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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Where GLP-1 coverage goes from here

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

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

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

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

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

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

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

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

The West Nile virus is spreading across the EU at record levels and is reaching new regions of the continent, health authorities said Thursday.

In a statement, the European Center for Disease Prevention and Control said 1,715 cases were reported this year, with 130 people dying from the virus, which is mainly transmitted through mosquito bites.

Greece, Italy and France are the worst affected countries, but the virus is spreading further north, authorities say.

“Recent detections in people and animals in Belgium and the Netherlands show that the virus is now circulating further north, a trend that is expected to continue in the coming years,” the ECDC said.

The Netherlands has reported 59 human cases so far this year, while Belgium has reported 15.

The West Nile virus is asymptomatic in 80% of humans — but can lead to fever and, in severe cases, cause neurological diseases and become deadly.

Preventive measures against mosquito bites are recommended to reduce West Nile virus risks.

“Anyone living in or visiting areas where WNV is circulating can reduce their risk by using mosquito repellent, wearing loose-fitting long clothing in the evening and at night, and using window screens, mosquito nets, or air conditioning where appropriate,” the ECDC said.

BRUSSELS — European leaders came for the budget. They’re staying for everything else.

A two-day European Council starting Thursday was supposed to be all about the money. Instead, leaders of the 27 EU member countries are heading into one of their most crowded summits in years, with a succession of geopolitical crises threatening to hijack the EU’s carefully laid plans.

European Council President António Costa originally wanted the gathering to accelerate negotiations on the bloc’s next seven-year budget, hoping to seal a deal before elections in France, Italy and Poland in 2027 make an already difficult agreement even harder.

But the world had other plans. Soaring energy prices, tensions with China, Russia’s war in Ukraine (and U.S. President Donald Trump’s ambiguity over it), migration and turmoil in the Middle East have all elbowed their way onto the agenda.

The result is a two-day marathon covering virtually every major challenge facing the EU, from keeping European factories competitive to ensuring the world’s most important shipping lanes stay open.

For anyone trying to follow the action without spending 48 hours glued to Brussels, here’s your guide to what matters.

With the usual warning: EU leaders are notorious for letting discussions drag on or reshuffling the agenda — that’s what our liveblog is for.

Thursday at dawn: The pre-match warm-up

Before the summit even starts, Europe’s political families will gather at the crack of dawn.

The European People’s Party meets from 7:30 a.m. at the Sofitel Brussels Europe — the place to be if you can get in, given how many center-right leaders will be at the summit table.

The Socialists gather from 8:30 a.m. at PES headquarters, with Costa, Spain’s Pedro Sánchez and Denmark’s Mette Frederiksen expected.

Renew kicks off at 8 a.m. at the Palais d’Egmont, with French President Emmanuel Macron and top EU diplomat Kaja Kallas among those expected.

Even without leaders in the summit room, the far-right Patriots got a head start Wednesday, with Marine Le Pen delivering a scathing attack on the state of the EU.

Thursday morning: The energy blame game and China

Leaders kick off with discussions on Europe’s struggle for economic competitiveness, starting with energy — potentially the most politically explosive debate.

Governments want immediate relief from soaring energy prices as a result of the war in Iran, and will push the Commission to introduce new measures on top of the wide-ranging but somewhat toothless package it announced back in March.

Expect finger-pointing between capitals and Brussels over who should act, and for climate policies like the upcoming Emissions Trading System on heating and transport to come under fire.

Next comes China. European Commission President Ursula von der Leyen will brief leaders on efforts to tackle the EU’s enormous trade imbalance with Beijing, following trade chief Maroš Šefčovič’s negotiations with Chinese officials.

Leaders are expected to renew their demand for Brussels to “urgently” tool up with further trade defenses to prevent further deindustrialization of the bloc and to shield further industrial sectors from Chinese competition.

There’s also time for the familiar fight over EU red tape, with calls for Brussels to stop legislating.

Thursday afternoon: Costa’s budget gamble

This was supposed to be the main event. Leaders will discuss Ireland’s negotiating proposal for the EU’s 2028–2034 budget slashed by €159 billion from the Commission’s original proposal.

The positions are well known: The self-styled “modernists” — essentially the old frugals in disguise — want to contain costs, while countries benefiting from EU spending are determined to defend their allocations, under the less glamorous banner of “friends of cohesion.” Positions on new EU-wide taxes are similarly entrenched.

But the real story is timing.

Governments have watered down a commitment to secure an agreement by December, according to draft conclusions seen by POLITICO. Costa wants a deal before a series of high-stakes elections in 2027 complicate negotiations; capitals fear a deadline could weaken their bargaining power.

Most importantly, Costa is moving into the driving seat as budget talks enter their most politically sensitive stage. Watch for clues about a possible extraordinary summit in late November — and whether December remains a credible deadline or leaders quietly start preparing for negotiations to spill into 2027.

Thursday dinner: Making room for new members

Over dinner, leaders will tackle enlargement and the EU reforms needed to accommodate new members — after all, October’s summit has historically been devoted to the bloc’s hopefuls.

Montenegro is edging closer to completing accession negotiations, while progress elsewhere raises questions about whether the bloc is institutionally and financially ready to grow.

The Commission has outlined proposals to prepare the EU for enlargement, and leaders will discuss how internal reforms should accompany the accession process. Watch for a positive signal to Montenegro and commitments on reforming the bloc itself.

Friday morning: Ukraine’s wish list

The second day begins with Ukraine and an expected appearance by President Volodymyr Zelenskyy. Declarations of European solidarity are all but guaranteed. The more interesting question is what leaders are actually prepared to do.

Kyiv needs air defense systems, interceptors and financing as Russian attacks intensify. Leaders could discuss tougher action against Moscow’s shadow fleet and visa restrictions for Russians. And while EU financing for Ukraine has already been agreed for 2026, the country’s needs beyond that remain an increasingly pressing issue.

Could this mean reopening the debate on using frozen Russian assets to plug future funding gaps? That remains a question mark — although no immediate breakthrough is expected.

Friday pre-lunch: Defense and three dangerous waterways

Before breaking for lunch, leaders will turn to Russian hybrid attacks, maritime security and the Middle East.

In the Black Sea, recent attacks on civilian shipping threaten Ukraine’s crucial grain export route. Turkey has floated new protected shipping corridors, while countries including Romania and Bulgaria are pushing to give the issue more attention.

Will leaders back concrete measures or stop at condemnation? That’s the question.

Discussions then turn to the Middle East and two other critical shipping routes: the Strait of Hormuz and the Red Sea. The fallout from the Iran–U.S. war, increased Iranian attacks around Hormuz and renewed Houthi threats in the Red Sea have disrupted global trade and energy flows.

The EU’s Aspides naval mission is short of vessels, and Kallas wants governments to contribute more. Watch whether leaders put ships behind their promises.

The broader Middle East discussion will also touch on Iran, Yemen, the West Bank and Lebanon.

Friday lunch: The migration showdown

Spain’s Pedro Sánchez, Italy’s Giorgia Meloni and Denmark’s Mette Frederiksen are worth watching as leaders discuss migration over lunch, following the crisis in Spain’s North African exclave of Ceuta.

Irregular arrivals have been declining, but disagreements remain over border crises, solidarity and tougher migration controls.

And with an election looming in Spain on Nov. 29, this could be Sánchez’s last tango — and a final chance to defend his government’s handling of the crisis while venting his frustration over the lack of European solidarity.

Watch whether the debate produces agreement or another political clash, as happened last time.

Bonus: Two pressers are better than one

With such a packed agenda, leaders won’t wait until the end of the summit for the usual joint press conference by von der Leyen and Costa. An additional one is planned for Thursday, after the budget debate.

On Thursday, watch Costa’s language on the budget deadline and whether von der Leyen offers any concrete measures on energy prices.

On Friday, look for promises of additional support for Ukraine, whether commitments on maritime security come with actual ships and resources — and commentary on how the migration showdown over lunch went.

Martina Sapio contributed to reporting.

When Maroš Šefčovič set out his strategy for engaging with China to European Union ambassadors in July, he had a warning for governments urging tougher action on trade against Beijing.

“Sometimes, it’s even popular to start a trade war, but it’s very difficult to finish it,” the EU trade chief recalled later in an interview with POLITICO.

Three months on, Šefčovič has secured a first breakthrough, reaching a deal in Beijing last week to sharply reduce imports of Chinese hybrid cars. The symbolic win marks a small step toward stabilizing a trading relationship that Brussels believes has reached a dangerous tipping point.

The agreement, which will initially cap imports at 350,000 vehicles a year, marks a significant concession from Beijing, whose carmakers have been flooding the European market with increasingly competitive vehicles. 

For Šefčovič, who negotiated last year’s tariff truce with Donald Trump, the agreement suggests his strategy of engagement backed by the threat of tougher trade measures may be starting to pay off.

Šefčovič agreed to launch the trade dialogue at a meeting with Chinese Commerce Minister Wang Wentao in Brussels in late June.

By focusing initially on cars — an area where the EU has leverage as one of the few major markets still open to Chinese manufacturers — the Slovak commissioner hoped to secure a confidence-building win before tackling thornier questions, from critical raw materials to China’s vast industrial overcapacity.

At the same time, he worked to coalesce European governments behind a parallel effort to strengthen the bloc’s trade defenses, reinforcing his negotiating position with the threat of tougher action to bring down the EU’s €1 billion-a-day trade deficit with China.

The hybrid deal, however, is only the opening move in a much bigger contest.

EU leaders meet in Brussels on Thursday to take stock, weighing the benefits of continued engagement against demands for more aggressive action to protect European industry from a surge in Chinese imports.

The meeting will test whether a commissioner who has made a career of finding compromises with difficult partners can maintain Europe’s support for a strategy whose success is far from assured.

“You have to deal with the same partner across the table,” Šefčovič said of the risks of starting a trade war, in the interview with POLITICO in August. “So if you can avoid this, it would be much better.”

Market power

Šefčovič’s opening move was to focus on an area where Europe still has leverage: access to its market of 450 million people.

China’s fiercely competitive manufacturers have become global powerhouses, but they are struggling with weak demand at home. A prolonged property slump has weighed on consumer spending, while cutthroat competition has triggered price wars. Domestic sales of passenger vehicles fell 28% in September from a year earlier.

That makes overseas markets increasingly important. With the U.S. shutting out Chinese imports, Europe remains one of the most lucrative markets still open to Chinese manufacturers.

Šefčovič gambled that Beijing would prefer to accept limits on exports rather than risk losing access to the European market altogether.

He set his sights on the automotive sector, where Chinese manufacturers have been making rapid inroads. Chinese carmakers accounted for just 2% of both the European hybrid and plug-in hybrid markets in 2024; by the first half of 2026, their respective shares had risen to 14% and 25%, industry figures show.

The Commission was preparing to restrict hybrid imports even without an agreement. But a negotiated settlement also offered Šefčovič something valuable politically: evidence that engagement with Beijing could deliver tangible results.

The negotiations were intense, according to a person familiar with the talks on the Chinese side.

“It was very, very tough,” the person said, speaking on condition of anonymity to discuss the closed-door negotiations. “Both sides hadn’t seen such intensity in a long time. No summer break, no holidays. They worked around the clock even one, two days prior to Šefčovič’s trip to Beijing.”

While pursuing dialogue, Brussels also wanted to convince Beijing that it was prepared to take tougher action if the negotiations failed.

Šefčovič had earlier flagged plans for a new “diversification instrument” that would require businesses in critical sectors to source essential inputs from at least three suppliers — a move to reduce China’s ability to exploit Europe’s dependence on its critical raw materials.

Then, just three days before Šefčovič’s trip to Beijing, France and Germany raised the stakes.

President Emmanuel Macron and German Chancellor Friedrich Merz called for a powerful new trade weapon that would allow Brussels to restrict — or even shut off — access to the European market within days for countries deemed to have severely distorted the bloc’s single market.

The proposal did not explicitly name China, but Beijing was its obvious target. 

Keeping it together

EU leaders are expected to welcome the agreement but also press the Commission to act quickly to strengthen the bloc’s trade defenses, according to several diplomats. The understanding reached in Beijing has bought time, but hasn’t settled how far Brussels should go if Chinese exports keep rising or negotiations stall.

“We’re losing thousands of jobs in industry; olive oil and ice cream won’t solve the core issue,” said one EU diplomat after Šefčovič briefed ambassadors on Sunday, referring to reported deliverables from the talks.

A senior German official welcomed the Beijing deal as a first step in the right direction. “It’s a positive sign — which, of course, doesn’t fully solve the problem of the trade deficit with China,” the official said.

But Berlin’s support for a tougher line might prove short-lived.

Alicia García-Herrero, a senior fellow at the Bruegel think tank, argued that Beijing’s concessions had been calculated to assuage Berlin, given the importance of the automotive industry to the German economy.

“I’m just hoping Merz doesn’t turn away from the letter he sent to the Commission,” she said. With the German chancellor politically weakened at home, García-Herrero fears he may be reluctant to risk a prolonged confrontation: “I worry Merz will take this quick win and run.”

That leaves Šefčovič facing a balancing act: keeping EU governments on board with continued engagement with China while maintaining a credible threat of tougher action if the talks break down. 

“I expect [leaders] to give the Commission a nod to move ahead with other trade defense measures. China may see this as a betrayal. If that is the case, we could return to conflict very quickly,” said Noah Barkin, a senior adviser at the Rhodium Group’s China practice.

The battle ahead

For Šefčovič, the challenge now is to turn a limited breakthrough on cars into a broader rebalancing of trade with China — while buying Europe time to strengthen its defenses should the negotiations fail.

“There is an argument for doing to China what China had done to Europe for years — bogging Beijing down in dialogue and process while Europe gets its tools in place. But the EU needs to make full use of the time that these talks provide,” said Rhodium’s Barkin. 

The trade chief is expected to hold a video call with Wang in January, before the two meet again next March. Those talks will test whether Beijing is prepared to make further concessions in sectors where European industry is increasingly on the defensive, including chemicals.

Another priority is critical raw materials, where China has agreed to continue issuing export licenses for rare earths. Beijing’s grip on their supply gives it considerable leverage over European manufacturers, underscoring the limits of Šefčovič’s negotiating position.

The Commission is also preparing two proposals for December: the diversification instrument, aimed at reducing dependence on Chinese supplies, and a mechanism to shield European industries and regions from retaliation.

The scale of the challenge is daunting. Chinese hybrid imports were worth €6.7 billion in the first half of 2026, against an EU-China trade deficit of €360 billion last year. The agreement offers some relief to European automakers but does little to address the underlying imbalance.

Brussels hopes the hybrid safeguard can serve as a blueprint for protecting other industries facing a surge in Chinese imports.

“We hear our industry. That includes the chemical industry, the wind industry, the furniture industry. We know where there’s a surge, and we know what hits the hardest in terms of our deindustrialization,” a senior Commission official said on Monday.

Šefčovič acknowledged the limits of dialogue in his August interview, warning that negotiations would become harder to sustain without tangible progress.

“What would be very important is to come back to say there is acknowledgment of the issue and there are already some pilot schemes which we want to test and to see if they are working,” he said.

“But if simply there will be no action, then of course it will be much more difficult for us just to talk about these issues.”

Jordyn Dahl in Brussels and Hans von der Burchard in Berlin contributed reporting. 

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

But in practice, things look quite different. 

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

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

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

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

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

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

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

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

Sex matters…but so does size

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

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

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

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

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

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

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

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

Why is the new model still falling short?

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

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

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

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

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

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

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

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

Toward liver donation equity for all

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

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

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

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

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

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

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

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

The European Union and China reached an agreement on Friday that will curb China’s booming hybrid car exports, delivering a breakthrough in negotiations aimed at rebalancing their trade relationship.

The announcement came as Trade Commissioner Maroš Šefčovič wrapped up two days of talks in Beijing, the culmination of a push launched in June to narrow the bloc’s €1 billion-a-day trade deficit with China. 

The deal marks a win for the EU executive, which has been under pressure to secure concessions from Beijing. Going into the talks, France and Germany strengthened Šefčovič’s hand by calling for the EU to take tough action on trade if China failed to curb a growing export glut.

Speaking in Beijing, the commissioner said the two sides had reached an agreement that would help to shield European automakers from low-price Chinese competition. He declined to enter into specifics before EU leaders officially mandate the EU executive to move forward. 

“We have reached a shared understanding to moderate China’s export of hybrids and plug-in hybrids to the European Union. This opens the prospect of cutting China’s exports by more than a half,” Šefčovič told reporters. 

The estimate was based on projections of how Chinese exports would grow over the next four years without the agreement. In practical terms, it would mean that “several millions of car exports from China to the European Union” would be prevented, he explained.

China’s Commerce Ministry highlighted the understanding on hybrids in a parallel 16-point statement, but offered no details on how exports would be restrained. It said the two sides “will continue to strengthen communication and cooperation under the trade monitoring mechanism and further leverage dialogue mechanisms to enhance mutual understanding.” 

Šefčovič declined to elaborate when asked whether the deal would allow the EU to impose safeguards — a mixture of import quotas and tariffs — a step that Brussels has been considering. He said the arrangement would comply with the rules of the World Trade Organization.

First step

Šefčovič said that Beijing had also agreed to lower duties on European goods worth €4 billion, ranging from olive oil to footwear, a move that would save exporters €225 million. 

“It is a crucial first step,” he said. “But only a first step in the process of rebalancing.” 

The Slovak commissioner said he would report back to European Commission President Ursula von der Leyen, along with EU leaders, when they meet for a summit in Brussels next Thursday.

He had focused on cars as a key deliverable going into meetings in Beijing with Commerce Minister Wang Wentao and Vice Prime Minister He Lifeng.

Chinese auto exports to Europe have been booming, accounting in August for one in eight cars sold in the bloc — mainly driven by sales of hybrids. Europe’s own automotive industry is feeling the pressure, with Volkswagen and Mercedes-Benz recently announcing job cuts and plant closures.

Aside from the deal on hybrids, Beijing said in its statement that it was “willing to continue” fast-tracking licenses to export rare earth elements to the EU. Automakers had been forced to shut down assembly lines after China temporarily restricted exports in response to U.S. tariffs last year. China dominates the production and processing of rare earths.

“We have reached a shared understanding to further facilitate China’s export licensing for rare earths and permanent magnets,” Šefčovič said. 

Road ahead

Brussels sees the agreement on hybrid electric vehicles as a blueprint that could be replicated to shield further EU sectors currently under strain, such as chemicals or machinery. The two sides plan to meet again in March 2027, and will hold a video call in January. 

The agreement on one of the EU’s top negotiating targets significantly reduces the risk of an escalation in trade tensions that could have led to a tit-for-tat round of retaliation. It remains to be seen whether the EU will act swiftly on the Franco-German call to empower Brussels to shut out exports from countries that destabilize its single market.

“Public opinion and the leaders clearly expect very fast action from our side. I am glad to say that the Chinese partners appreciated this very strong political argument, and therefore, we can proceed through the negotiated solution,” said Šefčovič.

Other areas of agreement include exploring easier market access for European medical devices, as well as promises by Beijing to scale back sweeping disease-control measures that have restricted European meat and livestock exports. 

While the deal will cool the most immediate tensions, a wider resolution to the economic imbalances that fueled the conflict remains distant. The EU’s trade deficit with China totaled nearly €360 billion in 2025, and is already up 12 percent so far this year.  

China’s automotive exports to the EU, which totaled €15.1 billion last year, are only a fraction of that.

This article has been updated.

As whispers circulate of plague in faraway Siberia, it’s worth remembering that Russian obfuscation is so ingrained that it’s become a meme.

In HBO’s dramatized 2019 series about the nuclear disaster at Chernobyl, a Russian atomic scientist scoffs at a radiation reading that suggests a major calamity is taking place. 

“Not great, not terrible,” says the fictionalized version of Anatoly Dyatlov, the real-life deputy chief engineer at Chernobyl in April 1986, as he looks at a dosimeter noting 3.6 roentgen per hour, just below a critical radiation level. 

Except that reading was not accurate. Not even close. The nuclear reactor had already exploded and unleashed catastrophic levels of radiation that would go on to cause thousands of cancer-related deaths in the worst nuclear power plant disaster in history.

While dramatized, the scene is emblematic of a long-standing Soviet and Russian desire to downplay critical incidents — and even cover them up. That pattern has flared this week, with senior world health officials, the European Union and U.S. President Donald Trump demanding that Moscow be more transparent about a suspected outbreak of plague in far eastern Russia.

In dark comedic twist in the face of the potential plague, Dyatlov’s dismissive remark is now ubiquitous. Not great, not terrible. 

Into the unknown

The death of a 28-year-old employee at the Irkutsk Anti-Plague Institute of Siberia and the Far East last week triggered unease across the globe due to her laboratory work — and a local Russian official linking her death to a case of plague.

Russia was quick to clamp down. Rospotrebnadzor, the country’s national public health agency, said that the employee died from “pneumonia of unknown etiology” and that no microorganisms associated with her work were identified in the patient sample.

Still, Russian health authorities placed nearly 200 people under supervision and local media reported that several hospitals were placed under quarantine. Rospotrebnadzor said Thursday these measures were taken due to “the patient’s professional activities.”

The World Health Organization, which leads global response to international health threats, got in touch with Russian health authorities on Oct. 3. It requested more information using one of the tools laid out in the International Health Regulations, which Russia is signed up to. Under the IHR, countries have 24 hours to respond to the WHO — though Russia sent its response on Oct. 6.

Russian authorities said that “no case of plague had recently been registered in Irkutsk” and “no pathogens of dangerous infectious diseases were detected among any of the contacts.”

As of Thursday, Russian health authorities maintain that there is no “epidemic risk” in the region. Rospotrebnadzor said that it had concluded health inspections and found “no emergency situations involving pathogenic microorganisms.” It had also completed monitoring of 90% of the contacts, without identifying any infections, the agency added. Simultaneously, Kremlin spokesperson Dmitry Peskov slammed media reports about the case as false and said Russia has been communicating with global health authorities.

Yet the WHO insists there’s still much left unknown about the events inside Russia.

“We don’t know exactly how this person died,” said Maria Van Kerkhove, director of epidemic and pandemic management, during a press briefing Wednesday. “We know that she had pneumonia. We know it was a fatal case. We understand that some laboratory tests have been done. They haven’t found the causative agent. This is why we need more information.”

The WHO said it requested further details on what laboratory tests were conducted, which pathogens were evaluated, which further analyses are being done to determine the patient’s cause of death — if not plague — along with more details on any potential lab incident and the 200 contacts.

Until those questions are answered, it’s impossible for the WHO to conduct a risk assessment.

“We don’t yet have the full picture of this event, and we are not able to conduct a full risk assessment,” said Tedros Adhanom Ghebreyesus, the organization’s director-general. “Timely, complete, and transparent information sharing under the international regulations is essential to clarify conflicting reports and enable an accurate assessment of potential public health risks.”

Omertà in Russian

It might be that the cause of death of the 28-year-old lab worker is not, in fact, plague. 

But Russia’s incomplete, late and hazy communication about the case is fomenting fears and uncertainty from Geneva to Brussels to Washington. It would also not be the first time the Kremlin has downplayed or attempted to cover up public health threats.  

That goes beyond the Soviet-era Chernobyl Nuclear Power Plant disaster, in what is now northern Ukraine, where the Kremlin was slow to take action and effectively denied the cause of the incident.

In 1979, according to an investigation by U.S. scientists, the Soviet Union covered up a deadly anthrax outbreak in the city of Sverdlovsk, now Yekaterinburg, which killed at least 66 people. Officials said the victims had fallen ill from eating contaminated meat, when in reality they had been exposed to anthrax because of an accident at a secret biological weapons lab.

Russia was also accused of covering up a mysterious 1988 alopecia outbreak in Chernivtsi region, in which more than 175 children lost their hair. Soviet authorities said the children suffered from thallium food poisoning, but later studies raised questions about that, with some suggesting the cause was hydrazine, or acid rain.

Over the years, the Kremlin has also dismissed, downplayed and underreported HIV cases, even while in the middle of a deadly epidemic. And, more recently, during the Covid-19 pandemic, Russia was accused of downplaying coronavirus deaths, particularly at the beginning. 

The tradition extends beyond public health. The 1999 apartment block bombings, the 2000 sinking of the Kursk submarine and the 2014 downing of Malaysia Airlines flight MH17 by Kremlin-backed separatists all raised questions over Russia’s public messaging and commitment to transparency.

Talks with Putin

The EU and the U.S. are monitoring the Irkutsk situation closely, with both seemingly growing impatient with Russia’s communication. 

“The whole world is waiting for the information from Russia,” said European Commission spokesperson Eva Hrncirova on Thursday.

“Russia should make information about the plague available as soon as possible,” she told reporters. “We need information from Russia. It’s linked to the Russian membership in the WHO Europe, sharing timely, precise, exact information so that the experts can assess the situation, because [it] can have cross-border implications.”

The European Commission’s directorate-general for health and food safety is planning to send a technical letter to Russia asking for more information, a Commission spokesperson confirmed.

In the meantime, Russia’s “patchy” communication is dangerous, said a Commission official, granted anonymity to speak candidly on the matter.

“This fuels speculation into all directions. It also renders preventive [and] precautionary action difficult, if not even meaningless,” the official said. These types of events happen all the time, but there is usually an exchange with the WHO and health authorities, the person added. “The lack of precise [and] reliable info is logically reducing adequate good preparedness.”

U.S. Secretary of State Marco Rubio on Tuesday urged Russia to share more information, adding that it would be “irresponsible” to speculate until then. The Wall Street Journal reported Wednesday that the U.S. sent a formal diplomatic message to Russia requesting more information about the woman’s death and reminding the Kremlin that it has obligations under international law to share information about disease outbreaks in a timely manner.

U.S. President Donald Trump even said Tuesday he had a “call scheduled” with Russian President Vladimir Putin “very soon” to discuss the situation. 

But, by Thursday, the two leaders were yet to talk, with Trump noting that Russia was “not saying much.” 

He still planned to talk to Putin soon, he added.

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

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

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

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

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

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

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

Why this Alzheimer’s surgery really might work

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

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

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

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

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

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

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

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

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

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

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

But let’s not get ahead of the science

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

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

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

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

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

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

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

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

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

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

Trade Commissioner Maroš Šefčovič is kicking off his visit to China today — and the stakes are high.

On today’s show, Zoya Sheftalovich and Sarah Wheaton discuss the most important topic on the agenda: Europe’s trade deficit with China. France and Germany are finally on the same page and want Brussels to get tougher on unfair trade. So can we expect results from the meeting?

Next, EU development ministers are meeting in Dublin to discuss the future of Europe’s development policy. But the timing is unfortunate, as governments prepare another round of cuts to the next long-term budget.

Finally, a mysterious death at a Russian anti-plague lab has an unexpected connection to Zoya’s own family.

Questions? Comments? Let us know on our WhatsApp here or at +32 491 05 06 29.

Articles mentioned in this episode:

• EU toughens China stance ahead of Šefčovič’s Beijing visit.
• EU-China trade talks zero in on cars.
• WHO seeks clarity on second pneumonia case in Russia amid plague fears.

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

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

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

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

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

Gregory Koblentz, co-founded the Global BioLabs project

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

But this historically persistent inequality is not a foregone conclusion.

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

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

How surgical procedures are valued

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

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

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

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King, the director of reproductive bioethics at Harvard Medical School Center for Bioethics and a contributor on the study, believes that when the RVU system was created back in the 1990s, gynecological services were largely ignored, leaving the specialty undervalued from the start. While Medicare and Medicaid Services has undertaken some efforts to make RVUs more equitable across specialties over the years, that undervaluation has persisted. 

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

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

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

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

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

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

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

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

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

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

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

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

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

How low reimbursement rates make women’s lives worse

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

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

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

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

Dr. Louise King

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The glasses stem from the startup’s goal of making hearing care more accessible by addressing the cost, comfort, and stigma associated with traditional hearing aids.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

How the US could fix our preventive visit headaches

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Patients say private health insurers are using AI to deny claims

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

AI is now making decisions for traditional Medicare claims too

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.”

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I don’t know about you, but whenever I go to see my primary care doctor, my mental health isn’t usually at the top of my list of things to talk about. But it should be. In fact, experts say that all of us could benefit from more candid conversations with our doctors about our mental health.

(This story discusses mental health issues and suicide. If you or someone you know is struggling or in crisis, help is available. You are not alone. You can call the national 988 hotline for support.)

For years, the United States has been trying to figure out “parity” for mental health care — to have it treated and paid for like any other medical need, not something that is carved out and separate. A big part of that has been pushing primary care doctors and OB/GYNs to do more screenings, to make your mental state a part of your well-being that you discuss with your doctor the same as your blood pressure or any physical ailment.

But that is easier said than done. A lot of people may not even realize that their depression or anxiety or stress is something they should talk about with their primary care doctor. Others might fear being judged, and for good reason — national policymakers warn there continues to be a stigma toward mental health conditions among doctors.

About one in three Americans say they have never been asked about their mental health by a doctor, which is unsettling considering that the nation has been going through a collective mental health crisis for several years. Men are significantly less likely to be asked about their mental health than women — perhaps a reflection of a culture that expects men to “tough it out” when it comes to their feelings. But those attitudes come with a price: Men are diagnosed with depression at half the rate as women, but die by suicide much more frequently.

Much of the burden for starting these conversations should fall on your doctor to be more curious and accommodating during annual exams. But you don’t have to wait to be asked to bring it up. Regularly talking to your provider about your mental health is the best way to get ahead of any problems and get treated if you need to be. In honor of Suicide Prevention Month, I reached out to a handful of doctors who have studied why it’s sometimes so hard for patients and doctors to talk about depression, anxiety, and stress — and learned some novel strategies for how you can take charge, push through any stigma, and start having more honest talks with your doctor about your state of mind. Here’s what you should know.

Know the relevant symptoms before you talk to your doctor

One of the tricky things about depression or any serious mental health problem is that it isn’t always easy to identify when you’re the one experiencing it. “Patients need to recognize their distress…as potentially emanating from depression,” Dr. Richard Kravitz, a general medicine professor at UC Davis who has studied depression screening in primary care, told me.

There is a checklist of sorts that you can go through on your own to understand whether you’re just having a tough couple of days or there’s something more serious at work, said Dr. Maria Garcia, an internal medicine physician at UC San Francisco. You might be feeling down or unmotivated or have a lack of energy, or be more agitated, angry, or irritable than usual. Sometimes there are less obvious signs, like trouble with money or problems at work. 

“If you’re not getting enjoyment from your normal hobbies or talking to the people that you would normally really enjoy talking to, if you find yourself isolating from people that you normally really enjoy spending time with, I think those are certainly triggers,” she said. Consider the duration of your symptoms, too: “If it’s every day for a couple of weeks, that definitely isn’t normal.”

And oftentimes, depression symptoms can mirror symptoms of other ailments or problems, like a lack of sleep, low appetite, or physical aches and pains. This is one reason why it is so important to talk with your doctor about it, Garcia said. Is that fatigue a result of depression — or is it a problem with your thyroid? Your primary care physician is best positioned to help you figure that out. One of the benefits of a long-term relationship with a physician is that they may be able to help you recognize symptoms of depression even if they aren’t obvious to you.

It’s hard to be that self-aware; I’m certainly not all the time. But the more you pay attention to your mood and how it’s affecting your life, the more you can tell your doctor about what’s really going on. You don’t have to know all the fancy clinical terms, said Paul Duberstein, a clinical psychologist and professor of health behavior, society, and policy at the Rutgers School of Public Health. “The language that people are most comfortable using are words like stress or frustrated or impatient or something like that,” Duberstein told me. “Those are the kinds of things we really do want to incentivize and encourage people to talk to their doctors about.”

How to bring up your mental health with your doctor

Okay, you feel like something might be off and you have a doctor’s appointment coming up. What do you do?

You might not have to do anything. These days, you are likely to be given a depression screening by your physician’s office before you ever arrive (usually as part of your pre-visit paperwork). Garcia said it’s important to be honest and to be thorough when answering those questions, as that will tell your doctor that your mental health should be a focus for your upcoming visit.

But if you aren’t proactively screened for depression and you have some of the symptoms described above or you just have a hunch that something might be wrong, try to alert your doctor in advance that your mental health is something you want to talk about. If that’s not possible, tell your doctor early on in the appointment that your mental state is something you want to discuss. Garcia said that, rightly or wrongly, doctors can sometimes be reluctant to dive deep into a discussion about mental health late into a visit; they only have so much time with individual patients, and they might balk at trying to squeeze in a mental health discussion at the end. The conversation is more likely to be productive if you proactively start it before your physician is sidetracked with your blood sugar. 

During this conversation, you can ask for a depression screening outright. Doctors have become adept at recognizing code words; if you say your mood has been off, they may pick up the signal that you may be experiencing mental health struggles. But there is a good argument for being very direct about how you’re feeling, Kravitz said.

“My advice…is just simply to say to the doctor, ‘I’ve been feeling down’ or ‘I’ve been feeling irritable’ or ‘I’ve been losing sleep’ or ‘Something’s wrong and I don’t know what it is. Do you think it might be depression?’ Just ask,” Kravitz said. If you aren’t sure if it’s a mental or physical issue, tell them that. Activate your doctor’s curiosity, Kravitz told me. Get them invested in figuring out what’s going on with you.

Once the conversation starts, your doctor is likely to ask how long you have been experiencing symptoms and how they are affecting your day-to-day function. When that happens, you should be as thorough and truthful as possible.

“Is it affecting your ability to take care of your family? Is it affecting your ability to go to work, get up in the morning, cook dinner, get out of the house, go grocery shopping?” Garcia said. “Those things are really helpful because then we can tailor the treatments for the amount of functional impairment.”

Talk to your doctor about your sleep, too, Duberstein said. Not only is it an important indicator of your physical health, but it will also tell your doctor something about your mental well-being. And it doesn’t require any special emotional vocabulary: You probably know if you’re sleeping well or not.

“If you think about major depression as a collection of, say, nine symptoms and you ask, ‘Well, what symptoms appear first? Is it the depressed mood? Or the difficulty concentrating?’ The first thing that appears typically is sleep,” Duberstein told me. “Disrupted sleep is something that I think people do feel comfortable talking with their doctor about.”

How to talk to your doctor about a treatment plan

If you have a productive conversation with your doctor and they recognize symptoms of depression, they’ll want to establish a treatment plan. This has historically been another barrier to honest conversations between doctors and patients about mental health: Patients don’t want to be prescribed antidepressants or referred to therapy, so they don’t bring it up.

But ignoring your symptoms is, of course, not the solution. Instead, use your appointment as an opportunity to ask all of your questions to make sure that you are fully comfortable with the doctor’s proposed treatment plan and can get on the road to better mental health.

Many Americans have doubts about antidepressants, which have been egged on by high-profile figures like US Health Secretary Robert F. Kennedy Jr. If you’re hesitant to take meds, you should tell your provider about the things that you’ve heard that give you pause, the negative experiences people have shared, or whatever major questions or concerns you have. They can help you understand the very real trade-offs that come with taking an antidepressant, Kravitz said. Your doctor can also debunk some of the misconceptions that make people hesitant to take these drugs even when they are struggling.

“The duration of therapy sometimes surprises people. But no, it doesn’t mean that you’ll have to be on it forever. No, most people don’t have serious withdrawal symptoms. Those can usually be managed by careful tapering if necessary and so on,” Kravitz said. He said you can ask your doctor outright: “What can I expect to happen over time? How long will I need to be on this?” 

If you’d rather not go on medication immediately, that’s totally valid. Your doctor may instead be able to help you find a therapist with a referral, Duberstein said. Therapists have historically been hard to find in the US — but one positive outcome of the pandemic was the proliferation of online mental health services.

“I think it’s important for the public to know that one of the major barriers to getting into psychotherapy or even seeing a therapist — like getting into your car, driving, finding a bus, finding a subway, whatever — that those barriers are gone,” he told me. “Because you could see a therapist online now in all 50 states.”

The goal is that you leave your doctor’s office feeling heard and feeling on-board with the approach, even if you still have some trepidation (which is very common). And if you don’t feel comfortable talking to your doctor about these issues, that may be a sign you need to find a new provider whom you feel you can trust with those sensitive discussions, Duberstein said.

The point is, your doctor should be your ally in pursuing whatever treatment you need for whatever ails for your mental health. Nobody has to go through it alone.

I haven’t been on a three-way call this emotionally taxing since junior high school. James is explaining the situation — so many dynamics, so much time urgency — to Rachel, and asking if she thinks it would be workable, while I just nervously try to follow the conversation, crossing my fingers and toes. There’s inevitably going to be heartbreak, but is it possible there could also be a silver lining?

So what is this all about? Well, I’m trying to figure out how to donate my 78-year-old dad’s brain. He has advanced dementia and is living in a memory care community. James Watkins is the research and study coordinator of the UCLA brain donation program. Rachel is someone who works at a crematorium, which, as it turns out, cannot make it work. 

Certainly, the demand is there for my dad’s brain. The World Health Organization describes dementia as “one of the greatest health challenges of our generation” and reports that 78 million people will have dementia by the close of this decade (a 188 percent increase since 2000), for an annual global cost of over $2.8 trillion. And yet, research into what causes it and how to cure it remains stymied by a lack of funding, high-quality data, and — this is where me and my family come in — poor coordination with people suffering from dementia and their caregivers.

My dad hasn’t been a part of any research studies, which I have come to understand is how most people who donate their brains get introduced to the process. Instead, I’m free soloing and it’s not going well. I do some research, make some calls, then lose track of it for months on end. I’ve got two kids — 10 and 12 years old — and there are constantly changing camp pick-up and drop-off times to coordinate with my husband, my mom’s post-op knee replacement appointments to make, and lest you think I’m Mother Teresa, a lot of television to binge and dive-bar beer to drink. Meanwhile my dad is getting worse and worse. 

Will I get the administration on this donation done before my dad dies? They don’t call dementia “the long goodbye” for nothin’, but still, the end is near — and a mind is a terrible thing to waste. 

How does one go about donating a brain?

First things first: Where does one donate a brain? 

Not at the DMV, where you are likely familiar with being asked if you would like to be an organ donor. Brains, unlike livers and lungs and the like, can’t be transplanted, so they are handled differently. 

Brains are donated to brain banks dotted all over the country, which have historically been territorial about their recruitment strategies and cache of post-mortem brain tissue. That began to change in 2013 when the National Institutes of Health created the NeuroBioBank, a consortium of sorts between brain banks that wanted to collaborate, rather than compete. The NeuroBioBank now includes Harvard, Mount Sinai in New York, the University of Maryland, the University of Miami in Florida, and UCLA in Southern California, and together, they share the tissue of 18,000 brains.

The NeuroBioBank has partnered with the Brain Donor Project to help potential donors register. Founded in 2016 by Tish Hevel, daughter of a brain donor, the Brain Donor Project has an online form where people like me can register interest and then they do their best to match you with a geographically proximate brain bank that can coordinate what they call “retrieval” (i.e., cutting your person’s brain out before you proceed with burial or cremation rituals). Over the last decade, they’ve pre-registered 30,000 people with all kinds of brains to help advance cutting-edge research. 

That’s how I ended up on that three-way call. We live in the Bay Area. Last fall, after a bunch of internet research, emails, and phone calls, I learned that neither UCSF nor Stanford would take my dad’s brain, because he hasn’t been a part of any of their studies. I lost steam and a few months went by.

New year, new me. Get your shit together, Courtney. In January of this year, I landed on the Brain Donor Project website and filled out their standard form. Within hours, I was chatting with Watkins — who has a bit of a Southern lilt to his voice and a can-do attitude. 

When I told him that my dad wished to be cremated, he explained that I would need to call them as soon as he died at his facility, get him transported to the crematorium, and then the crematorium would need to hold on to him until a “brain retrieval specialist” could come and get the brain. Some crematoriums weren’t willing to do that, so we would need to call them to find one that would, and hopefully wouldn’t charge anyone extra money for it. 

It is in this way that I have so often found myself taking a sharp turn into logistics and finances while doing what is actually pretty existential elder care these last few years. One minute, I’m wondering about my dad’s quality of life (Does he know me? Is he content? What still gives him pleasure?) and the next, I’m discussing whether he requires one or two people to transfer out of his wheelchair (which affects the monthly charges at his memory care community). One minute, I’m hoping my dad’s imminent death can benefit someone else’s expanded knowledge, and then I’m side-barring with Watkins about whether this crematorium is trying to rip me off. It’s jarring, to say the least.   

Watkins and I call seven crematoriums together. All of them claim to not have the right facilities to accommodate a brain retrieval. It’s feeling grim, but Watkins stays positive. “I won’t be doing my job until we’ve done absolutely everything we can think of to try to make this happen,” he reassures me. 

Hevel says that people like Watkins make all the difference: “It takes a special person because you are helping someone during what may be one of their darkest times. And you’re dealing with logistics…it takes sensitivity and smarts.”

The other “middle man,” as it were, is what they call a “brain retrieval specialist,” who must get to the body within 24 hours of death in order to extract the brain and ship it off to the brain bank. Believe it or not, Hevel reports that this role is often performed by freelancers these days. (Studs Terkel might come back from the dead for that interview!) 

But even if we find one, everything needs to align just right, with multiple specialists and institutions all working together, for us to have any chance to pull this off. 

What are the brains for? 

Looking at real brain tissue under a microscope is a vastly different experience for scientists than using imaging (MRI and PET scans) or blood tests. Dr. Melissa Murray, a professor of neuroscience at Mayo Clinic, compares it to “almost like looking into outer space.” 

The stars, in this case, are our cells, and being able to look so closely at them creates an opportunity to identify them more accurately and understand the most vulnerable among them — which, down the line, can lead to gene or cell-based targeting. “We are getting closer and closer to understanding the genetic underpinnings of everything,” Hevel tells me. “As weird as this sounds, it’s kind of thrilling.” 

It doesn’t sound weird to me. Part of why I want to donate my own dad’s brain is so I can get an accurate diagnosis of what kind of dementia he actually has. My dad’s gerontologist has said he likely has frontotemporal dementia with Lewy body dimensions, but this was her best guess based on examining him once he was pretty far along in his disease, and with no MRI (my mom and dad didn’t opt to get one). 

For many neurological diseases, the only way to know with certainty what someone had is to examine their brain after death. One of the benefits of donating a brain is that you get a neuropathology report that does just that; many people find out that their loved one had diseases that weren’t even on their radar. 

That’s what happened to Cathy Butler, whose husband died in 2024 of what she thought at the time was frontotemporal dementia (FTD). What she learned after donating his brain and getting the pathology report was that “if he hadn’t succumbed to FTD, there were plenty of other pathologies warming up in the bullpen.” 

His brain showed evidence of arteriosclerosis, Lewy body dementia, Alzheimer’s, Parkinson’s, and FTD. All these years later — how does she feel about the choice? 

“With benefit of hindsight, I’m glad I did this,” she said. “It’s the only meaningful opportunity we get to smack back at that miserable bitch FTD.”

Other top reasons that people register with the Brain Donor Project are serious mental illness, Parkinson’s, and traumatic brain injuries caused by — and this made me so sad to learn — intimate partner violence. But scientists desperately need healthy brain donations as well; after all, every experiment needs controls. It’s thrilling that the Brain Donor Project has gotten 30,000 people in the system, but also so inadequate when you consider the scale of these illnesses and their impact on all of us. 

The barriers to brain donation

So why don’t more people do it?  

Well, there are surely some who are religiously opposed to it or feel strongly about leaving their loved ones’ bodies intact. Others have very obvious reasons to distrust the medical and scientific communities (see: Henrietta Lacks). 

But I think more people don’t do it for a very obvious reason that has nothing to do with these oft-cited sacred values: sheer exhaustion. Those most likely to be dealing with the administration of getting a brain donated are burned out and overwhelmed. 

I asked my friend Tricia Boyle, whose mom died of dementia, if she considered donating her brain and she said: “I’m actually frustrated that no one in my family thought to talk about this, but there was so much I was dealing with. I’m giving myself grace for not being on top of it, but I am super sad, as my family likely would have easily said yes to it had someone asked!”

No one did. Not Tricia’s mom’s doctors, social workers, hospice workers, anyone at her assisted living community, etc. And this is true in the vast majority of cases. There just isn’t a centralized system or culture of making sure the people most in touch with those who can donate know it’s an option. 

And by the way, mentioning brain donation in your medical directives or your will isn’t the way to go either. Often those documents are not consulted until it’s too late and a brain bank needs to retrieve a brain immediately. 

Hevel is trying to raise awareness through a variety of creative strategies, including doing partnerships with “death influencers” like @HospiceNurseJulie, who wrote the book Nothing to Fear: Demystifying Death to Live More Fully and has almost 2 million followers on TikTok.

But even if Hevel succeeds in creating the will, there still isn’t much of a way. Take my situation as a case in point. Who wants my dad’s brain to be donated? Me and my family, my friend Watkins and the UCLA brain bank, neuroscientists all over the country, and the leadership at my dad’s memory care community. Who benefits from it happening? The whole society, which knows far too little about one of the most common, demoralizing, and expensive diseases. 

Who can make it happen? Despite the heroic efforts of the Brain Donor Project, the infrastructure needed to coordinate all these moving parts just isn’t there to meet the scale of the challenge. Someone needs to be the brains of the operation, so to speak. Without, that the individual family is responsible for duct taping a system together while we’re facing the imminent death of someone we love. 

My family brain plan

After six months of research, awkward phone calls, and holding my dad’s hand every week, we had a decent plan. When he died, I was to call Sunset View Cemetery, who would transport his body on ice to their facility. I would also call Watkins, who would rustle up a freelance brain retrieval specialist who could get my dad’s brain out and get it on a plane to LA as fast as possible. The cemetery would charge us a $500 fee for the room where the extraction would take place (the brain bank would pay for $200 of that and we’d have to spring for the other $300). For all this effort we’d get a “football-size” amount of ashes and a pathology report potentially unlocking important genetic information, not to mention the cathartic knowledge that our grand loss had furthered science just a little bit. 

Except, like so many best laid plans, it didn’t go that way.

At about 4:45 pm on Thursday, August 13, I noticed my dad’s breathing had significantly changed. I played “Blackbird” by The Beatles off my iPhone for him and then whispered in his ear, “Goodbye dad. I love you forever and ever.” 

He took one last gulping breath and was gone. 

After crying my eyes out, I called Watkins. He said, “We’re not going to be able to do it.” 

Sunset View Cemetery only allows for brain extractions from 9 to 5. Death, as it turns out, doesn’t abide by standard business hours. There was no way to get it to LA within the 16-hour window.  

When I spoke to Hevel when I was first trying to figure all this out, she assured me: “It’s a lot of work, but you will find some comfort in knowing that it wasn’t all for naught. It sounds so corny. I told myself, ‘I’m not going to say that to people when it happens to them,’ but everyone who donates actually says that to us. It’s just true. It restores my faith in humanity on the daily.”

If only it didn’t require so much luck and administrative stamina to do the altruistic thing. 

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The trial of Lindsay Clancy, the Massachusetts mother accused of killing her three children, is laden with painful what-ifs: What if she had more support? What if she had more people to confide in? Could all of this suffering have been avoided?

Those are urgent questions, whatever the outcome of this particular case, because millions of women experience postpartum depression. Severe postpartum psychosis may be extremely rare, but every year at least one in eight women who give birth in the US experience some depression symptoms — and that is likely an undercount. 

A jury will ultimately decide whether to convict her for her children’s deaths; by Tuesday morning, the jurors were still unable to reach a unanimous verdict but the judge in the case ordered them to keep deliberating. Their verdict will rest in part on whether they believe that Clancy was in her right mind when she killed her children — the defense does not contest the underlying facts — or whether, as her attorneys are contending, she was experiencing severe psychosis that should render her not culpable for her actions.

Clancy’s case has become a national flashpoint for maternal mental health — a gripping courtroom drama that also exposes how new moms’ mental well-being has been neglected by the health system and researchers for years. 

It’s easy to feel hopeless in the face of such a tragedy, and much of the coverage has — rightly — focused on the gaps it exposed in the system for women getting the care they need. But even now, there’s good reason to feel optimistic.

Doctors and health workers across the United States are experimenting with strategies that can improve postpartum mental healthcare. They have found a secret ingredient that can help new mothers when they are struggling: other moms who have been through the same thing before.

“You just had a baby. You’re responsible for a new human life. And it’s really hard to juggle everything in your life,” Dr. Jessica Gaulton, a pediatrician who founded FamilyWell Health, a postpartum mental health support service that incorporates peer coaches into its program, told me. “Oftentimes what women need is just somebody to be there and have their back.”

Postpartum depression is a health system problem, a public health problem — but it’s also a deeply personal one. Helping people make connections that make them not feel so alone is one way we can start to improve the postpartum outlook for American mothers.

And a wave of local programs — and research showing that they really work — is offering some promising new ideas about how to deliver more compassionate and effective care for postpartum depression.

How to help new moms with postpartum depression right now

During the Clancy trial, the Maternal Mental Health Alliance has listed five steps that could be taken to improve postpartum care. One of their top priorities is better care coordination among the different healthcare providers who see a new mom after she’s given birth. 

The so-called collaborative care model has been building momentum for years now, since it was first introduced for postpartum care for Medicaid patients in Seattle’s King County more than a decade ago. The model has since spread to other places, but the basic tenet is this: It takes a whole team to care for a new mother and watch out for her mental health, and they need a point person to help manage their care.

In Los Angeles, for example, where a group of nonprofits is wrapping up a five-year pilot program based on the collaborative care model, new mothers are assigned to a behavioral-health care manager. The manager performs assessments and brief interventions, works with a psychiatric consultant to continually assess how the patient is doing, and cooperates with the OB-GYN or primary care doctor to manage the patient’s treatment. Rather than waiting for a psychiatrist to have an open appointment when she’s struggling right now, the new mom’s preexisting healthcare providers can step in with support from a mental health professional to manage postpartum depression symptoms. 

In evaluations, the model has consistently outperformed other standards of care in reducing symptoms. But while we have started to see collaborative care spread to other parts of the US, its progress has been halting for various logistical and financial reasons. The Maternal Mental Health Alliance is urging health systems and health insurers to invest in more care coordination programs.

And now some providers are building on the collaborative care model with an important new element: peer support. In Washington, the MomCare program is now experimenting with peer “navigators” to help their patients figure out the appropriate place to get the care they need. In Massachusetts, Gaulton’s FamilyWell Health, which works with OB-GYN practices to provide mental health services, launched a pilot program that added certified behavioral health coaches. 

These people were recruited because they had their own life experience of giving birth and having postpartum depression symptoms; the coaches were frequently doulas, nurses, and midwives. Patients would talk once or twice a week with their coach to set goals and receive positive feedback, while the coaches had a protocol to follow if it seemed their patient required more serious support. A study published in April found that this new coach-driven approach was successfully reducing depression and anxiety symptoms. Patients experience remission of their depression symptoms within an average of nine sessions with a peer coach, versus eight sessions with a licensed therapist. In other words, the mothers assigned to a peer got better almost as quickly as those who saw a professional.

Gaulton said she introduced the peer-coach concept to FamilyWell Health because of her own experiences as a new mom. She struggled to recognize her own depression symptoms. When she did, she leaned on a friend and fellow neonatologist at the hospital where she worked for help. Then during Covid, she saw moms with otherwise healthy babies struggling during that world-altering public health emergency. 

“What I realized was that we were underutilizing coaches,” Gaulton said. “For decades, we’ve been using peer groups, peer coaching in this field to support, but it has never been formalized. There was no formal training.”

So she decided to found a new company dedicated to supporting new mothers’ mental health — and she brought those lessons with her.

This idea — training experienced moms to help new moms — has been gaining traction across the country. In Colorado, researchers from the University of Colorado launched a program called Alma, which connects new moms with another woman who has been through the same experiences and received specialized training to provide emotional support. The program’s mentors receive 80 hours of training and then meet up to 10 times with a new mother, either in person or virtually, to talk about what makes them feel good and how to incorporate it into their day, following long-held protocols for depression treatment called “behavior activation.” 

“There is a special kind of trust that can develop when someone feels that the person sitting across from them understands something about their life and their community — someone who has walked the same path,” Sona Dimidjian, a University of Colorado clinical psychologist who helped found the program, said in an email. “A peer can often say, in effect, ‘I have been there too, and I know how hard it can be.’ That shared experience can also help reduce the stigma and shame that many women feel about depression during pregnancy or the postpartum period.”

The concept was based on research from India that found “lay counselors” were effective at reducing mental health symptoms. With the US in a permanent mental health provider shortage, being able to tap into the general population to support new moms was an appealing idea. And evaluations of the program found that it significantly reduced symptoms of depression, anxiety and stress among the Spanish-speaking Latina women who were its initial focus.

The biggest endorsement of a peer-support approach like Alma or the peer coaches in FamilyWell Health’s coordinated care program is its target audience. A nationwide survey of new and expecting Latina mothers in the US found that the vast majority thought talking to a peer would make them feel less isolated and more understood compared to a mental health professional. And providers and policymakers around the United States have started taking notice: English and Spanish-language versions of the Alma program are now being implemented in California and New Jersey. 

There is no panacea for postpartum depression. As Amritha Bhat, who has worked on the MomCare program at the University of Washington, explained it to me: “Having a multipronged approach is a good way to ensure that treatment reaches those most in need.”

There are big-picture institutional-level changes that need to be made. The Diagnostic and Statistical Manual of Mental Disorders, the bible of American psychiatry, currently does not categorize postpartum depression as its own distinct diagnosis. As NPR reported, primary care doctors and pediatricians often do not receive sufficient training to help them recognize the signs of postpartum depression and provide patients with the support they need. There is never enough funding for research or for programs for maternal mental health: The Maternal Mental Health Alliance has been pushing Congress to add millions of dollars in funding for the federal programs that focus on new moms. Peer coaching has not traditionally been covered by health insurance; figuring out how to pay for programs like this is another system-level challenge. 

But connecting moms to other moms can help the people who need support right now. Sometimes that can happen through organized programs like Alma or FamilyWell; the experts working on those initiatives want to make them an integrated part of post-delivery medical care. But that support might also be found informally in a new parent’s everyday life. There are a lot of social media and in-person groups for new moms to get together, sometimes at a local library or other community organization. Gaulton leaned on a friend when she was struggling after her own pregnancy.

As Gaulton emphasized to me, most cases of postpartum depression never escalate into a tragedy. This is a scary condition — but it’s treatable.

“I just want laypeople to know that the typical case is someone like me who had some symptoms of depression, anxiety,” she said. “I found help. I got better.”