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 getting 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 was originally published in The Highlight. To get access to member-exclusive stories like this every month, become a Vox Member today.

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 part 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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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 have 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 services 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 number 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.

October 7, 2026, 5:50 pm ET: This story was originally published on October 2 and has been updated to include the sourcing on the RVU gap resulting from training for gynecologic surgery.  

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.”

This story was originally published in The Highlight. To get access to member-exclusive stories like this every month, become a Vox Member today.

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.

If there’s one thing that Americans can unite behind, it’s anxieties over artificial intelligence.

According to a recent NBC News/Decision Desk poll, 70 percent of adults say they are personally more worried than excited about the technology; it’s basically underwater in every area of society with one notable exception: its use in scientific research and medicine.

According to Dr. Dhruv Khullar, a physician at Weill Cornell Medicine and writer at the New Yorker, that optimism is well-founded.

Khullar uses AI tools in his own practice as a physician and writes about their advancements in the medical field. He says that “right now, at least, there’s a generally optimistic view of how AI will change healthcare going forward.”

AI in medicine is nothing new. In 2024, the Nobel Prize in Chemistry was given to researchers who developed an AI model that enabled breakthroughs in predicting protein’s complex structures. As it becomes more ubiquitous, it’s also emerging as a resource for doctors to get second opinions and as a tool to take notes on patient-doctor interactions.

On top of that, Khullar says, it might help unlock new medicines to treat diseases. 

Khullar joined Today, Explained co-host Sean Rameswaram to discuss the ways that AI is transforming drug discovery and research, as well as what it still can’t do. They also discuss how to think about AI’s potential in healthcare at the same time as top AI researchers are increasingly warning about the technology’s risk.

Below is an excerpt of the 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’ve been thinking about lifesaving AI innovation. Has AI already started saving lives?

I think it has. This is the fastest I’ve ever seen healthcare take up a new technology. Part of that might be that the healthcare system is so messed up that there’s an appetite for some type of change. It’s unaffordable, it’s inaccessible, it’s inconvenient, the quality is uneven. 

There’s at least a hope that AI is going to help with all of these things, and I think it’s already starting to make its way into the healthcare system. Now it’s our responsibility to figure out how to make the most of it without also promulgating some of the downsides.

For those who are unaware, tell us how it’s working its way into the system.

It’s helpful to categorize it into a few buckets, at least for healthcare. 

The most rapid uptake, and I think the place that it’s already starting to make a difference, is on the administrative side. Many people who have gone to a doctor recently might have noticed that there’s an AI scribe that’s taking notes now. And people seem to really like it, at least so far. Doctors are able to look their patients in the eye in the way that they weren’t able to when they were poring over their computers and just typing what the patient was telling them. 

The second big area is patient navigation. When is your next scan? When’s your next appointment? Do I need to take this medication on an empty stomach or not? There’s a huge opportunity for people, let’s say, who are diagnosed with a serious illness like cancer or heart failure to navigate the system more seamlessly. 

The third big area that I’m really excited about is drug discovery. AI is making a huge dent in the early parts of drug discovery. 

The last thing that I’m excited about and that I use every day when I’m in the hospital is [AI] as a second opinion. Now instead of having to get a consult or turn to a textbook, AI can be a very, very helpful clinical decision support. It’s not to say that I never consult someone, of course, but that first pass — I’m not sure what’s going on. What are some recent trials that might influence my decision here? Is there something I’m missing? Is there a test that I should be ordering that I’m not ordering? — all those types of things, they start to help with.

The biggest chunk of this positive view of AI and medicine is drug discovery. Tell me more about how that’s going so far and how it might be going in a year, or five, or 10.

I don’t want to leave this conversation and say that we’ve solved the cure for cancer because of AI, but I do want people to know that at least for the early stages of drug discovery — figuring out the very basic steps of is this an interesting molecule? Does it have potential biological applications? — AI is already very helpful for that. 

They’re trying to take, basically, what is an infinite number of drug-like molecules that are theoretically possible to be drugs and they’re trying to match that to some disease that’s going on inside a human. And human biology is incredibly complex as well. There’s tens of thousands of genes, hundreds of thousands of proteins, trillions of cells, and you have to match a potential molecule to a potential target within a human. 

In the past, a researcher might take years to study a disease or a biological pathway and figure out, okay, this protein seems to be involved. And actually, it might not be involved, it might be involved, it might be disrupted, but not be the causative agent. There’s a lot of uncertainty there, so now AI can take enormous amounts of data, and it can rank various potential targets that seem to be the most likely to be causing a particular disease and give you that short short list of potential targets that may have taken months or years in the past.

So now you know what to attack, but you have to figure out what to attack it with. So you need a molecule, you need to generate a molecule that’s going to fit into that target or disrupt that target in some way. 

Now again, AI can scour vast chemical spaces and give you a list of the things that seem to be most likely to be able to disrupt that target. And then it can actually help you generate that molecule in some cases. 

So now we have the target. Now we have something that we’re going to attack the target with. And then you have to do something called lead optimization, and that’s the third thing. Lead optimization means you have this lead and you have to optimize it.

“I would make the counterargument that healthcare is ripe for disruption and you don’t even need the frontier frontier models to make it a lot better with AI.”

Now we have to figure out, of all the molecules that seem to be good at potentially affecting this target, which ones are able to be absorbed in the body, which ones are going to get to the right tissue. AI models can predict the most likely molecule to give you that Goldilocks set of properties that’s needed for a safe and effective drug.

As we all know from anyone who’s asked AI to write an email for them or Googled a question, these tools have a certain degree of certitude, even though these tools can just be flat out wrong about stuff. Are you guys worried about that in the field?

Absolutely. And so this is why I think the narrative around AI just replacing scientists or doctors or other workers is incorrect. Because you still need a lot of judgment. 

You need to be able to adjudicate the output of these models to figure out what is most promising and what is potentially dangerous. That is going to require wet labs and scientists and reasoning based on prior experience and understanding the context. There’s all sorts of issues around, can you manufacture some of the drugs that are being proposed by these models? So just because it’s set, it dreams something up doesn’t mean you can actually make that thing in the real world.

Some of the drugs that it proposes might actually be toxic in certain ways that it didn’t predict. And of course, then you have to take this thing into clinical trials. You have to recruit l people who are willing to put this medication in their bodies. You have to find out who might benefit, you have to put it through the regulatory process. 

That’s why I said that the first part of drug discovery, where you’re trying to figure out how do we get the right drug candidates, what seems most exciting to test further, that’s going to be really accelerated. That whole second half where we actually have to figure out if it works in human biology, that is still going to be in some respects an analog process.

It doesn’t sound like you’re terribly scared that we are like ceding control of our hospitals, of our research facilities, to AI. This is very much in the sort of assistant bucket?

For now it is. And I think one of the challenges is to maintain our agency as these models become more and more sophisticated. As you lean more on these machines, if you’re a doctor, inevitably some of the skills, the critical thinking, the reasoning that we put into coming up with the diagnosis that we honed over the course of years, that can start to atrophy. 

These are the types of things that we still need to sort through as we’re implementing more and more AI into the healthcare system.

For the people who just say, shut it all down, this is too dangerous, the risk is far too great, we don’t actually need this, this isn’t doing anything for society, would you make a counterargument?

I would make the counterargument that healthcare is ripe for disruption and you don’t even need the frontier frontier models to make it a lot better with AI.

Even if we wanted to “slow the pace of the frontier,” fine. But there are models from a year or two years ago that could be very helpful in the healthcare setting. When we’re talking about slowing the pace of the frontier and the most sophisticated and potentially dangerous models, fine. 

But if we’re talking about shutting down AI and not using it in biotechnology or not using it in scientific research or not using it in clinical care delivery, that’s where I would push back pretty hard.

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.

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.”