“Victoria Gray sat in a Nashville, Tenn., hospital in 2019 while doctors infused her own genetically engineered cells back into her veins. Born with sickle-cell disease, Ms. Gray had spent much of her life in emergency rooms riding out bouts of pain. The infusion was a watershed. Ms. Gray, then 34, was the first person to receive treatment based on the Crispr method of editing genes. Home-bound before the therapy, she emerged from it free of the pain crises.
I am a physician. For most of my career, "cured" wasn't a word we could use for sickle-cell disease. Now we can. We also can say it of cystic fibrosis, a once-fatal illness that a pill called Trikafta has made manageable for most patients. We can nearly say it of obesity and diabetes thanks to GLP-1 drugs. The list goes on in our golden age of medicine.
But gold is expensive.
The therapy that helped Ms. Gray, now sold as Casgevy, costs $2.2 million.
A competing therapy, Lyfgenia, lists at $3.1 million.
Some 16,000 Americans with sickle-cell disease are sick enough to qualify for these treatments. Six in 10 are on Medicaid, which means a cure for a disease that overwhelmingly affects black Americans is, in practice, a state budget line before it is a clinical decision. A company that spends a decade and a fortune inventing a miracle prices it high and counts on a determined few to pay, often leaving everyone else out.
The system responds rationally by creating safeguards to manage access and control costs. If every plan paid $2 million for everyone who qualified for every new therapy, annual premiums would climb by thousands for families nationwide. We have a series of checks to prevent that: prior authorization, in which doctors must prove patients need the drug; "coverage criteria" that restrict access to certain circumstances; and "step therapy," in which patients must try older, cheaper treatments first. Increasingly, artificial intelligence reviews clinical information and claims so these policies are applied accurately and consistently.
Those rules for insurers, patients, doctors and manufacturers prevent ruinous costs. But what if they fail to keep pace with medical breakthroughs? I work for a company that supports better healthcare payment decisions and believes technology can guide patients to cures. Sometimes the rules themselves need to evolve.
Take hepatitis C, which kills more people in the U.S. than HIV. A decade ago hepatitis C became one of the first chronic infections a pill could cure in a few weeks. Then, because the pills cost tens of thousands of dollars and could bankrupt budgets, state after state decided you couldn't have the cure until your liver had scarred badly enough to prove you needed it. The rules required people to get sicker to qualify to get well. Since then, competing treatments emerged and prices are lower, but many patients still lack access.
The good news is that we figured out how to edit the code of life with Crispr and tamed sickle-cell disease and hepatitis C. We did the scientific heavy lifting. Now we must make sure cures reach patients. In some instances, we've already come up with ways.
They don't rely on charity alone. Rather, they align incentives so the moral decision is also the economically viable one. In 1987, Merck's life-changing pill for river blindness had no market. Its patients in Africa hadn't a spare dollar, so giving it away cost almost nothing and bought something no marketing budget could: nearly 40 years of goodwill. Regeneron's gene therapy to cure a rare form of deafness treats so few children that the company decided to make the treatment free. Regeneron folded the gesture into a broader bargain this year that spared the company steep tariffs and eased terms on its other drugs. Generosity and shrewdness, in these cases, reinforced each other.
Operation Warp Speed solved a different incentive problem. No company wanted to build a factory for a vaccine that might fail, so the government bought the doses in advance, before anyone knew whether they worked. Gilead had the reverse problem with its twice-a-year HIV shot, which it would never sell at American prices in the world's poorest countries. So it licensed cheap generics to 120 such nations, giving up revenue it would never have seen while protecting the $28,000 price it charges here.
For some preventive drugs, there's an even simpler idea. For two decades, the only shield against respiratory syncytial virus, which fills pediatric wards each winter, was a drug called Synagis. It was priced at thousands of dollars for a season of monthly shots and rationed, sensibly, to the highest-risk babies. Synagis's successor, Beyfortus, made the opposite bet. Its makers priced a season's protection at a fraction of the old drug's cost, delivered it in a single shot, and chased a recommendation for every newborn in America rather than a lucrative few. Studies show RSV hospitalizations falling by roughly 80% among infants who get it. In a boardroom, executives chose the larger, thinner-margin market, and hundreds of thousands of babies breathe easier for it. Good medicine and good business turned out to be the same decision.
Still, it's hard to change old habits. As a senior official at the Department of Health and Human Services in the Biden administration, I argued that we should guarantee a market for a sickle-cell cure the way we had for vaccines, a promise that the cure was wanted and worth building. I wasn't successful and the proposal didn't advance. Shortly after, the company that brought one of the first sickle-cell cures, Lyfgenia, to patients, ran out of money and was sold. Yet the government has also demonstrated ingenuity. Last year's most-favored-nation deals on GLP-1 drugs helped reset prices no single insurer could move alone, and now seniors can get them at low cost for weight loss.
This isn't a fight about single payer, or the Affordable Care Act, or whatever is meant to replace it. We should take the successful arrangements we already have and make more of them.
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Dr. Sanghavi, a physician, is chief medical officer of Machinify.” [1]
1. Lower Drug Prices Without Killing Innovation. Sanghavi, Darshak. Wall Street Journal, Eastern edition; New York, N.Y.. 11 Aug 2026: A15.