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What if I told you there’s a drug that treats obesity, diabetes, heart disease, sleep apnea, alcohol addiction, and possibly even Alzheimer’s? It sounds like snake oil from a late-night infomercial. Except it’s completely real.

These are GLP-1 agonist medications—drugs like Ozempic, Wegovy, and Mounjaro—and they might be the most powerful class of medications developed in decades. There’s just one problem: at current prices, using them for everyone who could benefit would cost our healthcare system $360 billion annually. That’s money we simply don’t have.

The Drugs That Changed Everything

For years as a physician, I’ve watched patients struggle with weight loss. The typical story goes like this: try every diet imaginable, lose 20 or 30 pounds, feel the overwhelming urge to eat return, and gain it all back—plus more. Some patients joke that they’ve “lost a thousand pounds” over their lifetime, but of course, they’ve also regained a thousand pounds.

I used to think this was about willpower. Eat less, exercise more, try harder. It seemed so simple.

Then GLP-1 drugs arrived, and they taught me I was completely wrong.

These medications work differently than anything we’ve had before. Yes, they help regulate blood sugar—that’s why they were initially developed for diabetics. But their weight loss effects come from three key mechanisms:

First, they slow food from leaving your stomach, creating a genuine sense of fullness. Second, they affect brain satiety centers, likely through dopamine pathways, reducing how hungry you feel. Third—and this is what patients describe as life-changing—they eliminate “food noise,” those constant thoughts about your next meal.

Patients who struggled for decades suddenly report that within days of starting these drugs, they just… stop thinking about food constantly. The cravings disappear. And the weight starts coming off.

The Clinical Evidence

The randomized trials are impressive. In the STEP trial, patients weighing an average of 220 pounds lost about 15% of their body weight—roughly 35 pounds—over two years. When Eli Lilly did something almost unprecedented and compared their drug Monjaro directly to competitor Ozempic in the SURMOUNT trial (most companies only compare to placebo because it’s easier to win), Monjaro patients lost 20% of their body weight while Ozempic patients lost 14%.

In late 2024, the FDA approved an oral version of Ozempic. In the OASIS-1 trial, patients lost about 13% of their body weight. The oral versions appear to work, though perhaps they’re one-third less powerful than the injections.

Beyond weight loss, these drugs are showing promise for conditions that may or may not be directly related to obesity. Sleep apnea and arthritis likely improve simply because patients lose significant weight. But improvements in heart attack risk and liver damage seem independent of weight loss—the drugs may have direct effects on blood vessels and inflammation. The SELECT trial demonstrated that semaglutide reduces major cardiovascular events by 20%.

Perhaps most intriguing: a large Swedish population study found that patients on GLP-1 drugs had 30% fewer hospitalizations for alcohol-related issues. Since these drugs reduce food cravings, they appear to reduce other cravings too.

The Reality Check: Side Effects and Discontinuation

Before we crown these as miracle drugs, we need to talk about the downsides.

The most common side effects are gastrointestinal: nausea, vomiting, diarrhea, and constipation. For most people, these improve over time—but not always. More serious risks include pancreatitis, gallbladder problems, thyroid cancer, and optic nerve damage.

The most concerning issue for nearly everyone is muscle loss. About one-third of the weight people lose may be muscle mass. If you lose 25 pounds, that could mean losing 8 pounds of muscle. This is especially problematic for older adults who are already losing muscle naturally. Anyone taking these drugs should do strength training and ensure adequate protein intake.

But here’s the biggest problem: many people quit. In real-world use (not carefully monitored clinical trials), about 65% of people taking these drugs for weight loss stop within a year. Even diabetics, who presumably have stronger motivation since it’s treating their disease, have a 47% discontinuation rate.

The reason? Side effects, cost, and the hassle of weekly injections.

And when people stop, the weight comes back. About two-thirds of lost weight returns. If you initially lost 30 to 50 pounds, you might ultimately keep off only 10 to 15 pounds—or possibly nothing at all.

For most people, these drugs represent a lifetime commitment.

The $360 Billion Question

This brings us to the economic crisis that Dr. David Rind and I discussed on my podcast. David is Chief Medical Officer at the Institute for Clinical and Economic Review (ICER), an organization that analyzes whether drug prices are fair both for individuals and society.

On an individual level, the math actually works. At current negotiated prices of $300-500 per month (down from initial prices of $500-1,000), these drugs provide good value. Using standard health economics metrics that value a year of healthy life at $100,000-150,000, the benefits—weight loss, reduced heart attacks and strokes, less diabetes, longer life—justify the cost per person.

David’s analysis found that these drugs are reasonably priced, which is rare for new medications in the United States. Monjaro, at newly negotiated government prices, might actually be cost-saving over a lifetime when you factor in avoided heart attacks, strokes, and other complications.

But here’s where individual math and societal math diverge catastrophically.

About 100 million Americans have a BMI of 30 or greater, qualifying them as obese. Many millions more are overweight with conditions like sleep apnea or arthritis that would make them candidates for these drugs. If we multiply even a conservative $3,600 annual cost by 100 million people, we get $360 billion per year.

Our healthcare system doesn’t have an extra $360 billion lying around. That’s why insurance companies, even though they recognize these drugs work and are fairly priced, are desperate to limit access. Without restrictions, premiums would skyrocket.

Possible Solutions

So what do we do? David suggested several creative approaches:

Subscription Model: The government could guarantee pharmaceutical companies perhaps $50 billion annually each in exchange for unlimited doses. No prior authorizations, no negotiations, no sales forces. Just a guaranteed revenue stream and access for everyone who needs the drugs.

Healthcare Bonds: Like any major infrastructure investment where benefits accrue over decades, the government could issue bonds specifically to fund GLP-1 access, recognizing that we’re paying upfront for long-term savings.

Competition: As more drugs enter the market, prices might drop naturally. But this could take 5-10 years, leaving millions without access in the meantime.

Calorie Tax: Perhaps most provocatively, we could tax the high-calorie, hyper-palatable foods that created our obesity epidemic to fund the drugs that treat it. Food manufacturers have engineered products to be almost addictive—why not make them help pay for the solution?

The Bottom Line

Are GLP-1 drugs miracles? For some patients, absolutely. They provide relief from decades of struggle in ways nothing else could. They’re teaching us that obesity is far more complex than “calories in, calories out” and that brain chemistry plays a huge role.

But they’re not perfect. They have side effects, many people quit, and the weight usually returns when you stop. They require a lifetime commitment.

And even though they’re fairly priced per person, we face an unprecedented challenge: how do we provide access to drugs that could help 100 million Americans when treating everyone would require money our healthcare system doesn’t have?

We need bold thinking. Subscription models, new financing mechanisms, calorie taxes—something beyond our current approach. Because right now, we have drugs that work remarkably well at prices that are individually fair, yet societally impossible.

That’s a problem that demands solutions as innovative as the drugs themselves.

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Related Episodes:

• Episode 4: Nutrition Fundamentals
• Episode 15: Weight Loss Strategies
• Episode 49: What You Eat Affects How Much You Eat

Claude is AI and can make mistakes.
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