Crowded Out: The True Costs of Crowdfunding Healthcare by Nora Kenworthy (MIT Press: 2024)
One chilly winter day, I (the author of this review) was standing in line at my university’s coffee shop for a hot drink when I saw a poster printed out amongst the ads for ongoing campus activities of a student asking for donations on GoFundMe to support medical expenses. “Please donate to support my mom’s surgery,” the poster read. Below these letters, a few pictures of cheerful people smiling and happy: healthy, white, likely middle- to upper-class, reminiscent of the “blond-haired, blue-eyed girl with rare cancer” (page 3) Kenworthy describes in the introduction of her riveting new book, Crowded Out. Below the photos was a large QR code with the words “Scan me!!,” which linked to the GoFundMe page.
In this moment, with all the subconscious bias that I’m ashamed to admit I still carry, I had so many of the thoughts that plagued the stories in Crowded Out.
“How could she post that publicly?”
“Isn’t she ashamed?”’
“How embarrassing to have to air your family’s dirty laundry like that.”
“Ugh, insurance is the worst.”
“Why does our [the United States] health system suck so much?”
In that moment, I realized that the fruits of the late capital neoliberal individual complex Kenworthy describes in what I consider to be tragically accurate detail is also, despite my attempts to root it out, embedded in my own subconscious.
Nora Kenworthy’s illuminating book shines light on the moral, social, and financial implications of crowdfunding for healthcare, particularly in the United States. The significance of crowdfunding hardly seems surprising if you consider it alongside an understanding of the United States’ healthcare system. According to the Commonwealth Fund, the U.S. ranks last in terms of overall performance compared to many of its high-income country counterparts (Blumenthal et al. 2024). While the U.S. outpaces all other countries in terms of healthcare spending, access and outcomes are nearly always significantly lower. The system is fragmented, with a complicated web of payers and providers, a high level of private insurance, and higher costs than any other country (Papanicolas et al. 2018). With folks (and particularly lower-income folks) maintaining a consistently high financial burden from healthcare in the United States (Shashikumar et al. 2024), alternative forms of raising funds for medical costs such as crowdfunding have surfaced (Panjwani and Xiong 2023). Similar to my coffee shop experience, most everyone in the U.S. knows about sites like GoFundMe. Yet despite crowdfunding being a multi-billion-dollar industry (Shneor, Zhao, and Flåten 2020), the empirical literature on the topic has only exploded over the last 10 years or so. A quick search on Google Scholar in March 2025 yielded only 3,360 results when searching between 1990 and 2015 (a 25-year window), but 9,100 when searching between 2015-2020 (a 5-year window), and 14,800 between 2020 and mid-2025 (a <5-year window).
Medical anthropologists are often concerned with the ways in which history, culture, and politics shape experiences of health and illness, and Crowded Out engages brilliantly with all of these aspects of the field in an approachable way. Using a mixed-methods approach, Kenworthy analyzes both qualitative data—including in-depth interviews with people who have created crowdfunding campaigns, as well as campaign pages and popular news/discourse—and quantitative data that included building multiple datasets of medical crowdfunding campaigns across the U.S. between 2016 and 2020. Kenworthy begins the book by describing in Chapter 1 what she calls the financial and moral toxicities that reproduce the status quo of individual responsibility, deservingness, and market competition that mark American society—deftly analyzing how crowdfunding has reproduced histories of racial capitalism, integrating with and reshaping American culture, and butting up against the U.S. political landscape that has created the need for crowdfunding in the first place (Flores and Greenwood 2023).
In Chapter 2, Kenworthy juxtaposes her examination of the U.S.’s history of structural racism and economic exclusion with the ongoing myths of deservingness and meritocracy, to demonstrate how those who are often most in need of financial assistance for care are often those seen to be the least deserving of it. She shows how this is perpetuated by the U.S.’s deeply inadequate and unequal healthcare system—one devised to fuel market competition and leave those most vulnerable behind. According to Kenworthy, normalizing this system has created a society where the right to health is ignored, and universal healthcare is considered by few as a serious policy option. She shows how selective deservingness has a rich history in the U.S., and medical crowdfunding is simple the latest iteration of this phenomenon in society.
From this history, Kenworthy then traces the path of crowdfunding campaigns in Chapters 3 and 4, highlighting how the moral toxicities of deservingness and individual responsibility are supported by the financial toxicities embedded in the U.S. healthcare system—a lack of universal care that extends to all regardless of perceived deservingness or ability to pay. Campaigns maintain these inequalities through the requirement for a baseline level of access to resources – internet, education, and a network of close ties willing to donate and share your campaign. Indeed, she explains that most crowdfunding campaigns make no money at all, and those that are hyper-successful—fueling media attention and selling a vision of what GoFundMe can do for us in a similar way to how the American dream is sold to immigrants—are rare. These findings mirror others in the medical crowdfunding literature, highlighting the severity of the problem (Burtch and Chan 2019).
Through this analysis, we can see that crowdfunding campaigns rely on a perfect storm of access, privilege, good timing, and a well-crafted story…marketing at its finest. In this way, crowdfunding becomes a platform of hope, a last-ditch effort for financing that should have been provided by the government but that woefully reproduces the status quo, leaving those most vulnerable in the exact same positions they were in before they got sick (Panjwani and Xiong 2023). Additionally, crowdfunding enables a form of care that alienates people from one another, maintaining an individualistic approach to both need and support in moments when people likely need human connection the most. As Kenworthy writes, “messages that celebrate rugged individualism, responsibility and bootstrapping success [are]…toxic not only because they are untrue but also because they project a world in which suffering, economic precarity, and even death comes down to individual responsibility” (page 102).
In Chapter 5, Kenworthy relays the commonly told public health parable illustrating upstream and downstream effects (McMahon 2022). Crowdfunding is, at its core, a downstream solution to a problem that can only truly be fixed upstream. In fact, she argues that it isn’t really a solution at all, that it is simply a distraction from the real issues. As such, GoFundMe is not a substitute for universal health coverage, or even the worst of employer-based private insurance plans. For most people, it ends up being nothing but a black hole: zero donations and continued vulnerability. As she writes, “With crowdfunding, we’re often not even successfully pulling people out of the river anymore… We’re standing on the bank of that river, watching in horror as someone drowns, shouting about how awful it is” (page 144). In other words, “Here’s $20, sorry you’re uninsured” (page 139).
At the same time that all of this deep analytical work is being done, we are confronted with the very real and complicated emotional responses elicited in the ethnographic data when people are forced to turn to crowdfunding for assistance. Common themes expounded across the book are reminiscent of some of my gut reactions to that university student’s poster: shame, stigma, pride, independence, deservingness, and exclusion. Similar to other ethnographic research in the field, crowdfunding is not merely transactional, but can be a deeply emotional endeavor (Lincoln and Kramer 2025). As Kenworthy writes, “It’s a strange and tragic dynamic in our society that the very systems that make us vulnerable in moments of crisis also make it hard for us to ask for help when we need it” (page 37). She writes in this way of the new forms of care that have been engendered by the crowdfunding movement, a Janus-faced platform that provides much-needed and welcomed forms of support and hope but also conflicting, ambivalent feelings, some false optimism, and even a lack of responsibility for real care that comes when donating a few bucks can soothe our desire to feel generous and do good.
I believe there is something in this book for everyone. From the engagingly written narratives of people’s experiences with crowdfunding to the political commentary on the U.S. health system, Crowded Out provides a powerful look behind the curtain at the complexities and paradoxes within a growing phenomenon that everyday Americans take as assumed. Kenworthy begins each chapter with a poem composed from snippets of campaign narratives that draw on the most widely described themes in the research. The conclusion ends on a more hopeful tone—describing how crowdfunding can potentially be tweaked to be more equitable, how we can work on reforming the larger structural issues that cause the need for crowdfunding in the first place, and, helpfully, what we can do in the meantime while that long-road structural work is being done. I find this book to be a powerful critique of the manifestations of late capitalism, racism, a broken healthcare system, and fierce cultural values of individualism, deservingness, and exclusion. But it doesn’t just leave us hanging: it gives us a helpful way to look forward beyond these toxicities.
I’m reminded of a comment that anthropologist Craig Janes said to me once after a presentation I gave on NGOs. “While you’re perhaps not wrong about these observations,” he said, “NGOs aren’t going anywhere. So given that reality, how would you respond?” And while the final chapter addresses this issue, I am still left pondering. Crowdfunding isn’t just a fleeting phenomenon; it’s a full-blown movement. Perhaps this will be a wave that crashes as abruptly as it began, but perhaps it will also become a more permanent household staple. Given the inequities baked into crowdfunding, and the social ills it is being used to address, I believe these discussions beg the question, how are we to think of this movement? It’s easy to vilify, sure, but is that a helpful response? What does the moral economy of crowdfunding say about our society—about our ability to see deservingness in everyone equally; about how we create new solutions for care and social protection when the government doesn’t; about how we consciously or subconsciously judge campaigns and the people in them based on our own worldviews? While there is much to be lamented about late-stage capitalism, this book helps us to ask ourselves, as with the meteoric rise of crowdfunding as a digital quick techno-fix for the flailing U.S. healthcare system, what comes next?
References
Blumenthal, David, Evan D. Gumas, Arnav Shah, Munira Z. Gunja, and Reginald D. Williams II. 2024. Mirror, Mirror 2024: A Portrait of the Failing U.S. Health System. Fund Reports. The Commonwealth Fund. https://doi.org/10.26099/ta0g-zp66.
Burtch, Gordon, and Jason Chan. 2019. “Investigating the Relationship Between Medical Crowdfunding and Personal Bankruptcy in the United States: Evidence of a Digital Divide Evidence of a Digital Divide.” MIS Quarterly 43 (1): 237–62.
Flores, Yesnely Anacari, and Harris Munger Greenwood. 2023. “The Future of Public Health Must Be Radical: Incorporating Racial Capitalism.” Health Education & Behavior 50 (4): 473–76. https://doi.org/10.1177/10901981231166572.
Lincoln, Martha, and Sasha Kramer. 2025. “Affective Economies in Crowdfunding for Cancer.” Medical Anthropology Quarterly 39 (1): e12874. https://doi.org/10.1111/maq.12874.
McMahon, Naoimh E. 2022. “Framing Action to Reduce Health Inequalities: What Is Argued for through Use of the ‘upstream-Downstream’ Metaphor?” Journal of Public Health (Oxford, England) 44 (3): 671–78. https://doi.org/10.1093/pubmed/fdab157.
Panjwani, Aniket, and Heyu Xiong. 2023. “The Causes and Consequences of Medical Crowdfunding.” Journal of Economic Behavior & Organization 205 (January): 648–67. https://doi.org/10.1016/j.jebo.2022.11.017.
Papanicolas, Irene, Liana R. Woskie, and Ashish K. Jha. 2018. “Health Care Spending in the United States and Other High-Income Countries.” JAMA 319 (10): 1024–39. https://doi.org/10.1001/jama.2018.1150.
Shashikumar, Sukruth A., ZhaoNian Zheng, Karen E. Joynt Maddox, and Rishi K. Wadhera. 2024. “Financial Burden of Health Care in the Privately Insured US Population.” JAMA Internal Medicine 184 (7): 843–45. https://doi.org/10.1001/jamainternmed.2024.1464.
Shneor, Rotem, Liang Zhao, and Bjørn-Tore Flåten, eds. 2020. Advances in Crowdfunding: Research and Practice. Springer International Publishing. https://doi.org/10.1007/978-3-030-46309-0.
