For years, employer health strategies have largely been built around two populations: employees who are generally healthy and may engage with wellness programs designed to help them stay that way, and employees with diagnosed conditions who may qualify for disease management or more intensive clinical support.
But what happens to those in between?
Consider the employee whose weight has been gradually increasing, whose blood pressure is starting to creep up, or who is noticing changes in mobility, sleep, or energy, but who doesn’t yet have a diagnosis that puts them on the radar of a disease management program. Nearly 40% of U.S. adults have obesity, which means this “in between” population isn’t a fringe case. It’s a substantial share of most employer populations, and a general wellness program may not be enough for them, yet they don’t qualify for disease management either.
As employers navigate rising GLP-1 utilization, increasing treatment options, and growing pressure to manage total healthcare costs, the “missing middle” population deserves a closer look.
The problem isn’t that wellness or disease management don’t work
Wellness and disease management each have an important role to play. The problem is that weight-related risks don’t always follow the same path as traditional health conditions.
Risk can build gradually, across multiple aspects of health, long before an employee appears in a high-cost claim. Weight-related risk can intersect with cardiometabolic health, mobility, sleep, and other aspects of well-being without fitting neatly into a single diagnosis or benefit category. Obesity is a root cause of several of the most expensive chronic conditions employers pay to manage, which is exactly why it’s so easy to underestimate until those downstream conditions have already developed.
That creates a population that is surprisingly easy to miss: they may not see themselves as “high risk,” their claims may not signal an immediate concern, and they may not see a traditional wellness program as relevant to what they’re experiencing. The distance between “generally healthy” and “managing a diagnosed condition” is where risk can quietly accumulate and where the people driving tomorrow’s healthcare costs aren’t necessarily the people generating the highest costs today.
GLP-1s have made the opportunity gap harder to ignore
The rise of GLP-1 medications has changed the weight health conversation for employers. GLP-1s now make up nearly 20% of employers’ total prescription drug costs, and prescription drug costs overall are rising 13–15% annually — a pace of change that can obscure the real conversation employers need to have about total cost of care.
Medication utilization and spend have become impossible to treat as a narrow pharmacy issue. But focusing only on the medication itself can obscure a larger question: what is happening with the population before someone ever gets to the point of needing or seeking medication? Medication alone isn’t a complete answer either. An estimated 65% of patients without type 2 diabetes discontinue GLP-1 use within the first year, and many who stop, regain the weight.
GLP-1s don’t make the missing middle less important. In many ways, they make it more consequential. Employers are now balancing several priorities at once: providing appropriate access to effective medications, managing rapidly changing costs, supporting employees who choose different approaches, and thinking about the health risks that may develop over time. The medication-versus-lifestyle debate can be a false choice. The real opportunity is a benefits strategy that supports different people with different needs at different points along the health continuum, all at once.
So, who is in the missing middle?
There isn’t a single profile. That’s part of what makes this population so easy to overlook.
Someone in the middle might be experiencing early or emerging risk without a formal diagnosis. They might be struggling with weight despite previous attempts to change their habits. They might have risk factors that aren’t yet driving significant claims. Or they may simply recognize that something about their health has changed and want more support than a traditional wellness offering provides.
The common thread isn’t a particular diagnosis. It’s that their needs have outgrown a one-size-fits-all approach but haven’t yet triggered a more intensive level of care.
That creates an opportunity for employers to think earlier: not just “Who is costing us the most today?” but “Who may need more support today to avoid a more complicated health journey tomorrow?” That’s a very different way of looking at population health.
Four questions employers can ask about the gap
Finding the missing middle requires looking more broadly at how a benefits strategy is designed and where employees are or aren’t engaging. Here are four places to start:
1. Who aren’t our current programs reaching?
Look beyond participation rates. Consider whether employees with meaningful weight-related risk are engaging with either wellness or disease management, and what might be keeping them from doing so.
2. What happens before a diagnosis?
Consider the support available between “generally healthy” and “clinically diagnosed.” Is there a meaningful path for someone whose needs are emerging but not yet acute?
3. Are we offering meaningful choices?
Different employees will have different needs, preferences, and motivations. A strategy that assumes everyone needs the same intervention may miss opportunities to engage people earlier and more effectively.
4. Can our strategy adapt?
New medications, evolving evidence, and changing employee expectations will continue to shape what effective care looks like. A benefit strategy built around one intervention or one moment in time may struggle to keep up.
Think continuum, not ladder
The traditional benefits model suggests a progression:
Well → At risk → Diagnosed → Disease management
But real people’s health journeys aren’t always that linear. Weight-related risk can emerge gradually, someone can move in and out of different levels of need, and the intervention that makes sense today may not be the one that fits six months or two years from now.
That means employers need to move beyond finding the right weight management benefit and focus instead on identifying the right person for the right care to deliver the right outcomes at the right cost.
It’s tempting to respond to this gap by adding another point solution. But the answer isn’t another wellness program, broader GLP-1 coverage, or disease management alone. It’s a strategy that identifies risk earlier, connects different types of support, and lets employees move through care as their needs change.
The missing middle is only the beginning
The benefits blind spot is easy to miss because the people in it don’t look like a traditional high-risk population. But that’s precisely why they’re worth paying attention to.
The opportunity isn’t just to manage today’s utilization. It’s to understand where risk is developing and what support employees need before that risk becomes harder and more expensive to address. The question for employers is no longer whether to offer wellness, disease management, or GLP-1 access. It’s how those pieces work together to support different people, different needs, and different points along the full spectrum of weight health.
Want a weight-loss benefit strategy that reaches the missing middle?
The employees hiding in that gap between wellness and disease management won’t stay invisible forever. Their risk will eventually surface, just later and at a much higher cost. Organizations that close this blind spot now, rather than waiting for it to show up in a claims report, are the ones who will bend their cost curve over the next 2–5 years, instead of just reacting to it.
Build your organization’s benefits playbook with Wondr Health. Connect with our team to identify your missing middle and explore a personalized weight management strategy at wondrhealth.com.
