the agency then spent two decades interpreting its way out of that position.

In 2013, the AMA House of Delegates formally recognized obesity as a disease requiring treatment. It changed the rhetoric. It changed almost nothing about coverage. By the early 2020s, the most-cited estimate was that only about 2% of eligible patients were receiving evidence-based obesity treatment.

Here is what I got right in 2022: I correctly named the access crisis. Here is what I got wrong: I concluded the fix was to integrate obesity care into the system that built the exclusion in the first place. I wanted to partner with the incumbents. I thought the problem was that obesity sat outside the railways. I had it backward. The railways were the problem.

Then the science detonated.

In TRIUMPH-1, patients on 12 mg of retatrutide — Lilly’s triple GIP/GLP-1/glucagon agonist — lost an average of 70 pounds over 80 weeks, and nearly half crossed the surgical 30% line. Those who started at a BMI of 35 or higher and stayed on therapy reached roughly 30% loss by 104 weeks. (Topline, press-release stage — full data at ADA this month, peer review pending.) Meanwhile, the field went oral: orforglipron reached the market as Foundayo, and an oral semaglutide tablet was approved in January 2026.

Demand did what you would expect. Semaglutide fills rose more than fourfold in three years, and the drugs sat on the FDA shortage list for nearly three years before supply caught up: tirzepatide came off the list in December 2024, and semaglutide in February 2025.

For the first time, something moved in epidemiology, too. The newest NHANES cycle reported adult obesity at 40.3%, and for the first time in two decades, the rate did not increase significantly. I want to be careful here, because the data cannot yet tell us why. The plateau coincides with the GLP-1 era, but coincidence is not causation, and severe obesity still rose from 7.7% to 9.7%, while childhood obesity kept climbing to roughly 21% — the one curve that has not bent. Still, after forty years of a line that only ever went up, the line bent. We finally have tools that work.

And here is the wall.

The most effective medications the field has ever produced entered a payment system structurally designed to ration them. The Medicare exclusion still stands. So the drugs are covered only when relabeled for something else — diabetes, or cardiovascular risk reduction after the SELECT trial earned Wegovy a CV indication in 2024. Prescribe the identical molecule for obesity itself, and Medicare will not pay.

Watch what happened when the system tried to fix this — because this is the whole argument.

In November 2024, CMS proposed reinterpreting the 2003 exclusion to cover anti-obesity medications under Part D and require them in Medicaid. In April 2025, the next administration declined to finalize it, citing a deregulation executive order. In December 2025, CMS came back with a different vehicle — the BALANCE Model and a “GLP-1 Bridge,” voluntary demonstrations rather than a statutory fix. Then, in May 2026, the Part D portion of BALANCE was delayed indefinitely.

Three administrations. Two decades. A bipartisan fix — the Treat and Reduce Obesity Act — has been introduced and left to die in session after session since 2012. The single sentence of the statute was never touched. That is not a system on the verge of reform. That is a system doing exactly what it was built to do.

So why won’t it change? Not because no one wants it to. Because the system is captured — protected by regulation that serves the incumbents, not the patients. A few of the load-bearing mechanisms:

Certificate-of-need laws. Thirty-five states and Washington, D.C., still require providers to prove “need” to a state board — often with existing competitors weighing in — before opening a facility or buying equipment. The federal mandate that created them was repealed in 1987 after the FTC found they raised costs. They survived anyway. Research finds CON states have roughly 30% fewer hospitals per capita. A law sold as cost control is, functionally, an incumbent-protection statute.

Facility fees and the site-of-service differential. Here is the mechanism in its purest form. A health system buys an independent practice, reclassifies it as a “hospital outpatient department,” and bills a facility fee for care delivered in the same room, by the same clinician, to the same patient. For some services, hospital outpatient prices are more than three times the physician office price for the same procedure. Over 40% of physician practices are now hospital-owned. The payment rules do not reward better care. They reward owning the building.

Complication capture. This is the one that should bother every obesity physician. Our system pays generously, reliably, and without prior authorization for the downstream of untreated obesity — the cardiac catheterization, the stroke admission, the joint replacement, and the dialysis chair. In the All of Us cohort, obesity was estimated to account for 52% of obstructive sleep apnea cases, 47% of metabolic dysfunction–associated steatotic liver disease (MASLD), and 36% of type 2 diabetes cases at the population level. In other words, obesity is not simply associated with these conditions—it may be responsible for a substantial proportion of the total disease burden observed in the United States. It fights tooth and nail against paying for the inexpensive outpatient drug that would have prevented all of it. The acute, billable complication is the system’s product. Prevention is its loss leader. A captured system has no incentive to prevent the disease whose complications it monetizes.

I spent years arguing we should bring obesity care into this. Partner with these stakeholders. Run obesity treatment along these railways. I now think that was the most naive thing I have written. You cannot reform a machine by feeding yourself into it.

The alternative is direct care — transparent, cash-pay treatment that operates entirely outside the third-party-payer maze. No facility fee. No PBM spread. A price the patient can see before they say yes. And it is already happening: direct and concierge primary-care sites grew 83% between 2018 and 2023, spawning a parallel direct-specialty-care movement. Directly priced semaglutide and tirzepatide are growing in popularity. Oral agents lower the cost of delivery further.

Now — the honest objection, the one I raised against B2C in 2022, and the one I owe you a real answer to. Isn’t direct care just care for people who can pay? High-fee concierge medicine, yes — that genuinely narrows access, and the researchers documenting this growth warn it can worsen shortages for everyone else. But that is not the only direct model, and it is not the one that matters here. A low-overhead, cash-pay practice that strips out facility fees, billing departments, and rebate games can offer a lower real price than the insured maze, which, for the millions of uninsured and underinsured — disproportionately the lower-income, Black, and Hispanic patients the disease already hits hardest — is not less access but more. The question was never cash versus insurance. It was a transparent price versus a hidden rent.

I changed my mind because the evidence did. The drugs work. The system had two decades and three administrations to let people use it, and chose not to. I am not willing to keep waiting on the railways.

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