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.

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

Every day it seems scientists are making breakthroughs in Alzheimer’s disease. 

New treatments that actually slow the disease’s progression — lecanemab and donanemab — have finally appeared on pharmacy shelves in the past few years, delivering real-world results for patients and their families. New blood tests promise to identify at-risk patients earlier in their lives, giving them the chance to make lifestyle changes and potentially start treatment to stave off symptoms. 

The media and wellness influencers are always reporting on new diets, workouts, or hobbies that can combat dementia. Just last month, there was even a report out of China about an experimental brain surgery that allegedly reverses the symptoms of Alzheimer’s disease — the Holy Grail that researchers have been pursuing for generations.

But hype has outpaced the science of treating Alzheimer’s disease before. Promising treatments have gotten a lot of attention before only to fizzle out a short time later. Less than a decade ago, many scientists were wondering whether we had the theory of Alzheimer’s disease completely wrong. 

For those of us who don’t work in the field, that confusing history can make it hard to make sense of these recent developments. It sounds like we are entering a new age for Alzheimer’s prevention and treatment — but are we actually? And, if we are, how can people benefit from it?

I called a couple of leading experts to find out.

Here’s the good news: They say scientists are genuinely shifting the paradigm for treating, detecting, and ultimately preventing Alzheimer’s disease. The two drugs on the market can actually slow down cognitive decline for many patients, something that had been out of reach for decades. And more treatments are coming.

“Diagnosis and treatment of Alzheimer’s has changed in a way that is revolutionary compared to, say, four or five years ago,” said Dr. Jason Karlawish, co-director of the Penn Memory Center.

At the clinic where he sees patients, “people are feeling a sense of hope and promise,” he said.

For a long time, the science on Alzheimer’s disease felt stuck. Now it’s moving. There’s only one thing that could stop it, according to experts: the Trump administration’s anti-science agenda.

Scientists are getting closer to game-changing Alzheimer’s treatments

In 2023, the approval of two drugs transformed the landscape of Alzheimer’s care: lecanemab (sold as Leqembi) and donanemab (sold as Kisunla), two IV treatments that target amyloid plaque in the brain of a person with Alzheimer’s. Before these two drugs — and the approval of aducanemab, a similar but less effective and riskier treatment — it had been decades since the last new Alzheimer’s treatment had come onto the market.

They are not perfect treatments. They are effective only for people with mild cognitive impairment, not more advanced stages of the disease. They can only slow the progression of Alzheimer’s for those people, not stop or reverse it. And they do come with the risk of serious side effects, particularly brain bleeds.

“The good news is, we have these two drugs that can help people,” said Tara Spires-Jones, professor of neurodegeneration at the University of Edinburgh and author of the forthcoming book, Fighting for our Minds: The Neuroscience of Defeating Dementia. “The bad news is, you don’t get any better. You’re still getting worse — you just get worse more slowly.”

These drugs are a start, not the endpoint. Researchers are already working on the next generation of treatments. The drug pipeline is becoming more robust because scientists are finally coalescing around a theory of the disease that’s more complex — and, crucially, opens more potential targets for new drugs. 

For a long time, Alzheimer’s research was dominated by the amyloid hypothesis. The theory posited that the buildup of plaque made from amyloid proteins was responsible for disrupting brain signals and creating the telltale loss of memory and identity associated with Alzheimer’s. Scientists are still confident that amyloid plays a role in Alzheimer’s — and the success of these amyloid-targeting drugs supports that interpretation. But there is also a stronger consensus that other mechanisms must be at work. Some people who have evidence of amyloid plaque building up in their brain nonetheless never develop Alzheimer’s disease. 

Another type of protein called tau seems to be associated with the disease. Scientists also increasingly believe that inflammation may play a role. Part of the breakthrough of the past few years is that scientists are no longer arguing about whether they even understand this disease at all. Instead, the mission is to pursue different drug targets and increase the chances of delivering new treatments.

“I don’t think people in the field are fighting over, ‘Your mechanism is wrong and mine is right,’” Karlawish said. “I think there’s a kind of general democratization. There are multiple promising mechanisms.”

New tau-targeting treatments are moving through clinical trials. Biogen has a drug called diranersen that aims to stop the production of the tau proteins moving through clinical trials. Preliminary results showed that the drug did appear to reduce tau and improve cognitive symptoms — although, curiously, the most effective response was at the lowest dose. Further research is needed before the drug could receive FDA approval. Another tau-targeting drug from Eisai has also entered clinical trials and is in the earlier safety-check phases. And new amyloid-targeting treatments aim to better penetrate the brain-blood barrier and deliver more effective relief for patients.

In the short term, scientists hope these drugs can slow or even stop cognitive decline better than the currently approved medications. In the longer term, these new approaches — and potentially a combination of different drugs with different targets — could eventually allow scientists to reverse Alzheimer’s. (As for that experimental surgery in China, as Nature reported, scientists say its results will need to be replicated in other clinical trials before we’re confident that it really works.)

“The brain is amazing. You can make new synapses,” Spires-Jones said. “If we could stop the insult, it’s theoretically possible in the future that we could have treatments that not only slow the progression but actually let you get better. But I think we’re pretty far from those. What I think is much closer is really, really meaningful treatments that will slow or even stop disease progression. We’re probably going to see something coming out in the next couple of years.”

How patients can get the most out of these new treatments

But even a “cure” in the long term will be conditional. Because Alzheimer’s eventually causes the brain to die (thus its 100 percent fatality rate), there may still be a point of no return once the disease is too entrenched. “A cure for people in the late stages is practically impossible because too much of the brain has died,” Spires-Jones said.

And that reality makes early detection all the more important. That’s the way patients can get the most out of the current medications and their eventual successors.

It used to be that doctors couldn’t confirm whether somebody had Alzheimer’s disease until the person died and they could perform an autopsy. But the new treatments can give people more time with their loved ones before the disease’s worst symptoms kick in. 

That means waiting is not an option. Patients are demanding better methods of detection.

“Treatment attracts patients, for good reason, and treatment demands diagnosis,” Karlawish said. “Treatment really does drive the business model for a disease.”

So, scientists are designing new blood tests that can detect the presence of tau proteins and predict the later onset of Alzheimer’s disease with impressive accuracy. And they are learning more about pivotal periods in a person’s life where their risk of Alzheimer’s might start to grow — and when interventions might therefore be more effective. New research has suggested that menopause may be an accelerant for Alzheimer’s progression, and therefore may represent an important point in someone’s life. 

These developments are shaping what the near-term future of Alzheimer’s care will look like. As a person ages, they will be able to take one of these blood tests to see if there are signals they are at a higher risk of the disease. If they are, they will have a growing number of medications that they could take to delay or potentially prevent dementia from setting in. For a woman at risk, for example, hormone replacement therapy has been associated with a reduced risk of dementia. Clinical trials are also underway to test whether existing drugs like donanemab and lecanemab can delay the onset of symptoms for somebody who is at higher risk but has not yet started to experience cognitive decline.

“We couldn’t get the right people at the right time early on — and now we can,” Spires-Jones said. “That’s a problem that’s almost solved now.”

Prevention may also be where GLP-1 drugs ultimately prove most useful. As scientists come to better understand the intimate relationship between vascular health and brain health, there is growing reason to think these medicines could help reduce dementia risk decades before symptoms appear.

That would make GLP-1s a complement to drugs such as lecanemab and donanemab, rather than a competitor. Those treatments are designed for people who already have early-stage Alzheimer’s. GLP-1s, by contrast, have so far shown little ability to slow the disease once cognitive decline has begun. In a disappointing clinical trial involving people with mild cognitive impairment or early Alzheimer’s, researchers found that the drugs had a negligible effect on the progression of the disease.

But that result doesn’t mean there isn’t a role for Ozempic and the next generation of GLP-1 drugs in the fight against Alzheimer’s. 

Scientists increasingly believe that chronic inflammation, obesity, and poor vascular health can all accelerate cognitive aging. GLP-1 drugs reduce inflammation, while their effects on weight and metabolic health can substantially lower cardiovascular risk. If US obesity rates continue to fall as these medicines become more widely used, their most consequential effect on Alzheimer’s may therefore be indirect: improving the health of millions of people long before the disease takes hold.

“I think where we’re going in the future is those semaglutide-type drugs will probably be very good for prevention,” Spires-Jones said. “If we can keep people’s obesity in check, that will probably more likely be a preventative treatment. That trial pretty conclusively told us that once you have symptoms, at least, that drug is not going to help.”

This summer, the Alzheimer’s Association announced a $100 million research project to examine whether lifestyle changes plus a GLP-1 medication could reduce the risk of dementia in at-risk older adults.

If you’re worried about your own cognitive health or that of a loved one, you have options, and those options are only going to grow. Talk to your doctor. There are FDA-approved blood tests you can already take. Ask about lecanemab and donanemab. You may also be a good candidate to help scientists in the most active areas of development. Researchers need people to participate in their clinical trials. The Alzheimer’s Association and the federal government have online tools to help people find clinical trials that you or someone you love could be a candidate for. 

Science funding cuts could slow down this progress

All the optimism about the future of Alzheimer’s treatment is based on research and clinical trials. When I asked Karlawish and Spires-Jones about where the story goes from here, they shared one concern: that science becomes so politicized that it would be difficult to get grant funding for research projects that could lead to additional breakthroughs.

“In some sense, the biggest threat is outside the science,” Karlawish said. “There’s deep concern that this politicization of the grant process will essentially wreck American science. We can’t sustain that kind of environment and still demand the results that we’ve come to expect.”

President Donald Trump and US Health Secretary Robert F. Kennedy Jr. like to present their crusade to reform American science as being targeted at frivolous DEI projects. But there are already examples of serious dementia studies being affected: Last month, the Trump administration canceled $15 million in grants for studies to evaluate how discrimination affects long-term brain health.

This is another place where we have more agency to impact what happens next: the ballot box. Use your individual political power to support lawmakers who defend the scientists and researchers doing critical work. 

“You can vote for people who will fund and support science as an endeavor,” Spires-Jones said. “Advances in science don’t happen on their own. We need all of society to get involved.”

Over the years, Julianne Holt-Lunstad has fielded many requests from startups looking for her help. These entrepreneurs came to the Brigham Young University professor with the well-meaning goal of “solving” loneliness; they believed their app or company could help consumers build genuine connections, and wanted Holt-Lunstad’s opinion on this feature or that business tactic. 

Across the pond, University College London professor Noreena Hertz was getting the same calls. They wanted her to join their boards, to advise them, to give their proof of concept a stamp of approval. 

“Of the many startups who’ve approached me, and it’s probably about 50 or 60 in the space,” Hertz told Vox, “there hasn’t been one where I felt convinced by their business model.”

That CEOs and founders were clamoring to pick the brains of these two women is entirely predictable — their work may have been the basis on which these startups were founded. Holt-Lunstad is among the most cited academics who study loneliness and social connection. The commonly repeated stat that loneliness is equivalent to smoking 15 cigarettes a day? That came from her research. She was the lead science editor on the Surgeon General’s 2023 advisory on loneliness and isolation. As for Hertz, in her 2020 book The Lonely Century: How to Restore Human Connection in a World That’s Pulling Apart, she coined the phrase “loneliness economy,” at the time, a fledgling market of niche services, like friends for rent and professional cuddling.

In the years since Hertz gave it a name, the loneliness economy has only ballooned. As public attention to loneliness has mounted — despite the fact that research doesn’t consistently show whether a loneliness epidemic exists in the first place — the market stepped in to offer solutions. No longer are the lonely limited to joining a running club, they can now rent friends and cuddlers. They can hire a coach to help vanquish loneliness and build a community. (One charges $3,000 for a three-month program.) They can attend a $1,000 weekend-long summer camp to make friends (with the option to pay in installments via Klarna). They can buy a $250 pendant that listens to their every word and can communicate back via voice or text. They can join a coworking space meant to quell loneliness with a nearly $300 a month price tag. They can enroll in a bootcamp for how to be less shy, hop in a group travel excursion with other solo venturers, download an app where AI pairs you with other strangers for activities. Loneliness is no longer a societal issue with mental and physical costs and structural solutions but one businesses hope consumers can buy their way out of.

But is it possible to disrupt the slow burn that is making a friend? To outsource the intimacies of friendship to AI? To put a price tag on human connection? 

“I would caution developers to really critically evaluate their business model and the barriers to who they’re actually reaching,” Holt-Lunstad told Vox. “Think about ways that [connection] can occur organically without monetizing it.”

The cottage industry of loneliness services is just another example of capitalism wrapping its tentacles around human desire. But in most cases, the cost of the app, or product, or experience is going to be much higher than the possibility of eliminating loneliness.

One person’s loneliness is another’s business opportunity

Since the early 2000s when Harvard political scientist Robert Putnam warned of the decline of civic and social spaces in his seminal work Bowling Alone, we have witnessed the “privatization of community,” according to Sam Pressler, a fellow at the Harvard Human Flourishing Program who studies community, connection, and class. Gathering spaces shifted away from places of worship and union halls to boutique fitness centers and private, members-only clubs. “There was already this dynamic in place where you could, at a premium level, sell people on community,” Pressler said.

The pandemic pushed the loneliness economy into overdrive. Widespread social isolation enabled researchers to study perceived levels of loneliness during lockdowns. Media coverage of loneliness outlined its harms. Although Vivek Murthy, the US surgeon general during the Obama and Biden administrations, first referred to loneliness as a “health epidemic” in 2017, his 2023 report opened the door for other iterations: the male loneliness epidemic, the Gen Z well-being slump, a worsening midlife crisis. Over the past five years, search interest in the loneliness epidemic grew over 600 percent.

Naturally, the startup world began to see a business opportunity, Pressler said. WeWork founder Adam Neumann launched a new residential real estate company with a goal of “solving loneliness” and $350 million in funding from Andreessen Horowitz. The app 222, which uses AI to pair strangers for group activities based on personality-based questions, raised $10 million in funding. “You then get this anchor within startup land that really has an approach of solve customers’ problems and pain points, in that loneliness is a customer problem or pain point to be solved, through productized market solutions,” Pressler said.

Brian Choi had heard of the male loneliness epidemic, but luckily didn’t feel like he fell into that category. He grew up in the Los Angeles area, where he still lives, and has plenty of friends, but he signed up for 222 several years ago as a way to supplement his social life and meet people who might be interested in activities his existing friends aren’t.

“Dance, for me, means a lot,” the 34-year-old video game character artist, told Vox. “For my best friends, hard to sell them on that. So 222 is a good angle on sharing that experience with other people who are presumably also open to dance.”

But most of the platform’s events, Choi found, were centered around dinner and drinks, which didn’t appeal to him. If there was a meetup with an interactive element, like brunch and a pottery class, he was more likely to engage. But despite attending about a dozen 222 events over the years, Choi hasn’t fostered any serious friendships. “It’s dependent on individuals to be proactive about inviting folks into their lives after the 222 event,” Choi said. “And that can be scary for a lot of people.” 

Once a market emerged for loneliness-adjacent services and products, influencers started promoting them. Over the last few years, the content creator Zaid Khan observed his peers hosting “community” events that seemed well-meaning enough until a few common themes emerged: The events seemed to be furthering the creators’ brands, they often came with a ticket price, and they were attended mostly by young, white people. This widespread commodification of community is what Hertz refers to as “WeWashing” — like greenwashing — because an occasional knitting club with a $50 fee does not a community make. 

Charging any sort of premium for a social event or service runs the risk of exacerbating inequities. According to Holt-Lunstad’s research, people with only a high school education or less or those who made less than $75,000 a year were less socially connected than those with higher education and incomes. People who stand to benefit the most from interventions to build relationships often can’t afford a $200 a month gym, or lack the time to swipe for friends. These spaces can then become, like Khan observed, homogenized by race, class, and ability. “I’m sorry, but young, attractive, white, straight, 20-somethings living in New York will have no issue. … You can walk into any West Village bar and meet those people,” Khan said. “It’s excluding the people who, I think, genuinely could need it.”

“Masking” a symptom

There is a contradiction at the heart of the loneliness economy: the need for human connection in the modern world is difficult to solve, let alone value and commodify. In order to make money, companies either have to charge top dollar for their social club or camp, or, they need their product to be used by as many people as possible, as often as possible, which inherently flies in the face of how relationships are fostered. 

“The ethical problem begins when a company intentionally exploits a consumer’s loneliness, insecure attachment, or fear of missing out to pressure that person into purchasing.”

Cindy Rippé, Terry College of Business at the University of Georgia

Relationships are projects of patience. They unfold after repeated interactions in a physical space, after slow revelations and disclosures and laughs. The loneliness economy isn’t built on unhurried bonding. Instead of consistently showing up to a community event and slowly building connections, some apps are effective at connecting users with strangers for one-time events, but are less focused on encouraging users to exchange numbers and hang out again. “We know from the research that relationships take time to develop, and that there needs to be consistency also over time. When you get to know someone, it takes time,” Holt-Lunstad said. “If you’re only doing it sporadically or once, that’s going to be less likely. If it’s all virtual, that’s going to be less likely.”

Just like hunger and thirst cue you to eat and drink, loneliness is a sign to interact. Swiping for friends may feel productive and occupy time, but without actually hanging out, it may just be a distraction, Holt-Lunstad said. “What I worry is that [apps] may be effective in masking that symptom without actually fulfilling any social needs,” she said. “It would be like no longer feeling thirsty, but we’re not actually drinking any water.”

The loneliness economy also fails to take into account the barriers preventing people from making friends in the first place. In recent surveys, the results of which have not been published, Holt-Lunstad has found both internal and external obstacles to connection, including anxiety, a fear of rejection, physical and mental health limitations, the economic cost of participation, and the time investment required with joining a club. “It might be, that’s a great program, but it’s too far away, or that’s a great program, but it costs too much,” Holt-Lunstad said. “And then, of course, there’s the internal barriers where there’s so much shame and stigma associated with this that many people don’t want to feel like I have to have an app or a program to make friends.”

These potentially lonely consumers may be more vulnerable to companies’ marketing efforts, even though the products are unlikely to solve the underlying issue. According to research, when people feel like they are lacking close, intimate relationships, they are more likely to buy themselves things. “One of the things, for instance, could be spending money to go on group activities rather than individual activities,” Aulona Ulqinaku, an associate professor of marketing at Università Carlo Cattaneo LIUC in Italy, told Vox. People could spend money to join a club you aren’t particularly interested in just to feel a part of something. 

Shopping can also serve as a social experience in itself, Cindy Rippé, a senior lecturer in the Department of Marketing at the Terry College of Business at the University of Georgia, told Vox in an email. Employees and other patrons can become familiar and friendly faces, effectively turning a retail space into a third place. A paid social experience, such as a club, could theoretically achieve the same fulfilling effects as shopping, Rippé said. But spending money isn’t what makes people feel better; it’s repeated social interaction, familiarity, belonging.

Because companies can track your activity online, users who search for local clubs or interact with these groups on social media may be repeatedly served ads for other community-centric businesses and thus spend more money on services that may not be effective.

“I hope that we are looking at a world where marketing can be looked at as an instrument for helping people rather than exploiting people,” Ulqinaku said. “The aim should not be, ‘I make money [off] of you.’ The aim should be, ‘I want to make you feel better. I don’t want to exploit you.’”

Putting a price tag on relationships

The pairing of lonely consumers who might be willing to spend money and businesses that definitely want to make it may be good for the bottom line in the short-term, but perhaps not for social health or for revenue in the long-term. (After all, if these products don’t work, people will stop paying for them, and if they do work as promised, people will also stop paying for them.) Friendship isn’t a product you can advertise or put a dollar amount to, Pressler said, and we shouldn’t apply market solutions to non-market goods.

“You can approach it with a consumptive mindset where it’s like, ‘Well, I just need to consume more relationships, and if I consume more relationships, ergo, I will not be lonely or disconnected,’” he said — but that’s not how real-world interactions work. The power imbalance between the companies earning money and the consumer spending it to fulfill a core human need may veer on exploitative, too, Rippé said: “The ethical problem begins when a company intentionally exploits a consumer’s loneliness, insecure attachment, or fear of missing out to pressure that person into purchasing.”

Which isn’t to say communal gatherings with a price tag are inherently exploitative. Live music and events, like concerts, successfully bring people together for shared experiences, according to Hertz, the professor and author. (Of course, tickets have become so expensive that seeing your favorite act perform is becoming a luxury.) Groups centered around an activity have the potential to connect people, too. But buying your own yarn and needles to bring to a weekly craft night at your local knitting shop is different from paying $50 to join a one-off “knitting club” organized by a VC-backed friendship app.

Because social health touches so many aspects of life — the physical spaces we inhabit, the technology that both facilitates and inhibits socialization, the costs of interacting — the path toward connection is more complex than marketable products or individual purchases. It involves government investment in public spaces and low- or no-cost community events; policies that allow everyone to lead a dignified life, which includes the space for leisure activities; and a societal shift that prioritizes slow, intentional relationship building instead of instant connection. 

“The need is real,” Hertz said. “The purported solutions are many. Some of them I think can be part of the solution. Some of them may well end up making us lonelier as a society.”

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