GLP-1 coverage debate mirrors century of public health shifts

The dispute over whether insurers should reimburse GLP-1 drugs such as Ozempic and Wegovy has reignited a long-running American argument about why people get sick: is illness primarily a matter of personal discipline, or the byproduct of social and economic conditions in which people live?

This debate sits atop a century of public health policy and research that repeatedly pits individual behavior against structural context. In the early 20th century, U.S. public health officials treated disease as a collective problem rooted in contaminated water, overcrowded housing, and inadequate sanitation. Local health departments inspected milk, enforced housing codes, and built sewer systems and municipal water works because evidence showed that contamination and crowding—not household virtue—drove illness. Public sanitation and infrastructure were framed as communal responsibilities, not private moral duties.

The consensus began to fray in the late 1940s and 1950s as investigators, politicians, and journalists increasingly linked chronic disease to individual behaviors. The rise of “risk factor” epidemiology reframed illness as the product of choices such as smoking, diet, and physical activity. The Framingham Heart Study, which began in 1948 with more than 5,000 residents of a Boston suburb, helped crystallize this shift by identifying modifiable risk factors that predicted heart disease, while also noting that socioeconomic and environmental factors influenced outcomes. Health education materials followed suit, urging Americans to quit smoking, eat less fat, and exercise, even as researchers acknowledged that housing, work conditions, and access to healthy foods also shaped health.

As the Cold War era intensified the public emphasis on bodily discipline, public messaging linked national strength to the ability of citizens to maintain fit, active lives. The era produced a broader narrative in which chronic disease became something individuals could and should prevent through self-control and lifestyle choices. The President’s Council on Physical Fitness promoted exercise as a civic virtue, and educational films dramatized the consequences of personal neglect. Public health agencies adopted a similar frame in later decades; the Healthy People initiative, for instance, framed chronic disease prevention as a matter of individual behavior change, thereby avoiding or deflecting more sweeping structural reforms.

Policy shifts in the late 20th century reinforced this orientation. Corporate debates around smoking—where tobacco companies framed smoking as “freedom of choice” and public health advocacy prioritized personal responsibility—became a template for how obesity and weight management would be discussed publicly. Governments increasingly moved to policies that shaped individual choices, such as regulating access to tobacco, promoting physical activity, and, in some cases, imposing work requirements in public programs. At the same time, researchers documented that neighborhood design, food availability, income, and stress could trump willpower in shaping weight and health outcomes. Global studies consistently showed that obesity tends to cluster in areas marked by economic inequality, suggesting that structural factors often drive weight trends more than personal preferences.

These historical currents illuminate why the GLP-1 debate has become a flashpoint beyond drug pricing or efficacy. Critics argue that reliance on potent, high-cost medications for weight loss signals a shortcut around the hard work of diet and exercise and could exacerbate inequities if coverage is uneven. Supporters contend that obesity and related diseases arise from entrenched social conditions—access to healthy food, safe neighborhoods for physical activity, adequate income, and chronic stress—that medications alone cannot fix. They point to decades of public health research showing that environmental and policy interventions, not just individual behavior, have yielded the greatest health gains.

In the contemporary policy arena, the tension is sharpened by evidence about the multifactorial roots of obesity and the reality that socioeconomic status shapes access to care. Obesity remains more prevalent in settings with economic disparity and limited resources, where the built environment constrains healthy choices as much as personal preferences constrain them. Even as scientists refine GLP-1 therapies and insurers weigh coverage decisions, the underlying question remains: should health policy primarily reward individual restraint, or should it prioritize interventions that change the conditions people live in?

This question is not new. The historical arc traced in contemporary scholarship suggests that the greatest public health advances often come from addressing environments rather than blaming individuals. Treatments and medicines can save lives, but they cannot by themselves erase the social determinants that shape who gets sick and who has access to care. The debate over GLP-1s thus sits at a crossroads of medicine, policy, and history: a reminder that modern health outcomes reflect a long, contested history of how society defines responsibility for health.

The essay from which these observations are drawn situates the GLP-1 discussion within a broader narrative about how public health has evolved in the United States. Zachary W. Schulz, PhD, EdS, MPH, a historian of public health and senior lecturer at Auburn University, frames these tensions as part of a century-long pattern. Made by History carries this analysis as a lens on headlines, underscoring that many of the most effective public health interventions addressed the environments in which people lived—clean water, housing standards, and workplace protections—rather than placing the onus entirely on individuals. Read More: Medicare Will Not Cover GLP-1 Drugs for Weight Loss.