The Century-Long Debate Over GLP-1s and Health Responsibility

The debate over whether insurers should cover GLP-1 medications such as Ozempic and Wegovy has revived a long standing American argument about why people become sick. Some commentators describe these drugs as shortcuts for people who lack the will to exercise or control their diets, warning that patients may be turning to GLP-1s instead of making lasting changes. Others counter that decades of research show income, food access, neighborhood design, and chronic stress shape body weight far more than personal resolve. At stake is a larger question: is health primarily a matter of personal discipline, or a byproduct of the social and economic conditions in which people live?

This debate sits within a longer arc of U.S. public health history. In the early 20th century, officials treated disease as a collective problem tied to contaminated water, overcrowded housing, and inadequate sanitation. Municipal inspections of milk, housing codes, and sanitation projects expanded sewer networks and water filtration, reflecting a belief that protecting health was a public responsibility rather than a private matter. The consensus began to fray in the late 1940s and 1950s as public health officials, politicians, and journalists increasingly framed illness as the result of individual choices that could be measured, governed, and moralized.

The Framingham Heart Study, begun in 1948 in a Boston suburb, epitomized the shift toward what epidemiologists later called modifiable risk factors. By following more than 5,000 residents for decades, the study helped identify smoking, high blood pressure, and physical inactivity as key predictors of heart disease. It also documented how socioeconomic and environmental factors shape disease risk. Health education campaigns adopted this vocabulary, urging Americans to quit smoking, reduce fat intake, and exercise regularly. This mid-century emphasis on behavior avoided confronting broader social constraints such as housing and work conditions that influence health.

The Cold War era reinforced the link between disciplined bodies and national strength. Public messaging encouraged physical fitness as both healthy behavior and a civic obligation. A widely used filmstrip, The Smoking Machine, illustrated how tobacco use could ruin lungs, while the Presidents Council on Physical Fitness cast exercise as a patriotic duty. Public health agencies embraced a framework that prioritized individual action, a stance that carried into later programs like the Healthy People initiative in the 1970s and beyond. Corporate strategy also followed suit: tobacco companies, facing mounting evidence of harm, stressed freedom of choice and personal responsibility; later, food and beverage interests adopted similar tactics as obesity drew attention.

By the 1980s, the political climate favored smaller government and market based approaches. The birth of a more expansive personal responsibility rhetoric coincided with policy moves that limited welfare spending and promoted behavioral expectations as conditions for aid. The Behavioral Risk Factor Surveillance System, created by the CDC, anchored national surveillance on self reported lifestyle factors, reinforcing the narrative that lifestyle choices largely drove chronic disease. In Medicaid, work requirements proposed by some states and echoed in national proposals sought to tie access to care to demonstrated responsibility, a stance associated with studies that showed mixed or modest gains in employment and health when such requirements were enacted.

Obesity thus emerged as a focal point where the tension between personal responsibility and structural determinants played out in real time. While many studies highlight how neighborhood design, food availability, and economic constraints shape weight patterns, public messaging frequently frames obesity as a failure of willpower. Global research, too, points to inequality as a major driver of obesity, suggesting that policy interventions aimed at improving living conditions yield substantial health gains.

The debate over GLP-1 drugs now intersects these long running questions. The drugs, expensive and transformative for some patients, have become a cultural flashpoint not only because of cost or efficacy but because they test deeply held beliefs about whether illness signals personal fault or a response to social conditions. History shows that the most durable public health gains have often come from altering environments such as clean water, safer housing, healthy work conditions, rather than solely exhorting individuals to change their behavior. If policy makers want to improve population health in the era of GLP-1s, they may need to pursue models that balance access to effective medical therapies with broader strategies that address the social determinants of health.