Being Fat Is Now a Choice

The Trump administration recently presented TrumpRx.gov, a (stunningly beautiful) website that helps Americans find prescription drugs with a coupon discount. Among the dozens listed, what many got excited about were the GLP-1 agonist drugs. These peptide medications, developed to treat type 2 diabetes, also suppress appetite and help lose weight. Hollywood was taken by storm by them in the last few years, but until now, they have been out of reach for most people due to the cost of $1000 to $1350 a month.

Now Americans can purchase these “fat shots” for cheap. $149 a month for Wegovy, $199 for Ozempic, $299 for Zepbound. The same prescriptions ran over a thousand dollars last year, which meant that for all practical purposes, they didn't exist for most Americans. That changed this week.

An obese employee costs their employer $6,472 a year in healthcare, missed work, and reduced output. A GLP-1 prescription costs between $1,800 and $3,600 for the same year. So, an employer who covered the drug for every overweight person on staff would actually spend less money than they currently lose by doing nothing. The prescription saves more than it costs before anyone even steps on a scale.

Then people step on the scale. Semaglutide (the compound in Ozempic and Wegovy) reduces body weight by roughly 15% in the trial data. Tirzepatide, which Eli Lilly sells as Mounjaro and Zepbound, reduces 22.5%. Each kilogram of excess weight lost costs about $590 in annual costs. Sick days, insurance claims, disability filings, all the downstream consequences that economists lump together as economic drag. And those savings recur, because the person stays lighter and healthier. Year after year.

You can do the multiplication yourself. 170 million Americans are overweight or obese. Get a third of them on a GLP-1, and that's 60 million people losing real weight inside of a year. The GDP impact alone would be above 1%, likely in the $300 billion to $1 trillion range, depending on the model you use and how generous you are with the productivity assumptions. The drug more than pays for itself. It's not particularly close.

The strange thing about all of this is that it came as a drug-pricing announcement. The White House said they were reducing costs for patients. Which they did. But what actually happened, sort of by accident, is that a president removed the one remaining obstacle between a hundred and seventy million people and a body they couldn't previously afford to have. The compounds worked fine. Everyone knew they worked. They were just priced for people with good insurance or cash to burn.

I keep turning over the philosophical part of this and not landing anywhere clean.

Discipline is the transformation. I've said that for years, and I mostly still think it. Running five miles every morning for a year while you rebuild the way you eat changes you in a way that swallowing a pill can't match. The person who did the work owns something afterward. I genuinely believe that. But I also think the discipline argument has had fifty years to prove itself at scale, and it hasn't. Gym memberships, diet plans, calorie counts on every menu in America, school lunch reforms, the whole apparatus. None of it moved the number. 170 million and climbing. There’s something wrong with the food, ingredients that make it addictive, formulations engineered for the “sweet spot” that make the taste just right while preventing you from feeling full.

So maybe insisting that the only legitimate route is willpower isn't a position anymore, and technologies designed against the human body (engineered food) need countermeasures.

If a $199 monthly prescription does in six months what decades of moralizing about portion control couldn't manage, the correct reaction to that is probably something closer to relief than disapproval. I think I'm coming around to that view, though it still feels strange to say.

Everybody gets more attractive, too, which isn't in the policy papers but which obviously matters more to most actual humans than a GDP chart does.

Being fat is now a choice. It always was technically, in the same way that beating a bacterial infection was technically a choice before antibiotics. Possible with enough willpower and luck, but unreliable. Now it takes a prescription and a few months. Genetic luck or discipline are no longer prerequisites for being thin, which is a genuinely new situation for the species.

What that does to how we think about effort, merit, health as character, I have no idea. Probably something worth paying attention to over the next decade or so. The economics, though, are already finished. $1.4 trillion a year in costs, a couple of hundred bucks a month in solution. Hard to argue with that math.