Exercise is medicine. Your mom believes it, your doctor believes it, even insurance companies believe it. It’s one of the few things in healthcare that’s universally agreed upon.
So if exercise is medicine, why isn’t it part of healthcare and covered by your health insurance? While that answer is certainly not universally agreed on, I’ll explain why the lack of coverage for exercise is the norm and what is being done about it.
Exercise is Medicine: A Brief History
The idea that exercise is medicine isn’t new, but it hasn’t always been accepted. As recently as the 1960’s, there were significant questions about both the safety and effectiveness of exercise. In fact, the Dallas Board of Censures even considered revoking the medical license of Dr. Kenneth Cooper (considered the “Father of Aerobics”) in the late 60s’, for conducting treadmill tests on people with heart disease. We’ve certainly come a long way since then, but maybe not far enough.
Currently exercise does play a role in the healthcare ecosystem. Physical therapy is supervised exercise for individuals with orthopedic issues. Cardiac and pulmonary rehab is a form of supervised exercise for individuals with more severe heart and lung issues. Both forms of supervised exercise are widely accepted as both safe and effective for addressing medical issues through exercise. Sadly, that’s the extent of where exercise is embedded into healthcare and therefore reimbursed by insurance.
Consider this: 90% of America’s $5 trillion dollar healthcare spend is dedicated to treating chronic disease, and exercise is one of the most effective interventions we have for addressing those conditions. If exercise is medicine for chronic disease, making supervised exercise a reimbursable service should be straightforward. Yet several systemic and related barriers have limited its coverage by insurance and integration into healthcare.
Barrier #1 — Fitness Industry Stigma
The most visible manifestation of exercise in modern culture is the fitness industry, and it has done itself no favors in terms of being taken as a legitimate part of the healthcare delivery system. Research consistently finds that both healthcare providers and the American public have significant distrust of the fitness industry. This is very likely why only about 20-25% of the American population actually engages with the industry.
This trust comes through multiple vectors. First, the industry has long been known for complicated and opaque billing practices. I’m sure many people reading this article found themselves locked into a gym membership they couldn’t get out of no matter how hard they tried. Some might remember being taken to collections by the (now defunct) Bally Total Fitness and its contemporaries back in the 90s. These deceptive billing practices left a stain on the industry that’s been hard to shake.
Next the industry has greatly overindexed on serving the already fit and already healthy. If you walk into most local gyms it’s more common to see the majority of members are fairly fit and fairly healthy. The research would also back up your visual scan.
This makes the traditional gym environment not feel very welcoming for people who aren’t already fit and healthy. This lack of inclusivity has been further exacerbated by the imagery most gyms use on their websites and social media. The overwhelming majority of these images feature young, fit, and often caucasian men and women exercising in very little clothing, all while showing off their physiques. While some in the fitness industry may call this aspirational marketing, I’d call it the fastest way to loudly say your environment is not inclusive to people of all shapes, sizes, and fitness levels.
Going further, the fitness industry has always hyperfocused on body composition and scale weight as the most important outcome they can help people achieve. You’ve seen the ads about getting ripped for summer or the before and after pictures that only emphasize the way someone looks. Exercise is about so much more than how someone looks. In fact, how someone looks is a side effect of exercise (it’s more of a direct effect of nutrition and genetics than exercise). The direct effect of exercise is we function better and we get healthier. But before and after pictures and weight loss challenges elevated by the fitness industry doesn’t suggest health. It suggests an idealistic aesthetic that can often be counter to overall health.
Lastly, the professional credentialing in the industry is a complex web of “certification” organizations that make up a big bowl of alphabet soup. ACSM, NSCA, ACE, NASM, ISSA, AFAA. Believe it or not the list could go on, given that there are about 20 organizations that “certify” personal trainers. This confusing professional credentialing system further sows distrust with the American public and the healthcare industry. I’m pretty sure most people would not be comfortable going to a doctor who was professionally trained by one of 20 organizations.
Barrier #2 — Lack of Data on Cost Effectiveness
As I said at the start of this article, we all agree exercise is effective at improving functional capacity and health. There have been literally millions of publications on what can simply be called exercise efficacy. Exercise does, indeed, have the ability to produce a desired or intended result for pretty much anyone, and that is the very definition of efficacy. The rate and magnitude of those results certainly varies from person to person, but the good news is no one is truly a non-responder to exercise. Simply put, if you exercise consistently, you will get healthier, but that’s not the question that needs to be answered for insurance to pay for exercise. The question to be answered for that to happen is around cost effectiveness.
In medicine, cost effectiveness looks at the amount of money spent on an intervention (a drug, surgery, physical therapy, etc.) and how much money the intervention can reduce future healthcare costs by. If for every dollar spent, you save more than a dollar (hopefully a lot more) it’s considered cost effective. If for every dollar spent healthcare costs are reduced by less than a dollar, it’s not considered cost effective.
Here’s a way to think about what that looks like in practice: if a $200-per-month supervised exercise program keeps one diabetic patient from a $30,000 hospitalization, that’s cost effective. But we’ve barely studied that question. A recently published study found only 8 individual research studies that explored cost effectiveness of supervised exercise directly within the American healthcare system. Millions of studies on efficacy, 8 on cost effectiveness.
Policymakers and insurance providers are asking for the financial evidence, and the research community hasn’t delivered it yet. This policy-driven research is the key to treating exercise as medicine within the healthcare system.
While those may sound like significant barriers, there is also significant work underway to overcome them. And the ask is more bounded than you might think. Physical therapy and cardiac rehab are already forms of supervised exercise covered by insurance. The goal is to extend that existing model to its logical next application: supervised exercise as a reimbursable service for the tens of millions of Americans living with chronic disease.
What’s Being Done About It
The Physical Activity Alliance is a national nonprofit that works with the federal government on physical activity policy and systems change. In full disclosure I am the current president of the PAA and this gives me a direct line of sight into how we’re addressing these barriers.
The PAA’s signature initiative called It’s Time to Move is a multi-year, multi-pronged effort to embed exercise assessment, prescription, and referral as a standard of care in medicine. The PAA has worked with federal agencies to make assessment of exercise a required vital sign in electronic health records. This requirement will go into effect in 2028. That means, just like your weight, height, and blood pressure; your doctor should ask you how much exercise you’re doing.
Furthermore, PAA has been working with the Centers for Medicare and Medicaid Services (CMS) on the benefit design for supervised exercise delivered by qualified exercise professionals. Given that CMS pays for approximately 50% of the healthcare in America, this is a huge step forward. In 2026, an innovation model was released from CMS that requires nutrition or exercise to be part of the program. The federal government is beginning to understand the power of exercise to control healthcare costs.
PAA has also been working with its partners at the Coalition for the Registry of Exercise Professionals (CREP) to unify professional credentialing standards and create a national registry (similar to what exists for registered dieticians and registered nurses) to verify professionals are adequately qualified. Doing so will start to eliminate confusion regarding credentialing and improve trust with healthcare providers and the American public.
Finally, while not insurance-related directly, PAA has been working with the Health and Fitness Association (the trade association for the fitness industry) to pass legislation to allow for exercise expenses to be covered by Health Savings Accounts (HSAs). This legislation nearly became law in the One Big Beautiful Bill Act of 2025, but just fell short. There is a strong chance it will become law in the future thanks to the tireless efforts of many dedicated industry advocates and congressional supporters, including current Senate Majority Leader John Thune.
The Take Home Message — If Exercise is Medicine, Healthcare Has to Treat It That Way
Healthcare costs continue to spiral. They were the driving force behind the longest government shutdown in American history last fall. Costs are consistently outpacing inflation. Employers and the government are shifting more of the burden onto consumers via higher insurance premiums, deductibles, and other forms of cost sharing. Medical debt is the leading cause of personal bankruptcy in America.
People want to reclaim ownership of their health. Businesses want to help employees do the same, both to increase productivity and to reduce spend. The government is starting to weigh the tradeoffs it has to make: infrastructure, education, military defense, healthcare. There’s only so much money to go around, and the costs keep climbing.
The good news is that the path forward is already being built. Exercise assessment in electronic health records by 2028. CMS innovation models that include exercise. A unified credentialing registry. HSA coverage for exercise expenses. These are concrete, measurable steps, and they’re happening now.
The next five years will mark a meaningful shift in how we treat exercise as medicine within healthcare. It is long overdue. And regardless of what happens with insurance reimbursement and other subsidies, if you want to take control of your health and your healthcare costs, exercise remains one of the best interventions we have.
In the meantime, there are things you can do right now: ask your doctor about an exercise prescription, talk to your employer about wellness benefits, and contact your elected representatives to support HSA legislation for exercise. Exercise is medicine. The system is finally starting to recognize that. You can help it move faster.
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