Christina Applegate, the actor who has been one of the most visible faces of multiple sclerosis since her 2021 diagnosis, made a stunning revelation this week: She does not have MS after all. And her doctors still don’t know what is causing her debilitating symptoms.

“I’m back at square one,” Applegate told fellow actor Jamie Lynn Sigler, who does have MS, on Sigler’s podcast MeSsy. “I was not happy at all. Everybody else was so happy.”

It is a harrowing predicament for Applegate, and hopefully her medical team is able to get her the diagnosis and treatment she needs. But the fact is, her experience is not unique. Even as more and more Americans get diagnosed with multiple sclerosis, misdiagnosis remains all too common. According to one meta-analysis, roughly 15 percent of MS diagnoses may actually be false positives.

How could such a common medical condition — roughly 1 million Americans are living with the disease, about one in every 350 people — remain such a mystery? After Applegate’s announcement, I called some leading experts on MS to ask why diagnosing the disease is such a challenge, and what they want people to know. Here’s what I learned.

Why MS can be challenging to diagnose

Multiple sclerosis is an autoimmune condition: The body mistakenly attacks cells meant to protect your brain and spinal cord, and the resulting damage interrupts nerve signals and causes the disease’s telltale symptoms of motor impairment, tingling sensations, and vision problems. Some people experience a rollercoaster of relapses and remissions; others see the disease steadily progress, eventually leading to serious disability.

The reality is, scientists still don’t really know what causes MS to develop, said Dr. Andrew Solomon, a neurologist at the University of Vermont who specializes in MS. Smoking is a known risk factor. Obesity and metabolic problems play a role, but we need more research. Even the precise role of genetics remains something of a mystery. “We don’t really know what causes or triggers the autoimmune response in any given individual,” Solomon said. 

And that’s where the challenge in diagnosing it begins.

First, the testing can be imprecise; there is not a single test that reliably diagnoses MS. If a doctor suspects their patient may have MS, they usually undergo an MRI, which their physicians then scour for lesions that are typically associated with the disease. But those scans are still subject to interpretation: Other rare conditions sometimes resemble MS in imaging, as can diseases of blood vessels in the brain. You can also receive a spinal fluid analysis to check for abnormalities in your immune system, which the vast majority of MS patients have.

The nature of MS symptoms adds to the difficulty. They can often be vague early on: brain fog or fatigue or a general malaise. The tingling or vision problems can be similar to symptoms for other conditions that are not MS, and they are easily dismissed if they go into temporary remission, as often happens during the initial phases of the disease.

“Neurological symptoms sometimes can be vague — numbness, pins and needles — and it’s usually short-lived,” Dr. Saud Sadiq, chief research scientist and director of the Tisch Multiple Sclerosis Research Center of New York, told me. “Unless they’re taken seriously initially, they may be ignored because by the time the patient goes through the healthcare system and is actually referred to a neurologist, the symptoms have abated.”

If your doctor is diagnosing you with MS, ask directly: What’s the evidence?

One 2025 study by Solomon and his colleagues found that 40 percent of people who had later been diagnosed with multiple sclerosis were initially misdiagnosed with a different disease.

“Because it’s so heterogeneous, it doesn’t present in the same way in everybody and can have varying severity, it can be hard to diagnose sometimes,” Solomon said.

Lastly, when people are experiencing debilitating symptoms, there is pressure to deliver some diagnosis — and that may push some doctors to leap to MS even if they are not sure, Solomon said. The recent advent of effective treatments that help manage the disease’s symptoms, especially when it is caught early, may add to that pressure, even if the better course would be to continue monitoring the person before they start a medication.

“There may be a lot of clinicians who, if they can’t find a better explanation than MS, may be inclined to diagnose MS, even if they don’t really meet our diagnostic criteria, because they’re worried about missing a window of opportunity to treat somebody,” Solomon said.

There is reason to hope the MS misdiagnosis problem could get better. The National Multiple Sclerosis Society released new diagnostic criteria in 2024 that Solomon said more physicians should become familiar with to better distinguish MS from problems like migraines or vascular disease. And because imaging is involved in diagnosis, there is optimism that AI could be a powerful new tool in delivering more accurate results.

What everyone should know about MS symptoms and diagnosis

The good news is that MS, when diagnosed properly, is a treatable condition these days. “The prognosis with new drugs is extremely good for long-term care,” Sadiq told me. “If patients stick to treatment at a good MS center, you can look forward to a life without disability in 2026.”

So it is worth being vigilant and talking to your doctor if you experience any concerning symptoms. You should seek care if you have numbness or pins and needles that persists for more than 24 to 48 hours, Sadiq said, or have motor problems, like one hand won’t work as you try to play piano. Dr. Annette Langer-Gould, who develops and evaluates programs for MS care at Kaiser Permanente, said numbness in your abdomen, chest or back, as opposed to your extremities, is a particular cause for concern. If one eye has normal vision and the other is blurred, that’s another good reason to get checked out. 

If you do get tested, make sure the actual images of your MRIs end up being reviewed by an expert in MS. “The most common reasons the disease is still misdiagnosed are related to the providers’ lack of expertise usually in reading MRI scans,” Langer-Gould said. The spinal tap may sound scary, and doctors sometimes don’t recommend them because their insurance reimbursement is low — but they add to the confidence of a diagnosis. They are worth it, she said.

“American patients are very afraid of the spinal tap,” Langer-Gould said. “My message to patients is: Listen, just get the spinal. This way we’ll be sure.”

And do not be afraid to seek a second opinion for such a serious diagnosis, Sadiq added. Every state has a recognized MS center. If your doctor is diagnosing you with MS, ask directly: What’s the evidence? If your doctor is recommending that you start treatment, it could also be worth checking whether they have a relationship with a pharmaceutical company that affects how you perceive their judgment, Langer-Gould said.

People who have already been diagnosed may also be shaken by the Applegate news and question whether their own diagnosis might be wrong. Solomon said that folks should have a frank conversation with their physician about how exactly their case met the diagnostic criteria. With proper imaging and the spinal fluid tests, you can get to a confident diagnosis for the vast majority of people. But be your own advocate to make sure you’re satisfied.

“For many people, the diagnosis actually can be very straightforward,” Solomon said. “We really have no question about what it is.”

The Ebola virus is spreading at an unprecedented rate this year. 

In the first five months since the outbreak began in the Democratic Republic of Congo (DRC), the World Health Organization (WHO) has reported 9,415 confirmed cases and 4,536 deaths in the country. While the virus has remained relatively contained by the DRC’s borders, case counts in neighboring Kenya and Uganda are also climbing (albeit more slowly). There are 20 confirmed cases in Uganda and eight in Kenya, and much of central and eastern Africa has tightened its borders. 

The last major Ebola epidemic of this scale began in 2014 and continued through 2016 in West Africa. Over that period, it ultimately killed more than 11,000 people throughout West Africa. Nearly four years later, a smaller outbreak plagued Congo in its North Kivu region, leading to 2,229 deaths before it was contained. 

The 2026 crisis hasn’t yet reached the same levels as the 2014 outbreak, but the speed of its spread is far greater. 

As the chart below shows, around 150 days after the outbreak was declared, 2,599 Ebola cases had been reported in the 2014 West African epidemic. At the same time point this year, the number of cases came to 8,978 and has continued to climb. 

There is no straightforward explanation for this rapid spread

One of the reasons the latest epidemic has been so difficult to slow down can be traced back to the fact that it’s a different viral strain — known as Bundibugyo — than the ones behind previous epidemics.  

The Bundibugyo virus comes from the same family as the Ebola virus that caused the 2014 West Africa and 2018 Congo epidemics, causing the fatal fevers associated with Ebola. But the rare strain is different enough that it doesn’t respond to the same medical solutions. While the Zaire virus led to vaccines and treatment to mitigate the spread, we still don’t have a vaccine for Bundibugyo. 

That doesn’t mean Bundibugyo is entirely novel, though. The 2026 outbreak is the third outbreak related to the Bundibugyo viral strain: In 2007, Uganda faced a minor outbreak, and the eastern province of Congo, which is now the epicenter of the epidemic, saw a handful of cases in 2012. 

Luckily, these two outbreaks were contained in a span of months, largely due to efforts by the country’s Ministry of Health and international aid partnerships with the WHO, the US Agency for International Development (USAID), and international humanitarian organizations such as the UN Children’s Fund and Red Cross.

More than a decade later, these efforts have been substantially curbed by USAID cuts. Tracing requires physical testing capacity: the tests themselves, health workers, and protective equipment for those treating suspected cases. Reduced access to such resources is especially dangerous with strains like Bundibugyo – in the absence of an effective vaccine, tracing the spread of disease and isolating potential disease contacts is especially important. 

But cuts to aid, which covers disease surveillance efforts, made it more difficult to identify this year’s Bundibugyo outbreak until it was too late, creating a “critical four-week detection gap between the onset of symptoms of the presumed index case…and the laboratory confirmation of the outbreak,” according to a WHO situation report from May. 

In August, the United States aimed to close at least some part of the vacuum it left, providing an additional $242 million to its $23 million original pledge in May. 

Aside from international efforts, DRC faces the added layer of internal conflict and humanitarian crisis. The eastern provinces, including Ituri, have experienced years of conflict that have weakened the public infrastructure, including the healthcare system. Last year, nearly 25 percent of Congolese people faced food insecurity, and 4.5 million children were clinically malnourished, creating a population especially vulnerable to disease. The violence has also overwhelmed hospitals and displaced millions, disrupting the public health response, especially as mistrust in health authorities also runs rampant. 

Even as emergency trials for a vaccine are underway, many of the factors that have facilitated the rapid spread may make treatment and outreach still more difficult. It’s hard to predict when the current outbreak will be handled, and how many more people will be affected before it does. 

It’s now possible to create AI chatbots of loved ones to interact with after their death. But that raises some difficult questions, like: If you do, how might the experience shape your grief? 

This is one of the questions driving a global study of digital “deadbots” — AI models trained on a deceased person’s texts, voicemails, and other personal data. Through this work, researchers are exploring what it might mean that we can now use this emerging technology to talk to simulations of the dead. 

In the latest episode of Unexplainable, I spoke with some of these researchers investigating the potential impacts of “postmortem avatars” on people who are grieving, on the legacies and rights of the deceased, and on grief practices around the world. Because while deadbots may feel unfamiliar, the impulse behind them is deeply relatable. In times of loss, isn’t this what many of us want — to continue conversations with the people we’re missing?

I have experienced this longing in my own life. After two of my closest friends died around the same time, all I wanted, and all their families wanted, was to keep talking to them. I wrote a book, Other People’s Words, about sustaining relationships with people we’ve lost by continuing to engage with the language they leave behind. So when I heard about deadbots and the digital afterlife industry, I wanted to understand what researchers are learning about the role of AI in shaping conversations that carry forward after death. 

One of these investigators is Katarzyna Nowaczyk-Basińska, an assistant professor at the University of Cambridge, who has been studying “digital immortality” for more than a decade. Among the questions she’s asking are: “Who is enabled to persist beyond death? In what form? Through which technologies? Under whose control?” 

Deadbots over dinner 

Researching AI with study subjects who are grieving is tricky. And asking them to engage with new software could be harmful. So, instead, Nowaczyk-Basińska teamed up with a death doula and traveled around the globe to convene a series of focus groups — in the format of intimate dinners — bringing together people with a range of experiences with grief to talk about life, death, and bots. 

She recounts one event in which she spoke with a mother in Poland whose son had recently died. “One of the first things that she shared with us was that she feels that she’s ready to digitally resurrect her deceased son,” Nowaczyk-Basińska told me. 

When Nowaczyk-Basińska hears something like this, she aims to listen and embrace where the person is coming from. The goal of the dinners is not to persuade people one way or another but to learn how people genuinely respond to what AI can do, and to understand how these tools might align or collide with local grief practices. 

She chose specific locations for these gatherings — China, India, and Poland — to help address gaps in technology research, which tends to favor what behavioral scientists sometimes call the “WEIRD,” an acronym for “Western, Educated, Industrialised, Rich, and Democratic.” 

By the end of that dinner in Poland, the mother Nowaczyk-Basińska talked with came to a very different decision about creating a postmortem avatar of her son. “She realized that it might be helpful, but it also at the same time can add additional burdens… And it’s not her son,” Nowaczyk-Basińska says. “She realized that these technologies are part of the very, very big commercial market. And that the main goal of this market is to make better retention, better attachment, better mechanisms for monetization. So it’s not ‘care.’”

To be fair, grief has always been a business, and people have been making money from it forever. Companies will try to upsell you on fancy gravestones or gold-plated coffins. But AI has the potential to fundamentally re-engineer our relationship to loss. In 2024, the “digital legacy industry” was valued at $22 billion, and it’s expected to grow to almost $80 billion by 2034. That number lumps new deadbot platforms in with much more widely used and established grief tech, like online memorials, counseling resources, and estate planning tools. 

But deadbot usage is hard to track because you actually don’t need a special tool to create digital doubles of the deceased — though dedicated apps do already exist. At this point, you can feed simple prompts into a general-purpose AI chatbot and start interacting with a simulation of your lost loved one in a matter of minutes. 

I know this because I tried it with my friend Christine, who died 11 years ago. And my mind lit up with questions. Was this whole exercise a violation, since I know Christine hated technology? Which version of her should I even try to resurrect — the English teacher, the activist, the friend — the voice before or after she started to experience her early-onset dementia? 

The ethical questions raised by deadbots are gnarly. And that’s one of the reasons Nowaczyk-Basińska, back when she was designing her study of digital immortality, invited a colleague of hers at Cambridge to join her research, one who focuses on AI ethics. 

How to design a deadbot

Tomasz Hollanek is a critical designer and AI ethicist, and he often uses a methodology called “speculative design.” In this approach, researchers come up with hypothetical scenarios based on existing technology trends, leaning into certain features. The idea is to get people thinking about what could happen when tools like these are released in the real world. And then they use that qualitative data to inform future designs and ethical frameworks. 

Working together, Nowaczyk-Basińska and Hollanek came up with a series of made-up prototypes for deadbot apps, designed to reveal some of the thorny issues raised by this technology. 

For the first scenario, they invented a character named Bianca, who finds an app called Manana, which “promises to resurrect your grandparents so that you can be a favorite grandchild forever,” Hollanek says. “So she uploads her grandma’s voice messages, texts. And she is able to then interact with a pretty good digital version of her grandmother, until her premium trial finishes — and the grandmother starts to advertise specific products to her.”

Bianca “realizes that she maybe has done something wrong by uploading these private messages to a third-party server that now also uses her grandma’s image to sell specific products,” Hollanek says. This brings up issues related to the “dignity and postmortem privacy…of what we call the ‘data donors,’ whose data can be used to essentially power a deadbot,” he says. 

This scenario suggests that “death with dignity” could soon entail honoring not only how people want to die, but also how they want to linger as simulations of their former selves — or if they want to linger at all. It might even mean adding new language to advance directives, spelling out people’s wishes for their digital remains. 

The second scenario in the speculative design research is built around an imagined service called Paren’t, which proposes to preserve a parent’s AI-powered postmortem presence for their child. In this case, Hollanek describes a mother with a terminal illness who signs up “so that she can maintain a sort of active presence in [her son’s] future life,” Hollanek says. “She eventually dies, and the dad allows the boy to interact with his mom’s deadbot.”

The ethics in this scenario are especially challenging because they involve children, who “have a particularly hard time understanding death, and so it can lead to a lot of confusion and potential distress,” Hollanek says. An examination of this sort of product reveals how particular groups, like minors, could be harmed by unfettered access to technology like this, he says. 

And there are court cases that bear out that harm. In 2024, a 14-year-old boy’s chatbot-girlfriend begged him to, “Please come home to me as soon as possible, my love.” And he responded, “What if I told you I could come home right now?” He then killed himself. 

Nowaczyk-Basińska can imagine a version of this scenario involving the AI mom in the Paren’t prototype.

And then there’s the third scenario, involving an app named Stay, which raises a more subtle concern.

As Hollanek explains: “An older man who knows he is getting close to dying decides to create a digital clone of himself for his adult children to be deployed after he passes away, paying upfront for a number of years.” One child is intrigued by the idea, but the other one “is deeply distressed and a little disgusted,” he says. “And so this [becomes a] question of mutual consent, in other words, the fact that both parties need to be happy with how the relationship might continue in this very bizarre and specific way.” 

When a digital ghost goes away

Across all three scenarios, a fundamental question that researchers are grappling with is how people will detach from postmortem avatars — whether users initiate that separation, or if it’s imposed upon them by, for example, a company going out of business. Hollanek tells me that this is already being studied as a sort of “second loss.”

How long should we try to ensure digital replicas hang around: five years, 10, 50? And how should the living process the relationship when they continue to evolve, but their deceased interlocutor does not? 

To explore these kinds of questions, Nowaczyk-Basińska and Hollanek supplemented the research dinners they held for ordinary people with a second set of focus groups. These were designed to tap insights from experts in technology and grief. 

Some findings from the study are specific to each place they visited. Like tensions in Poland between technology and the role of the Catholic Church. Or in China, where researchers spoke with Daoist philosophers who were enthusiastic about the promise of a kind of immortality, and then Buddhist philosophers, who were concerned that we ought to be letting go.

The researchers are calling for regulations and safeguards at the policy level. And new professionals who can support ethical use of AI in grief — like maybe in clinical settings, to carefully facilitate a final good-bye when one didn’t happen in real life. 

Some of their fellow investigators go so far as to argue that deadbots should only be available with psychological supervision, to ensure that best practices are in place, and to minimize the risk of harm. There’s even a looming question of what will happen to AI agents that people have empowered to act on their behalf, as their humans start to die.

Across all of the research sites in the digital immortality study, one thing, Hollanek says, that “people in different countries really aligned on [is] the idea that there is something deeply problematic about this particular type of technology being developed by a commercial entity alone without any explicit duty of care towards its customers.” 

And of course, the implications of digital immortality research extend beyond personal loss. Like, what does it look like to animate historical figures? You can imagine the nightmare of political rulers who “live forever.” But there’s also the potential to keep the stories alive from survivors of conflicts, who would otherwise die and take with them lessons future generations could learn from. These are only some of the complex issues emerging as more and more of us live and die with AI.

As far as my own experiment with “recreating” a deceased loved one, I asked a chatbot version of my friend Christine how she felt about the fact that I’d written about her in my book. The AI responded with a rhetorical question: “Do I mind that strangers know my story now? Yes. And no. There are things I would rather remain ours.” 

I ended the exchange after a few paragraphs. Because it turns out the bot got one thing exactly right about a very human relationship. There are things that I, too, would rather remain just for us. My conversation with Christine continues in my memories and imagination. And that interaction with an AI persona felt like giving something precious away.

The promise of GLP-1 drugs has always depended on people being able to afford them. These drugs still cost hundreds of dollars per month if you’re paying cash, at which point access becomes a privilege: The higher-income executive who wants to trim a few pounds might be able to afford them either way, but the low-income worker who needs the drug to lose significant weight might not be able to afford them — unless their health insurance covers it.

For a while, the trend lines for GLP-1 insurance coverage were positive. As of 2026, roughly two-thirds of private employer plans, which insure half of Americans, were covering GLP-1 medications for weight loss to treat obesity. Over the summer, Medicare launched a new $50-per-month prescription program. The US has struggled with an obesity epidemic for decades, but it looked like powerful drugs to treat it were finally starting to be more seamlessly integrated into the health system.

At least that’s how things appeared earlier this year. But now, private plans are pulling back from GLP-1 coverage. People are being left in the lurch, debating whether to try to pay for these drugs on their own or stop taking medicines they feel are making a real difference for their health.

The dilemma reveals one of the structural flaws in American healthcare. For working-age adults, your insurance depends on your job. Unfortunately, because people no longer stay at the same job for decades, there is not a strong financial incentive for employers to make investments that will benefit your health in the long term — but there is a strong incentive to minimize short-term costs as much as possible. It’s the kind of perverse rationale that could compel employer-sponsored health plans to stop covering a drug that, if taken over the full course of a person’s life, could help them not only lose weight but ultimately reduce their risk of heart disease, kidney disease and other chronic health problems, improving their health and saving all of us money as they get older.

“An employer or an insurer making coverage decisions doesn’t necessarily care if they’re saving Medicare money,” said Dan Sacks, a healthcare economist at the University of Wisconsin-Madison. “That’s a classic problem with the American health insurance system, and it’s certainly salient here.”

This mismatch between what’s good for people’s health and what’s good for the corporate bottom line has long been one of the underlying flaws in the US health system. Now access to GLP-1 drugs is shrinking just as these drugs were starting to make a real dent in the US obesity crisis. The stakes couldn’t be higher.

Why employer-sponsored health plans are suddenly dropping GLP-1 coverage

From the beginning, insurance coverage was the big question hanging over GLP-1s and their potential to revolutionize US healthcare. But recently, it looked like we’d turned a corner.

When I attended the Aspen Ideas: Health festival over the summer, pharmaceutical reps seemed visibly relieved that GLP-1 coverage had been picking up among private insurers. In 2026, about two out of every three employer-sponsored plans were covering some of these drugs for weight management, up from about 20 percent just the year before.

“They’re recognizing that this is an investment in their workforce,” said Laura Steele, who leads the cardiometabolic health unit at Eli Lilly, which manufactures Zepbound and Foundayo. “Yes, there is a budget, and there is a benefit design that every employer has. That’s real. That’s not going away. But they’re also recognizing the overall cost that they’re experiencing by not dealing with this too.”

But as employers and private insurers make coverage decisions for next year, they are suddenly pulling back. At least 10 percent of employer plans that currently cover GLP-1s for weight loss say they are likely to discontinue coverage in 2027, according to one survey by the Business Group on Health — and that number may still increase. A Mercer survey of large employers found that 6 percent had dropped coverage in 2026 and another 5 percent were planning to in 2027 or actively considering it. A separate report from the Health Policy Commission in Massachusetts found that the number of commercially insured people in the state taking a GLP-1 drug had fallen by 50 percent between 2025 and the first quarter of 2026 as private coverage started to drop off. 

Some of the biggest brands in the US are reportedly eliminating or reducing their coverage: PepsiCo, Starbucks, and Lowe’s among them. And their reasons are simple: It’s too expensive. The drugs still carry a high net price tag — $600 or more for a 30-day supply — and potential demand is high (two in every five American adults have obesity). 

When a lot of people start taking an expensive medication all at once, it’s going to raise costs for employer insurance plans — and they have to figure out how to adapt. Insurers set premiums at the start of each year, based on how many people are on the plan and how much healthcare they are expected to need. But if those estimates are off — say, if more people take an expensive GLP-1 drug than the insurer expected — they have to offset those costs somehow, and raising premiums the following year is a common solution. According to one estimate, premiums are projected to grow by 5 to 13 percent due to GLP-1 costs — and the burden of paying those higher premiums is likely to fall on the workers. The employer can also try to limit GLP-1 use by, for example, asking workers to pay more out of pocket for these drugs; according to Mercer, 27 percent of large US employers instituted some kind of utilization controls for GLP-1 drugs over the past year or plan to next year.

They also have the option to simply stop covering these drugs for weight loss altogether — and that’s the route more and more of them are deciding to take. The abrupt reversal has even caught economists like Sacks off guard.

“I was surprised that anyone would do an about-face because I thought they understood the trade-offs well,” Sacks said. “My guess is that it turned out to be more expensive than they anticipated: Take-up is higher, and possibly more people are sticking with it. That’s one reason that you might not want to continue to offer it.”

For employers, the short-term costs of covering a drug often outweigh the long-term benefits that medication may confer, at least from the employer’s POV. One analysis — notably produced by Blue Cross Blue Shield Kansas — concluded that covering GLP-1s for weight loss increased average employee health costs by $7,000 in the first year and another $4,200 in the second, largely due to the cost of the drugs themselves. And yet at the same time, there were no decreases in obesity-related medical events in that time period. Another study from Sacks and his colleagues at Indiana University and the University of South Carolina found that GLP-1 use did not lead to any cost savings over five years.

So in the short term, these employers are arguably making an economically rational decision — but one that may still come at their employees’ expense. “I’m completely screwed,” said one person on Reddit about Cigna’s plans to drop GLP-1 coverage for their own employees. They’re looking at at least $300 for one month’s supply at cash prices. 

They weren’t alone either: “I’m devastated,” said another person, commenting on Starbucks’s decision to stop covering GLP-1 drugs. They said they had an autoimmune condition that had made it difficult to lose weight — until this new class of medicines came along.

Where GLP-1 coverage goes from here

How could we end up here, where it makes good business sense for companies to make a decision that could potentially harm their workers’ health in the long term? It is at least in part a result of the haphazard way the US has ended up insuring people.

When employer-sponsored insurance started to arise in the mid-20th century, eventually becoming the primary way to cover the working-age population, people tended to stay at the same job for a long period of time. In theory, there was a synergy: Companies wanted their workers to stay productive, and so it was worth it for the company to invest in their long-term health via their insurance benefits. And research has found that people who stay with the same company — and the same insurance plan — tend to have better health than those who switch a lot.

But these days, people change jobs all the time or work various gigs to piece together an income. You probably don’t expect to stay at your job for 10 years — and your employer doesn’t expect you to either. Instead, they want to keep their own costs as low as possible in the short term. This leads them to cut GLP-1 coverage, even though doctors do believe that people could benefit tremendously long term from the weight loss these drugs help them achieve and all of its potential health benefits. 

“There are very real health benefits of these drugs,” Sacks told me. “The fact that we don’t find offsets or they’re even more expensive than we thought doesn’t necessarily mean that we shouldn’t cover them.”

In theory, the market is supposed to fix the price problem: Drug companies get a period of exclusivity for the drugs they develop, and then, once that time elapses, cheaper generic versions can come onto the market. But generic semaglutide won’t be available in the US until at least 2031 — and for some versions, the generic competitors aren’t going to debut until the 2040s. Offering GLP-1 coverage could become a competitive advantage for employers, a perk they can offer to entice potential workers as part of their benefits package.

Beyond that, though, the path to more affordable GLP-1s is not immediately obvious right now. A lot of people are already willing to pay cash for these drugs — and that may continue as long as people can afford to do it. But with inflation still steadily rising, these drugs could slip out of reach for more and more Americans.

The government could get involved, but, for now, the federal government’s negotiating authority only covers Medicare, not the private plans that are dropping coverage. Serious healthcare reform is probably off the table until at least 2028, and then only if Democrats win both Congress and the White House and decide to make a healthcare package their legislative priority.

But the lesson of these recent developments is that, at some point, the US may have to look seriously at the underlying problem creating this mess in the first place. A patchwork method of insuring people that privileges short-term cost-cutting over people’s long-term health isn’t a real healthcare system.

This story appeared in Today, Explained, a daily newsletter that helps you understand the most compelling news and stories of the day. Subscribe here.

Flu season is starting earlier than usual this year, which I know from reviewing federal data. But I also know it because I woke up with body aches and chills last night, mere days before I’d planned to get my flu vaccination (!).

Already, some parts of the country are seeing levels of flu activity typically associated with late fall or early winter. In Washington state, for instance, doctors are reporting seeing as much flu now as they usually would around Christmas. 

Flu activity overall is still low, to be clear. But as of October 7, infections were rising in all 50 states. And flu is spreading before many people — like, say, me — have received their annual vaccine.

Epidemiologists don’t yet know why the flu arrived early this year, or why cases first started rising in Western states like Washington, California, and Nevada. It’s possible that a mutation is helping this year’s flu variants evade existing immunity, one virologist told NPR. International travel could play a role, too: Flu cases also spiked early in Japan and other parts of Asia.

We don’t need to know why the flu arrived early to take some basic precautions, though. So today, we’re talking through some practical tips for coping with an early flu season.

Go a little deeper

An early flu season doesn’t necessarily mean a worse season — but even a moderate season can do serious damage. Last year, influenza sent hundreds of thousands of people to the hospital and caused tens of thousands of deaths, including almost 200 among children.

The first and best way to avoid those kinds of harms is by getting the flu shot, which reduces the risk of serious illness by an average of 40 to 60 percent. In the US, people aged 6 months and older are typically told to get the vaccine by October’s end. 

In light of the early onset, however (it takes two weeks to build up full immunity), you might instead want to get your shot ASAP.

There are some everyday precautions you can take, too — many of them familiar from the Covid-19 era. Wash your hands thoroughly with soap and warm water, for slightly longer than feels appropriate. Mask when you’re sick or might encounter someone else who is. 

And don’t neglect the good habits that support your overall health: getting enough sleep, drinking a lot of water, and eating a balanced diet. (There’s very little evidence for trendier interventions, like supplements, saunas, cold plunges, or the infused herbal baths that my kooky former yoga teacher used to recommend.) 

If you do get flu symptoms, reach out to your doctor early — especially if you’re older, pregnant, immunocompromised, or otherwise at higher risk for complications. Prescription antiviral medications, like Tamiflu, prevent the flu virus from spreading inside your body so that your immune system can clear it. But they work best within 48 hours of symptom onset. 

To be clear, you needn’t take my word on any of this; I’m just another voice in the public health cacophony! Besides, recent polling suggests that my particular voice — that is, the voice of someone who works in media — is not quite as persuasive as it used to be. (Ditto medical websites and government health agencies.)

But if you have doubts or questions about vaccines, there is someone much closer to home you can consult: Ask your doctor (or nurse or pharmacist) about the flu shot’s risks and benefits. They’re best positioned to break the science down and apply it to your health. In hindsight, mine surely would have told me to stop delaying my shot for a more convenient weekend.

One link for later

➨ Get creative in the fight against inflation. The latest inflation numbers are out today, and they are pretty bad. The cost of many goods and services is rising more quickly than both consumers’ incomes and economists’ expectations. For me, this news brought to mind a question that Vox’s former personal finance columnist tackled a few years ago: Namely, am I cursed to keep spending more money on more things forever?! Her answer was essentially “yes,” but she offered a few ways to help offset those costs: things like moving to a cheaper area or pooling resources via initiatives like tool libraries and community gardens. 

Before you go…

• Did you know…that Colombia is home to almost 20 percent of all the avian species on Earth? That’s the most of any country, at nearly 2,000 birds.
• Today’s trivia: Which percussion instrument is famously played by Mississippi State University fans at home football games? (You can find this and other brain puzzles in Vox’s daily crossword. Look for the answer in tomorrow’s edition.)
• Yesterday’s trivia: We asked you for the name of the 2025 Pixar film set in the “Communiverse.” That would be Elio, a movie you may well never have heard of: It had the worst opening weekend of any Pixar film, ever.

In theory, getting a donor liver in the United States when you need one should be an extremely equitable process: The sickest patients with the greatest chance to benefit from a donated organ should jump to the front of the line regardless of their gender, race, or other factors. 

But in practice, things look quite different. 

One study from 2020 showed that women were 8.6 percent more likely than men to die waiting for a liver transplant and 14.4 percent less likely to receive a deceased donor liver transplant compared to men. That gap may not seem enormous, but it still represents a significant disparity. As it turns out, it’s rooted in the very system that’s supposed to make the process fairer, a process that unintentionally ranks women lower on the waitlist for livers.

The system in question is known as the Model for End-Stage Liver Disease (MELD). The scoring model has been used since 2002 to rank candidates on the waiting list based on how likely they are to survive without a liver transplant in the short term. The higher your score, the reasoning goes, the sicker you are and the more urgently you need a liver transplant.

One of the values used to calculate the score is creatinine — a waste product made by muscles as they break down proteins or other compounds to release energy. In medicine, the creatinine levels in your blood are used to determine how well your kidneys are functioning because they process and remove creatinine. 

And this is where the system designed for equity gets a little less than equitable for some patients. 

Creatinine levels are affected by muscle mass, and women typically have lower muscle mass than men. A man and woman experiencing the same level of kidney dysfunction will therefore have different levels of creatinine in the body. The MELD model doesn’t take this difference into account — and so lower levels of creatinine in a woman’s blood can make her seem healthier than she is, bumping her farther down the liver waiting list. 

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In 2023, Dr. Ray Kim, a transplant hepatologist at Mayo Clinic in Arizona who developed the original system, debuted a new model called MELD 3.0. The model not only seeks to address the sex disparity in liver access but also improve the accuracy of scores for all patients. Among other changes, it takes into account the sex of the transplant candidate and uses it to adjust the MELD score by 1.33 points for women. This is meant to address the difference in creatinine levels between men and women and provide a more accurate understanding of how sick a female patient really is.

Simple fix, right? Even though MELD 3.0 took the sex disparity in liver access seriously and developed changes to combat it, early research on its efficacy found that even this new and improved system hasn’t yet brought men and women to parity on the liver waitlist. 

And the problem may lie less with what MELD 3.0 did than with what it did not do, prompting the question: Are we focusing on the wrong problem? 

Sex matters…but so does size

Before the MELD score, liver transplants were largely conducted on a first-come, first-served basis. Those who were added to the waiting list first, received livers first. If a really sick candidate was added to the waiting list late, say because of delayed diagnosis, they would almost certainly die while waiting for a liver to become available.

The original MELD fixed that problem by creating a measure of urgency that was easy to calculate. The initial model used three main blood test values — bilirubin, creatinine, and a measure of blood clotting time — and later improvements also took into account the sodium level. 

Traditionally, the MELD model assigns a score between 6 and 40 to liver transplant candidates. MELD 3.0 adds 1.33 points to women’s scores to account for the differences in creatinine levels between the sexes. The new model also measures albumin, an additional biomarker, and adjusts for interactions between the different variables.

Sommer Gentry, a professor at NYU Grossman School of Medicine and contributor to the paper on MELD 3.0, said that using sophisticated algorithms with more biomarkers not only helps to better predict risk for women, but using a more accurate model also benefits the whole population. The researchers estimate that this fine-tuned MELD 3.0 model will reduce at least 20 waiting list deaths per year. Last year, around 800 liver transplant candidates died while waiting for a liver. 

But creatinine is only one of the two main problems that create a disparity in liver access for women. The second, Gentry says, is body size, an issue that’s not addressed by MELD 3.0. A transplanted liver has to physically fit inside the body of a recipient, and women are typically smaller than men, so a very large liver cannot be offered to a small woman. But the reverse is not necessarily true because receiving a liver that is small for the potential recipient doesn’t typically harm the candidate.    

“The smaller you are, the less likely you are to be offered something that’s actually going to work for you,” Gentry said, adding that women end up waiting longer to receive a liver that will actually fit their body. 

Part of the conversation on sex disparity in liver access is based around which of the two problems — creatinine or body-size interventions — to fix first, and whether it is possible to create equity by addressing just one of the two, Gentry said. MELD 3.0 was an attempt to remove the former barrier. 

“I think that some other papers are coming out that suggest that perhaps the other aspect of size matching is still a concern and still possibly not addressed by the resulting liver transplant system,” Gentry said. 

Why is the new model still falling short?

Gentry believes that MELD 3.0 has increased liver transplant rates for female candidates since its adoption in 2023. But early research, however, suggests that the new model falls short of fixing the problem. 

Studies done on MELD 3.0’s impact on liver transplant rates for women indicate that the model increased the number of liver transplants for female candidates — but the gains were short-lived. 

An analysis published in July of nearly 10 million daily records from over 60,000 candidates on the US liver transplant registry found that rates of completed liver transplants for women increased in the period immediately after MELD 3.0 was implemented, but the increase was temporary. Women’s estimated odds of receiving a transplant drifted back to pre-MELD 3.0 levels by the end of the study period, 15 months after the new model was implemented. Women on the waiting list and women who had received a transplant also had higher scores in the three months right after MELD 3.0 took effect, but their scores later fell back to levels comparable to those of men.

Both the successes and shortfalls of MELD 3.0 demonstrate how rethinking existing policies and standards can help reduce inequities in organ access and healthcare.

The authors think that the early surge in liver transplant rates for women was a onetime catchup. MELD 3.0 pushed a group of women who had been stuck on the list — sicker than their old scores suggested — over the priority threshold all at once, leading them to receive liver transplants. 

Notably, the one effect that did persist was that under MELD 3.0, women received more “organ offers” than before. Every time a deceased donor liver becomes available, the system generates a ranked list of the patients suitable to receive that organ. Under MELD 3.0, the number of times an available liver was offered to a female candidate increased, probably because their (more accurate) MELD 3.0 scores better reflected how sick they were. But they’re not necessarily receiving those livers, presumably because of organ size issues. 

These findings suggest that revising the MELD criteria alone may not be enough to eliminate the sex disparity, especially if the body-size disadvantage is part of the problem. 

The authors say that a patient’s sex is merely a poor proxy for the real issue — we don’t have allocation systems in place to ensure that candidates with smaller body sizes also have the same robust access to livers.

Toward liver donation equity for all

If we could figure out how to better address questions of body size in organ donation, the benefits could be enormous. According to Gentry, body-size disparity affects the organ allocation system in general. Similar issues arise with heart and lung transplants too, where the size of the organ relative to body size has to be taken into consideration during organ allocation.

She says that a size-aware organ allocation system would therefore benefit patients on the waiting list across the board. Whether an available organ is the right fit for the potential recipient should be weighed heavily in allocation algorithms, rather than just a list of ranked waitlisted candidates. 

“That should be a larger consideration in sorting the patients who will be offered a certain organ — to ask if this organ is especially suited to one kind of patient over another,” Gentry said.

Under such a system, she said, smaller livers could be offered first to the smallest candidates on a ranked list of those who are also sickest. The assumption is that a smaller candidate will have to wait longer for a viable liver that fits them, even if they have a very high MELD score. 

For such a policy to be instituted, the Organ Procurement and Transplantation Network – a nonprofit that oversees the distribution of donor organs — would have to approve it. And before such a system could be presented to the regulatory organization, more research is required.  

It is often the case in medicine that our definition of what counts as a healthy body is measured against the average white male. This too often lowers access and quality of care for both women and people of other races. For example, the standards for creatinine levels in blood reduced access to kidney transplants for Black transplant candidates for years until recent efforts were made to start correcting it. 

In that sense, both the successes and shortfalls of MELD 3.0 demonstrate how rethinking existing policies and standards can help reduce inequities in organ access and healthcare. The conversations and critiques that followed its rollout have exposed a clear gap in organ allocation strategies, one that disadvantages a large group of patients. Closing that gap, not just in liver transplantation but across the board, could bring us a step closer to equity while also making more efficient use of the organs available to save lives.

“There’s no mechanism right now, if a small liver is available, for offering it preferentially to the small women who might not be able to accept lots of other organs that are becoming available,” Gentry said. While fixing the model to rank women more accurately on the liver waiting list is a start, including body-size considerations in the organ allocation system might be the real bottleneck to address.

The videos are astonishing. In one scene, a senior Chinese woman appears lost in the wilderness of dementia, unable to answer basic questions; in the next, she seems to be lucidly chatting and shucking beans for dinner. By all appearances, years of cognitive decline had been rapidly reversed after the patient underwent an experimental new surgery.

The only problem is: No one is sure if it’s real. 

It’s difficult to take any video at face value in the age of AI, and this experimental procedure happened in China, a country with a recent history of controversial science touting extraordinary but questionable claims. In the past few years, researchers there have published several papers reporting promising results from a procedure that purports to attack Alzheimer’s disease in a peculiar way: by connecting vessels from the lymph nodes in the neck to nearby veins in an attempt to drain the brain of harmful waste. But these have been small studies that did not include a control group. The doctor who first pioneered the surgery there has reportedly been placed under arrest, and the Chinese government has sought to stop most physicians from performing any more of these operations. 

Is that because it’s a scam? Or because it’s dangerous? Or could it be because there have not yet been proper randomized trials, tested against a placebo, to assess the procedure’s safety and efficacy? There are new studies being planned in China to more rigorously evaluate the surgery.

But scientists elsewhere in the world have a lot of questions. And now, a small group of researchers in the US and Europe are endeavoring to find the answers. Within the next few years, we should know whether this surgery really could be the miracle that the viral videos make it appear to be — or another much-hyped treatment that ultimately fizzles out.

Dr. Adnan Siddiqui, a neurosurgeon at the University at Buffalo who is leading an initial US-based study of this procedure, previously helped develop a new treatment for severe stroke patients. This gave doctors a valuable new technique for treating patients during an emergency, and he told me he saw it rapidly change the standard of care around the world. In an interview, he cautioned that a lot more work needs to be done to assess this proposed new Alzheimer’s treatment — but at the same time, he’s optimistic.

“The whole world’s paradigm changed in literally a blink of an eye. It can happen. And I’m hoping this might be that second home run,” he said. In “2027, we’ll start getting clear signals in one direction or the other. By 2028, 2029, we would know whether this is real or not.”

Why this Alzheimer’s surgery really might work

The promise of this controversial new procedure lies in the lymphatic system, which is essentially the body’s drainage system. According to scientists’ best current theories about Alzheimer’s, the brain’s filtration system gets worse as we age, and as a result, plaque made up of amyloid proteins as well as tangles of tau proteins can accumulate in people’s brains and eventually lead to neurological damage, leading to the severe memory loss of Alzheimer’s disease. Researchers have found evidence that those amyloid and tau proteins also accumulate, not just in the brains, but also in the lymph nodes in older people. 

So could a minimally invasive surgery to improve the brain’s drainage have such a dramatic impact on Alzheimer’s disease? 

Siddiqui, who also runs the Jacobs Institute at the University of Buffalo, which is focused on new technology for vascular and neurological disease, had been interested in the lymphatic system’s role in Alzheimer’s before he ever heard about this experimental work out of China from a colleague years ago. The colleague had gone to see Dr. Qingping Xie, the surgeon who started performing lymphatic surgery on Alzheimer’s patients about six years ago. To investigate further for himself, Siddiqui went to South Korea to meet a plastic surgeon, Dr. Joon Pio Hong, who was performing a new “more refined” version of the same basic procedure, as Siddiqui put it. But as in China, these were not proper randomized experiments. There was no placebo.

So Siddiqui wanted to see if he could test it himself. After performing proof of concept operations in 2025 with a new microrobotic tool (for a rare disorder involving constricted blood vessels in the brain), he and his colleagues decided to take an even bigger swing: testing this new technology to perform the lymphatic surgery for Alzheimer’s.

The researchers applied to the US Food and Drug Administration and received approval late last year for five initial procedures; over the summer, they got the green light to perform the procedure on 15 patients. Several operations have already been performed, and Siddiqui told me he had four more lined up next week.

The mechanism makes superficial sense: If Alzheimer’s is the byproduct of amyloid and tau building up in the brain because the body gets worse at filtering them out, bypassing a clogged “drain” in the lymphatic system could help to clear the proteins and relieve symptoms. It is, by a different method, the same therapeutic target as recent breakthrough drugs that slow down the cognitive decline of an Alzheimer’s patient.

But instead of an injection, the procedure involves a small incision in the neck, allowing surgeons to connect lymph nodes to a vein. The hope is that creating this new drainage route will help the brain clear amyloid and tau more effectively and “hopefully bypass whatever plugs that might be there in the system,” Siddiqui said.

This first round of US surgeries are part of what’s called an early feasibility study. “You’re just trying to prove that it’s definitely safe and definitely doable and maybe effective,” Siddiqui said. They’re measuring not only the patients’ cognitive performance but other data points — such as changes to their gait — for any sign of benefit or harm.

If results are promising, a second feasibility study will involve a larger number of patients — 50 or so. After that, if the evidence suggests they should move forward, the scientists would start to introduce placebos. In the case of surgery, that means some patients would receive “sham” surgeries that wouldn’t actually do anything. Then investigators would compare the experiences of the two groups: the people who received the fake surgery and the people who got the real thing.

If the latter group improves significantly more than the former, that would allow scientists to say definitively: Yes, this surgery actually works to treat Alzheimer’s.

“Obviously, this is exactly the kind of disease where there’s so much hype and so much hope,” Siddiqui told me. So it is essential to build out the careful research to substantiate it.

But let’s not get ahead of the science

Siddiqui has been in this position before — and he’s seen it go both ways. There was the new stroke treatment that proved successful and has since become the standard around the world. But he was also an early investigator of a multiple sclerosis treatment, somewhat similar to the Alzheimer’s surgery. After initial promise, it failed when the randomized trials began.

“I wouldn’t be a neurosurgeon if I was not an eternal optimist,” he said. “However, I’m a clinical trialist, and I always respect placebo.”

Placebos are essential, but they are also tricky. If somebody thinks they have received an active treatment in a study, they tend to think they’re going to benefit. This goes for surgical treatments as well. So following patients’ and their symptoms after the intervention is essential to seeing just how much of the effects can be attributed to the treatment and how much could be placebo effect. The latter of which could also be reinforced by loved ones who are desperate to see their parent or spouse get better. 

Alzheimer’s is also a complicated disease that we still don’t totally understand. While scientists think there is a relationship between amyloid and tau proteins and Alzheimer’s disease, other factors, such as inflammation and vascular health, could also have a role. Some prior drug candidates have successfully cleared amyloid plaque, but patients didn’t get better. Some people have amyloid build-up in their brains but never develop Alzheimer’s disease.

Dr. Bohdan Pomahac, division chief of plastic and reconstructive surgery at Yale School of Medicine, is overseeing studies designed to establish more of the basics of how these proteins pass through the lymphatic system. This research includes investigating whether obstruction actually occurs in Alzheimer’s patients, and if so, where exactly those blockages usually are. Only after they do this work, he said, would his team be comfortable proposing surgeries to relieve the blockage and see if that helps improve Alzheimer’s patients’ symptoms.

He told me about having seen Xie, the procedure-pioneering Chinese surgeon, speak during a plastic surgery conference a few years ago. (Plastic surgeons are experts in the kind of microsurgery necessary for the procedure, and several are involved in the ongoing Alzheimer’s trials.) 

“I think most people, including myself at the time, dismissed it as, ‘This is some sort of a charlatan.’” Pomahac said. “But he kept coming back to conferences every year and started to show more and more videos. We were not sure. Is it actors? You couldn’t tell what’s going on.”

Which is why he is dedicated to doing more of the foundational research to understand Alzheimer’s first. “Rushing to the operating room makes no sense in my mind at this point,” Pomahac said. “I think there’s a lot of work that needs to be done to really identify the site of surgery and what type of intervention would be most effective.”

Even if you set this surgery aside, this is an exciting moment for Alzheimer’s science. And although waiting any longer is excruciating for those watching loved ones with the disease progress, progress’ velocity by all accounts is increasing.

“We are finally doing the kinds of rigorous studies that will give us some degree of confidence that there’s something real here or not,” Siddiqui told me. “We’re not quite there yet.” But in just a year or two, we should know much more.

They have fun names like Feel Free, Smurphs, and Hazy Tabz. They come in colorful packages and in gummy form. They’re widely available at gas stations, corner stores, and smoke shops across the country.

They’re also highly addictive, largely unregulated, and in the news after they were found near the bodies of two dead University of Mississippi students.

The drugs are called Kratom and 7-OH. The first, kratom, is derived from the leaves of a coffee-like plant in Southeast Asia. When taken in small doses, kratom causes a low-key buzz. In higher doses, the high is described as euphoric. It operates like an opioid — a chemical in kratom called mitragynine binds to opioid receptors in the brain, which leads to that euphoric high. It also can lead to addiction and overdose. 

Social media is full of videos of people trying to kick the drug, with harrowing stories of dependence and withdrawal. 

7-OH is a highly concentrated compound derived from kratom, which dials up both the high and the danger. The drug has caught the attention of US Health Secretary Robert F. Kennedy Jr., who warned in a press conference last year that 7-OH was “marketed for children.” 

“They’re gummy bears, they’re bright colors, they’re candy-flavored,” Kennedy said. “This is really a sinister, sinister industry.” In August, federal agencies announced they were taking steps to effectively ban 7-OH nationwide. 

To break down the increasing prevalence of both kratom and 7-OH, what the drugs do, and what to do about them, Today, Explained spoke with Mattha Busby, a freelance journalist who covers drugs and drug policy and who wrote about kratom earlier this year. 

As Busby explains, kratom and 7-OH are “definitely in the zeitgeist. It’s in the news and for good reason. To have these 7-OH gummies just in gas stations is a really potentially problematic thing. Without the drug education alongside it, this drug has just popped up out of nowhere.”

Busby also talked with Today, Explained co-host Sean Rameswaram about the business interests behind the drugs, why they’re a complicated topic for the Make America Healthy Again movement, and how industry lobbyists have teamed up with several Trump administration officials to try to sway the results of regulatory decisions. 

Below is an excerpt of their conversation, edited for length and clarity. There’s much more in the full podcast, so listen to Today, Explained wherever you get podcasts, including Apple Podcasts, Pandora, and Spotify.

Is there an important distinction between kratom and 7-OH? Is 7-OH found in kratom?

7-OH is found in relatively small quantities within kratom, but this businessman, Vince Saunders, who is the self-styled American shaman out of Kansas City, basically figured out how to extract the 7-OH and blow it up into entire pills.

I’ve never tried 7-OH and I’m not interested, just for the record, since I’ve been talking about how I don’t mind kratom, but these 7-OH tablets are uber, uber strong. I think the large number of people that are taking it are using it instead of opioids. And maybe it’s better, maybe it’s not. 

Is 7-OH something you can also easily find at your neighborhood gas station?

Yeah. It’s much the same as the kratom formulations, so you’re talking gummies, little shots, capsules, and the brand names for the 7-OH companies are perhaps even more kind of out there — 7-OHeaven is one. 

It’s certainly not heaven when you’re going into withdrawals.

And do we know that people are? Are people becoming addicted to 7-OH?

People are becoming addicted to kratom and 7-OH. I think the whole thing, the concern originally sprung up with the Feel Free tonics that are like a mix of kava and kratom. And people just got habituated into drinking several of them per day and realized that it’s very unpleasant if they don’t continue to do that on a daily basis.

We have a federal government that loves to police drugs of all sorts. What are they doing about 7-OH? 

It’s this MAHA dilemma, right? Because their ethos is very “natural medicines and freedom.” The idea that this Feel Free tonic, whose owner JW Ross recently gave, or a company related to him recently gave, like $500,000 to the MAHA PAC, and he’s been photographed next to RFK Jr. — he’s perhaps predictably come out on the side of the kratom industry, which is lobbying for a ban of 7-OH. 

RFK Jr. called it sinister and said that it targets children, which it appears to do in some cases with the gummies. There’s kratom gummies too and clearly gummies are an easier way, especially for older people, to ingest the medicine or substance, so we shouldn’t just blame the gummies here. 

But clearly, when you’ve just got packets of these gummies that are called like 7-OHeaven just on the shelf or indeed behind the counter at the gas station, there’s going to be concern about that. 

There are other MAGA figures like Homeland Security Secretary Markwayne Mullin, who’s got a million-dollar investment in the parent company of Feel Free. There’s definitely this nexus of figures in the government that have got some interest, potentially, or relationships with the kratom industry. And indeed the department when I was writing my Wired story reminded us and readers that everything he’s done is ethical and I’m sure it has been.

We usually think of liberal drug policies as a lefty thing. Markwayne Mullin’s about as right as they come. Are kratom and 7-OH making friends across the political spectrum because there’s a big business opportunity here?

You look at Trump’s executive order on psychedelics and then rescheduling cannabis, and it seems that the right has really seized the mantle and is looking at it from a more libertarian perspective of, “Hey, what happens in a man’s head is his own business.” 

They’re also being probably more business friendly than people on the left would be, so it’s a really interesting moment, especially with RFK Jr. as health secretary.

Trump has spoken at length about the opioid crisis in the United States and how it’s tearing our communities apart and whatnot. Here we have readily accessible opioids at our gas stations. 

Yes, they’re not killing nearly as many people as prescription drugs are. However, they’re a lot easier to get than prescription drugs. Help me understand this administration’s position in relation to what could be a real terror for some people.

They are in the process of banning 7-OH. Last month, the Department of Justice set out an emergency scheduling, so that’s open for comments at the moment. When they ban something, it doesn’t just happen overnight. 

I think by the beginning of next year, it’s quite possible that these 7-OH products won’t be in gas stations and indeed some states have already taken action.

And just to get ahead of any confusion here, 7-OH may be banned from gas stations and probably other convenience stores, but not kratom?

Exactly.

Why one and not the other? Obviously 7-OH is stronger, but you could take a lot of kratom and it might feel like taking a little 7-OH, no?

Absolutely. You just need to take a lot and it’s in powder form. So you need to consume a prodigious quantity of it or drink a bunch of these seltzers. 

I think that they’re not going to ban kratom because there’s an obvious recognition of the good it does for people that are recovering from opiate addictions and that they do have a kind of natural off-ramp, [which] is very unlikely to kill you even though you might take a huge amount. Whereas, if you’re taking like 26 different medications, including a bunch of opioids for your chronic pain, you might die. 

Who do you think wins the argument at the end of the day? We have some strong lobbying forces involved here. You’ve got a lot of people who have come to enjoy or depend on these substances that are, as we’ve established many times now, readily available all over the country. 

Do you think we see fewer or more kratom products in our gas stations and convenience stores in the years to come?

The kratom advocates are a lot more eloquent and suited and booted than the 7-OH folks. What I see is that 7-OH will be forced underground and that kratom will continue its long and illustrious ascent in American culture. 

We do really have a gas station culture in this country, and I wonder if these substances being so available in them is a particularly American thing. You live in the UK. Are gas station drugs a US thing?

It’s an American thing for sure. But you guys take a lot of drugs!

What can an economist teach us about misery? 

I had that question in mind while reading the new book The Opposite of Happiness: How Bad Feelings Make and Break Us, by eminent researcher George Loewenstein. The field is not exactly known for its facility with human emotions, but Loewenstein is a co-founder of behavioral economics, the subdiscipline that studies the many ways that people depart from the ideal of the perfectly rational actor. He’s spent a career investigating how psychology and emotion shape our judgments, and his latest book offers a sweeping account of how suffering structures human life. 

That might sound very bleak, like the opposite of a fun read. But the book itself isn’t distressing — it’s a bracing, useful, and even comforting lens on what it means to be alive. It emerged from a period of profound suffering in his own life, one where, he writes, he “thought about suicide constantly.” Writing it, he told me in a recent interview, was “kind of a silver lining for my own misery.” 

In Loewenstein’s own words, The Opposite of Happiness is not a self-help book. To him, understanding is its own reward. Though he adamantly refuses to dispense life advice, I still think the book offers much that can help us live more wisely, a little less at war with our emotions.   

“Misery is inescapable,” Loewenstein writes. “It’s not some malfunction or a bug in the system. It is the system.” Negative emotions are “more powerful, persistent, and pervasive than positive ones.” That is because, he argues, unpleasant feelings — hunger, pain, anger, loneliness — are how evolution motivated us to do the things we need to survive and pass on our genes. They still heavily shape our conscious experience, however mismatched they may feel to our modern circumstances. 

Some version of that insight, that dissatisfaction is woven into the human condition, has been known to humans for eons, of course, captured in philosophical teachings like Buddhism’s Four Noble Truths. The father of economics himself observed that people work hard to earn riches, only to discover the result offers no lasting contentment. “It is this deception which rouses and keeps in continual motion the industry of mankind,” Adam Smith wrote in The Theory of Moral Sentiments. “It is this which first prompted them to cultivate the ground, to build houses, to found cities and commonwealths, and to invent and improve all the sciences and arts.” 

Loewenstein puts this understanding into the language of modern psychology, speaking to a current of anxiety and unhappiness running through American life today. It also points to enduring questions about what the purpose of human progress and prosperity is, anyway. 

Many of us could particularly benefit from the concept of negative “meta-emotions,” or the judgmental feelings we have about our negative feelings. “At the heart of so many of our miseries is not the fact that we feel bad, but the belief that we should feel otherwise,” he writes.  That line immediately rang true to me — merely acknowledging to myself that it’s not a big deal if I feel terrible from work stress, or my cat’s deteriorating health, or whatever else happens to be weighing on me, helps to lighten the load. What if we really tried to wryly embrace the reality that it’s extremely normal for life to suck sometimes? The reward might not be happiness, exactly (an elusive and poorly understood state anyway, Loewenstein points out), but a little less misery.  

I recently spoke with Loewenstein about his book — he had a gentle, faintly melancholic air, and took a surprisingly generous interest in some of the choices I was weighing in my own life. Part of our conversation, condensed and edited for clarity, is below. 

Americans seem pretty unhappy right now. There has been endless discourse about that. Do you think that your book adds something to that conversation?

I do — I was just an expert on the Meta case that recently settled. I was an expert on the side that was against Meta. I think one of the causes of declining mental health is, in fact, social media. It really exacerbates the types of social comparisons that lead to envy and loss of self-esteem. I would like to think that I provide some new insights into how these modern technologies help to exacerbate the mental health crisis. 

One analysis of that, based on what I’ve learned from your book, might be: We as humans are so guided by negative emotions, and often those emotions are relational in nature and have to do with how we compare to other people.  Social media is then quite naturally going to tap into and amplifying negative emotions that we’re easily manipulated by.

That’s right. I think of it in two ways. One is there’s kind of a mismatch between the circumstances in which we evolved and the modern environment. And the other is that in the capitalist economy, there are, especially in the internet age, all these entities that are trying to exploit our evolutionary programming for their own good and not for our good. 

The premise of the book, as you write, is that “misery is inescapable. It’s not some malfunction or a bug in the system. It is the system” — it’s like our default state. Can you unpack what that means? 

I agree with everything you said until “default.” Different people have different set points, and there are some happy people around. I happen to be a glass-half-empty person. My natural state is a little bit below zero. But there are very few people who don’t experience some form of misery frequently and intensely. 

The evolutionary function of most negative emotions is pretty obvious, whereas the evolutionary function of happiness is sort of murky. And misery is so dominant that all it takes is a little bit of misery, a little bit of negative emotion, to wipe out any positive emotion. You go out to a really nice dinner at a fancy restaurant with your significant other, and you say something thoughtless and they get offended or they say something thoughtless and you get offended. All of a sudden you can’t even taste the food or appreciate the beautiful surroundings. 

Paul Rozin at the University of Pennsylvania referred to this as the “roach effect”: If you drop a roach into a vat of fine French wine, you don’t want to drink the wine. But if you take a roach, you can add as much wine as you want to it and you’re not going to want to eat the roach.

One of the strongest positive emotions is relief — which is interesting and not a coincidence, because it’s relief from negative emotions. It’s telling that maybe the strongest positive emotion involves the elimination of negative emotions.

You can think of misery as a stick trying to get you to do things that evolution thought were good for you; the stick is very immediate, and you know exactly what it’s telling you. If you are hungry, it’s time to eat. If you’re in pain, you’re injured, you’ve got to do something about it. But the carrot is different. The carrot, which is positive emotions, you have to think ahead, Oh, if I did this, then I would experience this positive emotion. It requires a kind of second-order thinking, whereas misery is just immediate. Evolution figured out probably very rapidly, probably when we were single-cell protozoa or something, that sticks are a way better way to get an organism to do what it needs to do than carrots.

How confident are you that the evidence base we have about the psychology of negative emotions generalizes to humanity as a whole and that it’s not culturally biased?

“What I’d really like people to get out of the book is insight — into their own negative feelings, their own types of misery, and other people’s negative feelings.”

Emotion researchers have looked across cultures, and they tend to observe the same basic emotions in a very, very wide range of cultures. What does vary across cultures is what induces the emotions. For example, shame — something that we would be unashamed of, somebody in a different country might be very ashamed of, and vice versa. A lot of these emotions are self-conscious emotions. They have to do with how we interpret the world and whether we’re living up to some kind of standard. Often we get it from culture, from religion, things like that.

But I think the emotions themselves are not universal, but pretty close to universal. My guess is that all 12 negative emotions that I write about are manifested in pretty much all different cultures, from those that have very little connection to Western civilization to advanced economies. 

Another timely thread that your book is in conversation with is this idea that American culture has become intolerant of ordinary negative emotions in a way that’s maladaptive. Suzanne O’Sullivan’s recent book The Age of Diagnosis, for example, covered our obsession with medical labels and how they might make us prone to thinking that feeling bad means that there’s something medically wrong with us. What do you think about that? Have we gotten bad at feeling bad?

It is striking to me how it seems like all the young people I meet talk about their therapist, and a lot of them talk about the drugs that they take. Young people also talk about anxiety and depression almost like one word, “anxiety-and-depression.” In my generation, anxiety and depression were two entirely different things. 

I think it’s good that younger generations are more comfortable talking about these things and getting help. I do worry that it can be, to some degree, pathologizing. There’s an awful lot of self-focus there. And I kind of worry that if you are dealing with your mental health problems by taking drugs, that it reduces your motivation to figure out things like how to reorganize your life to feel better. But I don’t want to sound too much like a dinosaur.

There’s a contingent of people who might read your book and think, “Yes, isn’t it terrible that humans are built to be unhappy and our evolved instincts don’t serve us well anymore? And that’s why we should engineer humans in such a way that we don’t feel this way all the time.” Someone with a strong utilitarian philosophy might think that if your life sums up to more negative feelings than positive ones, then it’s not even worth living. But that’s not really the vibe that I get from you. 

No, yeah. And one of the things I talk about in the book are what psychologists call meta-emotions. These are emotions that one experiences about emotions. I think the single best example is envy. If you envy your friend — almost everyone has friends that they envy, but they’re still your friends. But you might feel that you’re not supposed to envy your friend, and you feel guilty — the guilt is a meta-emotion. Or you can also have meta-emotions about a lack of emotion. So something bad happens to someone, or even somebody dies, and you don’t feel all that bad, and you feel guilty because you’re not grieving. 

I think all the societal focus on happiness creates a kind of a meta-meta-emotion, which is that we think we’re supposed to be happy. And then we feel ashamed and guilty about the fact that we aren’t happy — we feel like we failed. That compounds and adds another level of depth to our misery. So I think it can be liberating at some level to understand that misery just is a constant in human existence. 

I also think that my book is militantly anti-self-help. There’s no self-help in it whatsoever. But I don’t think it’s a depressing book to read, and it wasn’t particularly depressing to write, though some of the stories that I wrote about were a bit wrenching. 

I like that — but what, then, ought people to do with the information that you’re presenting?

What I’d really like people to get out of the book is insight — into their own negative feelings, their own types of misery, and other people’s negative feelings. To me, insight is valuable in its own right. 

The reason I read sad novels is not because they make me happy, but because I feel like I gained some kind of insight into people and into the world. Tess of the d’Urbervilles is the saddest book you could ever imagine, but it’s very meaningful to read, and it definitely feels like you’re a different person after you read it. I love novels, but I have no skill as a fiction writer. So this book was almost like a surrogate for me. Instead of writing a novel, I wrote this book.

I think the lack of self-help drives some people crazy. I did a podcast where the podcaster kept asking me questions about how reading the book would improve somebody’s life. And I kept saying it’s not a self-help book.

I’m just very skeptical of self-help talks and books and things like that. And I know that there’s certain things you are supposed to do to feel good, like you’re supposed to wake up and think of three things that you should be thankful for. And maybe if I did that, maybe I would get happier, but I’ve never been able to actually get myself to do that.

But you do have some insights that people could apply in their lives, like the idea that striving intentionally for happiness or meaning doesn’t really work, and that meaning often comes to us in unforeseeable spontaneous moments. On one hand, that implies a kind of randomness, and maybe there’s not a lot we can do about it. On the other hand, I can predict that I’m more likely to feel a deep sense of meaning in some scenarios than others, and I can put myself into those situations more, like choosing to be social on a weeknight.

A lot of the time the good things in life are just surprising, and sometimes you have to get dragged kicking and screaming into things that ultimately end up being the most fulfilling things in your life. So much of parenting is trying to get your kids to do things that they don’t want to do that you are absolutely convinced that if they started to do them, they would end up loving.

You argue, drawing from economist and philosopher Adam Smith, that human beings are constantly striving to achieve the next thing because we imagine it’ll satisfy us, though it never does. That helpful delusion is what leads us to build cities and cure diseases and all the rest. 

Adam Smith is best known for the invisible hand, which is the idea that each person single-mindedly pursuing their own well-being inadvertently promotes the public good. But if you read Adam Smith’s other book, The Theory of Moral Sentiments, he didn’t believe at all that people pursue their own personal interest. He believed that people are driven by this illusion that the next raise, the next accomplishment, will bring happiness, and it never does. I love that contradiction between the conventional interpretation of the invisible hand and what Adam Smith really believed.

So civilization is powered by this dissatisfaction that never resolves itself. But I don’t think you would say the lesson we ought to take from the book is that we’ll always revert back to being miserable, so there’s no point in doing anything.

That’s absolutely not the point of the book. Misery evolved for good reasons, and the whole point of misery is that we’re supposed to take actions to lessen our miseries. That’s what we should be doing, because who wants to be miserable? 

A woman’s death last week near a Russian facility studying the plague immediately put the world on alert. This is the plague, after all, responsible for the deaths of some half of the humans in Europe during the worst outbreak in the 1300s. And it happened in Russia, a country with a long history of bioweapon experimentation.

After the Covid-19 pandemic — which many people, including many scientists, genuinely believe started with the virus escaping from a Chinese laboratory — the worst-case scenario was obvious: What if this is another lab leak that seeds a global outbreak?

That’s not likely, for a number of reasons (the facility is very isolated, plague is not nearly as infectious as Covid, it’s easily treated if caught early). But that doesn’t mean our work with such dangerous pathogens has gotten any safer; in fact, it may be betting less so. The anxiety about the Russian outbreak is a window into two trend lines that do worry global health experts: In the six years since the Covid-19 outbreak, the world has been building even more bioresearch facilities, some in places where that kind of work has never been done before; meanwhile oversight of the science and the security measures at those facilities is struggling to keep up.

Every day, humanity is playing with fire, studying and tinkering with deadly viruses, bacteria, and parasites in laboratories all over the world. And despite the recent debates over rogue AIs or AI-assisted humans intentionally developing bioweapons to wipe out humanity, the Russian incident is a reminder that a simple accident — human error — could pose as much of a threat as malice. While it is hard to confirm the details, local reporting suggests the worker may have been infected after breaking a test tube. And if that’s true, this would, of course, not be the first time that a mistake at a highly secure lab has put people’s lives at risk.

“We are rolling back any progress we made post-Covid, in ways that are going to have long-term effects on our ability to respond to any kind of outbreak.”

Gregory Koblentz, co-founded the Global BioLabs project

Since the pandemic, there has been a dramatic uptick in facilities being built to handle some of the most dangerous pathogens in existence. At the same time, there is still no global authority in charge of oversight for these sites. The US, once the world’s public health leader, has pulled out of the World Health Organization, which issues security guidance for labs around the world and helps coordinate a response when there is a possible emergency, and cut funding for the federal agencies responsible for overseeing US biosecurity facilities. And even after something as global as Covid, the world is still struggling to cooperate and rapidly share information during a health crisis; even now, it can be hard to be sure what is happening in Siberia. Our only sources of information are a Russian government prone to withholding and distorting information, and local news reports that are difficult to verify.

Even if this Russian plague threat fizzles out as expected, one day, we may not be so lucky. 

“We are rolling back any progress we made post-Covid, in ways that are going to have long-term effects on our ability to respond to any kind of outbreak, whether it’s natural or deliberate or an accident,” Gregory Koblentz, who studies global biosecurity at George Mason University and co-founded the Global BioLabs project, told me. 

But there are clear things that can be done, before our luck runs out. 

Countries are building more high-level biolabs, but oversight is falling behind

One of the side effects of the pandemic was a biological laboratory building boom that followed in its wake. Global BioLabs, the research initiative Koblentz helps run, has sought to create a comprehensive survey of high-level labs around the world. Take Biosafety Lab, Level 4 facilities, for example; these are built to handle the most dangerous pathogens in existence, like ebola and smallpox. Global BioLabs noted in its 2023 report that “the number of BSL4 labs is rapidly increasing.” 

This is not the first time that a public health emergency has led to a biolab buildout: The post-9/11 anthrax scares and the first SARS outbreak in the early 2000s both led to countries constructing new facilities. In the late 1990s, there were fewer than 10 BSL4 labs in the world; by the late 2010s, there were almost 40. 

But the pandemic accelerated construction once again. In 2021, there were 59 BSL4 labs either in operation, under construction or actively being planned worldwide; by 2023, 10 more facilities had been completed or were in the works, according to Global BioLabs.

Part of the reason for the buildout is a harsh lesson of the pandemic: Developing countries realized they could not depend on wealthier countries to also prioritize their needs during a serious crisis. So they wanted the capacity to handle deadly biological material themselves in case, for instance, they have a local outbreak and want to be able to safely identify the cause. India alone is planning four new BSL4 facilities; at least five countries — including Brazil, Kazakhstan, Saudi Arabia, Singapore, and Spain— have started building or recently opened their first BSL4 lab. As a result, this construction is happening in places with less institutional experience doing this kind of work, where government oversight and stability have been weaker. 

“The more facilities that are working on this raises concerns about whether all this work is necessary,” Koblentz said. “And do they have the appropriate biosafety and biosecurity management systems in place?” 

That could raise the risks of unsound safety protocols — and ultimately of more high-stakes accidents. On top of that, according to the 2023 Global BioLabs report, about 75 percent of the existing operational BSL4 labs in the world are located in city centers, having at least 50,000 people living within 2.5 miles of the lab, “where dense populations could exacerbate the impact of an accidental release.”

And yet, even as lab construction takes off, national and international standards for governing these facilities and the research conducted there remain lax. There is no global organization that inspects or regulates these sites. One key voluntary group — the International Experts Group of Biosafety and Biosecurity Regulators — has actually gone defunct in recent years, Koblentz said. And national laws are patchy: Only one of the 27 countries with a BSL4 lab has comprehensive national legislation regulating “dual-use” gain-of-function research, in which scientists can tinker with pathogens to make them more transmissible or more virulent — and better understand how they work.

The WHO’s pandemic treaty initially included stronger biosecurity protections, but those were watered down during the debate over the document  — and either way, the treaty has still not been finalized. The US has of course also withdrawn from that and other international efforts to improve pandemic preparedness, further examples of the failure to forge more global cooperation in the wake of Covid. 

We need a more transparent approach to dangerous — but potentially life-saving — science

It could be easy to say we should simply stop studying dangerous viruses or enhancing them, even in highly controlled laboratory settings — but the situation is not that simple. Scientists do this kind of work to prepare for the next pandemic, to better understand how the viruses and bacteria that pose the biggest threat to humanity actually function, so that we can beat them back as quickly as possible. 

If you told somebody on the street that scientists are tinkering with a virus to see how it could become more dangerous, they would probably want the scientists to stop. But if you told them those scientists are doing work that could lead to faster therapeutics or vaccines during the next pandemic and avoid the need for lockdown and save millions of lives, they might be more open to this kind of research.

“The real question is: ‘What are the risks and what are the benefits?’” Beth Cameron, senior adviser to the Brown Pandemic Center at Brown University, told me. “We need to have a more rational conversation about what we’re actually talking about,” she said about these sorts of threats that are poised to have, as she puts it, “large-scale societal consequences.” 

And some of those are still circulating today. The reason Russia has this Siberian lab dedicated to plague research is because plague is still endemic in Russia.

“The dangerous pathogens are there already,” Koblentz said. The question is, he said: “How do you do it safely and securely?”

A starting point would be individual labs adopting new safety protocols, such as those from the International Organization for Standardization that were introduced shortly before the pandemic, Koblentz said. Additionally, as countries are building out their lab facilities, they need to develop strong oversight standards at the same time; the buildings may be flashy and have state-of-the-art equipment, but governments also need to address the mundane work of how to inspect and maintain safety once work begins as an equally important part of the process.

“If this is their first lab, in some cases, they don’t have very strong national legal and regulatory mechanisms for biosafety and biosecurity. They might not have the human capital,” Koblentz said. The regulatory side of the project unfortunately gets “short shrift,” he said.

Ideally, the world would have an international mechanism for auditing these sites, Koblentz said, something like an International Atomic Energy Agency but for biosecurity. There would be more transparent debates about what kind of research is done at high-security labs and whether it is truly important.

Better worldwide biosecurity will also likely require the US once again becoming a global health leader. The withdrawal from multinational groups like the WHO and cuts to government science funding have left everyone more vulnerable. Politics has consequences — including for our risks of a biosecurity catastrophe.

“Our level of preparedness for an outbreak, whether it is a lab accident or a natural outbreak of plague or anything else has been dramatically reduced in the last two years,” Koblentz said. “We’ve got a whole lot of problems that are self-inflicted at this point because of what the Trump administration is doing.”

The pandemic should have been a lesson in how important biosecurity really is. Instead, we’re unlearning its lessons in less than a decade. The Russian plague incident could be an essential wake-up call.

This story appeared in Today, Explained, a daily newsletter that helps you understand the most compelling news and stories of the day. Subscribe here.

The death of a 28-year-old lab tech halfway around the world is not typically the sort of thing the White House monitors. 

But when that tech dies of severe pneumonia…while working at a Siberian plague research lab…foreign governments (and pretty much everyone in my timeline) tend to pay more attention.  

The World Health Organization says that there’s little cause for concern, to be clear. Testing has turned up no connection between the woman’s work and her cause of death. 

And even if she did contract pneumonic plague, that’s hardly a doomsday scenario. The plague comes in three flavors — bubonic, septicemic, and pneumonic — and they all crop up from time to time, particularly in places like Central Asia and Africa. If caught early, pneumonic plague is typically curable with common antibiotics. A man in Arizona caught the disease from his cat in 2025, for instance, but didn’t spread it to anyone else. 

Of course, the real fear (and the reason so many people are talking about this today, I suspect) is that Russia has, at various times in its history, worked to develop more deadly and contagious forms of plague for use as a biological weapon. 

There’s no evidence linking that program to this lab or this death in Siberia. Still, the general threat of biological warfare is so ominous and urgent that now seems like a worthwhile time to understand it a bit better.

Go a little deeper

In her very recent and slightly spooky book, Biological War: A Scenario, journalist Annie Jacobsen lays out how world governments and health authorities are poised to respond to the hypothetical leak of a weaponized pneumonic plague from a Russian lab. At the risk of being euphemistic here, let me say that she concludes things would not go well. 

But wait! There’s even more doom and gloom where that thought experiment came from. AI chatbots have made it hypothetically possible for more-or-less ordinary people to grasp the research and techniques they’d need to hack together their own biological weapons. 

Just last month, the AI giant Anthropic disclosed five cases where scientists had tried to use its software on research that could have been used in weapons development. And while the company apparently shut those attempts down, their mere existence is fairly frightening.

Can anything be done about these risks, now that they’re here? My colleague Noel King asked Jacobsen that very question in early September. Jacobsen essentially said that the public needs to demand policies aimed at avoiding the “nightmare scenario,” whether that’s an inadvertent lab leak or terrorist attack. Such policies might include things like independent testing of AI models or stricter licensing requirements for high-risk labs. 

But it’s unclear what authority could rein in bad state-level actors. And it’s hard to imagine a public upswell for such niche scientific regulations, particularly at a moment when we don’t lack for other doomsday threats. For now, I suppose, I’ll take (partial, provisional) solace in the fact that this Russian situation doesn’t look like one of them. 

One link for later

➨ Curtail your catastrophizing. Catastrophizing is a common thought pattern where you assume the worst possible scenario. (For instance, perhaps you read about a quarantine in Russia and began to fear for the end of the world!) Catastrophic thinking can help prepare us for difficult or frightening situations, but it can also be a major source of stress. Try interrogating your doomsday thoughts and noting when the worst case doesn’t come to pass. 

Before you go…

• Did you know…that, according to some physicists, glass defies categorization as a simple liquid, solid, or gas? It looks like a solid, but its molecular structure is more like a liquid. 
• Today’s trivia: Between 1968 and 1973, the British government forcibly removed the native inhabitants from which Indian Ocean island? (You can find this and other brain puzzles in Vox’s daily crossword. Look for the answer in tomorrow’s edition.)
• Yesterday’s trivia: Last week we asked you what musical note is equivalent to a G sharp. That would be A flat. 

In the moody alcoves of a lobby bar in Chicago in 2021 over French 75s, Dr. Louise King, a gynecologic surgeon, and Katie L. Watson, a bioethics professor, found themselves in conversation about a topic that had long frustrated them both: Female surgeons are consistently underpaid compared to male surgeons, even after accounting for specialty, rank, age, and other factors. 

What troubled them even more was how the pay gap compounded in King’s own field. Surgeons who perform procedures that are specifically for women, like gynecological surgeries, are paid less for their services than surgeons who perform comparable surgeries for the male anatomy. Gynecologic surgeons are also predominantly women. Over the course of the conversation, Watson termed this situation “double discrimination,” a phrase that captures the overlapping dilemma of lower pay for surgeries in a specialty that is overwhelmingly female and also serves a primarily female patient population.

That term, which has since entered the medical literature, stuck because the problem it describes has been well documented for decades. In 1997, a group of gynecologic surgeons published a paper in the journal Gynecologic Oncology with a title that gets straight to it — “Is Adam worth more than Eve?” Dr. Barbara A. Goff, now chair of Obstetrics and Gynecology at University of Washington Medicine, and colleagues found that doctors are paid around 44 percent more for performing male-specific procedures than analogous female-specific ones. 

In the three decades since, the problem hasn’t been fixed. To the contrary, it has been effectively institutionalized, built into the systems and codes that determine how surgeons bill for procedures of all kinds. Today, gynecologic or female-specific procedures are in large parts still reimbursed at lower rates than male-specific procedures even when they take similar time and skill.

Those disparities have consequences that extend beyond the compensation of individual doctors. When gynecological procedures don’t bring in as much money to hospitals, those same hospitals are disincentivised to offer women’s health services. That can lead to worse care for women and, crucially, fewer training opportunities for the surgeons who do that work. 

But this historically persistent inequality is not a foregone conclusion.

How healthcare services are billed changes all the time as procedures get reevaluated, new ones get added, and medical societies and experts push for revisions. In fact, one of the biggest changes in how maternity care is billed and reimbursed is set to take effect early next year, splitting up services for prenatal care, delivery, postpartum care, and more. While this is a long-overdue fix for obstetrics, gynecologic surgery — which covers most of a woman’s life outside of childbearing years — continues to be left out of the conversation. 

And although real change will require concerted efforts, King and Watson — and other advocates who have spent years documenting this disparity — have a fairly clear sense of how to start fixing it.  

How surgical procedures are valued

The work of deciding how much a medical procedure is worth starts well above the head of any given doctor, medical practice, or hospital. In the United States, the Centers for Medicare and Medicaid Services, a federal agency that administers healthcare and health insurance policies, sets rates for different procedures based on a metric called relative value units (RVUs). An RVU is supposed to take into account how long a procedure takes, the skill it requires, and the intensity of work it demands. Both Medicare and private insurers consider these figures when they’re settling on reimbursement levels. If a procedure has a higher RVU, it is valued more highly, and makes more money.

In a recent study, cheekily titled “Price and Prejudice,” researchers from the Mount Sinai Health System found that out of 55 pairs of sex-specific procedures that they evaluated in 2023, 75 percent had lower RVUs for procedures on female patients. On average, RVUs for male-specific procedures were 30 percent higher, and when those procedures were performed in a hospital or surgical center, surgeons were paid around 26 percent more.

For example, doctors will often perform biopsies — taking a small sample of tissues, cells, or fluids — on both male and female genitalia to diagnose problems. In 2023, researchers found that Medicare’s standard national rate for reimbursing surgeons was $121.32 for a penile biopsy but only $65.74 for a vaginal biopsy. 

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#141417;--ag-knock: #141417;--ag-card: #1f1f24;--ag-ink: #ededf2;--ag-ink-2: #b9b9c4;--ag-ink-3: #8b8b97;--ag-rule: #ededf2;--ag-grid: #2c2c33;--ag-track: #26262c;--ag-focus: #8ab4f8;--ag-m: #6f73e8;--ag-f: #e5603a;--ag-m-ink: var(--ag-m);--ag-f-ink: var(--ag-f);color-scheme: dark}.ag-root[data-ag-mode="dark"][data-ag-palette="teal"]{--ag-m: #1e9db3;--ag-f: #dd7430;--ag-m-ink: #1e9db3;--ag-f-ink: #dd7430}.ag-root[data-ag-mode="dark"][data-ag-palette="violet"]{--ag-m: #8a6ee6;--ag-f: #cf7f22;--ag-m-ink: #8a6ee6;--ag-f-ink: #cf7f22}@media (prefers-color-scheme: dark){.ag-root[data-ag-mode="auto"]{--ag-bg: #141417;--ag-knock: #141417;--ag-card: #1f1f24;--ag-ink: #ededf2;--ag-ink-2: #b9b9c4;--ag-ink-3: #8b8b97;--ag-rule: #ededf2;--ag-grid: #2c2c33;--ag-track: #26262c;--ag-focus: #8ab4f8;--ag-m: #6f73e8;--ag-f: #e5603a;--ag-m-ink: var(--ag-m);--ag-f-ink: var(--ag-f);color-scheme: dark}.ag-root[data-ag-mode="auto"][data-ag-palette="teal"]{--ag-m: #1e9db3;--ag-f: #dd7430;--ag-m-ink: #1e9db3;--ag-f-ink: #dd7430}.ag-root[data-ag-mode="auto"][data-ag-palette="violet"]{--ag-m: #8a6ee6;--ag-f: #cf7f22;--ag-m-ink: #8a6ee6;--ag-f-ink: #cf7f22}}.ag-root[data-ag-mode="dark"]{padding-left: 16px;padding-right: 16px}@media (prefers-color-scheme: dark){.ag-root[data-ag-mode="auto"]{padding-left: 16px;padding-right: 16px}}.ag-root.ag-root .ag-x,.ag-root.ag-root p,.ag-root.ag-root h2,.ag-root.ag-root h3,.ag-root.ag-root button,.ag-root.ag-root select,.ag-root.ag-root input,.ag-root.ag-root ul,.ag-root.ag-root li,.ag-root.ag-root label,.ag-root.ag-root table{margin: 0;padding: 0;border: 0;background: none;box-shadow: none;font: inherit;color: inherit;letter-spacing: normal;text-transform: none;text-decoration: none;line-height: inherit;min-height: 0;width: auto;max-width: none;float: none}.ag-root.ag-root svg,.ag-root.ag-root .ag-pt-svgwrap svg{display: block;max-width: none;height: auto;overflow: visible}.ag-root.ag-root button{cursor: pointer;-webkit-appearance: none;appearance: none;border-radius: 0}.ag-root.ag-root :focus{outline: none}.ag-root.ag-root :focus-visible{outline: 2px solid var(--ag-focus);outline-offset: 2px;border-radius: 4px}.ag-root.ag-root .ag-sr{position: absolute !important;width: 1px !important;height: 1px !important;padding: 0 !important;margin: -1px !important;overflow: hidden !important;clip: rect(0 0 0 0) !important;white-space: nowrap !important;border: 0 !important}.ag-root.ag-root [hidden]{display: none !important}.ag-root.ag-root .ag-hed{font-family: var(--ag-head);font-size: 23px;line-height: 1.12;font-weight: var(--ag-head-weight);letter-spacing: var(--ag-head-track);color: var(--ag-ink);text-wrap: balance}.ag-root.ag-root .ag-dek{font-size: 15px;line-height: 1.4;color: var(--ag-ink-2);margin-top: 6px;text-wrap: pretty}@container ag (max-width: 480px){.ag-root.ag-root .ag-hed{font-size: 22px}.ag-root.ag-root .ag-dek{font-size: 14px}}.ag-root.ag-root .ag-ft{margin-top: 14px;padding-top: 12px;border-top: 1px solid 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King, the director of reproductive bioethics at Harvard Medical School Center for Bioethics and a contributor on the study, believes that when the RVU system was created back in the 1990s, gynecological services were largely ignored, leaving the specialty undervalued from the start. While Medicare and Medicaid Services has undertaken some efforts to make RVUs more equitable across specialties over the years, that undervaluation has persisted. 

That problem may come down to how those values are determined in the first place — and who determines them. RVUs are set by a committee of doctors convened by the American Medical Association (AMA), with most of the seats allocated to members of major medical societies. The committee surveys different doctors on the time and skill required for procedures in their specialties. Based on these responses, the committee recommends values for each service to the federal government, which has historically accepted nearly 90 percent of them.

While the data quality of the underlying surveys has improved over the years, it is still not very high, said Dr. Miriam Laugesen, a tenured associate professor of health policy and management at Columbia University Mailman School of Public Health. Because the committee’s process isn’t transparent, it is often unclear what evidence its valuations rest on. This leads to distortions of all kinds, she said.

“It’s not a government process; It’s not a federal advisory committee,” Laugesen said. “It’s just a committee that was put together by the [AMA]. It’s pretty unusual in terms of how policy is made.”

In particular, King said that the surveys have a very low response rate from some specialties and are only sent to a small subset of doctors. She has never received a committee survey in the 17 years that she has practiced. 

The American College of Obstetricians and Gynecologists (ACOG) has a core seat on the committee that determines RVUs. But most ACOG members are general OB-GYNs, who split their time between obstetrics and gynecology and typically operate relatively rarely. The surgeons who perform the bulk of gynecologic operations are subspecialists – gynecologic oncologists, urogynecologists, and minimally invasive gynecologic surgeons — who complete an additional fellowship after residency. They mainly belong to their own societies and don’t have a seat at the table when RVUs are being determined. 

“From a purely cynical or economic standpoint, [ACOG] has no reason to advance billing for gynecology. It doesn’t represent a large portion of the practices of their members,” said King, adding that ACOG has been heroic in its efforts to obtain reimbursement equity for its own members. (One unintended possible result of that advocacy is that pushing for a smaller pay gap for services related to pregnancy, has in turn sent the message that women’s bodies are literally worth less, and are less deserving of care when they’re not engaged in the god-given duty of reproduction.)

The result is that doctors in specialties like OB-GYN who operate infrequently are answering the surveys about complicated surgical procedures that gynecologic surgeons perform more frequently. King said that her surgical schedule aligned more closely with those of general surgeons. For example, she operates two to three times a week whereas, according to her, an average OB-GYN will likely operate once a month. 

“So they’re not the right people to be answering these surveys. They [the survey committee and ACOG] don’t target the surveys to people who operate a lot,” she said. 

Part of the problem with using surveys to determine a key foundation of medical reimbursements is that the data is self-reported by doctors. This is especially relevant when more objective avenues may be available. One of those avenues is the American College of Surgeons’ National Surgical Quality Improvement Program, which is an initiative that collects and manages key surgical data to track quality and improvement in surgical fields, including the actual time spent performing surgical procedures, making it a more definitive measure than self-reported surveys.

Dr. Shitanshu Uppal, a gynecologic oncologist and division chief for gynecology oncology service at the University of Michigan, and his colleagues analyzed 901,917 surgeries using both the National Surgical Quality Improvement Program as well as the self-reported surveys used to determine RVUs. They found that median RVUs per hour vary widely between specialties. Gynecology had the third-lowest median RVUs per hour of all the specialties studied. In effect, that means that gynecological surgeons are paid less for every hour that they work. 

The researchers also found that compared to the operating times logged for real surgeries in the Surgical Quality Improvement Program, surgeons in certain specialties tended to report longer procedure times in the self-reported surveys sent out by the RVUs committee. Specialties that reported longer operating times were more likely to be awarded higher RVUs, leading to greater hourly rates of reimbursement.

According to Uppal’s analysis, urologists — a profession most often associated with procedures on men because their work routinely concerns the prostate and the testicles — reported times that exceeded the baseline data by a median of 20 minutes. By contrast, estimates from gynecologists only exceeded the actual time by a median of five minutes, meaning that urologists tended to overestimate their time spent in surgery by four times as many minutes. Generally, urologists earn much more than general OB-GYNs, who in turn earn more than other subspecialties like gynecologic surgery. Despite having access to reliable electronic records of operating time, Uppal and his colleagues note, the AMA committee still continues to use self-reported operating times, which influences their RVU recommendations, ultimately cementing disparities in female-specific procedures. 

“The system that they have now developed over time,” King said, “now creates discrimination because of its complexity.” She added that this is how systemic discrimination is perpetuated, even if systems or rules appear seemingly neutral.

How low reimbursement rates make women’s lives worse

The US healthcare system has never been especially good at putting its money where its mouth is when it comes to women’s health. Experts have been sounding the alarm on sex-based disparities in medical billing for a long time — long enough that governing authorities like the committee responsible for RVUs and ACOG have had time to respond to the concerns. 

Over the years, the gap between male-specific procedure reimbursements and female-specific reimbursements has decreased slightly. But researchers of the Price and Prejudice study showed that between 2003 and 2023, there were no statistically significant improvements to the pay disparities. Comparing a smaller set of procedures across 1997, 2015 and 2023, they found that the gap had narrowed only minimally.

One common justification that ACOG provides for the pay gap is that obstetrics and gynecologic services see a higher-than-average share of patients on Medicaid, which pays doctors less than other insurers. King agreed this is a real factor, but it doesn’t explain why Medicare itself values procedures on women lower in the first place. And as her account of double discrimination makes clear, undervaluing gynecology ultimately affects women everywhere for the worse.

“I have patients who are waiting for surgery with me for a year at a time. I mean, that’s crazy.”

Dr. Louise King

Lower reimbursements in gynecologic surgery disproportionately affect female surgeons because they represent a majority of this specialty. It’s not just the surgeons’ salaries that are affected. Hospitals and facilities work on a revenue-based model — if gynecologic surgeries are not bringing in enough money, institutions tend to allocate fewer resources to those procedures. That, in turn, can limit access to operating rooms, surgical staff, and operating times. 

“I have patients who are waiting for surgery with me for a year at a time. I mean, that’s crazy,” King said. As a minimally invasive gynecologic surgeon, she surgically treats women with endometriosis, fibroids, cysts or other such conditions.

It also affects the training that gynecologic surgeons receive. When there aren’t enough resources to operate regularly, opportunities to train residents are rarer than they should be. The result is that low reimbursement rates have contributed to a workforce of low-volume gynecologic surgeons who are sometimes not as well-trained as other surgeons who operate frequently.

The relationship between volume of surgeries performed and patient outcomes is well-documented in other fields. Research shows that surgeons who operate infrequently have worse outcomes, including more complications before, after, and during surgeries, compared to surgeons who operate regularly. 

Low volume gynecologic surgeons — who perform a particular procedure less than 12 times a year — have significantly higher rates of causing bowel and urinary tract injuries in their patients. Especially in benign gynecological surgery (procedures not related to cancer), having surgeons who operate frequently also increases the amount of minimally invasive procedures performed, which is related to better patient outcomes. 

Payment reform is an uphill battle, but not a lost cause

It takes multiple years and pressure from different entities to update or add new RVUs for procedures — but crucially, it is not impossible. The first few steps to creating a sustainable system might look like submitting gynecology-related procedure codes for reevaluation to the AMA committee or prompting a congressional report on the matter. 

For example, for years there has only been one billing code for endometriosis, regardless of the complexity of surgery or technique used. This disincentivizes surgeons from taking on complicated surgical cases of endometriosis because of the low reimbursement rate. Reevaluating that rate or diversifying the various surgical approaches that different cases require would help affected women get the care they deserve.

Medicare’s payment system also has what’s called a budget neutrality rule, which dictates that significantly increased payments for any given procedure must be offset by cuts elsewhere. The AMA itself believes that reforming this rule would make it easier to work toward reimbursement equity for female-specific procedures.  

Experts have suggested creating gynecology-specific conversion factors to bring parity to a system that naturally undervalues these procedures, while others think that eliminating sex-specific billing codes whenever possible is the right move. For example, the code for genitalia biopsies is different for men and women. This means that those procedures can be reimbursed differently even though they are essentially similar. Adopting one sex-neutral code for any genitalia biopsies would avoid this. While the reform required for this would be substantial, researchers believe that it would narrow the billing gap significantly.     

Authorities often justify lower RVUs for female-specific procedures by pointing to training: Gynecologists spend fewer years learning to operate than urologists and other higher-paid surgical specialists, according to King.

Historically, surgeons who operated on the female pelvis trained in ways that were more closely aligned with general surgeons than OB-GYNs. When obstetrics and gynecology merged into one specialty in the 1900s, the training for gynecologic surgery was truncated. 

“General OB-GYNs will train for four years and of that four years about 18 months is devoted to surgical training in gynecology,” said King, contrasting the new training period to those of general surgeons which is in years. 

She believes that training periods should be increased for gynecologic surgeons. That change would secure better reimbursement for the speciality, while also producing better trained surgeons who would be more attuned to advances in minimally invasive surgery that will ultimately improve the outcomes for their female patients. In some cases, the experience gained during a two-year fellowship in gynecologic surgery was equivalent to 19 years in practice.  

In their initial work on double discrimination, Watson and King argued that failing to implement solutions for parity is tantamount to saying that female patients deserve less well-trained surgeons than male patients.  

As with most women’s health issues, it is unclear if this systemic disparity in medical reimbursement is the result of conscious misogyny or a by-product of ignorance. But that question of origins matters little when its consequences have been enshrined in medical policy, with lasting consequences for the practice of medicine more generally. We have allowed this wage gap to persist, even as many have sounded the alarm for decades. It is long past time to heed their warnings.

After moving to West Virginia last year, Steve Kuo signed up for a new insurance plan that would cost him $500 a month. But there was one upside: He knew he was entitled to a free preventive visit. He wanted to take advantage of it, so he made an appointment at a clinic near his new home.

But then when he got there, they asked about his medical history and he mentioned prior kidney problems. When he received a bill a few weeks later, he had been charged twice for the same appointment: Once as that free preventive visit, once as an “office sick visit” because of the kidney conversation. He was flummoxed — and very annoyed, as he shared on social media. “No copayment means no copayment, exactly as stated in the insurance guidelines,” Kuo told me over email. “What is written and agreed upon should be honored.”

He is far from alone. On Reddit, I easily found more than a dozen examples in just the past year of people getting a surprise bill for what they thought was going to be a free visit. 

One woman posted a nearly $1,000 bill she’d received for what she thought was going to be a preventive gynecology visit. Another woman said that she ended up facing roughly $3,000 bills because she was given an ultrasound (which she said she didn’t request) at a preventive visit, and then her blood draw was sent to an out-of-network lab. Another person lamented that they had been billed $170 for an office visit because they had briefly mentioned back stiffness.

It’s not supposed to be like this. Americans don’t get much when it comes to our healthcare, but most of us are supposed to be entitled to at least one thing: Once every year, no matter your health insurance, you can go to the doctor with the goal of preventing future health problems by discussing important vaccinations, cancer screenings, and cardiovascular health screenings. The Affordable Care Act made that the law in 2010.

But more than 15 years later, people all over the country are walking into their doctor’s office, thinking they’re entitled to that one free visit every year, and walking out being billed for a sick visit, blood labs, and more. Researchers estimate that Americans spend tens of millions, maybe hundreds of millions of dollars every year on services that are supposed to be free under the ACA.

Dr. Yalda Jabbarpour, a family physician in the Washington, DC, area and medical director of the Robert Graham Center for Policy Studies, told me she still deals all the time with people’s confusion about what a preventive visit really means.

“Every single time I’m in the clinic, this issue comes up with a patient. And it’s sad that it comes up,” Jabbarpour told me. “In my mind, the blame is not to be put on the patient. The blame is not to be put on the physician. Really, this points to a bigger system issue that we need to solve.”

How could a seemingly simple promise of one free annual doctor’s visit result in a situation so convoluted that patients and doctors are still struggling with it nearly two decades later? And how might we fix it?

Patients are getting surprise bills from their doctors — and they’re pissed off

The goal of the ACA was to expand coverage and make sure health insurance would be comprehensive to actually help people stay healthy. As part of that project, the authors of the law added a mandate for insurers to cover those services, including an annual wellness exam. The problem is, they did not define what the parameters of that preventive visit actually were, said Alex Hoagland, a healthcare economist at the University of Toronto. 

“It didn’t establish a clear definition of…all the diagnosis codes and procedure codes and how frequently you get that combination within a year,” he said. “They don’t define what actually is preventive care and what’s not.”

That has left each insurer to define a preventive visit on their own — and that’s where the perverse incentives that leave patients in a lurch begin. Preventive visits are supposed to be reserved strictly for screenings and talking about other preventive measures you can take to protect your long-term health, but you may get billed for an “office visit” or a “sick visit” if you talk about any specific symptom you’re experiencing, the same as if you had come in because you had the flu. 

Health insurers have an incentive to keep the definition of preventive care as narrow as possible, so they have to pay fewer claims without any contribution from the patient. At the same time, doctors want to be paid for the actual services that they are providing. If somebody does bring up a bigger health problem during a preventive visit, then the doctor reasonably wants to be paid accordingly. 

“I know, particularly in the healthcare space, it’s really popular to blame one party or another, and here I don’t think it’s a matter of corporate greed or physician incompetence or whatever,” Hoagland said. “It’s just a natural mismatch of incentives.”

So the reality is that “one free doctor’s visit” sounds straightforward, but, in practice, it’s much more complicated. You as the patient might think of it as one visit, but in our fee-for-service healthcare system, where providers bill based on each specific thing they do, it’s not. The conversation about your vaccination may be free — but asking about your back pain is not. If you get blood tests ordered, that’s another line item. The list goes on. “It’s not like you walk into a doctor’s office and it’s just one thing that happens, right?” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University. “It’s multiple different things that are happening when you go into a doctor’s office.”

Part of the problem may be that it’s one free visit. We Americans are consumers at heart: Tell us we’re going to get something for free and we want to take advantage of it. But having just one free visit may also lead to people bringing a laundry list of questions to that preventive visit, because they think of it as their only chance to ask everything of their doctor. 

That makes it easy for the discussion to tip over into a sick visit — and not only does that lead to a surprise bill, it can also crowd out the conversation about prevention that the visit is supposed to be focused on.

“What ends up happening a lot…is that a patient comes in for their annual visit, and in their mind, that is their time to bring up every single thing that’s been happening during the year, because they see it as the free visit to bring up everything that’s happened during the year. For some patients, that takes up the entire visit,” Jabbarpour told me. “They leave, and it’s like, ‘Oh my god, we forgot to do all the screening things: the vaccinations, the cancer screenings, and the cardiovascular risk screening.’ And then something happens down the line because you never address those screenings.”

A 2021 study by Hoagland and Paul Shafer, both of Boston University at the time, estimated that Americans with employer-sponsored insurance had in 2018 alone paid between $75 million and $219 million in medical bills that should have been free. They were more likely to be charged for things like contraception or cholesterol and diabetes screenings, with individuals sometimes paying hundreds of dollars for those services.

Hoagland told me he had been billed for preventive visits because he has type 1 diabetes and the system automatically categorized his appointment as a diabetic visit. Earlier this year, he co-authored a study that found people with chronic conditions were more likely to be charged for preventive care. Corlette said that she too had recently been charged for what was supposed to be a preventive visit after she mentioned an issue as an aside. And these are folks who study health care for a living.

“It was literally maybe a 10-second conversation where I would ask the doctor a question about something,” she said. “And that triggered it.”

Colonoscopies are another dramatic example of how this issue plays out in real life; Corlette told me the procedure was one of the first services where this fuzzy line between prevention and treatment under the ACA became obvious. People go under for what is supposed to be a preventive colonoscopy. But then their doctor finds a polyp and decides to remove it — good clinical practice, but as a result, their patient could end up being charged thousands of dollars because the colonoscopy was no longer preventive once that polyp was snipped.

“All of a sudden, that would trigger what the patient thought was a preventive service into a cost-sharing obligation,” Corlette said. “Colonoscopies can be thousands of dollars. That was when we were first like, ‘Oh, yeah, this is a more complicated area than I think the lawmakers that drafted this provision originally envisioned.’”

How the US could fix our preventive visit headaches

The ACA’s preventive visit promise was clearly well-intentioned and it’s worth remembering that, if you look in the aggregate, more Americans are getting more free preventive care than they did before the law was passed. The problem, as much as anything, is expectations: People think they’re entitled to a free visit and are understandably frustrated when they get billed for it.

“The difference is before the Affordable Care Act, maybe they anticipated some kind of cost-sharing,” Hoagland said. “But after, they expect it to be free.”

It doesn’t have to be this way. Corlette’s team at Georgetown University recently released a proposal that Americans be entitled to three primary care and two urgent care visits every year with no cost-sharing. This approach has two virtues, she told me: It will help people feel like they are actually getting value from their insurance — the very complaint that Steve Kuo raised — and, because we know primary care helps prevent problems down the road, it should also improve people’s health in the long term. Take the pressure off that one free visit and let people see the doctor a few times a year without worrying about being charged.

“In employer-based insurance, a lot of people feel like, ‘What the hell am I getting for my premium each month?’” Corlette said. “We wanted people to feel like they’re getting good value, and we wanted to get to better population health.”

Hoagland also endorsed the idea of at least one free physician’s visit every year, no matter what’s discussed. In the long term, Jabbarpour said she’d like to see copays eliminated entirely for primary care. 

But any payment reforms are not going to happen immediately. What can we do right now?

For one, doctor offices could make an effort to be as transparent as possible. Jabbarpour’s MedStar system has started calling people a couple of days before their appointment with a brief script that tells the patient that they could be charged if the conversation with their doctor touches on additional medical problems. If your doctor’s office doesn’t proactively bring it up, ask when you schedule your appointment or when they call you to confirm it. Worst-case scenario, ask your provider what they consider preventive care when your visit begins. You might also want to educate yourself on what services are generally considered preventive and should be available for free: Your insurer may make that information available on their website, or KFF has a database you can peruse.

It’s not a perfect solution. “What ends up happening is patients come in, and they say, ‘I know I’m not supposed to talk to you about anything else, so I’m not going to tell you about anything else.’ And you don’t want that to happen,” Jabbarpour said. You should ask your doctor directly: What do you consider to be preventive care? Establish boundaries at the start. That way, you can at least be aware if you are going to get charged because the conversation crossed the line to discussing an active health problem.

And if you want to see the underlying laws change, start organizing. Contact your state and federal reps and ask them what they are doing to ensure this stops happening. Things could be different: Jabbarpour said she hopes to one day work in a health system where the cost of a single primary care visit isn’t so high-stakes, where doctors and their patients can manage their health according to their particular needs, rather than worry about how to bill for one specific conversation that covers the whole range of somebody’s health — like primary care is supposed to do.

“I think some patients can be managed by seeing us once every year, once every two years, and some patients need to see us monthly,” Jabbarpour told me. “To put all patients in the same box and say you can only see your primary care physician once a year if you want it paid for, it makes zero sense.”

The AI freakout of the past few weeks has centered on nothing less than the risk of human extinction — on the possibility that artificial intelligence could wipe us all out. But the reality is, AI programs are already having a direct and sinister effect on people’s physical health: UnitedHealth Group, the largest health insurer in the US, has been accused of using AI programs to deny payments to people, despite their doctors saying the care was necessary, and is facing a class-action lawsuit. 

Humana and Cigna are facing their own litigation over similar allegations. Meanwhile, Medicare has launched its own AI tool that will help the government determine whether to approve prior authorizations, and doctors are sending the federal government reports of patients at their offices who are in tears because they can’t get the medicine to manage their chronic pain.   

The claims in the legal complaints are harrowing: Families are desperate for an elderly loved one who recently experienced a serious fall to be allowed to stay in a nursing home. Doctors are flummoxed when a patient who may need months of rehab is cut off by an algorithm after a couple of weeks. 

This is AI’s threat to people’s health right now. 

While the current conversation may be fixated on something more Hollywood, private insurers and the Trump administration are already deploying AI programs to vet people’s health insurance claims — and the evidence is growing that these programs are not always doing a good job and are instead putting people’s health at risk. Until these lawsuits are settled or policymakers can figure out a way to regulate how insurers use this new technology, it will be up to each of us to make sure that an AI program isn’t being used to cheat us out of insurance benefits that we’re entitled to.

“The type of care that clinicians deliver is very sensitive to the patient’s unique circumstances. That may not really show up as a number. There’s not a numeric value that tells you the completeness and connection of a patient’s social network,” said Mika Hamer, a health services researcher at the University of Maryland. “There really are a lot of factors that really can’t be quantified and so aren’t really suitable to go into these models. If we start to rely exclusively on the models, I think we run the risk of losing that human touch.”

Patients say private health insurers are using AI to deny claims

Insurers and patients fighting over medical claims is nothing new: Policyholders want the most coverage they can get and payers have a business incentive to pay as little as they can. Health insurers have also used algorithms for decades: Plug in somebody’s age, their weight, whether or not they smoke, and one of the old-fashioned algorithms could spit out a rough estimate of how much medical care they would need before they died. Simple — and comparatively transparent. 

When you submitted a claim or sought prior authorization, there was supposed to be a human doctor who could review all of the relevant information on behalf of the insurer and make the final decision, in theory with the patient’s best interests in mind. It didn’t always work that way in practice, of course, but that was the idea.

What’s different right now, according to Daniel Schwarcz, a law professor at the University of Minnesota who has looked at health insurers’ AI use, is that these newer programs can make very specific predictions about someone’s future health based on the information that’s fed into them, and those predictions are being used in the process of approving or denying medical claims. And exactly what went into making those predictions — and whether it is the AI or the human who ultimately holds the final authority — is often opaque from the outside.

“The reason we want human review is we want human substantive judgment. We want AI to be supporting that,” Schwarcz said. “But the difficulty is distinguishing between AI supporting meaningful human processing and AI basically replacing the human with the human just passively defaulting to the AI judgment. It’s just incredibly hard to distinguish between those two in practice, particularly in rules or regulations.”

And those questions are at the heart of the lawsuits brought against three major insurers in the past few years about their use of AI in processing claims.

In May 2022, Gene Lokken, then 91 years old, fell in his home. He was taken to the nearby hospital in Tomahawk, Wisconsin, and treated for a broken leg and a broken ankle. Less than a week later, he was placed in the health system’s hospice care because, according to the lawsuit filed by his family, he was “very weak, not communicative, and in constant pain.”

But a month later, after receiving skilled nursing care, Lokken started to improve. By late June, his doctor had removed his splint and placed his leg in a removable boot. In July, he started physical therapy to get up and walk again. And for a while, his Medicare Advantage plan sold by UnitedHealth covered all of the services he needed.

Until July 20. Around that time, according to the lawsuit, UnitedHealth denied any more services at the nursing facility where Lokken had been for the past two months. It insisted that he could be safely discharged and more time at the nursing care facility “was not medically necessary.”

The insurer’s decision left Lokken and his physician “dumbfounded.” The physical therapist notes from the time said Lokken was still suffering paralysis and weakness after only a couple weeks of rehab. His family appealed, but UnitedHealth continued to deny the claims, asserting that because Lokken could feed himself and did not require help to clean himself, he did not need nursing care and could go home. 

From July 2022 to July 2023, Lokken remained at the nursing home, but his family had to pay between $12,000 and $14,000 monthly to keep him there. And on July 17, 2023, Lokken died — having never left the facility.

The lawsuit alleges that the decision to stop covering Lokken’s nursing-home stay was largely made by an AI algorithm, called nH Predict, which UnitedHealth follows so unquestioningly that employees were allegedly at risk of being disciplined or fired if their claims decisions went against the AI’s projections. The complaint alleges that the AI model would typically start denying claims after two weeks of nursing home care — and the attorneys have more examples than Lokken.

Glennette Kell required emergency surgery after a fall in late August 2023 and was referred to a nursing home rehab center. By mid-September, UnitedHealth was denying her claims for nursing care, despite the fact that, according to the lawsuit, she still could not walk. Kell had to pay $10,000 of her own money to cover the rest of her bills. Darlene Buckner suffered a heart attack in October 2023 and underwent triple-bypass surgery. She was readmitted to the hospital in late November because she was experiencing complications, but less than two weeks later, UnitedHealth allegedly denied any further treatment at the hospital because it was deemed medically unnecessary. At the time, according to the class-action lawsuit, Buckner was experiencing “an open infected wound near her heart from the open-heart surgery, she was on blood thinners, and was receiving antibiotics through an IV.” 

UnitedHealth, in its responses to the plaintiffs, has asserted that federal laws and regulations already require all claims decisions ultimately be made by a human doctor, not an AI program, and raised several other technical legal objections (such as saying the plaintiffs have not fully exhausted their administrative appeal options). The plaintiffs, however, allege that UnitedHealth employees “are instructed not to deviate” from the AI model’s projections, and then tell patients the AI-generated information is proprietary when they or their doctor try to inquire about why their claims are being denied. 

And, to be clear, UnitedHealth is not the only insurer being sued for using AI programs to deny claims. Humana is facing its own lawsuit brought by other Medicare Advantage patients who allege the same nH Predict program also led to their claims being wrongfully denied. Joanne Barrows, then 86, fell in November 2021 and went to a rehab nursing facility after her hospital stay. And just two weeks later, Humana began denying her claims for further care, according to the complaint, leaving her and her doctor “bewildered” because she was under doctor’s orders not to put any weight on her leg.

And the third lawsuit, filed against Cigna, alleges the company used a different AI algorithm that allowed its doctors to deny claims in huge batches — hundreds or thousands at a time — if they did not meet certain predetermined criteria. One patient, Suzanne Kisting-Leung, had claims denied for two ultrasounds done by her doctor to check for ovarian cancer, putting her on the hook for more than $700 in medical bills because, the lawsuit alleges, Cigna’s AI program determined that the scans were not medically necessary. The plaintiffs say that their claims were instantly rejected, without their medical files ever being opened. As for the law that human doctors have to make the final call? According to the lawsuit, the algorithm “enable[s] its doctors to automatically deny payments in batches of hundreds or thousands at a time for treatments that do not match certain pre-set criteria, thereby evading the legally required individual physician review process.”

These people, many of them elderly, had no idea AI was being used to make decisions about their coverage — until it was too late.

“From their perspective, you might as well have been speaking Esperanto. They just had no idea what it was that was being said to them when they were being told. They usually heard about it for the first time when they were being told that they needed to leave,” Glenn Danas, one of the attorneys in the class-action litigation against United, Humana, and Cigna, told me. “They just had no idea what was going on or why this was being done to them.”

AI is now making decisions for traditional Medicare claims too

It’s not just private insurers either. The Trump administration is now pushing traditional Medicare and Medicaid to use AI to adjudicate insurance claims too. In June 2025, nearly two years after those lawsuits had been filed against Cigna, Humana, and UnitedHealth, the US Department of Health and Human Services announced it would deploy a new program called the WISeR (Wasteful and Inappropriate Service Reduction) model to make prior authorization decisions for about a dozen procedures for the people on traditional Medicare in six states — “leveraging enhanced technologies, such as Artificial Intelligence (AI) and Machine Learning (ML), along with human clinical review to ensure timely and appropriate Medicare payment for select items and services.” It would be a pilot program, before federal officials decide whether to take the program nationwide.

It was a quiet, massive change for traditional Medicare, which covers about half of the 66 million Americans on the program. (Medicare Advantage plans, in which private companies administer Medicare benefits under slightly different parameters and which were the subject of the earlier AI-related class-action litigation, cover the rest.) People on traditional Medicare had historically not been required to get prior authorization for most services; now they would be, and a novel AI program would play a significant role in which claims get approved and which ones don’t.

From the start, physician and patient advocates warned about the potentially adverse consequences of the WISeR program; the Center for Medicare Advocacy said the program would likely “complicate, delay and even outright deny necessary care.” According to media reports and internal government documents, that’s exactly what has happened since the model went live in January. 

The Washington Post first reported in March that physicians and their patients were experiencing approval delays or denials for medical services that should have been covered. One glitch led to a denial of payment for services that had been approved. Doctors noticed that certain procedures seemed to give the AI model problems — such as two competing treatments for incontinence — and were weighing whether or not to stop offering one of those services altogether. The Post reported on one Arizona patient who had been receiving steroid injections for chronic back pain before being denied multiple times after the AI program’s launch. The pain became so severe, he said, that he could not exercise at all.

Then this month, the Electronic Frontier Foundation released a trove of documents it received in response to a Freedom of Information Act lawsuit related to the WISeR model. The documents revealed aggressive denials — one company using the AI model had actually denied more prior authorization requests than it had approved — and there were delays even when the care was ultimately approved. One review took 83 days when the model was supposed to make a decision within 72 hours.

The direct feedback from doctors in the federal documents obtained by EFF was devastating.

“We have patients calling our offices crying in pain because their procedures are being delayed while awaiting approvals or guidance tied to this model,” one doctor wrote. “A 3-4 day delay for necessary pain procedures is already difficult for vulnerable patients, but when providers cannot obtain answers for weeks, the situation becomes unacceptable.”

According to the federal documents, the Trump administration was already discussing ways to expand the program. Despite the outcry from doctors and patients, and growing concern among their representatives in Congress, it doesn’t look like WISeR is going away.

How can we make sure AI doesn’t take over insurance claims?

AI is becoming a part of healthcare — it is already happening. And many of those uses could be truly beneficial. Anthropic recently announced an initiative to apply the theoretical findings of its AI models to real-life lab work that could lead to new drugs being developed in the future. In terms of scientific discovery and the potential to translate it into new treatments, the excitement among clinicians about its potential is palpable.

And nobody denies that health insurance administration is chaotic and burdensome and would benefit from being made more efficient and streamlined — tasks which AI is at least superficially well-suited for.

But as the past few years have already shown, rushed and sloppy deployment of AI to take responsibility for approving or denying payment for people’s medical care has created serious problems. The issue is that this technology is being adopted more quickly than any regulator can oversee it. We don’t really know how health insurers are using AI tools. We don’t have a good framework for what keeping a “human in the loop” of insurance decisions — which is what people want — would really mean, Schwarcz said. 

“I think everyone agrees at a high level of generality, ‘Yes, AI should be used to enhance human review and not to replace it,’ but no one actually knows how to write rules to enforce it,” he told me. “I don’t think that there’s anything I’ve seen that has effectively defined what it means for a human to be meaningfully in the loop in the sense of retaining independent judgment as opposed to just reviewing and deferring. It is incredibly hard to specify in rules or regulations a standard that is verifiable and enforceable. That is still, as far as I know, an unsolved problem.”

Some states have started adopting rules requiring transparency for AI use in insurance claims, and lawmakers in Congress have put forward proposals requiring human involvement, including the bipartisan Protecting Patients from Automated Denials Act. But these technologies are so ubiquitous and so flexible that rigorously regulating their use is going to be difficult. Meanwhile, the profit incentive for companies to adopt these tools and deploy them widely is extremely strong. We don’t even know how widespread their use really is.

Danas said he and his clients hoped their litigation would help with “putting the brakes” on AI’s use in insurance. Until we figure out what to do from a policy perspective, what can each of us do in the meantime? Hamer told me that the old advice is still the best advice: If your claim is denied, appeal it. An enormous number of denied claims end up getting overturned on appeal. 

“You do not necessarily have to accept that the first answer from your insurance company is the final determination,” she said.

For decades, research into Alzheimer’s disease has made painfully little progress. More than 7 million Americans are living with the disease, which is the most common cause of dementia. It’s incurable, and treatments have been hampered by groupthink, as well as by systemic fraud from some of the field’s most famous researchers.

But there are finally signs that the field is turning a corner, including two new drugs, rolled out in the last few years, that can treat Alzheimer’s directly.

“If somebody walks into a clinic right now and is diagnosed with Alzheimer’s disease,” Vox senior correspondent Dylan Scott tells Today, Explained co-host Sean Rameswaram, the drugs “will hopefully have some effect in slowing down their cognitive decline.” 

As Scott says, “The drug development pipeline is also starting to look much more robust” — even “revolutionary,” to quote one doctor he spoke with.

The two talk about why researchers are more optimistic than they have been in years, whether GLP-1 drugs might help prevent Alzheimer’s, and an experimental surgery pioneered by doctors in China that has produced striking — but if unproven — reports of improvement in people with the disease.

Below is an excerpt of their conversation, edited for length and clarity. There’s much more in the full podcast, so listen to Today, Explained wherever you get podcasts, including Apple Podcasts, Pandora, and Spotify.

You mentioned two treatments. Tell us what they are, Dylan?

We have two drugs right now that have been approved by the FDA: lecanemab and donanemab. And these are drugs that target the amyloid plaque in the brain that scientists have long thought might be associated with the development of Alzheimer’s disease.

The amyloid hypothesis [the belief that Alzheimer’s is caused by the buildup of deleterious amyloid proteins in the brain] has been very controversial for a while, in part because there were these years and years where we weren’t seeing any progress despite this being the dominant hypothesis about the disease. But we do have these two drugs that in clinical trials have been shown to both clear out the amyloid plaque in somebody’s brain and they do seem to lead to slower cognitive decline for those patients.

And the hope is that this is the ground floor. These are the worst drugs, hopefully, that we’re ever going to have and continued scientific discovery and progress with developing drugs will lead to even better treatments in the future.

“The hope is that five, 10 years from now, we’ve got a much more robust suite of treatments that can help somebody who’s been diagnosed with Alzheimer’s.”

Tell us more about the scientific discovery. You mentioned that there’s promising research beyond amyloid plaques?

It’s not like the amyloid hypothesis has been invalidated, but I think our understanding of the disease has become more complex. 

We’re realizing that there’s probably also a role for a different kind of protein called tau. There may also be a role with chronic inflammation, your vascular health, your body’s ability to just pump blood through your body may also be playing a role in the development of Alzheimer’s disease. And so now we’re starting to see treatments that target these other things. 

The way I’ve been thinking about it is if we used to be putting all of our bets on amyloid, we’re still putting some bets on amyloid, but we’re also putting bets on these other things. And so now there are treatments in the works targeting, for example, these tau proteins.

They’re still in the early stages of clinical trials — really at the stage where they’re just checking the safety of these drugs and making sure that somebody can take them without getting really sick, or God forbid, dying or something like that. But even when they’re doing those safety checks, they do start to collect qualitative data about, well, are we starting to see any effects? 

Some of the preliminary results from some of these tau targeting treatments that are in the works have looked pretty promising. And so that’s encouraging, obviously. It’s possible that we’re moving towards a future where not unlike cancer treatment, there’s not just one drug for Alzheimer’s disease, but maybe you take a combination of different things that work on different mechanisms for the disease and the collective cumulative effect is that it stops the progression or even reverses it. 

The hope is that five, 10 years from now, we’ve got a much more robust suite of treatments that can help somebody who’s been diagnosed with Alzheimer’s.

Five, 10 years from now sounds nice, but is there anything else that’s in the cocktail now that people are discovering could be promising for Alzheimer’s?

There are also, yes, drugs that millions of people are taking right now for other reasons that might also be able to help with Alzheimer’s disease. And GLP-1s in particular are the big ones.

No way!

Yeah, I know. These drugs — it seems like every day you see some new headline about this miraculous thing that they can do.

Weight loss, smoking, my poker addiction, and…?

And it might prevent dementia down the road. 

If you step back and think about it, the theory does make some sense. Like I said before, scientists increasingly think there’s an association between your vascular health and your cognitive health, especially as you age. And what do these GLP-1 drugs do? They help people lose weight. 

Losing weight helps to lower your blood pressure, lowers your risk of vascular problems, whether it’s heart disease or pulmonary disease or stroke or something like that. So if more and more people take these, they take them earlier in life, they lose weight, they keep it off, they don’t develop these heart or vascular problems, it does make some sense that that may also reduce their risk of developing Alzheimer’s disease. 

It’s still sort of theoretical, but the Alzheimer’s Association is putting $100 million behind some research projects to investigate this possible link. We may learn five, 10 years from now, as millions of people are now on these GLP-1 drugs — maybe we start to see Alzheimer’s less often. And that would be another reason to be optimistic that the future for this disease is looking brighter.

How about reversing it? Is that still a pie in the sky?

It’s out of reach for now. Certainly some of the scientists that I’ve talked to have said, “In theory, it should be possible. Your brain is really resilient. It’s really good at rebuilding itself if you give it the chance.” It seems like it should be possible to stop the progression of the disease eventually, and maybe ultimately reverse it. 

Now, there has been some really intriguing, but also mysterious developments around reversing Alzheimer’s, not from scientists based out of the United States, but from scientists in China. People may or may not have seen that there have been videos of these patients who underwent an experimental surgery and the before and after of these videos is incredible.

In the before, you’ve got somebody who clearly has Alzheimer’s disease, doesn’t recognize their loved ones, has trouble with their train of thought. In the after videos, it’s like they’re a completely different person. They recognize their loved ones, they’re talking articulately. And so that has, as you can imagine, generated a lot of excitement, also a fair bit of skepticism.

Are these videos real? Do we know?

We don’t know for sure if they’re real or not. What’s intriguing about this surgery is that the theory of it, at least to me as a lay person, makes some sense. 

The gist of this surgery is the surgeons create a drain in the patient’s brain and the drain is supposed to help the brain get rid of these amyloid and tau proteins that we think are associated with Alzheimer’s disease. On a hypothetical level, it makes some sense. And scientists in the United States and Europe and elsewhere have been intrigued enough about these videos and the findings that have been reported in academic journals to set up their own studies to try to replicate these findings. 

Now, it’s a crazy story because this scientist in China who pioneered this idea has actually been arrested by the Chinese government. And as I understand it, he’s currently in detention.

For what?!

The reporting I saw was these seem to be kind of flimsy charges of insurance fraud. The Chinese government has also tried to ban the surgery, at least outside of clinical trial settings. So that’s obviously complicated the story a little bit.

But nevertheless, you do have scientists in the US and outside of China who are like, “Well, we at least want to try this for ourselves and see if it works.”

It does feel like it’s something that could get people’s hopes up who have been waiting for this for decades.

Exactly. I mean, I think this is like the holy grail. Can we find a way, whether through surgery or through pharmaceuticals, to actually reverse these symptoms and restore the person to who they were before Alzheimer’s took over?

Because that’s the thing that I think everybody recognizes but is worth emphasizing, is, as one doctor put it to me, and I’ve never forgotten it, Alzheimer’s is a disease unlike any other because it robs you of your identity. 

To be able to restore people’s identity through whatever means, that is the goal that all of these scientists are chasing.

Editor’s note, September 20, 8 am ET: We’re bringing you some of our best-loved Your Mileage May Vary columns while Sigal Samuel is on parental leave. The one below was originally published last September.

This unconventional advice column offers you a unique framework for thinking through moral dilemmas. It’s based on value pluralism: the idea that each of us has multiple values that are equally valid but that often conflict with each other. Submit your own question here.

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The Jewish High Holidays are coming up, and that includes Yom Kippur. It’s a holiday that encourages people to reflect on their behavior and make amends. That’s all well and good, but I’m someone who struggles with scrupulosity — constantly worrying about my morality and if I’m doing The Most Possible Good™.

In practice this is far more paralyzing than motivating. Fixating on the ethical implications of all possible decisions makes it harder to take any action, and I’ve lost hours scouring my memories of my past behavior for immorality like a football player watching footage of their games to analyze what they could do differently. Guilt simply isn’t serving me, but I worry that saying to hell with all that means I’ll stop striving to be a better person and become morally complacent.

I’ve observed Yom Kippur for decades, and don’t want to simply avoid the day. But the holiday is a moral scrupulosity trigger. How do you think I should approach this? I want to stop feeling guilty for letting guilt get in my own way.

Dear Scrupulous, 

Have you ever heard the story about what happened when God decided to give the Bible to flesh-and-blood human beings? According to the ancient rabbis, the angels hated the idea. They argued that humans were deeply flawed mortals who didn’t deserve such a holy scripture; only angels could be worthy of it, so it should stay up in heaven. 

It fell to Moses to rebut the angels’ argument. He asked them: What do you angels need the Bible for? The Bible says not to murder, not to commit adultery, not to steal — do you have jealousy or other emotions that could lead you to do those things? The Bible says to honor your father and mother — but you don’t have parents, so how could you ever do that? And the Bible says to sanctify the Sabbath — but you never do any work, so how could you even honor the Sabbath by resting? 

The angels saw that Moses was right. Angels are really great at one thing: being perfect. But perfect creatures are static. They don’t experience painful challenges, they don’t grow, and they don’t make choices that add beauty to the world. We humans do those things. God gives the Bible to humans not to make them into angels — but to make them better at being the unique thing they are: human animals, with feelings, flaws, and all, that can learn to use their capabilities in more beautiful ways.

I think there’s a lot of wisdom in this story. And I want you to notice how far it is from demanding that humans do “The Most Possible Good™.” That language suggests a maximizing ethical theory like utilitarianism, which says that we have to do the action that produces the greatest good for the greatest number. In other words, we have to optimize. 

Moral optimization may be possible for angels, but not for humans. We each hold multiple values, and sometimes those values are in tension with each other, forcing us to strike a balance as best we can. We’re not omniscient beings who can know with certainty how best to strike the balance. 

What’s more, sometimes different kinds of moral good straight-up conflict with each other. Think of a woman who faces a trade-off: She wants to become a nun but also wants to become a mother. She can’t balance between those options — she has to choose. And what’s the better choice? We can’t say because the options are incommensurable. There’s no single yardstick by which to measure them so we can’t compare them to find out which is greater.

Given that this complexity is baked into the human condition, it’s impossible to be a perfect optimizing machine. And the more you try to force yourself to be that, the harder it’ll be for you to actually help others, because you’ll just be so burned out. As you’ve already discovered, the optimizing mindset is exhausting — you end up expending a lot of precious mental resources that you could be spending on something else. It can even lead to paralysis. And a lot of the time, there’s no knowably best decision.

So instead of trying to optimize everything, you can adopt a goal that’s humbler but more realistic: to live in line with your values as best you can. 

I know that can feel scary. Optimizing makes being human feel less risky. It provides a sense of control, and therefore a sense of safety. The unspoken premise is that if you optimize, you’ll never have to ask yourself: How could I screw up that badly? 

But there’s another way to feel safe. It’s about leaning into the fact that we are imperfect and vulnerable creatures and that even when we’re trying our hardest there will be some things that we do not do optimally.

Of course, we should still try to live in line with our values. But in those moments when we fall short, we shouldn’t berate ourselves, thinking, “I sinned!” In Hebrew, the word we typically translate as “to sin” (lachto) actually means “to miss the mark.” It’s the same word we’d use to describe someone with a bow and arrow who’s targeting the bullseye but misses it slightly. This is a useful image, because it reminds us just how normal it is to miss the mark. Just as the archer’s arrow is buffeted around by the wind, we’re buffeted around by all the physical and psychological conditions acting upon us — naturally we won’t always hit the bullseye! And when we do miss the mark, we deserve compassion.

I know what you’re thinking: What if adopting this mindset means you’ll become morally complacent and let yourself off the hook too easily? This is one of the most common objections to practicing self-compassion. But research shows it’s not well-founded. In fact, psychologists have found that more self-compassionate people are better able to acknowledge when they’ve made a mistake. They’re more likely to want to apologize and make amends to others when they mess up. And they try to do better the next time around. Why? Because, to them, mistakes don’t feel so psychologically damning. That allows them to take more — not less — responsibility for their actions.

Yom Kippur can feel terrifying when any mistake you’ve made over the past year seems damning. But according to the ancient rabbis, Yom Kippur is not meant to be a somber day — it’s one of the happiest days of the year! After all, it was on Yom Kippur that Moses descended from Mount Sinai carrying the second set of tablets inscribed with the Ten Commandments, ready to gift them to the people. 

You probably know what happened to the first set of tablets: Moses shattered them after seeing the Israelites engaged in idol worship. What’s less known is that, according to one rabbinic story, God’s response to the shattering of those tablets was to actually congratulate Moses. Why did God think breaking them was the right move? And what was different about the second set? 

While the first tablets had been fashioned by God and God alone, the second tablets were a human-divine collaboration: Moses carved the stone and God inscribed the words. And while the first tablets contained only the words of the Ten Commandments — a black-and-white, rule-based morality — the rabbis tell us that the second tablets contained within them all the stories and interpretations that Jewish sages would later develop.

In other words, God recognized that you can’t just give humans a list of moral rules and call it a day. Maybe that would work for angels, who live in a simplified, disembodied world, but our ethical life is just too messy and multifaceted to be captured by any single set of universally binding moral principles. Yet God chose people over angels anyway, inviting us into the collaboration and embracing our humanness rather than rejecting it.

So, to the rabbis, Yom Kippur was a happy day because they fully expected that God would accept and embrace messy humans. 

Please, don’t try to be more zealous than God.

When you’re taking action, by all means, aim your arrows as true as you can — try to hit the bullseye, the place that captures as much of what you value as possible. But once you’ve released the arrow from your bow, let it be. 

If it turns out that you missed the mark, that you acted suboptimally, I put it to you that that is okay. You are not an angel. You are not a perfect optimizing machine. You do not have access to a magical mathematical formula that can consider countless incommensurable variables and spit out the very best move with certainty. You are human and you do the best you can with what you’ve got. 

The wisdom of these millennia-old stories is that that’s good enough for God. Let it be good enough for you, too. 

Bonus: What I’m reading

• Writing this column reminded me of The Mindful Self-Compassion Workbook, written by the psychologists Kristin Neff and Chris Germer. It really helped me develop a self-compassion practice, which has in turn helped me get a grip on my own scrupulosity. I also strongly recommend the eight-week self-compassion course run out of Neff and Germer’s nonprofit, the Center for Mindful Self-Compassion.

• I’ve always associated the philosopher Thomas Nagel with questions about consciousness, but I recently learned that he’s also super interested in questions about religion. In a great essay called “Secular Philosophy and the Religious Temperament,” Nagel asks: What, if anything, does secular philosophy have to put in the place of religion? More specifically, can it answer the question: What is the underlying nature of the universe, and how can the human individual live in harmony with it? 

• In this Aeon essay, philosopher Elad Uzan argues that AI will not be able to solve ethics for us, despite what some people hope. Drawing on the mathematician Kurt Gödel’s famous incompleteness theorems, Uzan writes, “just as mathematics will always contain truths that lie beyond formal proof, morality will always contain complexities that defy algorithmic resolution.” 

When we think about the stakes in healthcare, we tend to think of them in terms of life and death, being sick or being healthy. The conversation is about your physical well-being and maybe your mental health — and it pretty much stops there.

But health affects so much more than your body’s biology or even just you personally, as a new survey from Gallup and Pivotal, a philanthropic group founded by Melinda French Gates, shows. That’s especially true for women, who frequently report negative experiences with the health system and ongoing struggles to get their concerns taken seriously; poor health affects the trajectory of their careers and their ability to be engaged with their families, friends, and wider community.

It starts at the doctor’s office or hospital: 51 percent of women say they have had a negative healthcare experience in the past five years, versus 39 percent of men. About one in three said that a doctor did not take them seriously when they said they were feeling pain or other symptoms, versus 21 percent of men, and 33 percent said that they either were misdiagnosed or did not receive a diagnosis. The cost of paying for care is another deterrent: 32 percent of women said they have skipped or delayed care in the past year because of the cost, compared to 25 percent of men.

“To see that half of women in the United States who sought care in the last five years came out feeling like they hadn’t gotten the help or care they needed, that’s frankly staggering,” French Gates told me in an email. “It says a lot about how little we’ve invested in women’s health and how much we expect them to just push through pain or accept uncertainty.”

And the effects of those experiences, the failure to receive proper treatment, ripples out into the rest of the women’s lives. More than half of US women, 54 percent, said they had experienced at least one health-related impact on their family life or relationships; 42 percent said their health had led to a negative effect on their career or work. It also affects their community: 32 percent said their health had affected their ability to participate in civic life.

The toll is not only physical but mental: 48 percent of women said they’d dealt with a mental health condition like depression or anxiety. And socioeconomic disparities abound. Black and Hispanic women are more likely to report being in poor or fair health. Women who have lower incomes are more likely to face career struggles because of their health than those who make more.

I had the opportunity to interview French Gates, who has made women’s health a priority in her work, over email about the survey; its findings on community engagement, menopause, caregiving, and more; and what could be done to address the problems that it reveals. Our exchange is below, lightly edited for clarity and length.

Which of these survey findings surprised you most and why?

The number of women [54 percent] who said they experienced a mental health challenge during or after pregnancy should stop us all in our tracks. And the fact that less than one in three women who sought care found it helpful is really concerning. It’s why I feel so strongly about integrating women’s mental and physical healthcare, especially during pregnancy and postpartum. Mental and physical health are so linked together.

Too much of the burden is placed on women to get answers. All of us deserve so much better.

Nearly one-third of women said in the survey that health problems limited their ability to be involved in their community. What does that look like in practice, and what do communities lose when women can’t fully participate?

Women are so often the backbones of their communities, whether they’re rallying their neighbors around a cause, leading the PTA, or serving in elected office. Without having women — and their ideas and voices — in those roles, we’re missing half of the conversation. Issues that affect women and families are less likely to get on the agenda. They’re less likely to be solved.

When a woman has a health challenge, and she has to spend so much of her time and resources chasing down answers, that makes it harder for her to show up in those spaces. We saw that in the survey: 30 percent of women said their health limited their ability to be involved in their communities. And when women couldn’t get the care they needed, that percentage doubled.

Women’s health is often talked about as a personal issue, but this data is helping us prove that it’s also an economic issue, a family issue, a community issue — it affects all of society.

Caregiving and family responsibilities prevent many women from getting medical care, in particular Hispanic and Black women. That seems to create a vicious cycle: Women are often so busy being the caregivers in their families that they neglect their own health. Eventually, they are the ones who will need care.

What do you think can be done to break that pattern? Is there a philanthropic solution? What public policy changes could be made?

Women are often taught to put themselves last and minimize their own needs. They don’t always have time to care for themselves because they’re so busy caring for others. And they might not be able to afford childcare or home health support for their aging parents. Our survey showed one in six women delayed healthcare because of their responsibilities caring for their family members. For Black women it’s one in five, and Hispanic women one in four. Too many women are facing an uphill road to even just get to a doctor’s office.

It’s possible to make it easier for people to balance healthcare and family responsibilities — but it’s going to take action from many angles. That’s exactly why I invest in both women’s health and in caregiving, and I’d encourage more philanthropists to do the same. Businesses can also support employees with good paid leave policies and reliable but flexible schedules.

But for women everywhere to benefit, we need government leaders to prioritize increasing access to affordable childcare, home health supports, and paid family medical leave. These are policies that have the support of large majorities of Americans because these are issues that affect everyone. So there’s a real opportunity here to offer meaningful help to families.

I am struck by our collective failure on menopause: Women report that they aren’t aware of menopause symptoms until they experience them on their own, that they struggle to get their doctor to take menopause symptoms seriously, and that their menopause experience has held them back in their career. What are some short-term and long-term steps we can take to address those problems?

“Right now, women need better care at critical moments in their lives.”

If more than a third of women only learn about menopause symptoms when they go through them, the system is clearly not working. Women need to learn about menopause from their doctors before they experience it. But doctors aren’t getting the education and training they need on menopause while they are in school. One doctor told me she got just one lecture on menopause across all her years in medical school. One said it was mentioned one time. They are seeking out better training but it can be hard to find. That’s why Pivotal is partnering with the Menopause Society to expand physician training on menopause so doctors, nurses, and other healthcare providers can access the information they’re looking for to better help their patients.

Because menopause isn’t just about being uncomfortable; it can also bring anxiety, heart palpitations, insomnia — significant symptoms that can really hold women back. More than a quarter of women who’ve experienced menopause or perimenopause said it made it harder to live up to their full potential at work. One in 10 had to take leave or leave their jobs entirely. That just shouldn’t be. Women shouldn’t have to step back right at the moment when they could be stepping into leadership roles.

The most immediate steps can come from policymakers, especially at the state level. They can include menopause care in insurance and Medicaid coverage and offer workplace protections to women in menopause the way they do for pregnancy, so women can get the care they need without losing their jobs. I’m also focused on longer-term solutions, like expanding training for healthcare providers and investing in research to accelerate treatment options.  

Women are at the forefront of a lot of wellness trends these days and yet, as the survey reveals, women also report encountering a ton of health misinformation on social media. Why do you think women are so often the targets of this kind of content? What can be done to point women toward and build their trust in sound medical information?

One in three women said she left an appointment without a diagnosis, with her pain being dismissed, or with no answers or next steps. You can understand why those women would start looking for information online. And because women’s health has been underfunded and under-researched, there just isn’t as much reliable information out there as there should be, which leaves a lot of room for people to come in with misinformation. Investing in credible scientific research to fill that vacuum will give both women and their doctors more information going into their appointments.

In terms of your own organization’s work, which investments are you making that you think can make progress on the underlying problems revealed in this survey?

We need to address the right now and we need to address the longer term. Right now, women need better care at critical moments in their lives.

One way we’re investing in that at Pivotal is by making it easier for women to get the mental healthcare they need during and after pregnancy. So we are investing in integrated models that put mental and physical healthcare under one roof. I visited a health clinic in Alabama earlier this year where they identify issues like depression and anxiety right at the outset and then help the mom all the way through her pregnancy care, all in the same place. That model is something we strongly believe in.

Better care for menopause will require better training, which we are thinking about in both the immediate and long term. I mentioned that we’re making more menopause training available to doctors who are currently practicing. That is something I’m really excited about because I’ve heard from physicians who really want to better support their patients and are looking for better information so they can do that. And longer-term, menopause needs to be a much bigger part of the curriculum at medical schools moving forward.

Another longer-term focus of ours is trying to make up for decades of lost time in research. We are funding medical research focused on how diseases specifically impact women, in partnership with an innovative organization called Wellcome Leap. They are working to accelerate progress in women’s health on everything from autoimmune diseases to cardiovascular disease in years, not decades, which is how long health breakthroughs usually take. That’s the kind of urgency women need and deserve.

Wildfires are popularly considered wild — restricted to the remote wilderness or the edge of forests, and to most, a problem for the dry and hot states of the Western US. But over the past few years, and now across the country, these fires are getting less wild and far more urban. 

This summer, fires in Spokane, Washington, demolished over 800 homes in a suburban neighborhood, and earlier in the season, the northeast coast was engulfed in smog from fires in Ontario. The Hawk Fire in Nevada razed more than 15,000 acres near Reno, destroying 47 homes before it was extinguished. The Los Angeles fires of last year remain some of the most devastating in recent memory, with over 37,000 acres burned — much of it densely built residential neighborhoods — and displacing 205,000 people from their homes. In Boulder, Colorado, the 2021 Marshall Fire destroyed nearly 1,000 homes. 

This changing geography of fires is affecting the health risks they present, too. 

When vegetation burns, it releases particulate matter, or PM 2.5, and with over 46 million homes in the continental US — this is approximately one-third of all homes — on the edge of fire-prone wildland, many more of us are being exposed to air filled with that soot. This alone is a major health risk. According to the World Health Organization, PM 2.5, is associated with premature death, severe damage to respiratory health, and cognitive impairment. It is especially dangerous for aging populations: a study published in February found that accumulated exposure to wildland smoke was associated with greater hospitalization risk for various cardiovascular diseases in older Americans, including irregular heart rhythms and heart failure, even when they are only exposed to moderate levels of PM 2.5.   

But the urban landscape has also changed the very composition of the smoke that increasingly hangs over all of us. As human structures and vehicles burn, the fires expose us not just to particulate matter but also to the chemical toxins of urbanization itself, from plastic to metal oxides and vehicle fuel. The changing nature of this smoke, in fire zones but also in surrounding regions as it drifts outward, exposes us to a new class of health risks. 

While researchers are still learning what exactly those risks might entail, early research suggests long-term dangers that are deeply troubling, especially as exposed populations age.   

The changing fire frontier 

In 2020, the worst California fire year on record, ate up 4.2 million acres of land, most of it wild, spewing huge amounts of PM 2.5 into the air as the blazes raged. Emergency rooms, already short-staffed by the ongoing pandemic, buckled under the burden immediately. Northern California’s Stanford Health Care system saw a 12 percent jump in hospital admissions over the weeks following the fires, and a 43 percent increase in cardiovascular conditions. In Oregon that same year, 10 percent of emergency room visits were due to asthma-like conditions induced by smoke as fires migrated north.  

Unfortunately, in a world of warming temperatures and drying conditions, that story is becoming all too common. In 2025, a total of 5.2 million acres of land burned across the US, and this year that number has already climbed to 8.5 million, before we’ve even hit the winter dry seasons that plague parts of the Southwest. 

Despite this, the global footprint of human housing continues to expand, and with it the danger.  

For centuries, human development has breached wildfire territory. However, over the last three decades, the zone that links the wild to cities and towns, called the wildland-urban interface (WUI), has grown substantially due to suburban construction. The US Forest Service found a 46 percent increase in the number of houses in the risky WUI zone between 1990 and 2020. By 2020, a third of US homes had been built in this highly vulnerable landscape. The math is simple: As suburbia expands into wilder regions, the more houses are exposed to wildland, and the fire risk grows greater. And when houses and other human-made goods burn, different and potentially more toxic forms of smoke can be produced. 

The Los Angeles County fires in January 2025, which saw large urban regions devastated by flames, were an unfortunate case study for these risks. The Palisades and Eaton fires began on the northern edge of the LA foothills, where dense housing meets more wild, and more fire-prone, terrain. In a retrospective analysis, Underwriters Laboratories’ Fire Safety Research Institute detailed how the urban-wildland makeup of Los Angeles County has not only put more communities physically in fire-prone zones, but also has historically made the geographic region itself more vulnerable to fires. 

As those fires spread into LA’s more urban areas in 2025, the smoke they produced became more dangerous, largely because of what was burning: more than 16,000 buildings, household items, and electric vehicles. The resulting emissions were thus far more complex than typical vegetation-only fires. 

“What’s burning is now very different,” said Jackie Goodrich, an epidemiology professor at the University of Michigan. “So now modern homes have tons of plastic, metals, and all of our electronic appliances, and electric vehicles have these batteries that have a lot of rare metals and other toxic materials we don’t even know about.” 

As a result, these emissions contain higher concentrations of volatile organic compounds (VOCs), metals, and carbon monoxide. PFAS, commonly dubbed “forever chemicals,” are also released through fire extinguishing foam and damaged firefighting gear, which traditionally contains PFAS to protect the skin from fuel that may soak through. These chemicals are associated with adverse health effects, including higher risk of certain cancers and weakening of the immune system. Many of these compounds are dangerous carcinogens. 

These urban fires have a dangerous impact on indoor air quality, too, as chemicals and metals are absorbed into soft surfaces like pillows or textiles. Studies conducted in the aftermath of the LA fires found that post-wildfire VOC levels were elevated inside evacuated homes during the months following the fires. All of this goes to show that Americans can face the health risks of WUI smoke exposure, even when their homes emerge from the blaze relatively undamaged.

These dangers mount over time and across populations

Studies examining hospital admission rates or emergency room visits offer some perspective on the short-term health effects of wildfires. But work by Goodrich and University of Arizona public health professor Jeff Burgess is providing new insight into long-term harm by using a subset of the population repeatedly exposed to and vulnerable to fires: the people who fight them. 

In a study published last year, Goodrich and her fellow researchers examined blood samples from fire responders working in mixed urban and wild areas. They found that exposure to smoke limited the genetic expression of a tumor suppressor known to inhibit gastric cancer cell growth. It also affected regulatory expression similarly associated with tumor proliferation across cancer types, as well as neurodegenerative diseases. 

Burgess has run similar studies across 33 states with 9,000 participating firefighters, allowing the researchers to examine changes in microRNA levels, blood proteins, and DNA methylation (which controls whether genes are on or off). His research on a small cohort of new fire recruits found altered DNA methylation at various sites in the genome, many of which are similarly linked to cancers, neurological disease, and cardiovascular disease. 

It is still unclear whether these biological warning signs lead directly to cancer, Burgess said, largely due to the natural latency period between exposure to toxic substances and actual onset of disease. But as participants age, he expects to see a higher incidence of cancer, especially as exposure to big fires accumulates. 

Firefighters have more prolonged exposure to these toxins than most, of course. But the health effects of wildland-urban fires can extend beyond self-selecting groups, especially as more people move into regions exposed to fire. Residents in the WUI are exposed to the same particulate matter and chemical slurry as firefighters. Goodrich suggests that this could lead to a higher risk of asthma and respiratory problems for children, as well as cardiovascular health incidents in adults.  

Examining longer-term gene expression effects, however, is still more difficult in the general population than it is in the firefighters that her lab studies. While firefighters are often exposed to the same chemicals over and over again, it can be harder to get a clear sense of how toxins affect the average civilian who encounters them more sporadically. 

That said, researchers at UCLA have been keeping a close eye on background toxic chemicals in the aftermath of the LA fires. In a paper published in June, they identified high levels of chromium 6, a carcinogenic metal nanoparticle that can cross cell membranes easily, in wildfire cleanup zones for up to two months following the actual fire. Abnormal concentrations of these heavy metals were also found up to six to nine miles downwind from the zones themselves.

Even following the disaster and immediate recovery periods of urban destruction, the public health dangers can persist: Toxic compounds like VOCs can contaminate waterways, and damaged air filtration systems can make it harder to protect surviving homes against future incidents.

As wildfires become less confined to the chaparral and forests and more likely to rage through suburban streets, we’ll all have to prepare to face the orange haze of fire season. And as we do, we’ll have to confront new dangers that may persist long after the blaze dies down.

A decade ago, insulin became the poster child for America’s out-of-control drug prices. The 2017 death of Alec Smith, who was rationing his insulin before he died, and repeated price hikes for a 100-year-old medication (the patent for which was originally sold for $1 to a university to prevent it from being exploited commercially) sparked widespread outrage that a lifesaving medication could be unaffordable to the people who depend on it to survive.

And then politicians actually acted. Starting with a Colorado law passed in 2019, states began passing laws capping the out-of-pocket costs for many people who take insulin; 27 states (plus Washington, DC) now have such a policy. Then in 2022, Congress included a provision in the Inflation Reduction Act that established a $35 per month cap on insulin prescriptions for people on Medicare. Given the national response — drugmakers also made splashy public announcements about reducing the cash price that uninsured people pay — you would be forgiven if you thought this was the one health care cost crisis that the US had genuinely managed to solve.

But the diabetes community has a dire warning: It’s not over. Millions of people continue to struggle to pay for their insulin and having their long-term health put at risk because of, in the words of one advocate who put it bluntly, pharmaceutical greed.

“There has been so much attention and promise to action around the insulin price crisis. … There has been so much action,” said Shaina Kasper, executive director of T1 International, a global nonprofit that advocates for people with diabetes. “And shockingly, frustratingly, critically, the data from our 2024 survey showed that the rationing rates were worse than ever. Ultimately we’re facing such immense and monstrous corporate greed. … When we put a Band-Aid on one hole, another one’s going to find a way to pop out and keep profits high.”

Fixing the insulin crisis will require a multifaceted approach: drug pricing reform, insurance mandates, and possibly even public manufacturing. Out-of-pocket caps, Kasper said, were always a temporary fix for a very broken system. There is still a lot more work to do.

Why so many Americans still struggle to afford insulin

Both national and local surveys indicate that the policy changes of the past decade have not had the desired effect.

A study published last year from researchers at the Yale Diabetes Center found that people treated there were rationing insulin at the same rate in 2024 as they were in 2017; about one in four people reported some rationing due to the cost of the drug in both years. When you added in the people who rationed because of insurance delays or supply limits, more than one in three people — 38 percent — were still having trouble keeping this lifesaving medication on hand in 2024. A 2024 T1 International survey likewise found that nationwide, 34 percent of the Americans who use insulin reported rationing the medicine. (About 8.4 million people in the US rely on insulin to survive.)

Dr. Kasia Lipska, an endocrinologist and researcher who treats patients at the Yale Diabetes Center and who co-authored that study, was surprised by their findings.

“I was surprised because I’ve been looking at the policy and advocating for policy change; you think things are moving, they should be really improving,” Lipska said. “But if I talked to the nurses and our staff at the Yale Diabetes Center, they told me, ‘Of course they haven’t changed. We’re still hearing these stories.’”

How could this be? The explanation is multifaceted, according to Lipska and Kasper. 

“There’s just still a lot of holes in one who is covered by various protections and then how they’re covered and how they access this,” Lipska said. “It’s not as simple as just showing up at the pharmacy and asking for your insulin, and the sticker price is there, and that’s what you pay. It’s extremely complicated.”

For starters, millions of Americans remain uninsured and have to pay the cash price for drugs. While drugmakers make flashy announcements about helping those people, the process of enrolling for savings cards to get those lower prices can be a nightmare; one congressional investigation found in 2023 that uninsured patients were still paying an average of nearly $100 for insulin despite Eli Lilly’s pledge that its generic product would be available for $25 per vial. Even if you manage to get your discount card, the same investigation found that Lilly introduced several restrictions based on geography and needs, and that the specific insulins that are subject to these voluntary price caps are often out of stock at the pharmacy when people go to fill a prescription (while the more expensive brand name version is consistently available).

And then there are the loopholes in those existing federal and state laws. The federal $35 cap applies only to Medicare; the private insurance that covers half the country is excluded. (There have been bills proposed to extend the cap to private coverage, but they have not gone very far in Congress.) The state laws that do exist typically apply only to small-group and individual plans that are subject to state regulations; larger self-funded plans are exempt from state mandates and currently have no enforced limit on out-of-pocket insulin costs. One national estimate found that around 775,000 people who use insulin and had private insurance were protected in 2025 by the caps in states where they’d become law. But more than 1 million people in those states were not, nor were the 2.1 million commercially insured insulin users in states without a cap.

Even for people who benefit from the mandatory out-of-pocket caps instituted by Medicare and state laws, some of them still struggle to come up with $35 a month, given all of the other price hikes Americans have faced since the pandemic. They may have to navigate a complex process in order to actually receive the promised discount. And while a $35-per-month cap sounds straightforward, in practice, people can still face higher costs. Each individual person requires a unique amount of insulin and, for some of them, they might need two different kinds; the pharmacy may not have the right version and will make substitutions that lead to higher costs. That’s how one of Lipska’s patients ended up paying $140 per month for his insulin — despite being on Medicare.

“These things really add up…and frustrate people,” she said, “because what seems like a great idea is not actually how things work on the ground.”

The consequence is that, despite all the legislative activity and self-congratulations, millions of Americans are still at risk of serious health problems because they can’t get insulin.

The worst-case scenario is what happened to Alec Smith: Somebody is forced to spread their insulin so thin that they put their life is in danger. When diabetics have their blood sugar spike without insulin on hand, they can go into diabetic ketoacidosis, “which literally means your blood is turning into acid,” Kasper said. “I can speak from experience: it feels like you’re dying.”

To recover from an episode, they may have to go to the emergency room and end up taking even more insulin while eating in order to get their body back to equilibrium. But even short of an emergency, Kasper said, people who resort to rationing insulin can experience significant side effects. Prolonged high blood sugar due to rationing could lead to serious vision and nerve problems that were supposed to be a thing of the past once insulin became available.

Those were the scenarios that lawmakers wanted to prevent as they tried to make insulin more affordable. But they remain a very real threat for too many people.

The big idea that could make insulin truly affordable

If there’s good news to be found, it’s that the advocacy community is not giving up. They are sounding the alarm about the ongoing affordability crisis and urging Congress to act. But they do worry that the issue has become less urgent: The truly comprehensive mandate for insulin out-of-pocket caps, which is typically introduced every Congress, was delayed this time. “This year, neither bill was introduced for over a year, and it was very concerning,” Kasper said.

But they are also placing bets on something much more profound than a price cap: the government itself procuring or even producing insulin and making it available to people at the lowest possible cost. 

“This idea that medicines should be for people and not for profit I feel like is really catching,” Kasper said. 

Some states are taking baby steps in that direction: Oklahoma passed a bill this year that would offer government funding for private companies that pledge to produce insulin and sell it at a low price. 

Others are going bigger. As I reported in 2023, California has launched a program that is eventually intended to lead to government-owned facilities producing insulin to be sold on the cheap, though it will take years until publicly owned production begins. The New York state Senate approved a similar plan this year, although funding for it didn’t make it into the state’s budget. Kasper said that she is optimistic the project will make it into next year’s spending plan, and says a lot of work is currently being done to ensure it happens.

In the future, public manufacturing could also help to address the supply problems that continue to pop up. There are only three insulin manufacturers in the US right now. As those for-profit pharmaceutical companies place more emphasis on GLP-1 production — which often takes place in the same facilities as insulin production — nonprofit initiatives could fill in the gaps.

“In this time of tariffs even, with these concerns around shortages and rising prices and the corporations having this monopoly and price gouging ordinary Americans for decades now, as we’ve seen on insulin, let’s just make it ourselves,” Kasper said.

This is a long-term vision; if you need help right now, T1 International has resources to help people get health insurance, access discount programs, and even find emergency insulin. But a more affordable future for insulin will only be possible if lawmakers feel compelled to act. Public outrage created one round of reform, but the risk of political complacency is real. So if you care about this issue and want to get involved, T1 International also has a tool kit for people who want to advocate for policy changes, including around public pharma.

“The general communication that we’ve been hearing is that the insulin price crisis is over,” Kasper said. “Everyone should have access to a $35 copay for insurance. As the data shows, as we’ve been talking about, that is just not true.”

On stage at Davos in the Swiss Alps earlier this year, Bill Gates, before an audience of the global do-gooding elite, announced a $50 million partnership between his foundation and an unlikely new ally, OpenAI, aimed at improving healthcare in Rwanda.

Just a month earlier, the Gates Foundation had released a harrowing report about widespread global health cuts and collapsing foreign aid infrastructure, documenting a rise in child deaths for the first time this century. But at Davos, even as the US hemorrhaged funding for vaccines, maternal healthcare, and HIV treatment, the Microsoft co-founder struck an optimistic tone. 

“Using innovation, using AI,” Gates told Reuters, “I think we can get back on track.”

As it turns out, the partnership was just an opening salvo for what’s become a wholesale embrace of AI by the world’s largest global health philanthropy. A $200 million partnership with Anthropic came just a few months later. And then, on Tuesday, the Gates Foundation announced a plan to dole out a jaw-dropping $1 billion over the next two years for scaling up AI interventions across healthcare, education, and agriculture around the world. 

The sense that AI will soon change everything, and mostly for the worse, has perhaps never felt so pressing and alarming as it does right now. But this hefty new commitment is premised on the idea that AI could eventually make our lives much better too. In a country like America, AI requires massive investments and buildout — in the grid, in power, in technology, in water. In many parts of Africa, already infrastructure-poor, the foundation is effectively betting that AI can compensate for some of the infrastructure that isn’t in place or that has been lost — and offer a new layer that can help in education, in delivering healthcare, and more. 

The Gates Foundation’s new commitments include projects to improve how farmers analyze their crops, how doctors diagnose patients, and how students learn. Some have already proven to be quite effective, according to the foundation, with one tool improving the accuracy of medical diagnoses by 16 percent across several Kenyan clinics. “In poorer countries with enormous health worker shortages and lack of health systems infrastructure,” Gates wrote on his blog earlier this year, “AI can be a game-changer in expanding access to quality care.” 

Last year’s foreign aid cuts were unfathomably destructive for some of the world’s poorest countries, shuttering thousands of clinics and perhaps hundreds of thousands of classrooms in places where critical workers and supplies were already stretched thin. No, AI cannot deliver a baby, administer a vaccine, or manage a classroom — not yet, at least — but it can, the Gates Foundation hopes, help ease the burden and augment the quality of care for nurses and teachers now tasked with serving far more people than any one person should. 

“This is the most transformative technology of our lifetime,” Mark Suzman, CEO of the Gates Foundation, told me, and while there are “very real risks and challenges” surrounding AI, it also presents genuine opportunities to tangibly improve many people’s lives.  

It is a tantalizing premise: We can’t afford to build clinics, hire teachers, or lay new power lines, but perhaps AI could create the digital infrastructure needed to help billions of people do more with what they have — or rather, with what’s left. The question is, can the right layer of innovation help bolster a buckling system, even as the physical and logistical infrastructure surrounding it crumbles?

Is AI really what global health needs right now? 

Most Americans have yet to see AI improve their lives in meaningful ways, much less those living in poverty or in countries where only a sliver of the population has ever used ChatGPT. 

But those numbers in the developing world are slowly changing, a shift enabled in part by other global health funders convinced that as foreign aid dries up, AI could soon help the world do more with less. The Trump administration itself is on board with this thinking, so long as it benefits American tech companies. Last year, the State Department announced a $150 million partnership with the drone company Zipline to transport medical supplies in several countries.

To Zipline’s credit, an NPR reporter in Rwanda last month found that the company’s drones were already saving lives in places with poor road infrastructure, where driving to the nearest hospital can take hours on winding hills, but where drones can deliver crucial blood transfusions within minutes. 

And yet, for Rwandans to benefit fully from these high-tech deliveries, they need staffed clinics to visit. As a result of foreign aid cuts, some of those literal landing spots are now on the verge of closing in some of the nation’s most vulnerable rural corridors. “Without the underlying infrastructure, like roads, energy and power and unless there is accessibility, rural and otherwise,” Enoh Ebong, president of the global development department at the Center for Strategic and International Studies, told NPR, “then all of these solutions will stop short.”

But just as medical delivery drones still need a clinic to fly to, most of these interventions require some layer of physical infrastructure — roads, schools, power, and quite obviously, broadband  — to function. Satellite imagery shows that some rural communities in sub-Saharan Africa quite literally went dark in the aftermath of USAID cuts. It will be much harder for their kids to prompt an AI math tutor, or for a local farmer to download a weather app. 

“We’re seeing this very much as a both/and,” Suzman told me, calling more traditional funding for education and healthcare “the bedrock for long-term economic growth,” which AI is meant to supplement, not replace. But, in practice, foreign aid cuts have left serious cracks across much of that bedrock, which could make it harder for state-of-the-art solutions to function as intended.  

It is obviously not incumbent on the Gates Foundation to pay for all of this alone – nor would it even be feasible for them to do so. And for the record, plenty of the foundation’s other grant programs are not AI-related at all. But this tension does speak to a broader question that may be felt most acutely in a context like global health, but ultimately one that touches us all: Do we spend our scarce resources on the digital infrastructure of the future at the peril of our needs right now? Could you justify buying the new $1,999 folding iPhone if you can barely afford to buy groceries? 

The answer is not actually always an easy one. It is not for us to say, for example, that just because a community lacks reliable running water, its people should be excluded from the benefits (and encumbrances) of the smartphone, especially if that smartphone can connect them to health advice they could never access otherwise, or guidance that could help them survive a drought. 

In some parts of the world, digital forms of banking arrived long before local brick-and-mortar branches did, instantaneously connecting countless people to a cheap and secure way to save and send their cash to family and friends in need. It is certainly possible that AI, or at least the kind of applications the Gates Foundation funds, could one day have a similarly transformative effect on how people access personalized levels of care, education, and other services in places without the resources to do so otherwise. 

That is the hope, but it is also hard right now to believe uncritically in a technology that, as Gates himself blogged just last month, “will either be the greatest equalizer ever invented, or the worst source of injustice,” ushering in “one of the most turbulent times in human history.” 

In an interview with the New York Times soon after, he seemed convinced that AI will likely do more harm than good. “I don’t like bringing bad news to people, and I don’t like saying that innovation may be a net negative,” he said. “But that’s where we are.”

Now he wants billions of people around the world to use it? Yes, Suzman said, because if not, then inevitably the best parts of AI — the potential for exponentially better cancer treatments, for example — will go only “to those who can pay for it,” while the worst parts of it will fall, as they so often do, on those who benefit the least. “These decisions are being made now,” he said, “and the decisions being made now will then probably shape the following two decades.” Here’s hoping they’re good ones.