The drug is insulin. Discovered in 1921 by Dr. Frederick Banting and Charles Best at the University of Toronto, insulin remains the only life-sustaining treatment for Type 1 diabetes more than a century later. No pill, no gene therapy, no medical breakthrough of the last 104 years has managed to replace it. For the roughly 8.75 million people worldwide living with Type 1 diabetes, insulin is not optional — it is the difference between life and death, administered daily, without exception, for the rest of their lives. Before insulin, a diabetes diagnosis was a death sentence measured in weeks or months.
Leonard Thompson, a 14-year-old boy wasting away in a Toronto hospital, became the first human to receive an insulin injection on January 11, 1922. He survived. The discovery was so immediately and obviously important that Banting and John Macleod received the Nobel Prize in Physiology or Medicine just one year later, in 1923. What makes insulin’s story remarkable — and in many ways troubling — is not just its medical significance but everything that happened afterward: the price gouging, the access failures, and the fact that in 2026, half the people on earth who need this century-old drug still cannot reliably get it. This article covers how insulin went from a $1 patent to a drug with a 1,200% price increase, what recent legislation and new biosimilars mean for patients and families in 2026, and where the science stands on alternatives that might one day — though not yet — make insulin injections a thing of the past. For those caring for loved ones with both diabetes and cognitive decline, understanding this landscape is not academic. It is urgent.
Table of Contents
- Why Has No Drug Replaced Insulin After More Than 100 Years?
- The Cost Crisis That Turned a $1 Patent Into a 1,200% Price Increase
- What Changed in 2026 — New Price Caps, Biosimilars, and State-Produced Insulin
- Managing Insulin When Cognitive Decline Complicates Everything
- Emerging Alternatives — Promise and Hard Limitations
- What the Insulin Story Reveals About Drug Access in Aging
- Where Insulin Goes From Here
- Conclusion
- Frequently Asked Questions
Why Has No Drug Replaced Insulin After More Than 100 Years?
The short answer is biology. Type 1 diabetes is an autoimmune condition in which the body’s immune system destroys the beta cells in the pancreas that produce insulin. Without those cells, the body cannot regulate blood sugar at all. Insulin is not treating a symptom or managing a risk factor — it is replacing a hormone the body can no longer make. That is a fundamentally different challenge than, say, lowering cholesterol or reducing inflammation, where multiple biochemical pathways can be targeted with different drugs. There is no biochemical workaround for the absence of insulin. You either supply it from outside the body, or the body fails. This is why, despite over a century of pharmaceutical advancement, there is no oral substitute or cure that eliminates the need for insulin in Type 1 diabetes patients.
Researchers have tried. Oral insulin formulations have been explored for decades, but insulin is a protein — stomach acid and digestive enzymes break it down before it can reach the bloodstream in meaningful amounts. Inhaled insulin exists (Afrezza), but it supplements rather than replaces injected insulin for most Type 1 patients. The fundamental problem remains: delivering a precise, reliable dose of a fragile protein hormone multiple times per day is an engineering challenge that, so far, only injections and insulin pumps have solved at scale. Compare this to other century-old drugs. Aspirin, discovered in 1897, has been joined by ibuprofen, naproxen, and dozens of other anti-inflammatory options. Penicillin, first used clinically in 1942, now sits alongside hundreds of antibiotics. Insulin stands alone. Not because the pharmaceutical industry has ignored diabetes — it is one of the most heavily researched diseases in history — but because the biological requirement is so specific that nothing else can do what insulin does.
The Cost Crisis That Turned a $1 Patent Into a 1,200% Price Increase
When Banting and Best understood what they had discovered, they made a deliberate ethical choice. They sold the insulin patent to the University of Toronto for $1 each. Banting reportedly said it would be unconscionable to profit from a discovery that could save lives. The intent was clear: insulin should be universally accessible. For decades, it more or less was. Then the modern pharmaceutical industry got involved. Between 1999 and 2019, insulin prices in the United States rose over 1,200%.
The drug itself was not meaningfully different. What changed was a practice called “evergreening” — manufacturers made incremental modifications to insulin formulations, delivery devices, or manufacturing processes, then filed new patents on those modifications. This strategy effectively prevented affordable generic versions from reaching the market for nearly 100 years. Three companies — Eli Lilly, Novo Nordisk, and Sanofi — controlled the vast majority of the global insulin market, and list prices climbed in near-lockstep. Patients who could not afford their insulin rationed doses, a practice that has been directly linked to hospitalizations and deaths. However, this picture has begun to shift. If you or a family member was paying hundreds of dollars per month for insulin as recently as 2022, the landscape in 2026 looks meaningfully different — though not uniformly so, and not for everyone. The improvements are real but uneven, and anyone managing diabetes alongside dementia or other cognitive conditions should understand exactly what has changed and what has not.
What Changed in 2026 — New Price Caps, Biosimilars, and State-Produced Insulin
The most significant policy change came through the Inflation Reduction Act, which capped insulin costs at $35 per month for Medicare beneficiaries starting in 2023. For the millions of older Americans on Medicare — including many managing both diabetes and dementia — this was a concrete, immediate reduction in out-of-pocket costs. But the cap applied only to Medicare, leaving many privately insured and uninsured patients still exposed to high prices. That gap began to close in January 2026 with two developments. First, Civica Rx — a nonprofit pharmaceutical company — launched its biosimilar insulin glargine pens at a wholesale price of $45 for five pens, with a consumer-facing cap of $55 per box. Critically, this price is available to anyone with a prescription, regardless of insurance status.
Second, California became the first state in the country to produce and sell its own state-branded insulin through the CalRx program, also at a suggested retail price of no more than $55 for a five-pack. Meanwhile, the three major manufacturers — Eli Lilly, Novo Nordisk, and Sanofi — have cut their list prices by 70 to 78% in recent years, responding to political pressure and competition. These are genuine improvements, but they come with caveats. Biosimilar availability varies by pharmacy and region. The $35 Medicare cap does not apply to insulin pumps or continuous glucose monitors, which many Type 1 patients also need. And for the estimated one in two insulin-dependent patients globally who cannot access or afford insulin — a figure from the World Health Organization — American price reforms do not help at all. The access crisis is a global one, and it remains largely unsolved.
Managing Insulin When Cognitive Decline Complicates Everything
For families navigating both diabetes and dementia, insulin is not just a medical necessity — it is a daily logistical challenge that becomes more dangerous as cognition declines. Insulin dosing requires calculation, timing, and physical dexterity. A person with moderate Alzheimer’s disease may forget whether they have already taken their dose, inject the wrong amount, or fail to eat after injecting — any of which can cause life-threatening hypoglycemia. The tradeoffs here are stark. Tighter blood sugar control reduces long-term complications but increases the risk of dangerous lows, which are harder to detect and respond to when cognitive function is impaired. Many geriatricians and endocrinologists recommend relaxing blood sugar targets for patients with dementia — aiming for an A1C of 8% or even 8.5% rather than the standard 7% — specifically to reduce hypoglycemia risk.
This is a deliberate compromise: accepting somewhat higher blood sugar in exchange for fewer acute crises. For caregivers, the practical priority shifts from optimization to safety. Continuous glucose monitors can help by alerting caregivers to dangerous blood sugar swings, and long-acting insulin formulations reduce the number of daily injections and decision points. But these tools add cost and complexity. The $35 Medicare cap on insulin is helpful, but it does not cover the monitoring technology that makes insulin safer for cognitively impaired patients. Families often face the impossible math of choosing which diabetes supplies to prioritize.
Emerging Alternatives — Promise and Hard Limitations
Researchers are pursuing several approaches that could, in theory, eventually free Type 1 diabetes patients from daily insulin injections. The most advanced is stem cell therapy. A clinical trial using zimislecel — stem cell-derived insulin-producing islet cells — found that 10 of 12 participants achieved insulin independence at one year. Those results, published in the New England Journal of Medicine, are genuinely remarkable. But every participant required ongoing immunosuppressive therapy to prevent their body from rejecting the transplanted cells, which introduces its own serious risks including increased susceptibility to infections and certain cancers. Gene therapy represents another frontier. Kriya Therapeutics is developing KRIYA-839, which uses a viral vector to deliver insulin-producing genes into muscle cells, essentially reprogramming the body to make its own insulin from a non-pancreatic source. Human trials are planned but have not yet produced clinical results.
Separately, Sana Biotechnology is engineering gene-edited islet cells designed to evade the immune system without requiring immunosuppressants. In their first test patient, these cells were still producing insulin after 12 weeks — an encouraging but very early data point. In March 2026, ScienceDaily reported on what researchers described as a “bold new plan” to cure Type 1 diabetes, though the article acknowledged that a full cure remains elusive. The critical limitation across all of these approaches is time. Even the most optimistic timelines place a widely available, practical cure years away. Stem cell therapies require specialized medical infrastructure. Gene therapies are in early-stage trials. For anyone managing diabetes today — especially alongside cognitive decline — insulin remains the only option. These alternatives are worth following, but they are not worth counting on in the near term.
What the Insulin Story Reveals About Drug Access in Aging
Insulin’s 100-year journey from a $1 patent to a drug that bankrupt families — and then partially back again through legislation and biosimilars — is a case study in how drug pricing affects older adults disproportionately. People over 65 are more likely to have diabetes, more likely to be on fixed incomes, and more likely to face complications from cost-driven rationing. The intersection with dementia makes this worse: a patient who cannot advocate for themselves depends entirely on caregivers to navigate insurance formularies, pharmacy availability, and assistance programs.
The lesson for families is both practical and political. On the practical side, know that the $35 Medicare cap exists, that Civica Rx biosimilars are available without insurance requirements, and that California’s CalRx program may signal a model other states follow. On the political side, insulin’s history demonstrates that drug pricing is not a force of nature — it is a set of choices made by companies, regulators, and legislators, and those choices can be changed.
Where Insulin Goes From Here
The next decade will likely bring the first real alternatives to insulin for some Type 1 diabetes patients, but “some” is the operative word. Stem cell and gene therapies will almost certainly reach the market in limited forms — expensive, available at specialized centers, and initially restricted to patients who meet narrow eligibility criteria. For the vast majority of insulin-dependent people worldwide, the drug discovered in a Toronto laboratory in 1921 will remain their daily reality.
What is more likely to change in the near term is access. The combination of biosimilar competition, state manufacturing initiatives like CalRx, and federal price caps is creating downward pressure on insulin costs that did not exist five years ago. If these trends hold, the most shameful chapter of insulin’s history — the one where people died because they could not afford a century-old drug — may finally be closing. That is not a cure, but for millions of families managing diabetes alongside aging, cognitive decline, and limited resources, it is not nothing.
Conclusion
Insulin is the rare drug that is both a triumph and an indictment of modern medicine. Its discovery in 1921 transformed diabetes from a rapid death sentence into a manageable chronic condition. More than a century later, no alternative has matched it — not because of a lack of effort, but because replacing a fundamental hormone is one of the hardest problems in biology.
The emerging science around stem cells, gene therapy, and engineered islet cells is genuinely promising, but none of it is ready to replace the vial and syringe today. For caregivers and families managing diabetes alongside dementia or other cognitive conditions, the immediate priorities are concrete: take advantage of the $35 Medicare cap, explore biosimilar options like Civica Rx, check whether state programs like CalRx are available in your area, and work with your medical team to set blood sugar targets that prioritize safety over perfection. Insulin may be imperfect, expensive, and burdensome — but 104 years after Leonard Thompson received that first injection in Toronto, it is still the thing keeping people alive.
Frequently Asked Questions
Is there a pill that can replace insulin for Type 1 diabetes?
No. As of 2026, no oral medication can replace insulin for Type 1 diabetes. Insulin is a protein that breaks down in the digestive system, and no oral formulation has successfully delivered it to the bloodstream in reliable therapeutic doses. Oral medications like metformin are used for Type 2 diabetes, which is a different condition.
How much does insulin cost now with the Medicare cap?
Medicare beneficiaries pay no more than $35 per month for covered insulin products, thanks to the Inflation Reduction Act. For those without Medicare, Civica Rx offers biosimilar insulin glargine pens at $55 per box regardless of insurance status, and California’s CalRx program offers state-produced insulin at no more than $55 for a five-pack.
Are stem cell cures for diabetes available yet?
Not as a standard treatment. A clinical trial of zimislecel showed that 10 of 12 participants achieved insulin independence at one year, but all required immunosuppressive drugs. This therapy is still in clinical trials and is not widely available. Other approaches, including gene therapy and engineered islet cells, are even earlier in development.
Why did insulin prices increase so much if it was discovered over 100 years ago?
Primarily due to a practice called “evergreening,” in which manufacturers made incremental modifications to insulin products to extend patent protections and block generic competition. Three companies controlled most of the market, and prices rose over 1,200% between 1999 and 2019. Recent legislation, biosimilar competition, and public pressure have begun to reverse this trend.
Is it safe to relax blood sugar targets for someone with dementia?
Many geriatricians recommend higher A1C targets — around 8% to 8.5% rather than the standard 7% — for patients with dementia, specifically to reduce the risk of hypoglycemia. Low blood sugar episodes are particularly dangerous for cognitively impaired patients who may not recognize symptoms or respond appropriately. This decision should always be made in consultation with the patient’s medical team.
