OMAHA, NEBRASKA HAS BEEN BUSTLING with activity these past few days thanks to the annual Berkshire Hathaway weekend, when tens of thousands of investors from around the world gather to hobnob with Warren Buffett while they figure out how to maximize their portfolios.

But inside one office, a woman named Amy Behnke has been preoccupied with something very different and much more urgent. She has been furiously working the phones with state officials, trying to figure out how to keep some of Nebraska’s poorest residents from losing their health insurance.

Behnke is CEO of the Nebraska Health Center Association, which represents clinics that provide care to the state’s underserved population. Since 2020, she tells me, the percentage of total patients showing up to member clinics with no insurance at all—the ones who represent the biggest drain on clinic finances—has dropped from half to one-third.

That’s a sign of progress, and it’s no mystery what’s behind it. In October 2020, Nebraska officially became part of the Affordable Care Act’s Medicaid expansion. By taking advantage of federal funding that the state’s GOP officials had long refused—but that voters eventually approved via ballot measure—Nebraska was able to open up its program to any citizen or qualifying legal resident with income below 138 percent of the federal poverty line.

More than 70,000 Nebraskans are now on Medicaid because of the expansion. But as of May 1, they are also subject to new “work requirements” that became law last summer as part of the broader Medicaid cuts in President Donald Trump’s “One Big Beautiful Bill.” That legislation calls on states to impose their work requirements by January 1, 2027. Nebraska decided to go first, thanks to Republican Gov. Jim Pillen, who has said the rules will make sure Medicaid is a “hand up, not a hand out.”

Just how big that change will be in practice is impossible to say right now. As in the rest of the country, the majority of non-elderly adult Nebraskans on Medicaid expansion already work or are in school, according to estimates by KFF. In theory, they should have no problem getting and staying on the program. And of those who don’t work, many have a disability or caregiving responsibilities or something else that is supposed to exempt them from the requirement.

But what is supposed to happen and what will happen are two very different things.

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IF YOU DON’T LIKE ROBERT F. KENNEDY JR. setting national health policy, how do you feel about Joe Rogan? The question is a serious one that deserves a serious answer, given what transpired when Rogan showed up in the Oval Office a little over a week ago.

He was there to watch President Donald Trump sign an executive order promoting psychedelic drugs as a treatment for mental illness, a cause that Rogan has long championed. But it turned out the podcast host wasn’t just another invited guest. He was the one who had prompted Trump to act.

“I sent him that information,” Rogan said, revealing he’d texted the president about the ways psychedelics might help with conditions like depression and PTSD (post-traumatic stress disorder). “The text message came back, ‘Sounds great. Do you want FDA approval? Let’s do it.’ It was literally that quick.”

This does not appear to be an exaggeration.

Mehmet Oz, the celebrity doctor who oversees Medicare and Medicaid programs, told reporters that Rogan’s text set off a frenetic week of internal deliberations that culminated in the executive order. Kennedy played a role too, as Trump recounted in his own remarks. “I said, ‘Bobby, let’s just do it and get Oz involved and it’s going to get done so quickly,’” Trump recounted. “And you guys did a great job.”

The executive order calls on the Department of Health and Human Services to make more funds available for research into psychedelics, while telling the Drug Enforcement Agency to update its legal guidelines to allow legitimate academic and therapeutic uses to go forward. Those moves reflect a widespread recognition that psychedelics have real potential as a breakthrough therapy for some patients. And it’s hard to find anybody—even among frequent administration critics—who finds this sort of action beyond the bounds of normal presidential prerogatives.

“It’s well within the remit of any administration to decide that research in a given area is a priority for them, and to make it easier for researchers to do that work,” Peter Lurie, president of the Center for Science in the Public Interest, told me.1

But the executive order also instructs the Food and Drug Administration to give psychedelic manufacturers so-called priority vouchers that expedite reviews. This provision is setting off alarm bells because it suggests the president is doing an end-run around the FDA’s normal scientific processes, quite possibly because he wants to quiet a politically influential podcaster who has been giving him grief over Iran. It also seems possible Trump might be looking to boost companies that stand to profit bigly from psychedelics—companies who count among their investors well-known Trump allies like Peter Thiel.

“The optics of the situation are quite concerning,” Rachel Sachs, a Washington University law professor and expert on drug regulation, told me.2 “It appears that the president is directing FDA, at the very least, to issue these priority vouchers to these products—and based on his public statements, will be exerting some type of pressure on FDA to ultimately approve the products.”

It wouldn’t be the first instance of such meddling: Career FDA staff have told STAT News that they have come under pressure from administration officials seeking priority vouchers for pharmaceutical companies that agree to the prescription drug pricing deals Trump keeps hyping. And it’s not like it takes journalistic sleuthing to establish the connection to Rogan: Trump and several other administration officials came right out and said it exists.

None of this means that the FDA will ultimately bend to pressure from top Trump officials, or make ill-considered decisions when it comes to any particular treatments. But the threat itself is enough to damage the agency’s credibility, in ways that could ultimately hurt everybody—including both the companies that want to manufacture psychedelics and the people who might genuinely benefit from them.

MODERN INTEREST IN THE THERAPEUTIC BENEFITS of psychedelics, like so many key episodes in medical history, traces back to an accident in the lab. In 1943, a Swiss chemist named Albert Hofmann was synthesizing a substance he hoped would lead to respiratory stimulants when he inadvertently absorbed a tiny amount. The substance was a version of a compound we know as LSD.3

The LSD altered his vision and perception, and made him feel like he was in a “mystical” state. He decided to try again a few days later, and experienced even more dramatic changes in perception and mental status. Hofmann famously rode his bicycle home while on what we would now call an acid trip, which is why historians (both professional and amateur) call the April 19 anniversary of that ride “bicycle day.”

Hofmann worked for a company called Sandoz Laboratories, where he and his colleagues quickly recognized the potential of such a powerful mind-altering drug. Sandoz distributed research samples to psychiatrists, kicking off a wave of promising studies in the 1950s that suggested potential to treat depression, personality disorders, and alcoholism.

Publicity around these developments attracted lots of attention, and not just among people with mental illness or those trying to treat it. Counterculture leaders in the ’60s hailed the drugs (still legal for purchase back then) as a way for everybody to alter their state of consciousness. Meanwhile, the CIA experimented with LSD as a way to wage psychological warfare.

Both those developments fed a backlash. Researchers stopped studying psychedelics, Sandoz stopped producing LSD, and the National Institutes of Health pulled funding. Eventually the federal government declared psychedelics to be a Schedule I controlled substance, making studies even more difficult to conduct.4

That was basically the end of research on psychedelics—until 2000, when scientists at Johns Hopkins University launched a new study on the effects of Psilocybin, the active ingredient in magic mushrooms that indigenous central Americans had long used in religious ceremonies. That project and a series of followups picked up where the studies from the ’50s and ’60s left off, yielding results suggesting psychedelics might work as a treatment for alcoholism, anxiety among people facing life-threatening cancer, and other conditions.

Recently some especially influential research has demonstrated that treatment with MDMA, the active ingredient in ecstasy, could help veterans with PTSD who were not responding to more traditional therapies. The potential to reach these veterans and others facing similar struggles has been a big theme of Rogan’s promotion, and got plenty of attention from Trump in the Oval Office last weekend.

“Today’s order will ensure that people suffering from debilitating symptoms might finally have a chance to reclaim their lives and lead a happier life,” Trump said while signing the order.

Later he asked, jokingly, “Can I have some, please?”

AS WITH ANY DRUG, the challenge with psychedelics lies in demonstrating they can live up to their hype. That means fully studying possible adverse effects, which is no small thing given the potential of some psychedelics to raise blood pressure and the possibility that others could trigger psychosis or worsen symptoms of bipolar disorder.

But it’s not just questions about safety that need answering. It’s also questions about efficacy, which for psychedelics can be particularly challenging to assess.

The best way to test how well a drug works—and under what conditions—is through “double-blind” experiments in which neither the researchers nor the subjects know who is getting the treatment and who is getting the placebo. But anybody participating in a psychedelic study is going to figure out pretty quickly whether their mental status is changing. That can bias the findings, especially for a drug where results depend so much on how test subjects say they feel rather than measurable physical signs.

Researchers will also know who’s really getting the treatment, because they’re going to be watching as it happens. The proper way to administer psychedelics is in lengthy sessions that last many hours, with a therapist guiding the patient through talk therapy while they are in the altered mental state.5 That’s how the drugs appear to work: People in that altered state are able to get past mental blockages from past trauma, in order to grapple with underlying causes of depression, substance abuse disorder, and other conditions.

Concern over the reliability of data was among the reasons that an FDA panel two years ago voted overwhelmingly against approval of an MDMA-based drug that would have been the first new major PTSD treatment in decades. That disappointed advocates and researchers, some of whom felt FDA was being too rigid. But the FDA has issued guidance on the kind of evidence it would need and—even before last week’s announcement—companies were lining up with new applications they were optimistic would succeed, with plenty of investment money behind them.

Now Trump has gotten in the middle of things, creating several potential hazards. Probably the most obvious is the possibility that his order pushes the FDA to rush the review process, in ways that make it more likely scientists overlook warning signs about safety problems. “The speed of review here that they contemplate is very, very rapid,” said Lurie, who noted that psychedelics were already eligible for the quicker of two review tracks at the FDA.

Expediting reviews of psychedelics could also force the FDA to slow down reviews of more promising therapies, especially when the agency is operating with fewer personnel thanks to DOGE-ordered layoffs and DOGE-induced departures. “We stand a risk of FDA scarce resources being devoted to things that are actually less important from a public health point of view,” Lurie said, “in which case patients suffer.”

Some enthusiasts of psychedelics might not worry so much about what happens to other drugs. But, as Sachs pointed out to me, the stigma and controversial history of psychedelics mean their manufacturers are especially dependent on collective trust that any approval was based purely on scientific merit.

“If there is a perception that a podcaster texted the president, and that’s why these products were approved, that’s a problem for these companies,” Sachs said.

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TRUMP’S ORDER BY NO MEANS represents the first time officials in the executive branch have interfered with FDA decision-making.

In the early 2000s, the Bush administration famously blocked over-the-counter sales of emergency contraception to minors. A few years later, the Obama administration just as famously did the same thing, despite an explicit promise to let science—not politics—dictate agency decision-making.

But those were isolated incidents, confined to one particularly controversial type of drug. “We cite these specific examples because it was a rare occurrence,” Sachs said, “and it was often criticized quite strongly when it did occur.”6

Under Trump, by contrast, interference with decision-making has become common across health care agencies—whether it’s canceling funding for projects simply because their abstracts contain keywords that sound like DEI, or dispensing with normal CDC procedures to pull back on support for vaccination. “Those [previous controversies] felt like exceptions to the rule; now it’s not even clear what the rules are,” Lurie said.

FDA arguably has held up against Trumpian political influence better than some other scientific agencies. But the pressure has taken a toll. And Lurie worries it’s only a matter of time before the agency loses the independence and credibility that is the foundation for the pharmaceutical ecosystem, and upon which the well-being of so many people depends.

“You can get to a place with the FDA where people assume they only approved a particular drug—or didn’t approve it, as the case may be—because it was politically useful,” Lurie said. “At that point, patients don’t know what to do, doctors don’t know what to do, insurers don’t know what to do, because they simply can’t trust what’s coming out of the government. And it’s very difficult to really advance patient care under circumstances like that.”

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EIGHT CHILDREN DIED in a mass shooting in Shreveport, Louisiana this weekend.

Eight children.

The oldest was 11. The youngest was 3. One had just celebrated bringing up his literacy scores, the schools superintendent recalled at a press conference Monday. Another loved to run outside and play with Nerf guns, as a grieving family member told the Washington Post.1

Investigators are still piecing together exactly what happened early Sunday morning. But it appears the children were victims of domestic violence, killed by an Army National Guard veteran who was father to seven of the eight.

Neighbors and friends have said the man was angry at the two women who were the children’s mothers, and who lived in the two homes where the shootings seem to have taken place over the span of about an hour. One of the women, to whom he was married, was in the process of seeking a divorce.

The two women survived their wounds. A third, the killer’s sister-in-law, escaped with a 12-year-old when they jumped off the roof during the rampage. As for the alleged killer, he is dead—shot either by himself or by police at a house where he tried to hide after the murders. Friends and family say that he had a history of mental illness, and that he had talked about “dark thoughts,” as one relative put it.

Still, they said, he seemed to love his children. Two days before the killings, he had posted a photo to his Facebook page showing his 11-year-old daughter sitting in the passenger’s seat of a car, a drink and ketchup packets in her lap while she bites into a burger.

“Lol!!!! Took my oldest on a lil 1 on 1 date had to catch her down bad ugh ugh…” the post says, followed by several cheery emojis.

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THE SHREVEPORT MASSACRE is the deadliest mass shooting in the United States since the January 2024 killings of eight people in Joliet, Illinois. The most lethal from previous years were the October 2023 killings at a Maine bowling alley and restaurant, the May 2023 killings at a Dallas-area outlet mall, and the January 2023 killings at a dance studio in Southern California. And before that? There were the Uvalde school massacre and the Buffalo mall shootings, both in May 2022.

Just to list all of these is to remember how routine mass shootings have become in the United States. But this one was different in one disturbing way. All the other incidents commanded national attention, sometimes for days. Sunday’s killing made far less of an impression, getting second- or third-tier treatment on both television and online.

You had to scroll six or seven times on a smartphone just to find the story on the New York Times homepage. And that was on the day it happened. More than forty-eight hours have passed as I type these words, and—although outlets like the Post, Times, and Associated Press have reporters on the ground in Shreveport—the story has mostly vanished from the news.

Unless you live there.

Local media have provided nearly nonstop coverage—of the incident itself as well as the official followup and community reaction, which started organically on Sunday night when the owner of a nearby restaurant decided to close for the evening and host a vigil that attracted about fifty people.

“I just felt moved to do it—I have kids,” Leon Bell told me by phone. His restaurant, Tha Thing, is just minutes from Cedar Grove, the lower-income, predominantly black neighborhood where the killings took place and where he grew up. “We need to come together as a community . . . and to let people know that if somebody needs help, don’t be afraid to reach out and call.”

That was also the message of James Green, a pastor and city council member. He got a call about the shootings at around 8 a.m., while teaching Sunday School, and then announced the news while leading services two hours later to an audience he described as stunned. “All I can describe it as is a bust in the gut, that takes the air out,” Green told me.

During public appearances and in interviews, local officials have mentioned that gun violence is a familiar experience in Shreveport, breeding its own kind of indifference. That is part of why leaders like Alan Jackson, a pastor and city council member, say the tributes and investigations are so important.

“It’s gut wrenching,” Jackson told me in a phone interview. “This senseless violence has to stop, and I’m hoping this can be a wakeup call.”

And it might be, at least in the Shreveport community, where the tragedy will linger in all kinds of ways—and in all kinds of places. Quanerick Milton, lead pastor at the Tabernacle Baptist Church-MLK in Shreveport, told me that he spoke to a teacher who had one of the murdered children in their class—and who described a day of open weeping from children and instructors alike.

“It was a very emotional day for that particular classroom,” Milton said, “because now that seat will be empty, because of that child that once sat there.”

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MAYBE IT’S THE SHEER REGULARITY of mass shootings in America that explains the national indifference to the Shreveport massacre. People have just become numb to the whole phenomenon.

Or maybe it was the specific circumstances of what happened in Shreveport. The killings took place in private homes, rather than a mall or a school where anybody could imagine their children being present. The victims were low-income and black.

These sorts of killings happen all the time, all over the United States, just not usually at this scale. Even before Shreveport, 58 children under the age of 12 had died from shootings already this year, according to a tally at the Gun Violence Archive. That’s right in line with the usual trend, with roughly 200 to 300 children across America dying from gun violence every year. Children who are black or Latino, or come from lower-income communities, have a higher probability of being victims.

Their deaths stopped being “news” a long time ago. This is a uniquely American phenomenon but one we’ve come to accept. The gun homicide rate in the United States is larger than in any other economically advanced country, and it’s not even close. In fact, if you limit the comparison to Europe and East Asia, the difference is literally an order of magnitude: Guns kill more than ten times as many people in the United States as they do in Greece or Norway, Slovakia or Japan.

The simplest explanation for the difference is also the one most researchers think is the best: We have way more guns in circulation, statistically more than one for every single person living here. Or to put it another way, more than 40 percent of all the world’s civilian-owned firearms are in the United States.

The seeming futility of addressing that problem may also contribute to our collective ambivalence about gun deaths. Significantly reducing that gun stock would require enacting dramatic new restrictions on gun ownership, and then some kind of gun buyback program—the kind that Australia conducted in the 1990s, after the massacre of thirty-five people in Tasmania prompted a national demand for action.

That kind of action seems not even remotely possible in the United States. The political obstacles to any kind of action on guns are formidable, as advocates for restrictions learned after a presidential-led effort to pass relatively new limits in the wake of the 2012 Sandy Hook killings failed.

And now there are massive legal obstacles too, thanks to a 2022 Supreme Court ruling written by Justice Clarence Thomas that renders even modest gun regulations constitutionally suspect.

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BUT IT’S A MISTAKE TO ASSUME those obstacles render action futile, or that anything short of a total ban is not worth pursuing. “Real and important changes take time,” as my Bulwark colleague Jim Swift wrote about guns two years ago. And the Shreveport killings, precisely because they were so typical of what happens in America, show why.

Start with domestic violence, which is so frequently when guns are used to injure and murder.2 Local efforts to identify and then monitor likely abusers have been shown to reduce the incidence of violence. Funding shelters, providing rental vouchers and other forms of housing assistance can also have an impact, according to research, simply by allowing them—and their children—to get out of harm’s way.

Initiatives that integrate mental health workers into police responses or seek to intervene before violence happens—through local, credible messengers who can act as conflict mediators—have also shown promise.

And then there are the guns.

Nobody is getting rid of them anytime soon, or maybe ever. But there’s evidence that requiring a license to own a gun (in the same way states require a license to drive a car) reduces gun violence. The same goes for Extreme Risk Protection Orders, more commonly known as “red flag” laws, that allow police to take guns away from people who pose a threat—like, for example, expressing the sort of “dark thoughts” the Shreveport killer did.

To be clear, the evidence on these interventions is not as solid as it is for other policy interventions, as a thorough, ongoing review of studies by the Rand Corporation has demonstrated. And, generally speaking, the evidence on the effectiveness of Red Flag laws in reducing homicide is weaker than evidence around their effectiveness in reducing suicide.

Partly that’s because restrictions on research into gun violence—enacted following pressure from the gun industry, eventually eased following pushback led by congressional Democrats—made studying the effects of restrictions difficult. Partly that’s because the gun trade is interstate, making it difficult to isolate the effects of restrictions states act on their own.

And partly that’s because some of these initiatives are relatively new or have proliferated only recently. There just hasn’t been a lot of time to study them.

But the cost of trying these policies is relatively small, in both the figurative and literal sense. The targeted interventions are not hugely expensive—hundreds of millions of dollars at the national level, where budget allocations are measured in tens or hundreds of billions. Plus they have real potential to generate savings, given the many expenses of dealing with gun violence after the fact.

As for the gun restrictions that are part of the current debate, they also don’t meaningfully impinge on the rights of gun owners, except maybe to make the process of acquiring firearms a little more arduous.

EVEN THAT ADDED DIFFICULTY is likely more than some opponents of gun restrictions are willing to accept. But the majority of Americans are willing, according to the best available polling.

That is probably why, now and then, outbursts of gun violence here do lead to change. The 2018 school shooting in Parkland, Florida led that state to enact a red flag law, which twenty-two states plus the District of Columbia now have. The Uvalde massacre led to a bipartisan federal law that made significant, if underappreciated, investments in mental health care.

Even the Supreme Court has shown some flexibility. Two years after issuing the decision striking down whole categories of firearm restrictions, it issued an opinion clarifying that authorities can still take guns away from people who represent “credible” threats of domestic violence.3

But simply protecting recent gains will prove a challenge in the coming years. Community initiatives may help explain the recent nationwide decline in gun violence, as a lengthy analysis in the Trace showed last fall. But the federal funding for those efforts was part of pandemic relief efforts that are expiring.

Meanwhile, the Trump administration has cut resources that go to mental health for veterans and rescinded funds for domestic violence programs. It has also proposed a rule that would make it easier for convicted criminals, including those who had been found guilty of domestic abuse, to get back their rights to own firearms.

At the state level, gun rights advocates are trying to repeal the red flag laws already on the books while blocking the adoption of new ones. One state where a red flag effort failed happens to be Louisiana—where, to the delight of the National Rifle Association, the focus has been on rolling back what few restrictions exist in the state.

Change can’t come soon enough, to the nation or the state or the city. Green, the pastor and city council member, told me there was another outburst of firearms violence in the area Monday night.

This time it wasn’t children and it wasn’t a mass shooting. It was just two young men, Green said. They got into a fight and went for their guns. Both are now dead, in yet another grim reminder of what happens and what is allowed to happen every day in America. Even when almost nobody notices.

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IT’S BEEN A ROUGH FEW DAYS for Robert F. Kennedy Jr. and a promising few days for public health.

Maybe.

On Thursday, President Donald Trump announced his intention to name a permanent CDC director, filling a post that has been vacant since last summer when he fired then-director Susan Monarez.1 She had been on the job for just a few weeks when she refused to sign off on some of Kennedy’s efforts to roll back federal support of vaccination.

Kennedy as secretary of health and human services didn’t have the power to dismiss her directly, so he got Trump to do it. It was among the clearest public indications of how much sway Kennedy held within the administration—and how much room Trump was giving him to reshape public health policy, especially on vaccines.

But that was then. The administration’s new choice to lead the CDC is Erica Schwartz, a Brown University-educated physician who served as deputy surgeon general during Trump’s first term. Schwartz has extensive experience as a public servant, including as a decorated Navy veteran who was medical director for the Coast Guard. More revealingly, she has a record of promoting vaccination.

To put it a bit more directly, Schwartz seems to be a well-qualified appointee with views that put her squarely within the bounds of mainstream medicine. And you don’t have to take my word for it.

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Among those vouching for her is Jerome Adams, who served as surgeon general during Trump’s first term and who has been among the most outspoken critics of Kennedy’s anti-vaccination efforts. Adams said on X Thursday that he had “personally selected” Schwartz to be his deputy, then went on to describe her as “a battle-tested leader with decades of distinguished public service” who “has the expertise, credibility, and integrity to lead the CDC effectively.” He ended with “Well done, @realDonaldTrump” and the applause emoji.

But the most telling reaction to the Schwartz pick came from the other side of the debate—from leaders in the anti-vaccination movement, who are treating her appointment as a significant betrayal.

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MITT ROMNEY WAS BACK IN MASSACHUSETTS this week to celebrate an achievement that still doesn’t get the credit it deserves—both for how it improved people’s lives and for how it modeled a kind of cooperative, solution-oriented governing that feels increasingly rare.

The achievement was the 2006 Massachusetts health care reform law. The people who put it together call it “Chapter 58” because that’s the official title in the state legislative record. You may know it as “Romneycare,” because Romney was the conservative Republican governor who worked with liberal Democrats to craft and then enact it.

On Monday, Romney and his former partners, along with dozens of other dignitaries, gathered in Faneuil Hall, the eighteenth-century meeting place where Romney had signed Chapter 58 almost exactly twenty years ago to the day. They were all there to hail the law’s sweeping effects, and to reminisce about how they’d teamed up to make it a reality.

“Political rivals respected each other, buried political weapons and worked together to find solutions,” Romney said in brief remarks—which came, fittingly, after both the current Democratic governor (Maura Healey) and Romney’s Democratic successor (Deval Patrick) had praised him, generating hearty applause from the audience.

All that magnanimity wasn’t just for show. It was a recognition of genuine, quantifiable progress. In just the first four years after Chapter 58 became law, the percentage of non-elderly adults without insurance in Massachusetts fell from a state-estimated 13.4 percent to 5.8 percent, even as the percentage nationally was growing because the economy at the time had plunged into recession.

As of 2024, that figure sits at 3.7 percent, according to the Census Bureau.1 And while there are still people with insurance who have a hard time covering premiums and out-of-pocket costs, research has shown that the law has reduced economic hardship while improving access to medical care, and that people seem to be healthier.

But Chapter 58 may be just as important for the way it reverberated in national politics, helping to launch a reform effort that eventually produced the Affordable Care Act. Key architects of that law have described Chapter 58 as proof of concept—both in the sense that the Massachusetts policy architecture was a prototype for what Obama and his allies ended up creating at the federal level, and in the sense that Chapter 58’s passage demonstrated how enacting a quasi-universal coverage scheme was politically possible.2

In some ways, the impact of “Obamacare” nationally has been similar to the impact of Romneycare in Massachusetts: The number of Americans without insurance has fallen to historic lows, with data showing that Americans are better off financially and medically as a result. But most of the rest of America hasn’t gotten as close to universal coverage as Massachusetts has. A big reason for that is vitriolic opposition from Republicans.

For starters, Florida, Texas, and eight other states where Republicans hold sway have refused to expand their Medicaid programs, a step that more than half the states (including Massachusetts) took in 2014 and most of the remaining states did in the next few years. Because those states, preponderantly in the South, have held out, millions of Americans have remained without coverage, even though the Affordable Care Act means the federal government would pick up most of the cost.

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Then there were the repeated efforts to undo the law. During Trump’s first term, Republicans came within one senator’s vote of repealing it outright, and when that failed Trump proceeded to use the levers of executive authority to undermine it. Since returning to office last year, Trump has worked with Republicans to weaken the Affordable Care Act even more—by enacting history’s largest cuts to Medicaid, by refusing to renew temporary extra subsidies Joe Biden and the Democrats had put in place, and by dialing back the requirements for what insurance must cover.

In that sense, the story that Romney and the Massachusetts dignitaries were celebrating on Monday is bittersweet. It’s a reminder of what could have been—and what could still be—with a different political mindset, especially in Washington. And probably nobody knows that better than Romney, whose journey through public life allowed him to see policymaking at both its most constructive and its most destructive.

IF YOU DOUBT HOW IMPORTANT Chapter 58 is to Romney, all you have to do is glance at his portrait hanging in the Massachusetts State House. At his request, the artist depicted a copy of the signed law on the desk. The only other item there (besides a lamp) is a portrait of Romney’s wife, Ann.

But Romney had not come to office promising to tackle health care, and didn’t take much interest in the issue until a longtime friend and business associate suggested it—appealing to Romney’s analytical side, as a former investment banker, by pointing out that the cost of treating uninsured patients in emergency rooms was likely raising costs for everybody else. “That began to grind in my mind,” Romney told me in an interview after the anniversary event, “and I began to wonder what in the world can we do.”

Even that might not have turned health care into Romney’s legacy if not for another circumstance. Massachusetts was on the verge of losing hundreds of millions of dollars a year in extra hospital funding, which it had been receiving through a special program that the administration in Washington—George W. Bush’s—didn’t want to renew. The only way to keep the money was to use it differently, to pay for insurance rather than continue subsidizing hospitals directly.3

This was the point when Romney forged a partnership with Ted Kennedy, the iconic liberal Democratic senator from Massachusetts. It would be difficult to exaggerate how unlikely a pair they made, characterologically as well as ideologically, and that’s not to mention the fact that the two had faced off in a bitter, frequently nasty Senate race when Romney tried to unseat Kennedy in 1994.

But “we were friendly on a personal basis,” Romney told me, “we just had different ideas on how to get things done and what was the best thing to do for people.” And the situation with federal funding meant both men could get a win. Romney would get a chance to keep state finances whole, without having to raise taxes or cut spending elsewhere. Kennedy would get a chance to see Massachusetts get close to universal coverage, as he’d long wanted.

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The two ended up visiting the then-outgoing secretary of health and human services on his last day before stepping down, then headed next door for a reception where—by some accounts, though Romney told me he doesn’t remember—the two entertained a crowd by telling jokes about each other. But the Bush administration’s agreement was only the beginning of the process. Massachusetts still had to come up with a new health insurance system, which meant Romney had to work with the overwhelmingly Democratic state legislature.

They were far apart on everything from the role of employers to the generosity of insurance. They also had to wrangle interest groups—hospitals, insurers, labor unions—each with different agendas and the power to kill a deal. Motivated to save that extra federal money, and pushed by advocates who had spent decades clamoring for universal coverage, Romney, legislative leaders, and their respective advisers worked through it all with weekly in-person meetings and daily phone calls. At one point, when negotiations were stalling out, Romney showed up—unannounced—on the doorstep of the House and Senate leaders to demonstrate his commitment to the project.

“I thought he was drunk and lost,” former state Senate President Robert Travaglini deadpanned in his remarks Monday, prompting loud laughter because Romney is an observant Mormon who doesn’t drink alcohol. But Travaglini struck a serious note too, recalling that “we were capable of putting aside egos, personalities, party affiliations for the good of the people that we represented.”

They really were—and a year later, all of them were together onstage at Faneuil Hall, where organizers had brought in a fife-and-drum corps and Kennedy quipped that his son had said “when Kennedy and Romney support a piece of legislation, usually one of them hasn’t read it.”

TED KENNEDY HAD MADE no secret of his hope the Massachusetts law would inspire national action—and he would go on to play a key role in making that happen after Obama was elected, up through Kennedy’s death in August 2009. It’s safe to assume Romney also had visions of how the law might play nationally, though more as a signature accomplishment he could tout in his own future run for the presidency.

A big part of that was the way Romney had insisted on an “individual mandate”—that is, a financial penalty for people who didn’t get insurance. Taking the advice of economists and analysts—and after satisfying himself by poring over the data—Romney was convinced the mandate was necessary in order to keep insurance pools stable. But he also believed it was true to his conservative principles on individual responsibility.

“If you’re a young person that’s healthy, you’ve got to have health insurance,” Romney told me, making the same pitch he made countless times while promoting his plan. “We can’t let you just be out there driving your car, skiing, paragliding and so forth—and if you get hurt, expecting everyone else to pick up the bill.”

But by the time of his 2012 presidential campaign, fighting the Affordable Care Act had become a defining political cause among Republicans, with the mandate a particularly sore spot among conservatives and libertarians who saw it as the federal government—and Democrats—coercing people into being part of the system.

Romney made the case then (as he did to me Monday) that he too supported repealing the Affordable Care Act, because he never envisioned the Massachusetts system as appropriate for every state. But while he was able to get the nomination, it was yet one more way he never won over the party’s emerging, more extreme wing—which, years later, would become the MAGA base.

“It strikes me as a Republican idea to say that if you can afford to buy insurance, you’ve got to have insurance, rather than showing up and expecting to get free care—that strikes me as conservative and Republican,” Romney told me. “But as soon as Barack Obama started talking about this, Republicans ran for the exits.”

Republican anger at the Affordable Care Act didn’t dissipate when Romney lost. It festered, and led to actions—such as the elimination of a federal fund designed to stabilize the insurance market for the first few years of the program’s operation—that made the already difficult task of implementing such a complex law even more difficult.

That attitude was a stark contrast to the way things unfolded in Massachusetts, where the spirit of cooperation across party and interest groups prevailed even after Romney’s term ended. Early on, stakeholders and local leaders met regularly on how to publicize the law and encourage enrollment, with even the Red Sox (through their charitable foundation) lending a hand with promotion.

And Massachusetts lawmakers didn’t stop trying to improve the system, with each successive governor after Romney (two of them Democratic, one of them Republican) pushing for reforms to address underlying forces constantly making health care more expensive—in part, to make the system more sustainable. That was actually a big theme of the festivities on Monday—the recognition that extending coverage was just one step toward making health care more affordable for everybody, and that success would require the kind of effort that had first led to Chapter 58.

“What made that progress possible in Massachusetts is needed again for this next hurdle we face, which is really around cost and affordability,” Audrey Morse Gasteier told me. Gasteier is executive director of the Massachusetts Health Connector, which operates the state’s insurance marketplace and which organized Monday’s event. “It was part of our hope that this gathering would help remind the Massachusetts health care community that it has it in it to do hard things, and that progress is possible.”

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ROMNEY IN HIS PREPARED REMARKS alluded to the rarity of that kind of cooperative spirit in national politics nowadays: “Having spent six years in Washington, I have greater appreciation for what we did here in Massachusetts.” He was talking about his term in the U.S. Senate, representing Utah from early 2019 through 2025.

That is when he carved out the identity for which he’s probably best known today—as a principled conservative who stood up to Trump in his first term, becoming the first senator in history to vote to convict on impeachment charges a president of his own party. That legacy-defining decision earned him all kinds of grief from within the party, especially back home among the MAGA faithful, some of whom famously harassed him and chanted “traitor” as he was flying back to Washington for the January 6, 2021 certification of Joe Biden’s 2020 election win.

Two years later, Romney announced that he wouldn’t seek a second term—lamenting in a press briefing that “the Republican party today is in the shadow of Donald Trump.” He went on to explain that

my wing of the party talks about policy and about issues that will make a difference to the lives of the American people. The Trump wing of the party talks about resentments of various kinds, and getting even and settling scores and revisiting the 2020 election.

Romney had said he was optimistic that his wing of the party would become ascendant again. On Monday, I asked him if he still felt that way. “I’m obviously hopeful, but, no, not optimistic—not optimistic for anytime soon,” he said, moving immediately to speculation on who would inherit the party’s mantle after the president leaves the scene. “I think Vice President Vance is very much in the footsteps of Donald Trump, and will pursue that course if he’s the nominee. I’m not sure about Marco Rubio, maybe he would as well. But I don’t see a big departure.”

Romney did allow that both Vance and Rubio were “smart guys” who might not be prone to make the same sort of errors Trump has. (Romney didn’t specify which errors, but it’s not hard to imagine what he might have in mind.) And throughout our interview, Romney made clear he thinks Democrats deserve plenty of blame for the degradation of politics—because, he said, they took actions (like using executive orders to wipe out student loans) that violated constitutional norms and staked out positions on cultural issues (like transgender athletes) that he believes made more Americans sympathetic to MAGA.

But it says something that the MAGA base treats Romney as a persona non grata, while Democrats in one of America’s bluest states will embrace him the way they did on Monday. It’s not because those Massachusetts liberals see in Romney a kindred ideological spirit. It’s because they came to know him as somebody who—despite significant differences of opinion—worked with them to achieve something they could all find worthwhile. That too is a legacy, one especially worth celebrating now.

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Ann Arbor, Michigan
ROUGHLY SIX HUNDRED PEOPLE filled a University of Michigan lecture hall for a campaign rally last Tuesday evening. That’s pretty high turnout for a campus political event, let alone one taking place while many students were still hungover from celebrating their basketball team’s national championship from the night before.

The event was for Abdul El-Sayed, one of the three Democratic contenders for Michigan’s open Senate seat. But it was not any old political rally: El-Sayed was joined by a figure who, in the last few weeks, had become the subject of heated debate: left-wing influencer Hasan Piker.

If you follow politics—or read my Bulwark colleague Lauren Egan—you know why the event was such a big draw, and a source of national controversy. Piker is a Twitch and YouTube streamer with a combined follower count on those platforms of nearly 5 million. His history includes inflammatory and provocative statements like saying that “America deserved 9/11” and that “It doesn’t matter if fucking rapes happened on October 7. That doesn’t change the dynamic for me.” (He later said that the former remark was “inappropriate” but that he stands by the latter.)

El-Sayed’s decision to appear alongside Piker drew lots of criticism, including from fellow Democrats. Unbowed, El-Sayed proceeded with the plan, which included another (and equally well attended) rally in East Lansing at Michigan State University.1

During press appearances afterwards, El-Sayed refused to disavow Piker’s comments, arguing that Democrats need to reach the young, frustrated Americans who make up Piker’s audience. El-Sayed also said he doesn’t consider himself responsible for everything Piker—or any other supporter—might say. “This whole gotcha game, platform policing, cancel culture—I thought we were over it,” El-Sayed told Politico.

I’m not here to weigh in on the merits of the Piker controversy. (That’s for the likes of Tim and Sarah to hash out.) I’m also not here today to comment on the substance of El-Sayed’s remarks, his rhetoric in general, or his policy platform. (That’s for another newsletter, which, I promise, is coming.) I am here to ponder the question likely to be on the minds of many Democratic voters casting ballots in the August primary: Can a candidate like El-Sayed, running a campaign like he is, actually win in my home state of Michigan?

The question is vital because Democrats’ hopes for a Senate majority depend on winning every single contest they can. Michigan is on the list of seats they hold now and should be able to keep, following the retirement of two-term incumbent Gary Peters. Democrats have been winning most statewide races for the past decade, thanks in part to a bevy of politically talented leaders, including the popular, two-term governor Gretchen Whitmer. And with Donald Trump’s poll numbers in the dumps, the environment seems favorable to Democrats.

But this is still a purple state that Trump won twice. The archetype of a successful Michigan Democrat has been a moderate like Peters or Whitmer—or like Elissa Slotkin, who narrowly won the Senate seat that Debbie Stabenow (another moderate) vacated for 2024.

El-Sayed is a different kind of candidate. He’s an unabashed progressive, running against Haley Stevens (an establishment U.S. House member who profiles as another Peters or Stabenow) and Mallory McMorrow (a state senator who leans more progressive but is part of her caucus’s leadership). And El-Sayed is not just challenging a pair of more conventional rivals. He is also challenging the conventional view of what it takes to prevail here.

El-Sayed has been called the “Michigan Mamdani” for that reason, a reference to the New York City mayor who is also an unabashed progressive—and who, by the way, is the first Muslim to hold his job, just as El-Sayed would be the country’s first Muslim senator. But Mamdani didn’t lean into controversy the way El-Sayed has by embracing and (literally) standing by Piker. On the contrary, even though Mamdani had the luxury of trying to win over a far more Democratic electorate, he called Piker’s 9/11 comments “objectionable and reprehensible.”

Mamdani made those comments during a televised mayoral debate, a month after catching flak for dodging questions about Piker. That’s a reminder that campaign dynamics evolve, as they surely will in Michigan, where it’s a long four months until the primary. The candidates are still introducing themselves to the electorate, and to some extent still figuring out how they want to present themselves.

Given all that, it’s hard to be confident about what will happen—or even what could happen. And watching Tuesday’s rally unfold, I found myself constructing two very different theories—one for why El-Sayed could win, one for how he couldn’t.

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HIGH-PROFILE DEMOCRATS HAVE BEEN saying their health care agenda can’t simply be about undoing all the damage that Donald Trump has done to Medicaid and the Affordable Care Act—that they need to focus on the underlying forces driving up costs, which ultimately make health care more expensive for everybody.

A prominent think tank with close ties to the Democratic establishment is about to unveil a proposal designed to do just that.

On Wednesday morning, the Center for American Progress will introduce a set of proposals to limit what hospitals and insurance companies can charge, while also limiting the ability of insurers to deny coverage that doctors recommend to their patients.

The proposals, which CAP senior staff shared exclusively with The Bulwark, aren’t fully fleshed out in the way, say, a bill in Congress would be. It’s a starting point for future legislation—a set of ideas that political leaders could debate and refine, tout on the campaign trail and, eventually, attempt to pass into law.

CAP is widely known as the unofficial policy incubator for moderate-to-liberal Democrats, which means its proposals are likely to get a serious hearing in Washington. Veterans of past Democratic administrations are heavily represented in the group’s upper ranks. Many would probably end up back in the executive branch—or with jobs on Capitol Hill—if Democrats get control of either or both in upcoming elections.

And insofar as CAP’s agenda is indicative of where the party establishment’s brain is right now—or, at least, where CAP current leaders would like it to be—this new proposal signals a few important shifts in thinking about health care.

For one thing, the focus of this new agenda is very clearly on improving affordability for everybody, rather than getting coverage for those who are uninsured. “If you want to address people’s concerns about health care, their concerns are driven by high health care costs,” CAP president Neera Tanden told me in an interview. “It’s important to put forward ideas that will help the 91, 92 percent of Americans who have insurance.”

Tanden said the decision to focus on costs didn’t mean CAP was backing off its commitment to universal coverage. “We believe health care is a basic human right,” she told me. Nor did Tanden suggest deemphasizing the importance of reversing GOP cuts to Medicaid and the Affordable Care Act, which together are projected to leave tens of millions of Americans either with more expensive coverage or altogether uninsured.

But, Tanden and her colleagues said, it was important to address the cost issues as soon as possible. They also said it was important to address sources of everyday frustration for those who are already insured, especially when it comes to denials of treatment that, in the worst of cases, can make it difficult for people to get the care they need.

“It doesn’t mean we shouldn’t talk about expanding coverage—that’s always going to be a part of the agenda,” Topher Spiro, a CAP senior fellow who oversees health policy, told me. “It’s just a recognition that we’re at a breaking point on costs . . . and we need to take that on.”

The CAP plan seeks to accomplish that by having the federal government get a lot more aggressive about using its regulatory power to hold down costs. Mainly it targets hospitals, by attempting to set a ceiling on what they can charge, and insurers, by putting new limits on their ability to raise premiums. There’s also a set of provisions that would change the way insurers review recommended treatments for approval, in some cases removing altogether their right to block specific treatments.

CAP is billing the proposal as a “patients’ bill of rights,” on the theory that it would protect patients from both unfairly high costs and unfair scrutiny of their medical care.1 And like any such proposal, it’s sure to draw objections from serious people who think it would do too much or too little, or simply wouldn’t work well.

But whatever its virtues or flaws—both worthy subjects of future debate—the proposal represents an important departure from the status quo. To see how and why, it helps to understand a sharp turn in policy that took place about fifty years ago.

PICK ANY PEER COUNTRY you want—Germany, France, Japan, the Netherlands—and you’ll discover they spend far less on health care than we do, in both the collective sense (i.e., measured as a percentage of their total economic output) and the individual sense (i.e., measured as each individual’s financial obligation).

The reason is that their national health systems do more than simply guarantee coverage for everybody. They use government leverage to limit or set prices for what hospitals, drug makers, and every other provider of health care can charge patients.

The United States has at times attempted to regulate prices in similar ways, even without a national health plan in place. And that has included efforts—mostly at the state level—to restrict what hospitals could charge. But by the late 1980s and into the 1990s, nearly every state had taken its hospital price regulations off the books.2

One reason was that the whole concept of government meddling with prices on health care—or any good for that matter—had fallen out of political fashion. It was the height of the Reagan era, although this thinking was by no means limited to Republicans and conservatives. Plenty of Democrats and liberals agreed, following the cues of trusted advisers who believed that competition among providers of health care, as well as among insurers, was the best way to drive down prices while promoting more efficient, higher-quality medical care.

You can see that thinking in the way American health care works today—including through the Affordable Care Act, which attempts to tap market forces by, for example, having insurers compete for customers on HealthCare.gov. But while there’s a respectable case that the law as a whole really did restrain health spending, relative to what it might have been, in recent years costs have once again started to increase more quickly.

A likely culprit in this is an increase in costs from hospitals, which are the single biggest component of overall health spending. And there’s lots of evidence that consolidation is driving that increase, because larger, newly merged hospitals have a lot more power to demand high fees—in some cases, acting like monopolies.

That realization has prompted many analysts—even card-carrying economists who a decade or two ago would have been content to let the free market do its thing—to suggest it’s time for the federal government to intervene more directly.

“Markets in the U.S. have become broken,” Zack Cooper, a Yale economist who has published groundbreaking research on the effects of hospital mergers on pricing, told me.3 “I don’t think it’s a lack of faith in the virtues of competition. I think it’s a question of whether a large share of markets can generate competitively set prices. And there’s evidence to suggest they can’t.”

The CAP proposal takes that thinking and runs with it, by calling on the federal government to prohibit hospitals in “concentrated markets” from charging fees that are more than three times what Medicare currently pays. Nonprofit hospitals with higher charges could lose their tax-exempt status under the CAP proposal, while for-profit hospitals could face some kind of financial penalties. A separate set of proposals would seek to limit what some insurers could charge, while strengthening existing restrictions designed to limit how much of their money goes to profits and overhead.

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The proposal leaves out lots of important details—including, for example, exactly how officials would determine what qualifies as a “concentrated” hospital market where the government’s rules would kick in. It doesn’t take a ton of imagination to guess the kind of scrutiny it’d draw from the left, where critics would probably say the proposal is too complex and tries to dodge the broader restructuring necessary for real relief. It is similarly easy to imagine attacks from the right, where critics would say regulations are bound to push prices either too high or too low, forcing excessive spending or shortages or some combination of the two.

But whatever the merits of those arguments, it says something that the analysts whom CAP consulted on the plan include some of the best known figures in the field. Several told me they thought the package was a sensible, promising step toward getting health care costs under control.

“It’s not bad economics, it’s good economics—it’s letting the market work until it doesn’t,” MIT economist Jonathan Gruber, who played a key role in shaping the Affordable Care Act, told me.4 “This is the lesson I teach my students in basic economics: You trust markets until markets stop working. And at that point, you start to think about regulation.”

THE OTHER BIG WAY THE CAP PROPOSAL envisions breaking with status quo thinking is by limiting the ability of insurers to restrict access to care by requiring approval in advance—or, as it’s known in the business, “prior authorization.”

If you’ve ever had to see a specialist or get a procedure, you’re probably familiar with how difficult this process can be. It’s been the rule rather than the exception ever since the 1990s, when private insurers adopted the practice as a way to scrutinize health care decision-making.

The theory behind it was that the old system, in which insurers paid for whatever doctors ordered up, created incentives to seek and get care that might be unnecessary or even harmful. Prior authorization represented a strategy for deterring that practice, in a way that would not only improve care but hold down costs. And there’s certainly evidence it’s worked that way, at least some of the time.

But there’s also evidence that prior authorization can push health care spending higher, by adding a bunch of costly administrative work. And that’s not to mention the potential for insurers to apply standards arbitrarily or excessively. They can deprive people of care they actually need to stay healthy—which can, as a side effect, increase overall health care spending by creating even worse medical problems in the future.

Prior authorization “can powerfully delay coverage, and sometimes deny coverage outright,” said Miranda Yaver, a University of Pittsburgh health policy professor whose forthcoming book, Coverage Denied, examines how prior authorization veered from its original purpose.5

The CAP plan proposes to change these practices—in part, by prohibiting prior authorization altogether for certain kinds of emergency, routine, and chronic care, as Massachusetts recently announced it was doing. Insurers could still review other kinds of claims. And for the types of care that data shows are frequently overused (like some kinds of back surgeries) the insurers could still review claims before payment. But they’d have to run it through outside organizations that follow clinical guidelines.

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Like CAP’s proposals for regulating hospital and insurance prices, the proposals to change prior authorization leave lots of unanswered questions—like precisely what would qualify as an emergency case exempt from review. And here too, it’s easy to imagine analysts from a variety of perspectives raising serious concerns—including whether, by taking away a tool insurers have used to hold down health care spending, this proposal might actually drive up costs.

But one of the experts CAP consulted on the proposal is Zirui Song, who in addition to being a health policy professor at Harvard is also a practicing physician. And one thing he likes about the proposal, he told me, is the way it recognizes that different sorts of care call for different sorts of scrutiny.

“When I think about improving the system of prior authorizations, it’s less of a yes or no [question] . . . and more about making sure decisions align with the clinical evidence base,” Song said.

ULTIMATELY THE CHALLENGE in attempting to translate something like the CAP policy into legislation isn’t just about getting the policy right. It’s figuring out the politics too. And as much as this proposal is designed to meet the moment, by addressing worries about costs that voters say are a top concern, it would almost certainly run into stiff resistance from insurers and hospitals.

But industry opposition isn’t always insurmountable. Just a few years ago, Joe Biden and the Democrats managed to enact new regulations on prescription drug prices, despite hard-core pushback from the pharmaceutical industry.

It helped that the idea was inherently popular. But it also helped that the process of crafting that legislation started years before Biden took office, because it meant there was time to work out the substance and the presentation. Something similar could be starting now.

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DONALD TRUMP LAST WEEK gave an unexpectedly candid riff on his governing priorities—and, in the process, revealed that he’s losing one of his most important political skills.

It happened on Wednesday, during a private Easter luncheon at the White House. Here’s what Trump said:

We’re fighting wars, we can’t take care of daycare. You’ve got to let a state take care of daycare, and they should pay for it, too. They should pay—they’ll have to raise their taxes, but they should pay for it. And we could lower our taxes a little bit to them, to make up for—but we—it’s not possible for us to take care of daycare, Medicaid, Medicare, all these individual things. They can do it on a state basis. You can’t do it on a federal [basis]. We have to take care of one thing: military protection. We have to guard the country.1

Typically, Republican leaders try very hard to deny they are starving social programs to fund the military, leaving Democrats to make the case on their own. Yet here was Trump coming right out and saying it. And while the president frequently blurts out statements that have no bearing on reality, in this case his description of how he’d like to rearrange federal spending priorities was pretty much on the nose.

In fact, just two days after he made those remarks, his administration released its budget for fiscal year 2027. It envisions a $1.5 trillion increase for defense, then proposes to offset that cost with a 10 percent reduction in domestic spending. Among the casualties would be a program that helps low-income Americans pay for heating and cooling—yes, right at a time when electricity prices are on the rise.

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Not that it takes a new budget to see Trump’s priorities in action. It’s been less than a year since he worked with Republicans to pass historic cuts to Medicaid and food assistance, while refusing to extend Affordable Care Act subsidies holding down insurance premiums for more than 20 million people.

None of this has been popular. Most Americans are opposed to the Iran war, according to polling, just as most Americans opposed the Medicaid cuts and wanted to see those “Obamacare” subsidies stay in place. That’s going to hurt in the midterms, as my Bulwark colleague Catherine Rampell observed last week.

But Wednesday’s riff and the governing record it matches threaten to undermine Trump’s appeal in another, more fundamental way—one that requires thinking back to 2015 when he was first seeking the Republican presidential nomination.

IT’S BEEN A WHILE—more than ten years!—so it’s easy to forget the extent to which Trump presented himself as a different kind of Republican, one who was willing to buck his own party’s establishment.

A lot of this was about trade, war, and immigration—how, as Trump told it, Republican elites had bankrupted the country with foreign interventions and sold out working Americans by shipping jobs over to China, all while allowing the country to be overrun with dangerous immigrants stealing everyday jobs. But Trump went out of his way to say he disagreed with the GOP establishment on matters of the welfare state as well.

“I’m not going to cut Social Security like every other Republican and I’m not going to cut Medicare or Medicaid,” he told the Daily Signal in 2015, making a promise he’d repeat many times over the course of the campaign.

And while Trump from day one was pledging to repeal the Affordable Care Act, he repeatedly told audiences, interviewers, and anybody else who would listen that he would replace it with something better, so nobody had to go without health care.

“Everybody’s got to be covered,” Trump told 60 Minutes in 2015, adding, “This is an un-Republican thing for me.”

Trump, in making this pitch, sounded a lot like a political archetype familiar in Europe, where some right-leaning parties have long opposed immigration while supporting government programs that provide generous health care, childcare, and other benefits. There’s even a term in the political science literature for this type of appeal: “welfare chauvinism.”

But anybody following Trump closely had good reason to question whether his pledges would translate to actual policy. His campaign rarely released formal policy proposals, and when they did they were comically devoid of details. During debates, he served up gobbledygook. Word got around that (as Trump more or less admitted) he strongly preferred memos keep to no more than a single page, preferably with graphs and visual cues, suggesting he was either uninterested or uninformed or both—and that, in office, he’d defer to congressional leaders who were precisely the old-style Republicans he said he was rejecting.

Which is just what happened, especially during his first year in office. Trump embraced congressional plans to repeal the Affordable Care Act that would have wreaked havoc with coverage for tens of millions of people, slashing Medicaid and private insurance subsidies to pay for tax cuts that disproportionately benefited corporations and the wealthiest Americans. And while he didn’t succeed on repeal, he did get the tax cut.

Through it all, however, Trump talked a good game on standing by the welfare state, including during the 2018 midterm campaign when he accused Democrats of attacking the big entitlement programs. “They’re going to hurt your Social Security so badly, and they’re killing you on Medicare,” he declared at one rally. “Just remember that. I’m going to protect your Social Security.”

Trump also made a high-profile effort to show he was prepared to help families dealing with the strains of work and raising children, most memorably in 2019 when he convened a White House summit on the subject. “With more women working today than ever before, we now have a historic opportunity to enact long-overdue reforms,” Trump said. “It’s time to pass paid family leave and expand access to quality childcare.”

THAT CHILDCARE AND PAID LEAVE EFFORT was supposed to be led by Trump’s eldest daughter, Ivanka, who back then was both a visible administration spokesperson and a regular presence in the West Wing. But it never got a real push from the White House.

Ivanka isn’t part of this new Trump administration, and neither is warm presidential rhetoric about providing struggling parents with help getting time off or paying for childcare. In fact, it’s hard to think of a single meaningful thing Trump has said on the subject—except those comments this past Wednesday, when Trump said the federal government couldn’t afford it.

Probably the closest Trump has come to channeling his first-term self on social welfare has been when he talks about prescription drug prices. He has put a lot of energy into negotiating deals with pharmaceutical manufacturers that—in the White House’s telling—are right now producing dramatic drops in the prices of prescription drugs.2 But the savings are mostly illusory, and hardly enough to offset the big price hikes for the more than 20 million Americans who had been getting assistance from those lapsed Affordable Care Act subsidies.

And that effect is hitting already. New data compiled from HealthInsurance.org shows that 10 percent of people who bought insurance this year shifted from “silver” to less generous “bronze” plans, almost certainly because they couldn’t keep up with rising premiums. That’s on top of people who are just eating the cost increases, or going uninsured altogether.

Whether that registers politically is a separate question. It depends on whether voters link their hardship to decisions that Trump and his Republican allies have made, which depends in part on whether Democrats can show the link exists. But Trump’s daycare riff on Wednesday makes that easy. Democrats can just run ads playing his remarks, verbatim.

The president gave them a gift. The one who occupied the Oval Office ten years ago never would have made that mistake.

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ROBERT F. KENNEDY’S JR.’S LATEST MOVE on public health seems like the setup for a joke: The preternaturally bronzed member of Donald Trump’s image-obsessed administration just quashed an attempt to protect people from cancer-causing tanning-bed rays. But the decision is no laughing matter, as retired dermatologist and Northwestern University professor June Robinson reminded me this week when she recounted the story of a former patient.

A “gorgeous” woman in her early twenties, the patient was a Polish immigrant who spoke very little English and had found work cleaning houses in Chicago. “She arrives in my office,” Robinson explained in a phone interview, “and she’s very embarrassed because she has a lesion—a spot—in her private area, and she doesn’t want to see a male physician.” Robinson noted the woman’s deep full-body tan, found the lesion high on the inside of her thigh, and instantly realized two things.

The first was that the lesion was probably melanoma, the most dangerous form of skin cancer. The second was that it had almost certainly come from ultraviolet light inside a tanning bed. “This is a place where, in reality, the sun should never have” reached, Robinson said. “Even if you were on the beach, in your bathing suit, you just would never have gotten sun right there.”

Robinson asked: Have you used a tanning salon? Yes, the patient answered, she had started bathing in tanning beds regularly when she was a teenager. “She proudly tells me it’s because she . . . wanted to appeal to her boyfriend,” Robinson said.

Melanoma is among the more survivable kinds of cancer with sufficiently early detection. But the odds have always been far worse when the cancer metastasizes and spreads into distant organs.1 And that’s what had happened with this patient. Cancer was already in her lymph nodes. She died not long after.

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It was precisely to prevent such tragedies that the Food and Drug Administration in 2015 proposed new, tighter restrictions on tanning beds. One of those restrictions would have prohibited minors from using the devices at all, on the theory that young people’s still-developing bodies were more vulnerable to the carcinogenic effects of tanning-bed light, and that their still-developing brains were less capable of assessing the risks of exposure.

The proposal looked a lot like the FDA’s initial move to ban youth cigarette sales back in 1997, including the way it represented the culmination of a decades-long advocacy led by physicians like Robinson who had seen firsthand the damage tanning beds could do. And although the FDA rule sat in limbo for a decade, while tanning-salon operators and their allies stuffed the official public comment portal with objections, advocates for the prohibition have remained hopeful that it would eventually take effect.

Those hopes were dashed last week, when the FDA formally withdrew the proposed rule. The official notice from the Department of Health and Human Services—of which the FDA is part—cited “scientific and technical concerns” that had come up in the comments, along with questions about possible “unintended consequences.” It was RFK Jr.’s name on the order, just as it was his lieutenants and allies at the FDA who had made the decision.

HHS spokesperson Emily Hilliard told me over email that the FDA simply wanted “to reassess how best to address the issues [the proposal] raised, including how to balance public health considerations with consumer access and choice.” She also made clear that the agency was not disputing that tanning beds are dangerous. “Exposure to ultraviolet radiation, including from sunlamp products, is known to increase the risk of skin cancer,” she said.

But Hilliard didn’t respond to my question about whether Kennedy had weighed in with the FDA, either through official consultation or informally. And whatever role Kennedy did or didn’t play in the decision, the tanning bed announcement is emblematic of decision-making he’s brought to HHS. It is the latest sign that his promises to prioritize “gold standard” science and fight special interests are meaningless—and that, even as his political influence may be waning, he is finding new ways to undermine public health.

THERE ISN’T MUCH MYSTERY LEFT when it comes to the mechanism of how tanning beds lead to cancer.

The energy from any kind of ultraviolet light can damage both surface and deeper layers of skin, producing rogue cells that grow and reproduce in ways that the body’s normal defenses can’t handle. In other words, they become tumors. And especially when tumors appear in melanocytes—the inner layer of cells that produce pigment—they can spread to other organs, where they can become deadly, as they were for Robinson’s patient.

Whether ultraviolet light has this effect on any single individual will depend on a variety of factors, including genetic predispositions. But a key variable is the length and intensity of exposure. And although the sun is the most obvious and most significant source of potentially dangerous ultraviolet rays—that’s why you hear so much about sunscreen2—tanning beds represent a whole other kind of threat.

“This is the most mutagenic form of UV radiation, equivalent to being at high noon at the equator,” Hunter Shain, a cancer biologist and associate professor at the University of California, San Francisco, told me. “So if you’re living in North America, you can’t even get this type of sunlight anywhere, not even in Miami.”

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The light in modern tanning beds mostly comes from what are known as Ultraviolet A rays, which lead to tanning, rather than the Ultraviolet B rays that cause burns. Promoters of indoor tanning sometimes cite this as proof tanning beds are safe. But that’s nonsense, according to scientists like Shain, because the light levels inside are so much stronger than the natural kind. “Even if you’re in there for just fifteen minutes, that can do quite a bit of damage.”

The supposed safety of modern tanning beds is just one of the arguments the industry and its supporters sometimes make. Others include claims that “pre-tanning” before vacations in sunny places can protect people from cancer because tanning is the result of the body producing extra melanin in order to protect itself. One problem with that claim is that a tan is roughly equivalent to wearing sunscreen rated SPF3 or SPF4—i.e., far too minuscule to protect against carcinogenic effects.

But it’s not just the physiology of skin cancer that makes tanning beds such a public health hazard. It’s also the way they get used in real life—and by whom. Tanning has been a sign of high status ever since the early twentieth century, around the time cameras caught a glimpse of a sun-soaked Coco Chanel walking off a boat in Cannes and established a complexion standard that pasty-white factory and domestic workers could only envy. That helps explain why tanning beds became so popular in the 1970s, when they arrived in the United States and offered a sunning option for people who couldn’t afford a trip to the French Riviera.

Nowadays, they make up a multi-billion-dollar industry.3 And while tanning beds are dangerous for anybody, scientists and advocates worry especially about the threat to young people, because effects on both psychology and physiology can last into adulthood. “This has been studied extensively, and the risk of skin cancer is higher in people who use tanning beds when they are younger,” Eleni Linos, a professor of dermatology and epidemiology at Stanford, told me. “Some of it is the longer duration, some of it is habit formation.”

And lots of habits are being formed. Robinson led what is thought to be the first comprehensive survey of tanning bed use, which found that in the early 1990s in Illinois, roughly 16 percent of girls aged 17 to 19 were using tanning beds. She said it wasn’t so surprising given the ubiquitous advertising.

“We’d have Joe Camel advertising smoking right next to billboards for indoor tanning,” she said. And that was on top of more direct forms of promotion, something Robinson witnessed one day on her way to work in Chicago when a young woman gave her a flyer with a coupon for a nearby salon.

“I saw that and thought, this is one of the stupidest things I’ve ever seen,” Robinson said.

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THE ILLINOIS SURVEY became part of the evidence cited by medical societies, cancer patient groups, and other public health advocates pushing for restrictions on tanning beds—including a ban on use by minors—across the country. The years of education, advocacy, and persuasion became a real slog, said Robinson, whose own efforts included launching a campaign while she was serving as president of the American Society of Dermatological Surgeons in 1994.

She remembered in particular a 2006 meeting at the FDA. Officials there made clear they agreed on the dangers of tanning beds, Robinson said. But they felt they could do no more than require device inspections, warning labels, and consent forms. More change would require legislation, they said.

Advocates pressed for just that, and won quite a few victories at the state level. Today, the majority of states have laws restricting tanning bed access for young people, though the ages and level of restriction vary. Advocates also kept pushing the FDA, which in 2015 finally proposed the rule to institute a total ban on use by minors.

Tanning beds are “dreadful, and young people typically do not weigh the risks properly,” Ezekiel Emanuel, an oncologist who is a vice provost at the University of Pennsylvania, told me. “That is why we don’t let them smoke, we don’t let them drink alcohol. We shouldn’t let them use tanning beds. It’s just as toxic, with no upside benefits.”

But the proposed rule didn’t move forward. It just sat there, waiting for action through the final year of the Obama administration, and then both Trump’s first term and Joe Biden’s presidency as well. And while there may be no simple, single explanation for the long delay, a likely suspect is all the pressure from the industry, which made its presence known in overt and subtle ways.

“We found that the studies that had financial links to the industry were much more likely to downplay harms compared to studies without these financial links,” said Linos, who published a widely read paper on the influence on research used in political debates. “It may seem obvious, but science should not be influenced by the incentives of any industry—whether it’s Big Tobacco or Sugar or Pharma. Science should be independent.”

Industry pressure is, of course, something Kennedy vowed to fight as HHS secretary, just as he vowed to prioritize high-quality science. But so far, he’s mostly used those rallying cries as justification for attacking vaccines, despite all the evidence that they are safe.

Meanwhile, the danger of tanning beds is an actual case of a well-documented, high-quality scientific finding that really has been waiting for government action, in part because of industry pressure. But instead of pushing the process forward, Kennedy’s department is yanking it back—while he himself is showing off his ultra-tanned body at seemingly every opportunity, including that now-infamous HHS video where he shares a hot tub with Kid Rock.

It would be amusing, maybe, if there weren’t evidence that messages Kennedy sends about health have real-world effects on people’s behavior.4 It’s no stretch to imagine Kennedy’s tanning inspiring people to use tanning beds, especially if they are already sympathetic to his politics.

The experts are worried, not just about the public health message he’s sending but about his personal health as well.

“Look at his leathery skin and his wrinkled face—that is what chronic exposure to ultraviolet light does to you,” Robinson told me. “He really needs to be looked over by somebody, to check for skin cancer.”

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THERE ARE SIGNS that the debate about health care in America is about to get out of the rut it’s been in for about fifteen years—and that Democrats are preparing for the moment when it does.

Ever since 2010, the most high-profile fights in Washington have been about the Affordable Care Act and Medicaid. Mainly that’s because Donald Trump and the Republicans keep attacking those programs—as they did last year when they enacted the largest-ever cuts to Medicaid, then refused to extend lapsing “Obamacare” subsidies that had helped millions to get coverage, and reduced premiums for many millions more.

Democrats are determined to reverse those two steps, somehow, and you can expect them to make that a rallying cry in their campaigns for November’s midterm elections. But at least some Democrats don’t want to stop there. On March 19, a dozen of the party’s senators released an open letter announcing their intention to develop policies that would address a broader topic: The underlying increase in health care costs that is affecting everybody, not just people who are uninsured, on Medicaid, or buying coverage at HealthCare.gov.

The roughly 170 million Americans who get coverage through their employers are now paying (directly and indirectly) an estimated $27,000 a year on average for a family policy. “The American people need relief from rising premiums and deductibles that are forcing families into financial ruin,” the Senate Democrats wrote in their letter. “They also want an insurance system that doesn’t require them to jump through hoops and hack through red tape every time they need care.”

That may sound like a bunch of frothy boilerplate, given that the letter contained no specifics. But it’s not just these Democratic lawmakers who say it’s time to have a broader conversation, one that goes beyond undoing what Trump and the Republicans have just done. You hear the same thing from prominent analysts and advocates like Anthony Wright, president of the pro-coverage, pro-consumer organization FamiliesUSA.

“I do think people recognize that, as we wage the fight to defend coverage and consumer protection and specific communities under attack, that we don’t fall into a trap of defending the status quo that people thought rightly was broken,” Wright told me in an interview. “We need to show that we have a plan, not just to repeal bad stuff, or even to rebuild—but to reimagine what the health system should look like.”

That kind of reimagining can’t happen right away. Trump and the Republicans seem incapable of putting forward serious reform proposals, unless they involve hacking away at insurance coverage for people who need it. And the first chance Democrats might have to govern with a trifecta is nearly three years away. But it’s with an eye to that possibility that Democrats and their allies are starting to plan now—to make sure they are “prepared to take action on these issues the next time Democrats have an opportunity,” as the Senate Democrats put it in their letter.

And there’s an unmistakable parallel here, to a politically similar time when Democrats and their allies started laying the groundwork for future legislation. “This moment feels a bit like twenty years ago,” Larry Levitt, executive vice president for health policy at KFF, told me in an interview, “when groups of policy experts, advocates, and politicians started to talk about health care ideas that ultimately coalesced into the passage of the Affordable Care Act.”

But the challenge is different this time, and in some ways more difficult. Reducing health care costs inevitably involves reducing the flow of money into somebody’s pockets, which just as inevitably angers powerful constituencies and industry groups. Democrats aren’t even close to having a consensus on what to do. And 2029 is a lot closer than it might seem.

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ONE PERSON WHO KNOWS THIS all too well is Ron Wyden, the senator who organized the open letter and who hopes to lead discussions inside his caucus. He’s been focusing on health care ever since the 1970s, when as a freshly minted college graduate he helped to establish Oregon’s chapter of the Gray Panthers, a grassroots organization to defend the interests of seniors.

The unfailingly earnest Wyden will bring this up anytime you talk to him about health care. It’s part of his wonky charm, if you’ve gotten to know him as some of us have, and a point of information that is genuinely relevant. Helping elderly Americans get health care really has been a signature cause, going all the way back to 1981 when he first got to Congress.

In fact, when I spoke to Wyden last week, he said he was still angry over testimony that Mehmet Oz gave a year ago, during hearings for his confirmation as administrator of Medicare and Medicaid. The celebrity doctor had refused to stand by a Biden-era rule that raised the minimum staffing standards for nursing homes—requiring more personnel and a nurse on duty 24/7 by 2029—instead arguing that technology and telemedicine could take the place of extra staff.

“Are you kidding me,” Wyden said in our interview, “an 85-year-old woman trying to go to the bathroom in a dark bedroom is somehow going to be able to be safe and get there by an algorithm?”1

But Wyden has also put in the time to think about and propose policies for non-elderly Americans. In late 2006, shortly after Democrats won control of the House and Senate in that year’s midterm election, he unveiled what he called the “Healthy Americans Act”—a detailed legislative proposal, complete with a financing scheme and independent analysis of its likely cost and impact.

It was a watershed moment, because it signaled that mainstream Democrats were serious about trying to enact legislation to achieve or at least approach universal coverage. Democratic leaders had mostly abandoned that effort in the 1990s, after a failed reform effort by then-President Bill Clinton helped to fuel a political backlash that ended up giving Republicans full control of Congress for the first time in decades.

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Wyden’s proposal didn’t ultimately become the template for new reforms, partly because it envisioned everybody—even people who already had employer insurance—buying coverage on their own through newly regulated markets. That violated what most strategists believed was the single biggest lesson of the Clinton fiasco: Don’t mess with employer insurance, because it will spook anybody who has it already.

Another reason Wyden’s proposal didn’t go far was that he was not in charge of the Finance Committee, whose jurisdiction over taxes, Medicare, and Medicaid make it the single most critical committee for health care legislation. The chairman at the time was Montana Democrat Max Baucus, whose politics skewed more conservative and whose close ties to industry lobbyists 2 enraged many of his fellow Democrats. Baucus—whose relationship with Wyden was never great—favored the less ambitious reform model that eventually became the Affordable Care Act, which left employer coverage in place.

Wyden finally got his chance to legislate years later, as ranking minority member and then (after the 2020 elections) chairman of the Finance Committee. That’s when he helped craft the Inflation Reduction Act’s prescription drug price reforms, including provisions that allow Medicare to negotiate with manufacturers over the prices of certain high-priced drugs, a longtime Democratic goal.

Wyden is in line to again become Finance chairman if Democrats retake the Senate in 2026, meaning that he would once more have the staff and jurisdiction to shape legislation. And he’s already taking the initiative, in case the opportunity presents itself. The March 19 open letter outlines steps, including a series of conversations with both fellow senators and outsiders who have something to say, that Wyden hopes can lead to some kind of framework for legislation that the Finance Committee would formally release.

“Senate Finance Committee Democratic staff will develop policies that lower costs, make it simpler to get and use insurance, and rein in shameless profiteering by corporate insurance companies,” the March 19 letter states, hinting at the directions Wyden and his colleagues want to go with policy.

This letter is actually the second one Wyden and his colleagues have released. The first was about prescription drugs. There are plans for a third, which will focus on long-term care. It’s a lot to take on, which is why—Wyden told me—it’s important the work gets started now.

“It takes a lot of sweat equity if you want to get into major changes,” he said.

WYDEN IS BY NO MEANS THE ONLY MEMBER of the Democratic caucus who is thinking big thoughts on health care, or who would be expected to play a key role in legislation should the party get a chance to govern. The list of others starts with Bernie Sanders, the independent and self-described democratic socialist from Vermont, who has spent a political lifetime making the case for a single-payer, “Medicare for All” system.

Should Democrats regain power, Sanders would be in line to take over the Health, Education, Labor and Pensions Committee—which, despite its name, has traditionally played a junior role to the Finance Committee on health care issues because it has more limited jurisdiction. But Sanders’s long history on health care, plus his position as leader of the party’s progressive wing, means he would have to be part of any serious legislative effort.3

Sanders isn’t on the open letter. But a few other high-profile progressive Democrats are (Elizabeth Warren of Massachusetts, Peter Welch of Vermont) as are some more conservative senators (Elissa Slotkin of Michigan, Mark Warner of Virginia). And it’s not just on Capitol Hill where there’s broad interest in thinking about the long term. There have been stirrings of activity in the world of think tanks and advocacy groups, too.

“There are various interactive conversations in this world, including advocacy and think tanks, and they are just starting,” said Wright, whose experience includes more than two decades spent helping to lead reform campaigns in California. “I don’t want to overstate how far they’ve gone—really just getting underway, a lot of it informal. But you can tell people are thinking ahead.”

One reason such efforts led to legislation in the past, with the Affordable Care Act and with prescription drug reforms, is that Democrats were able to coalesce around some core ideas. Doing that now is going to require working through some contentious, complex questions, starting with one that dominated the 2020 presidential primaries—i.e., the last time Democrats were the party out of power—when the debate was about whether or not to endorse Sanders’s version of Medicare for All.4

That debate is certainly worth having. Among other things, Medicare for All represents one way to deal with costs, since the early-stage proposals from Sanders and others generally envision the federal government controlling spending through a combination of budgets and price regulation, as countries abroad with national health systems do.5

But like all proposals it comes with tradeoffs. It would be taking money away from at least some parts of the health care industry—including hospitals—and those affected sectors would argue (plausibly or not, depending on your point of view) that the change would lead to rationing. And that’s to say nothing of the fact that—like Wyden’s old plan—the purest schemes envision the new public insurance system replacing existing employer coverage.

A healthy internal Democratic debate would consider that idea, just as it would consider other ideas for controlling costs—including some that haven’t yet gotten a ton of political attention. That might include, for example, going after costs with budgets and price controls but without requiring everybody to shift into a new public insurance plan.6 It could also include proposals that create a new public plan but that make enrollment purely voluntary—what’s come to be known as a “public option.”

Yet another way to go would be to focus on a set of discrete, targeted reforms—like expanding the new prescription drug negotiating powers or resurrecting the once-popular idea of a “patient’s bill of rights” that restricted the ability of insurance companies to deny treatments. One advantage of this approach is that, depending on the specifics of the proposals, Democratic lawmakers might be able to pass narrower reforms more quickly. (Most likely, they’d have to use the budget reconciliation process to avoid a Republican filibuster.) That could help build trust with voters for subsequent efforts.

Of course, even the smaller, more targeted ideas would also come with tradeoffs. More aggressive drug price regulation, for example, could affect innovation. And deterring insurance company reviews could end up making it harder for them to control costs. That’s the whole point of taking up these ideas now: To weigh those tradeoffs, figure out how to present the worthwhile ideas, and then build a consensus behind them.

“You can’t win health reform before the election, but you can lose it,” said Wright. “If you don’t set things up, then you won’t be ready when the window opens.”

And the window is bound to open, probably in the next few years, because that’s how it goes in American politics. Big debates about how to reform health care reliably start once the problems of the status quo have become impossible to ignore, and once the battle scars from previous debates have started to fade. Typically the cycle takes about two decades. And it’s been almost exactly two decades since the start of the process that led to the Affordable Care Act.

This doesn’t mean the Affordable Care Act was a failure, as Republicans frequently claim. It simply means there is a lot more to do, because—as Barack Obama tweeted last week—the law “was always meant to be a first step.”

And now, just maybe, it might be time for the next one.

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GENERAL MOTORS JUST ROLLED OUT A CAR that’s perfect for the moment. It’s the 2027 Chevrolet Bolt—a relatively cheap, all-electric subcompact that will let you drive right past gas stations, and dodge those high prices from the war in Iran.

But if you want a Bolt, you’d better act fast, because they won’t be on dealer lots for long. GM has already confirmed that production will end next year. The plan is to convert the Bolt’s factory in Kansas City back to manufacturing vehicles with internal combustion engines.

GM says it made its decision to limit the Bolt a while ago, and remains committed to producing other EVs. That’s almost certainly true. But it’s also true that GM has dialed back its overall EV ambitions—by, for example, shelving plans to convert more factories to EV production—and that other companies are doing the same. Just this past week, Honda announced it was scrapping plans for three EVs it had been preparing to manufacture at factories in the United States.

There’s no single, simple explanation for the retrenchment. But a big part of the story is Donald Trump. Since taking office, he has launched an all-out assault on EVs—by working with Republicans in Congress to eliminate tax breaks for vehicle production and purchases, and by using his regulatory powers to gut federal and state emissions standards that favored fuel efficiency.

“It wasn’t just the subsidies that Trump removed,” Corey Cantor, research director at the Zero Emission Transportation Association, told me. “It was the fuel economy standards. It was the California regulations. So it was almost a triple whammy of policy pullback.”

Trump has insisted that these old policies—the bulk of which were put in place by former President Joe Biden and the Democrats—were forcing the auto industry to make unprofitable vehicles, while sapping America of its petroleum-powered swagger. But high gas prices are turning that swagger into a stagger: Edmunds, the website for car buyers, says it has in recent weeks seen a rise in customer inquiries about EVs. You can safely assume that’s going to continue as long as gas prices stay high, which means that more American consumers are going to be looking for vehicles that U.S. manufacturers are becoming less able to provide.

The saddest part may be that it’s all happened before. Demand for fuel-efficient cars surged after a series of oil price spikes in the 1970s, starting with the 1973 embargo by countries in the Middle East. American automakers were unable to meet the demand, because they had staked their future on the ability to keep selling large vehicles that guzzled gas. GM and the other Detroit legacy companies fell behind international competitors like Toyota, ceding big chunks of the market they were never able to recover.

Now the American automakers are poised to suffer another huge setback, under strikingly similar circumstances. But there is one critical difference between then and now.

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WELL, WELL, WELL. The brainworm may finally have turned.

Robert F. Kennedy Jr. has spent the past year systematically dismantling federal support for vaccines. From his perch atop the Department of Health and Human Services, he has canceled funding for vaccine research, published misinformation about supposed vaccine dangers, forced out or fired respected scientists who might resist his agenda, and withdrawn federal recommendations for a half dozen childhood vaccines.

Until recently, Kennedy had run into little resistance. Donald Trump, who gave Kennedy all this power, has lauded Kennedy and amplified his attacks on vaccines. Bill Cassidy, the high-profile Senate Republican and Louisiana physician has—despite some angry statements—refused to use his chairmanship of the Health, Education, Labor and Pensions Committee to demand changes or even explanations for Kennedy’s actions.

But this week Kennedy suffered a major setback. And it came at the hands of the judiciary.

On Monday, a federal judge in Boston blocked several of Kennedy’s most consequential policy changes, arguing that he had violated legal rules for how the HHS secretary is supposed to make key decisions. The 45-page ruling was a big win for the plaintiffs—a group of medical organizations and affected individuals led by the American Academy of Pediatrics—who have been protesting Kennedy’s actions from the get-go.

“There is a method to how these decisions historically have been made—a method scientific in nature and codified into law through procedural requirements,” Judge Brian Murphy wrote in his opinion. “Unfortunately, the Government has disregarded those methods and thereby undermined the integrity of its actions.”

Murphy’s order “stays” several key actions taken by Kennedy’s department—meaning that they are not fully prohibited, but rather they are put on hold as the legal proceedings fully play out. Judges in higher courts may not see things the same way; they could reverse some or all of Murphy’s ruling if the Trump administration appeals, as officials are already promising to do.

“HHS looks forward to this judge’s decision being overturned just like his other attempts to keep the Trump administration from governing,” HHS spokesman Andrew Nixon told reporters after the ruling.1

The underlying legal issues here include genuinely complex questions about which powers the HHS secretary really has and the extent to which judges can or should determine who qualifies as an expert. It also involves questions over who has legal “standing” to bring a lawsuit like this. Murphy is a Joe Biden appointee, with a reputation as a liberal. It’s not at all hard to imagine conservative judges—including Trump’s appointees on the Supreme Court, if the case gets that far—ruling differently.

But Murphy’s order will help keep vaccines in the news. And that alone has important consequences, given how the politics around the issue seem to be shifting.

In just the last few weeks, the White House has taken a series of steps to get a tighter grip on operations at HHS, and to tamp down on some of the anti-vaccine rhetoric coming from Kennedy and his camp. It’s not clear whether Trump is having second thoughts about his full-throated endorsements of Kennedy. What is clear is that people around the president have gotten nervous that the anti-vaccine agenda is alienating the majority of voters who support vaccination strongly.

In short, Team Trump would prefer to change the subject. Murphy’s ruling makes that harder.

Which, perhaps, is appropriate. The debate here isn’t simply about whether Kennedy is making decisions in ways that comply with the law. It’s also about whether he is making decisions in ways that are good for public health. And this case highlights multiple ways in which he is not.

MURPHY’S RULING FOCUSES on two important, highly controversial decisions Kennedy made.

The first involves the Advisory Committee on Immunization Practices (ACIP), a group of up to seventeen outside experts who vote on which vaccines the Centers for Disease Control and Prevention should recommend. Service on the committee is voluntary, but it’s considered a big honor and appointees have historically had sterling, widely recognized credentials. Typically they have served staggered terms, with a handful coming on or leaving each year.

“The point of an advisory committee is that it’s not overly controlled by the incumbent administration—it’s not controlled by day-to-day politics,” Sam Bagenstos, a University of Michigan professor and expert on health care law, told me. “Instead, it’s driven by the outside expertise of people who actually worked in the field.”

The HHS secretary does have final say over who serves on the committee. But Kennedy has exercised that power in unprecedented ways—first by firing all of the committee’s sitting members at once, then by replacing them largely with people with histories of criticizing vaccines, vaccine mandates, or both.

Murphy, in his ruling, said Kennedy overstepped his authority, violating requirements of laws governing both the composition of federal advisory committees generally and the makeup of ACIP specifically. Murphy went on to state that the people Kennedy picked for the committee didn’t satisfy legal requirements that membership represent a “balanced” set of perspectives, drawn from people with relevant experience.

“This charter says we need people who are experts in vaccines, immunologists, public health, and so forth,” Dorit Reiss, a law professor and expert on vaccine policy at the University of California, San Francisco, told me. “When the judge looked at these people, he wasn’t looking at the question, ‘Are these people good people to be on the committee?’ He was asking, ‘Is the appointment process—and the credentials—in compliance with what the charter requires and what the law requires that they represent?’ And so he looked at them and said, ‘Here, you need people who represent these kinds of expertise, and that’s not what we got.’”

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After ruling that Kennedy had illegally sacked and replaced the old committee members, Murphy put on hold the decisions the ACIP made last year, including a December vote—later endorsed and implemented by the then-acting CDC Director Jim O’Neill—to withdraw a decades-old recommendation that all children get vaccinated against hepatitis B at birth.

But Murphy’s order also covered a separate, even more controversial change: the CDC’s decision in January to withdraw federal recommendations for a half-dozen other vaccines—including rotavirus and meningococcal disease. O’Neill didn’t even bother consulting with the committee on that decision. He made it on his own, citing an assessment memo written by scientists well known for the criticism of vaccines.

Circumventing the normal process in this way, Murphy ruled, was illegal because federal law requires CDC to consider ACIP’s views when making this decision. And on top of that, Murphy argued, the rationale CDC cited was conspicuously thin.

Instead of the sort of evidence-dense, lengthy guidance documents that CDC would typically review, it relied on a relatively thin memo that barely discussed some of the vaccines under consideration. And that memo relied heavily on selective, sometimes unsubstantiated arguments about the kinds of policies that might earn public trust, or how other countries have made their decisions about vaccines.

In issuing these findings, Murphy was stressing that officials legally had to take into account the law’s purpose—which is to ensure vital decisions about public health get serious, careful consideration in ways that take into account the best available evidence, as interpreted by people qualified to assess it.

“In a democracy, you don’t just get to do what you want—you have to operate within both the law and norms of good governance,” said Reiss. “The secretary has a lot of discretion, the secretary can determine the schedule and so forth, but he needs to go through legal procedure and have decisions that are well reasoned. . . . At the stroke of a pen, the secretary decided to overturn decades of careful decision-making that is aimed to protect children in the public health. And the court is saying you need to think about this a little more, because the law requires you to do that.”

Bagenstos, who served as HHS general counsel during the Biden administration, told me he could remember plenty of instances when officials were weighing complex decisions and would have loved to have acted quickly, bypassing some of the usual consultations and procedural steps.

“Look,” Bagenstos said, “it’s always faster to do things without procedure, right? The question is whether it’s better.” And when it comes to the decisions coming out of Kennedy’s HHS, there really isn’t any question, Bagenstos added.

“It’s haphazard and driven by some combination of whim and anti-vax ideology and the sort of weird obsessions of the particular people who’ve been put in positions of power in this administration,” he said.

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MURPHY’S RULING MOSTLY REJECTED the Trump administration’s arguments, which focused less on how Kennedy and his lieutenants made their decisions and more on whether the courts had the right to intervene.

Kennedy has broad discretion over who serves on ACIP, the administration argued, and a judge has no business questioning—as Murphy did—whether the credentials of specific scientists meet the standards that HHS has set in the past. As for the vaccine recommendations, the administration argued, they are just that: recommendations. Because states, insurers, and ultimately individual patients and doctors are free to make their own decisions, the recommendations should not be subject to a judge blocking them.

Then there is the question of legal standing, which is the idea that in order to challenge a federal regulatory action somebody has to show they have suffered a direct harm from it. Groups like the American Academy of Pediatrics can’t show this, the administration argued, and thus have no right to bring a lawsuit.

But most of all, the administration argued, the groups behind the lawsuit are really just seeking a legal excuse to block a policy they don’t like, but have been unable to stop politically. That is pretty much how Robert Malone—whom Kennedy put on the ACIP, and whose claims on supposed vaccine dangers mainstream scientists keep refuting—characterized the ruling after it came out Monday.

“Secretary Kennedy and the Trump administration came into office with a clear mandate: restore transparency, scientific integrity, and parental choice to America’s public health apparatus,” Malone wrote in a lengthy Substack post. “What they encountered instead was a bureaucratic fortress built over decades, defended not by persuasive science but by procedural technicalities and sympathetic federal judges. Today’s ruling is the latest skirmish in that battle.”

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THE LEGAL DOCTRINES here are subject to enough legitimate debate that even likeminded jurists might reach conclusions different from Murphy’s. But whether the case even moves ahead depends on whether the administration follows through on promises to appeal. And this is where the tricky politics of vaccines come into play.

Trump advisers have been warning about the electoral effects of Kennedy’s agenda for months, going back at least as far as August, when pollster Tony Fabrizio released the first of two surveys showing that most voters still support vaccination. Public polling has backed this up. In one particularly devastating finding, a recent survey found Kennedy had even less of the public’s trust than former top National Institutes of Health official Anthony Fauci, whom Kennedy and Trump—and their followers in MAHA and MAGA—have attacked relentlessly over his actions during the pandemic.

Earlier this year, not long after CDC issued the order pulling back on the childhood vaccine schedule, administration officials began telling reporters they wanted Kennedy to focus more on issues like encouraging physical activity, or discouraging consumption of ultraprocessed foods. That has basically happened. Kennedy hasn’t said much about vaccines recently, and neither has anybody else at HHS.

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And it’s not just the rhetoric shifting. It’s the personnel too. Jay Bhattacharya has taken over as acting CDC director, even as he continues his duties as director of the NIH. He’s replacing O’Neill, who moved over to the National Science Foundation. Chris Klomp, a technocratic health care entrepreneur who had been working on Medicare and Medicaid, has become chief counselor at HHS.2 Ralph Abraham, a Louisiana physician and prominent vaccine critic whom Kennedy had installed as the number two at CDC, unexpectedly left just weeks after taking the job.

Officially, none of this was about the administration trying to make changes tied to vaccination. Abraham cited family reasons for his departure, for example. But it’s hard not to read between the lines. There’s been one conspicuous policy move, too. Last month, the Food and Drug Administration reversed a decision not to consider a new flu vaccine. And it did so, reportedly, after the White House objected.

Plenty of Kennedy’s followers were unhappy about this, just as plenty have grumbled that Kennedy hasn’t already done more on vaccines. But at least for the moment, the White House has given no indication that it is rethinking its strategy of doing what it can to avoid more headlines about vaccines.

That’s why Murphy’s ruling is so important, no matter what happens next. If it remains in force—and if the administration declines to appeal—then it will stop at least some of Kennedy’s most far-reaching policy moves from taking effect. And if it doesn’t—or even if the administration pursues appeals—then the case will continue to serve as a reminder of what Kennedy is trying to do on vaccines, keeping it on the minds of voters.

Malone was right when he said this lawsuit is really just a skirmish. With Kennedy in charge, it’s always one battle after another.

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MOST AMERICANS HAVE no firsthand knowledge of what measles can do to people, because it has been half a century since the disease was circulating widely in the United States. But there are exceptions—like Therese Vogel, whose older sister Nancy got the disease when she was 4.

This was back in the 1950s, when hundreds of thousands of children got measles each year. And while most recovered fully within about two weeks, Nancy was one of the kids who didn’t. She developed encephalitis, a known, potentially devastating complication of active measles infection in which inflammation of the brain disrupts normal function.

Nancy was in the hospital for weeks, with a fever so bad that some of her hair fell out. She lost some of her verbal skills, struggling to regain them after coming home. And although she had hit all of her developmental milestones before the disease, she was unable to pick up reading like the other kids her age—or even her younger sister.

“I was at my mom’s side as she was teaching Nancy to read, and I basically picked it up easily . . . and I kind of thought, why is this so hard for her?” Therese, who is now 73, told me in a phone interview last week. “I think that’s when I must have realized there was something different about her.”

There was. The damage to Nancy’s brain was permanent, as it was in about 20 to 40 percent of cases of measles-induced encephalitis. She would never be able to read past a sixth-grade level, and once she got to the eighth grade the administrators at the Catholic school the two sisters attended told their parents that Nancy didn’t have the ability to keep going on a standard education track.

Nancy still had a life full of joy and meaning, Therese says—whether as part of a Girl Scout troop that made her an honorary member, even though she couldn’t complete the badges, or alongside other people with impairments at a “sheltered workplace” where she held down a job heat-sealing small manufactured goods inside of plastic bags. But as Therese went off to college, settled into a professional life, and started a family of her own, she found herself thinking constantly about what might have been for her sister.

“Sometimes she would say, I wish I could go to college,” Therese said of Nancy. “She knew that she wasn’t able to do the things that I did.”

Therese said Nancy’s experience was one reason she decided to specialize in pediatric nursing. And since 2019, when Nancy died at the age of 70, Therese has been looking for ways to keep her sister’s memory alive. Last year, she found one when she heard about a fledgling organization—Grandparents for Vaccines—trying desperately to stop a comeback of diseases like the one that robbed Nancy of so many opportunities.

The cause is urgent. Already this year, authorities have documented more than 1,300 measles cases, putting the count on track to surpass last year’s total—which, in turn, was the highest in thirty years. And it’s no big mystery why this is happening. Fewer people are getting immunizations, thanks partly to an anti-vaccination movement that spreads misinformation and now has one of its champions, Robert F. Kennedy, Jr., leading the Department of Health and Human Services.

The goal of Grandparents for Vaccines is to push back against this movement, while getting Americans thinking about what’s at stake if the trends continue. And while that’s an awful lot to ask from a group of seniors, most of them political novices still learning the finer points of social media, they have two powerful weapons for making their case:

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CASEY MEANS IS DONALD TRUMP’S NOMINEE to be surgeon general, a position that would, in theory, make her the nation’s most important doctor. If you want a glimpse of how she would approach the job—and a sense of why her nomination has become so controversial—consider a key moment from her confirmation hearing before the Senate Health, Education, Labor, and Pensions (HELP) committee two weeks ago.

The moment came when Means, a Stanford-medical-grad-turned-wellness-influencer, got a question about vaccination for seasonal influenza—that is, the flu shot. The senator asking, Virginia Democrat Tim Kaine, wanted to know whether Means agreed with her would-be boss, Health and Human Services Secretary Robert F. Kennedy Jr., who had claimed in January that there’s no evidence to show the vaccine is effective.

Initially, Means declined to answer, saying she hadn’t heard Kennedy’s statement directly. Fine, Kaine said, forget about Kennedy’s comments and stick to the science. “Do you believe,” the senator asked, “that there’s no evidence that the flu vaccine has efficacy in reducing serious injury and hospitalization?”

Still Means wouldn’t answer. Instead, after a pause and some stammering, she said that she would endorse CDC guidelines, whatever they are, and that she personally believes vaccination in general saves lives. Those two statements were versions of platitudes that she had offered previously in the hearing. Notably, neither revealed what she thought of the flu shot.

Only after this had gone on for more than two minutes—and only after Kaine asked for what was the eighth time—did Means concede that evidence showed the vaccine to be effective “at the population level.” Kaine acknowledged the response, such that it was, adding with exasperation that “this was not a hard question.”

It certainly should not have been. There are literally dozens of high-quality, peer-reviewed studies showing that if you get the flu shot, you’re significantly less likely to become severely ill or need hospitalization. That is no small thing given that flu in the United States leads to hundreds of thousands of hospitalizations every year, and tens of thousands of deaths.

So why wouldn’t Means give a straight answer? One possibility is that Means shares Kennedy’s skepticism of the shot, but was trying to downplay her feelings because recent polling has shown the public turning against Kennedy’s anti-vaccine crusade.

Relatedly, Means might have been nervous about holding on to support from key Republicans on the committee—like chairman Bill Cassidy, a Louisiana physician—who have been outspoken supporters of vaccination despite their support of Kennedy’s nomination.

Another possibility is that Means knows the flu vaccine research and accepts its validity, but didn’t want to undermine Kennedy—or, at least, didn’t want to anger leaders of the MAHA movement who are still crusading to stop government support of vaccines. Her confirmation hearing came right after the White House issued a controversial decision on pesticides that infuriated many in the MAHA movement. It’s not hard to imagine why she’d be nervous about alienating those activists further.

Those are three different reads, obviously. But they have one key thing in common. They all suggest Means was tailoring her statements to avoid political blowback, to an extent that past surgeons general have not. That’s a big warning sign on a nomination where the lights were already blinking bright red.

ON PAPER, THE SURGEON GENERAL of the United States does not have a lot of power. The primary line authority of the office is to oversee the U.S. Public Health Service, a uniformed group of roughly 6,000 health professionals who work alongside other public employees at federal health agencies like CDC and NIH, with occasional call-ups for special initiatives and emergency duty.1 The work is vital, but it’s part of a much broader federal health enterprise over which the surgeon general has no administrative responsibility.

The real power of the surgeon general comes from the chance he or she has to shape the national conversation about health care, as then-Surgeon General Luther Terry famously did with his 1964 report declaring that smoking was “causally” related to lung cancer. That report is widely believed to have played a critical role in launching the war on tobacco that, since the 1960s, has reduced smoking in the United States by about 75 percent and almost certainly saved millions of lives.

The surgeon general’s reach was just as visible two decades later, when C. Everett Koop issued a groundbreaking report on AIDS and produced a brochure on the disease that went out to every American household. The plain-language, eight-page document not only offered practical advice on prevention, including the importance of condoms, it also played a pivotal role in transforming the AIDS fight from a moral controversy into a public health crusade, fueling research, prevention, and treatment efforts that likewise saved millions.

A more recent instance of a surgeon general exerting that kind of influence came during Trump’s first administration, when Jerome Adams made combating the opioid epidemic a top priority of his tenure. In 2018, Adams issued an advisory urging wide distribution and use of naloxone, the fast-acting, potentially life-saving agent that reverses the immediate effects of opioid overdoses. Greater use of the agent (known by many as “narcan,” after its first commercial version) is widely understood to be a big reason opioid deaths have dramatically fallen in the past two years.

As it happens, Adams has emerged as one of the most visible critics of confirming Means to serve as surgeon general. And like many of her detractors in the public health community, he has cited past statements she has made on vaccines (like her telling Joe Rogan there might be a link to autism, despite mountains of research finding no such link) as proof she spreads misinformation.2

“Right now, we’re in the grip of a massive, record-shattering measles outbreak: over 1,100 cases already in 2026 alone, on pace to eclipse last year’s historic high,” Adams tweeted last week. “We can’t afford health leaders who hesitate on vaccines.”

ANOTHER BIG ISSUE in the Means nomination has been her resume—or, more precisely, what is not part of it. Means never completed her surgical residency, instead turning to a career of entrepreneurship and advocacy. That is how she—along with her brother—became prominent members of the MAHA and MAGA universe.3

Means and her supporters say she left the conventional medical track because she had grown so frustrated with the focus on treatment rather than prevention—partly because of what she saw in residency, and partly because of what she saw when her mother died from pancreatic cancer. Critics say her financial stakes in companies that sell wellness products represent conflicts of interest, and that her theories about “metabolic health” are rife with pseudoscientific hooey. They also wonder if she left her residency because of stress, rather than philosophical disagreements, as some people who knew her back then have told reporters.4

Whatever the true circumstances of her departure—and whether or not she’s got conflicts of interest—there is no question about her current professional status: She currently has no active license to practice medicine. That is meaningful, Adams told me during a phone interview this week, because so much of the surgeon general’s job involves understanding the nature of medical care and getting the people who administer it to change their behavior.

“As a practicing anesthesiologist . . . I can stand in front of physicians and say, ‘Here is the problem that we face, and here’s what I need you to do,’” said Adams, who during his tenure kept up his clinical work by treating patients at Walter Reed Hospital. “An unlicensed Casey Means, who never finished her residency, is not going to be able to stand in front of the American Medical Association, or ACOG [the American College of Obstetricians and Gynecologists], or a group of licensed nurse practitioners with any credibility.”

Adams isn’t the only one openly wondering what kind of credibility Means would have—or with whom—should she be confirmed.

“I don’t know why anyone would get their health advice from a social influencer who lacks scientific credentials and public health experience,” Lawrence Gostin, a distinguished university professor at Georgetown and widely respected public health scholar, told me. “She will not be trusted by the wide swath of the public, except for Secretary Kennedy’s political base in the MAHA movement.”

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AND THEN—ABOVE AND BEYOND ALL THAT—there are the questions about her political mettle. One reason Terry’s report on smoking was so important was that it helped break a political stalemate on tobacco, one being kept in place by the industry’s powerful allies in Congress. Koop’s report on AIDS was a breakthrough because it was a rebuke to the many public officials—including many of his colleagues in the Reagan administration—who still saw AIDS as a moral problem rather than a medical one.

You could say nearly the same thing about the Adams advisory on naloxone, which challenged officials—again, including many who were serving alongside him—who saw the opioid crisis primarily as a moral issue, and were at best ambivalent about anything that deviated from zero-tolerance policies.

Adams, in our interview, noted that he was hardly alone in making the case for the use of naloxone and other public health measures to save lives and reduce harms. He said he was one of several scientists who, as part of a broader anti-opioid strategy, were making the case from within the administration.

“It shows in a positive way that even in difficult times—and even under administrations and political groupings that might seem hostile to what you’re proposing—you can advance policy if you’re willing to stand up for the science, and present it in an evidence-based way,” Adams said. “And I just worry that Casey Means has not demonstrated that she would be a person who would do that in the midst of the current crises.”

There is of course no way to know whether Adams is right to worry about that, just as there is no way to know exactly how Means would use the power of the surgeon general’s office if it were hers. At least in principle, it’s not that hard to imagine somebody with her priorities using the platform to promote desperately needed changes in medical care and lifestyles—or to check the influence of powerful lobbyists in the drug and food industries—without the kind of medical quackery that has come to personify RFK Jr.’s tenure.

That could genuinely make America a healthier country, leaving the kind of legacy that Terry, Koop, and Adams all did when they were in office. But the starting point for all three was an ability to speak clearly and confidently about what scientific research showed. The question from Senator Kaine was a test of whether Means has that ability. She failed.

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THE STANDARD NON-MAGA TAKE take on Robert F. Kennedy Jr. is that it’s too bad he’s such a brain-wormed lunatic about vaccines, because he’s a surprisingly thoughtful visionary about food and farming. After Donald Trump chose him to be health secretary, an Atlantic essay headlined “RFK Jr. Is in the Wrong Agency” captured this conventional wisdom, with a memorable subhed emphasizing the problem was the job, not the man: “He could be a great agriculture secretary.”

But it was always strange to assume that a brain worm would pick and choose which judgments to infect. While Kennedy’s progressive-sounding ideas about unhealthy food and industrial agriculture are more popular than his retrograde theories about lifesaving vaccines, many of them are just as pseudoscientific, conspiratorial, and wrong. In fact, they’re grounded in the same strain of sloppy and simplistic thinking popular with biohackers and yogis on the right and left, the naturalistic fallacy that anything “unnatural”—including genetically modified crops, pasteurized milk, fake meat, and chemical pesticides as well as mRNA jabs—must be bad for our health and our planet.

It’s woo-woo nonsense—the kind that results in the nation’s top health official urging Americans to binge on fries (as long as they’re made with beef tallow rather than seed oils) and Coke (as long as it’s made with cane sugar rather than high-fructose corn syrup). The inconvenient truth is that you shouldn’t worry about seed oils or GMOs; that “natural” cane sugar is just as unhealthy as processed corn syrup; that plant-based meat isn’t health food but is already healthier than cow-based meat; and that while some agrichemicals are genuinely dangerous, the weed killer glyphosate, Public Enemy Number One for Kennedy’s Make America Healthy Again movement, is unusually benign.

Like the proverbial broken clock that’s right twice a day, Kennedy has a few non-bonkers food beliefs. Yes, ultraprocessed junk like Twinkies is bad for you. No, we don’t need artificial food dyes in our cereal. Yes, “real food” like fruits, vegetables, and whole grains is as nutritious as it was when Michelle Obama was pushing it. But Twinkies aren’t unhealthy because of their processing or even their long ingredient list full of GMO crops grown in monoculture fields; they’re unhealthy because they’re sugary, high-calorie, low-nutrient junk that everyone knows is junk. They’d still be junk if their corn syrup and starch came from organic non-GMO corn grown in diverse rotations.

It’s telling that Kennedy is also an outspoken advocate for red meat, which is associated with increased risk of cancer and heart disease. The steaks atop the Trump administration’s new food pyramid come from industrially bred cattle stuffed with GMO grain in unnaturally crowded feedlots and then “processed” in assembly-line slaughterhouses, but they’re vibes-aligned with caveman-diet meatfluencers like Joe Rogan, as well as Republican livestock-industry donors. Red meat also happens to be an environmental disaster; in the United States, we use more than half our agricultural land to produce beef, which provides only 3 percent of our calories.

In other words, Kennedy’s food fights have as little to do with science as his antivax fights. There’s no better example than the recent Trump world brawl over glyphosate, the active ingredient in the herbicide Roundup. Jonathan Cohn recently wrote about this chemical warfare here in The Breakdown, explaining how MAHA moms who consider glyphosate a toxic menace are furious about Trump’s new executive order in support of glyphosate production. They’re particularly mad that Kennedy, who has condemned Roundup as a poison fueling a national disease epidemic, was forced to defend the order on ludicrous national security grounds, when Trump was obviously just pandering to the agricultural and chemical lobbies.

It’s an important political story, and it was fun to watch Kennedy—who, as an environmental lawyer, often sued Monsanto over glyphosate—endure one of the ritual humiliations Trump loves to inflict on his underlings. But in his public statement, Kennedy continued to insist that glyphosate was “toxic by design,” and that American farms were just too dependent on it to ban it immediately; he assured his MAHA fans that the Trump administration is still gradually “accelerating the transition to regenerative agriculture” that can “increase biodiversity” and “reduce reliance on synthetic chemicals.” When Trump’s nominee for surgeon general, Casey Means, historically another ferocious glyphosate basher—“For the love of God never buy Roundup,” she once tweeted—bent the knee in her Senate testimony, she also declared it too entrenched to abandon right away: “We cannot overturn the entire agriculture system overnight.”

That’s true enough. In 2021, Sri Lanka’s president thrilled regenerative advocates by banning all agrichemicals, and it was an overnight disaster: Farm yields crashed, creating food shortages, food riots, and a government collapse. So it’s nice Kennedy is publicly rejecting that model, even if it’s only because his boss wants to pander to donors. But the MAHA notion that all agrichemicals are evil, even if sometimes a necessary evil, is as childish as the Trumpian notion that they’re inherently good, at least as long as the campaign donations keep flowing.

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Glyphosate is relatively good. It’s less toxic than caffeine, and way less toxic than the herbicides that would replace it if it were banned. Some studies have suggested rodents that ingest massive amounts of it might face higher disease risks, but only tiny traces of it are in our food. Florida’s quack surgeon general, the antivax crusader Joseph Ladapo, is trying to stir up a new MAHA panic over glyphosate, but it isn’t what’s making Americans sick. Another inconvenient truth: The way food is grown has very little to do with how healthy it is. The cows on organic dairies don’t get antibiotics (organic farmers usually sell them to conventional dairies when they get sick) and the crops on organic farms don’t get sprayed with chemical pesticides (organic pesticides are often even nastier) but none of that makes much of a difference to the nutrition that reaches the consumer.

What effective weed killers and other agrichemicals can do is help farmers grow lots of food per acre, so they need fewer acres to grow the same amount of food. That’s a big deal for the environment, because farms and pastures have already overrun 40 percent of the Earth’s habitable land—and they’re on track to overrun another dozen California’s worth of forest to feed a growing global population by 2050. The world doesn’t have another dozen California’s worth of forest to spare. And when regenerative and organic farms produce lower yields than conventional farms, as they usually do, they drive more deforestation as well as malnutrition. They’re also driving habitat destruction, so they’re destroying biodiversity.

The RFK conviction that agriculture should return to its kinder and gentler and more natural roots appeals to our romantic notions of small pastoral red-barn farms where soil is treated with love and animals have names instead of numbers. But there’s plenty of evidence that those farms tend to be worse for the environment, and no evidence that they produce healthier food. Most rational people reject the dopey nostalgia of the antivax movement, the Luddite delusion that things were better before science and innovation started messing with natural processes. We don’t need to let nature take its course with our food, either. We can pasteurize our milk so that it’s safe, fertilize our crops so that they’re abundant, and ignore the charlatans who want to banish modern technology from what goes into our bodies.

Michael Grunwald is the author, most recently, of We Are Eating the Earth: The Race to Fix Our Food System and Save Our Climate (Simon & Schuster, 2025).

DONALD TRUMP SPOKE ABOUT prescription drugs for more than three minutes during Tuesday night’s State of the Union address. That’s practically an eternity, given the context and setting. But it’s not so surprising if you’ve been following the news.

For months, Trump and his advisers have been saying they want prescription drugs to be a central focus of the Republican midterm campaign. Specifically, they want to make sure voters know about the deals Trump reached with major drug companies that—according to Trump—mean Americans are now paying “the lowest price[s] anywhere in the world.”

“Other presidents tried to do it, but they never could,” Trump said Tuesday, repeating a line he’s used many times before. “I got it done.”

The boasts serve more than Trump’s vanity. They also serve a political purpose: They are a way for Republicans to show they are addressing “affordability”—and to distract attention from what they’ve been doing to Medicaid and the Affordable Care Act.

But claims that Trump accomplished what no other president has accomplished on drug prices—and that Americans can now get the lowest prices in the world—do run into one small problem.

They’re mostly bullshit.

If you want to see why, just

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DONALD TRUMP ISSUED an executive order last week to boost production of glyphosate, a widely used pesticide that’s long been the subject of lawsuits over possible effects on health. And the reaction on social media was exactly what you’d expect to hear from environmentalists on the left.

“Absolutely disgusting and shameful”

“Literally no justification for the way this was done”

“A middle finger to public health”

But these posts didn’t come from Trump’s progressive critics. They came from some of his most enthusiastic supporters: influencers who identify as part of the Make America Healthy Again movement.

MAHA is the loose coalition of activists, social media figures, and like-minded voters who believe America is being slowly poisoned by the food and pharmaceutical industries. Their preoccupations include fighting environmental toxins and hawking wellness products, promoting natural diets, and challenging mainstream science on vaccines.

In 2024, they threw their support behind the presidential campaign of Robert F. Kennedy Jr., who had adopted the MAHA slogan as a twist on Trump’s MAGA branding. The informal coalition got behind Trump after Kennedy withdrew from the race and Trump embraced Kennedy and his agenda.

Early on, they felt their faith was being rewarded. Trump tapped Kennedy to lead the Department of Health and Human Services, with a mandate to “ensure that everybody will be protected from harmful chemicals, pollutants, pesticides, pharmaceutical products, and food additives.”

But that was then. In the wake of Wednesday’s executive order and a series of episodes leading up to it, MAHA’s leaders say they feel like Trump has betrayed their trust and, in the process, alienated their followers.

“Have we ever lost the midterms this early or is this a new record?,” the conservative, MAHA-adjacent podcaster Alex Clark tweeted.

The question was rhetorical and, obviously, the fate of the GOP’s congressional majorities won’t depend on MAHA’s mood alone. But it’s not hard to see why Clark and her fellow MAHA faithful have so many doubts about Trump’s true priorities—and why those doubts are evidence of a significant fissure that’s developed within his coalition.

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“I READ AN ARTICLE TODAY,” Trump said during his January 2026 cabinet meeting, “where they think Bobby is going to be really great for the Republican party in the midterms.”

The article he had in mind ran in Politico. It was one of several dispatches in the media citing GOP strategists who said Kennedy and his agenda could help Republicans hold on to—and even energize—swing voters who were becoming disenchanted with Trump over his handling of the economy, immigration, and other issues.

The evidence for this included polling showing that broad, bipartisan majorities support Kennedy’s calls for healthier eating and more exercise. And there’s good reason to think Trump’s advisers believe it. In the last few weeks, Kennedy has been one of the administration’s most visible public emissaries, headlining a “Take Back Your Health” tour that is hitting politically important states and sitting for interviews with both 60 Minutes and Theo Von.

That kind of publicity campaign doesn’t happen without the White House’s encouragement, although it’s an open question as to how much the tour is actually helping. The Theo Von podcast was where Kennedy talked about snorting cocaine from a toilet seat. And just a few days later the HHS social media team posted a video of Kennedy working out in jeans and chugging whole milk in a sauna with Kid Rock, the aging arena rocker turned MAGA provocateur.

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But a bigger political problem with making Kennedy the front man for the administration is not the occasional odd video. It’s that a big part of his agenda—and the one for which he is most beloved among some MAHA adherents—turns out to be highly unpopular.

“The food and pesticide piece is the most compelling part of the MAHA narrative—that is what appeals to the vast majority of folks, even across some political lines,” Marissa Padilla, executive vice president at Global Strategies Group, a Democratic-aligned PR and polling firm, told me. “Where it gets more split and divided is on the vaccine front. . . . That’s where we’ve seen some of the MAHA movement lose credibility.”

Padilla is a veteran of the Obama administration who advises Democrats and liberals. But some prominent GOP strategists have reached the same conclusion. Among them is Trump pollster Tony Fabrizio, whose firm released several surveys warning, as one December report put it, that “while the MAHA agenda is broadly popular in the area [of] food and agriculture, vaccine skepticism stands as an outlier, rejected by most voters even within the MAHA movement.”

It’s not clear how much of this advice got to Trump. He has for years expressed his own skepticism of vaccines, including multiple instances in 2025 when he espoused wild, flagrantly untrue statements about the numbers of vaccines children receive and supposed links to autism. And as recently as this January, he was on social media spreading some of those same false claims while praising Kennedy’s decision to scale back official childhood vaccine recommendations from seventeen to twelve.

But Trump has had less to say about vaccines recently. And this past week, the White House interceded with the Food and Drug Administration, which was refusing to review the application for a new seasonal flu shot by the vaccine maker Moderna. After a meeting in which Trump reportedly made clear he was unhappy with the FDA’s posture, the agency said it would review the vaccine after all.

The reversal mollified some of the administration critics who were nervous that the FDA’s initial decision might spook investors and undermine the finances of vaccine development. But it infuriated some MAHA influencers, who saw it as a sop to the drug industry and a retreat on Kennedy’s broader agenda to scale back federal support for vaccines.

A particularly blunt protest came from “medical freedom” advocate Toby Rogers, who addressed a tweet to White House Chief of Staff Susie Wiles. “If the Moderna mRNA flu shot is approved, the medical freedom movement will abandon the Republican Party in the midterm elections,” wrote Rogers, a political economist at the MAHA-aligned Brownstone Institute. “That’s not a threat, that’s a promise.”

Rogers posted that on Wednesday, at around two in the afternoon. Three hours later, the White House released Trump’s order on glyphosate.

GLYPHOSATE IS LITERALLY the most-used weed killer in history. In the United States, corporate and family farmers spray nearly 300 million pounds of it each year on corn, soybeans, and other crops. Glyphosate comes from a compound that scientists first synthesized in the 1950s, and that the company Monsanto introduced as a commercial product called Roundup in the 1970s.

You might recognize the name because the consumer version is a popular home gardening spray, or perhaps because it has been the subject of well-publicized litigation over possible links to cancer.1 The word “possible” is important because the actual connections remain in dispute, with a World Health Organization agency concluding the substance is “probably carcinogenic to humans” and the Environmental Protection Agency concluding it is “unlikely to be a human carcinogen.”

Among those convinced of the dangers of glyphosate are MAHA’s leaders, and that very much includes Kennedy. In 2018, while still working as an environmental lawyer, he represented a groundskeeper with cancer who said he likely got the disease from Roundup. The jury hit Monsanto with a $289 million judgment for failing to warn consumers about its herbicide’s potential dangers.

Kennedy has continued to warn about the threat of glyphosate—including in 2024, while he was still running for president. He even vowed during the campaign that he would ban the substance. And in just the last month, he reaffirmed his belief that glyphosate causes cancer while on Katie Miller’s podcast and then again during the appearance with Theo Von.

But in that same interview, Kennedy said there would have to be some kind of “off-ramp” because the U.S. agriculture industry was so dependent on the herbicide to keep up its output. That dependence was what Trump cited in his Wednesday executive order, in which he invoked his authority under the Defense Production Act to make sure manufacturers prioritize glyphosate as needed to maintain supply. Shortly after the announcement, Kennedy put out a statement supporting the order on the same grounds.

The order’s legal rationale seems shaky, given the general understanding of the Defense Production Act as a tool for addressing emergencies or meeting true national security needs. And exactly how the order will impact glyphosate production going forward is unclear.

But the decision comes after a much-anticipated MAHA strategy plan from Kennedy conspicuously stopped short of calling for tougher pesticide regulation. And in December, the Trump administration backed an attempt by Bayer (which now owns Monsanto) to limit future liability for alleged harms from glyphosate through a case going before the Supreme Court.

Those episodes were very much on the minds of high-profile MAHA influencers like Vani Hari, better known as the “Food Babe.” After Trump issued his executive order, Hari posted on X that Bayer “threw a grenade at MAHA & is loving this.” And in an interview with the New York Times, Hari made clear whom in the administration she holds responsible for aligning agriculture policy with Bayer’s interests. “Secretary Kennedy has done everything he said he’s going to do,” Hari said. “He has upheld his commitment to the American people. Now, whether his boss is doing that is another story.”

THIS PAST WEEK’S ANGER could dissipate with time, especially if Trump and Kennedy pick new fights that win back support from the MAHA base. But to hold seats in November, Republicans need this swath of voters energized, not merely content. And that will be tough with so many disenchanted MAHA influencers, because of the unique role they play as storytellers and trusted guides for an audience primed not to trust experts, public officials, and mainstream media.

“It’s a big shift in how this world has worked before,” said Padilla, who was coauthor of a detailed report on MAHA influencers that her firm published in December. “These influencers are really able to drive a narrative.”

The influencers also serve a second, more subtle role in maintaining Trump’s governing coalition. Because they focus so much of their energy on attacking corporations—and because so many of them are “MAHA Moms” who talk about raising their children—their support reinforces Trump’s claims to be standing up for average Americans against an elite cabal that’s taking advantage of them and lining its own pockets.

But Trump’s populist rhetoric belies his actual governing record, which includes dismantling agencies that protect consumers from financial fraud, cutting taxes for the wealthiest Americans, and undermining health insurance programs on which millions of poor and working-class Americans rely.

And that’s not to mention the big news from Friday, when the administration announced it was dialing back limits on power-plant emissions of mercury, which the Environmental Protection Agency classifies as a “potent neurotoxin” that can harm the developing brains of infants and children.

In general these efforts have not rattled or provoked protest from Trump backers. And that very much includes Kennedy, whose silence on issues like mercury emissions—a hazard he spent much of his career fighting—has been conspicuous.

But the pesticide announcement seems to have gotten the attention of his supporters, judging by last week’s reaction. If the anger lingers and MAHA influencers start protesting Trump policy changes that truly jeopardize public health, that could put political pressure on White House decision-makers—enough, maybe, to stop some of those changes from happening. That could make a real difference in the lives of Americans, regardless of what happens in November at the polls.

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THE TRUMP ADMINISTRATION ANNOUNCED last week that it is winding up to deal yet another blow to the Affordable Care Act. But don’t feel bad if you haven’t heard about it.

The warning was tucked deep in the Federal Register, which is where agencies post notices of new regulations they hope to put in place. It was part of what’s called the “Marketplace Integrity and Affordability Final Rule,” which the federal government issues every year to guide operations of the Affordable Care Act.

The annual rule, hundreds of pages long, is a chance to tinker with the program—and not simply for the sake of adapting to the ever-changing health care economy. Administrations have traditionally used the rule to pursue their agendas, which under Barack Obama and Joe Biden meant finding ways to maximize the Affordable Care Act’s reach.

Donald Trump has a very different agenda and his administration’s proposed rule, which would affect how the Affordable Care Act works in 2027, reflects that. It would roll back requirements on what insurers must cover, while encouraging a shift into plans that have lower premiums—but only because they also have much higher out-of-pocket costs.

Philosophically, the changes are of a piece with what Republicans have been trying to do ever since the Affordable Care Act became law in 2010. The administration’s own accounting suggests the net effect would be between 1.2 and 2 million fewer people enrolling in Affordable Care Act plans. It’s not the same kind of impact as, say, repealing the law outright, which is what Republicans tried to do in 2017. But it’s still a lot of people.

The proposal is not a fait accompli. The administration has to allow public comment for a few weeks, during which time it could decide to modify or delay provisions, especially if insurers ask for more time to make what could be substantial adjustments. Any changes the administration eventually puts in place could also face a legal challenge, as happened last year when a lawsuit blocked a similar Trump administration proposal.

And that is to say nothing of the possible political pressure the administration could confront. The proposal is landing less than a year after Trump and his Republican allies cut more than $1 trillion out of federal health programs, including the Affordable Care Act—and just weeks after they allowed for the expiration of extra financial assistance Democrats had put in place to help people buying coverage through the marketplaces.

All of that is making health care more expensive, especially for people buying Affordable Care Act insurance at HealthCare.gov or one of the marketplaces that states run. And there are plenty of signs the higher prices are rattling people. Already enrollment is down by more than a million, and the higher cost of health care is

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THE VACCINE MAKER MODERNA decided this past week to tell the world about bad news it had received from the federal government.

A potentially groundbreaking vaccine for seasonal flu that the Massachusetts-based company had developed would not be getting approval from regulators. In fact, it wasn’t even getting formal consideration, Moderna announced in a Tuesday press release, because officials were refusing to accept the application.

This is not the type of development you would normally expect a pharmaceutical company to broadcast. But that’s because there’s nothing normal about the way the federal government is behaving in this saga—or, for that matter, how the government has been behaving ever since President Donald Trump put anti-vaccination crusader Robert F. Kennedy Jr. in charge of America’s public health.

Moderna’s flu shot, which uses mRNA technology made famous during the COVID-19 pandemic, is the product of a lengthy research and development process that goes back years. Along the way, Moderna scientists consulted directly with officials at the Food and Drug Administration, the agency inside of Kennedy’s department (Health and Human Services) that is responsible for reviewing and approving vaccines.

Such consultation is normal. And a major focus of the discussion between the company and the regulators was how Moderna should test the new shot to demonstrate its safety and effectiveness. There was some back and forth—again, pretty routine—but ultimately the FDA agreed that Moderna’s design for a trial was “acceptable,” according to communication Moderna cited in its press release.

Moderna proceeded with the testing, got promising results and submitted its application. It had good reason to believe it would receive consideration and, in due time, outright approval. Instead, on February 3, Moderna got what’s known as a “refuse to file” letter from the FDA, in which the agency said the company had not put the new vaccine to a sufficiently demanding test.

This was not a decision to reject the Moderna vaccine. It was a refusal even to think about approving it. The FDA rarely takes such a step, and when it does it’s usually because an application is missing a whole component or includes suspect data. Nobody is suggesting Moderna’s application has those kinds of issues.

On the contrary, the available evidence suggests this is a case of the FDA disqualifying a vaccine on questionable grounds, while changing its standards for review late in the process because it was trying to find a way to reject the vaccine. And based on reporting in outlets like STAT and the Wall Street Journal—along with some details I was able to confirm myself—the decision didn’t come from senior career staff working most closely on the application.1 They actually thought the review should go forward. The decision to refuse instead came directly from Vinay Prasad, a physician-researcher whom Kennedy installed as director of the FDA’s vaccines and biologics division.2

A director overruling career staff on a decision of this magnitude is highly unusual. But it’s indicative of the Trump administration’s broader, dramatic departure from past practices that had emphasized careful deliberation, input from staff and outside experts and lots of public discussion.

“Even if a product didn’t work, ultimately—even if it wasn’t shown to be effective—there was at least a well-defined process to get to that endpoint,” Michael Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy, told me. “What you saw this past week was the FDA completely turning that process on its head.”

This new way of doing things doesn’t look like the “gold standard science” and “radical transparency” Kennedy promised to bring to HHS. But hypocrisy isn’t the main issue here. Rather, it’s the loss of reliable federal support for vaccines, and how that loss is already dissuading companies from developing new shots that could someday protect hundreds of millions of people from dangerous, even lethal infections.

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SEASONAL FLU IS ONE of those diseases. You probably know all about the symptoms, which include fever and chills plus an assortment of respiratory and gastrointestinal problems that resemble a common cold or stomach bug except that they are more severe. What you may not know—or, at least, may not fully appreciate—is that for many hundreds of thousands of Americans every year the flu won’t simply knock them out of work or school for a few days. It will send them to the hospital and, in the most dire cases, to the morgue.

The Centers for Disease Control and Prevention estimates that last season’s flu, circulating in late 2024 and early 2025, killed tens of thousands (and maybe more than 100,000) in the United States. The toll from this season’s flu will depend in part on how many people get a vaccine, which research has shown significantly reduces the risk of hospitalization and death.

But the flu shot is better at reducing disease severity than preventing infection. And its effectiveness varies from season to season because the virus mutates so frequently. When designing each year’s new vaccine, scientists have to predict which strains are likely to circulate. That is not easy and they have to do so with plenty of lead time, because the companies create the key material for most of today’s flu shots by growing it inside of eggs.

One advantage of mRNA vaccines is that the production process is a lot quicker than a chicken’s reproductive cycle. Once scientists have identified a pathogen, manufacturers can start to mass produce a vaccine within a matter of weeks. That’s how Moderna and a handful of other companies were able to churn out effective vaccines so quickly after COVID-19 first appeared on American soil in early 2020.

The same technology could let scientists wait a bit longer into the year—and get a little more data—before picking which virus strands to include in each season’s flu vaccine. That would, in turn, increase the chances the final composition is a good match for whichever variants end up circulating. Another potential advantage of mRNA production is that it avoids the possibility that the virus will mutate while inside the eggs, which can happen.

But to unlock all that promise, a company like Moderna has to demonstrate to federal officials that a shot actually works. Figuring out how to do that was the subject of exchanges between Moderna and FDA officials back in 2024, with Moderna proposing to run a randomized trial with a sample of more than 40,000 people—half getting the Moderna shot, half getting an older shot already in wide use. The testing would take place across eleven countries and, according to Moderna, would cost more than a billion dollars to run. The subjects would all be at least 50 years old, because that’s the market Moderna has in mind for its vaccine.

FDA officials made a counter-suggestion: For the portion of subjects over 65, they said, Moderna should consider testing their vaccine against a second shot that’s on the market already. That second shot has a higher dose—basically, more pieces of virus to stimulate a bigger immune response—because your immune system weakens as you age. Moderna wanted to stick with its proposal.

Exactly how hard federal officials pushed and exactly why Moderna resisted—these things are still unknown. But Moderna officials say the FDA made clear that testing the shot against only the standard dose was okay—and then conveyed the same message a year later, during “pre-review” meetings.3 On top of that, Moderna did submit data showing its shot generated more antibodies than the higher-dose alternative for seniors. That’s not the same as running a trial comparing outcomes like hospitalization, but it’s the kind of meaningful evidence the FDA would typically consider.

That record explains why Moderna officials say they were “completely surprised and honestly pretty confused” by the FDA’s refusal to consider the application, as company president Stephen Hoge put it in an interview with the New York Post. And he’s not the only one who feels that way, or who worries about the implications.

“Moderna appears to have been set up—like they were given a set of expectations, and now the rug has been pulled out from under them,” Ian Spatz, founder and CEO of the Rock Creek Policy Group, told me. “It really will hurt the ability of the industry to make those investments if they can’t count on the FDA to honor the communications they have with them.”

Spatz has spent decades working in and around the pharmaceutical industry. But you’ll hear something very similar from Joshua Sharfstein, a former FDA principal deputy director with a reputation as an industry critic.

“For FDA to change a decision at this late stage, the rules should be similar to instant replay in football—you need new evidence and a compelling explanation to overturn the call on the field,” Sharfstein, now a professor at Johns Hopkins University, told me. “I don’t see how that’s the case here.”

OVER THE PAST FEW DAYS, Trump administration officials have defended their actions on Moderna’s vaccine through a variety of channels—including a statement (also provided to me) from HHS spokesman Andrew Nixon arguing that the company “refused to follow very clear FDA guidance” by declining to test its vaccine against the higher dose recommended for seniors.

But the idea that Moderna defied “clear” guidance doesn’t square with the FDA’s 2024 statement that the company’s test was acceptable, unless Moderna is lying about that quote or taking it way out of context.4 And the underlying logic of the FDA’s new demand doesn’t make a lot of sense either, because a new vaccine doesn’t have to be better than all existing alternatives in order to have value.5

On the contrary, simply having multiple options on the market has clear advantages—like offering alternatives to people who can’t tolerate certain vaccines because of allergies and protecting against sudden supply shocks for a particular vaccine type. The latter is a real possibility in a world where avian flu is wiping out whole poultry flocks.

Knowing which vaccine is best is certainly useful information, and can be helpful for deciding which version of a vaccine to recommend—or to finance. But that’s different from clearing a vaccine for use, which has always been the FDA’s job. And that’s not to mention the fact that even if the FDA felt strongly that Moderna needed to test its vaccine more rigorously for people over 65, that was no reason to discount the results for people between 50 and 65. The agency could have simply approved the vaccine for people in that age range exclusively.

Administration officials speaking to media late last week hinted that something like that might eventually be possible, with one unnamed federal official telling reporters on a conference call that Moderna might have more luck with a second, narrower request for approval if the company showed some “humility” when it made the submission. But the idea that approval of a vaccine might depend—even a little bit—on whether the manufacturer says ‘pretty please’ speaks volumes about what role scientific judgment is now playing in the approval process.

It also helps to explain why so many people in the world of vaccines find the flu-shot decision alarming. It takes years and sometimes decades to develop a vaccine. And while there’s lots of money to be made, there’s lots to be lost too.

“Developing something that is an effective treatment for a disease is a long-term process and a long-term investment,” Patricia Zettler, an Ohio State University law professor who has worked in general counsel offices of both the FDA and HHS, told me. “And so companies—if they don’t have certainty about what kinds of expectations FDA is going to have, or what FDA’s views on the science are—that long-term investment in innovation is difficult to do.”

That’s especially true given that changes to the approval process are taking place as part of a broader retreat from a decades-long embrace of vaccinations. That retreat includes a downsizing of official recommendations for vaccines people should get, a rewriting of official government guidance to raise doubts about vaccine safety, and the canceling of hundreds of millions of dollars in government support for mRNA vaccine development.

These decisions, like the refusal to consider Moderna’s flu shot, came directly from leaders rather than career staff—and in some cases, they came from Kennedy himself. And though HHS officials have said he was not involved in the Moderna flu-shot decision, it’s difficult not to see his influence at work given his long (and dishonest) record of attacking mRNA technology.

“It’s kind of naïve to think that there’s never been any sort of political interference with the FDA decisions over many years, but there’s never been anything like this,” said Spatz, who is also a lecturer at the University of Southern California. “There’s never been this kind of involvement from the secretary—and from the people working for the secretary, up to the FDA commissioner himself—in terms of involvement in these kinds of decisions.”

THE COMPANIES AND THEIR INVESTORS have taken notice—and action. Even before the flu-shot imbroglio, Moderna announced it was putting on hold research into potential mRNA treatments for other conditions. And as companies dial back on R&D, it won’t just be for current threats like seasonal flu. Early studies suggest versions of mRNA vaccines could be effective against certain kinds of cancer too. Now companies will have to wonder if the animus towards mRNA vaccine will spill over into those efforts too.

“If this is going to happen—and if it’s going to happen again and again—it can really cast a pall over the field, and the ability to develop new approaches and new technologies to be delivered to people with not just infections, but a variety of diseases,” Adam Lauring, a professor and infectious disease physician at the University of Michigan, told me. “That’s what I’m watching, because it’s concerning when, even if something works, there’s regulatory uncertainty and it’s not clear that it’s ever gonna see the light of day.”

And that’s to say nothing of the potential of mRNA vaccines to fight another pandemic, a nightmare scientists fear could become reality if a strain of avian flu starts spreading through human-to-human transmission. It’s the kind of threat for which an mRNA vaccine might be particularly well suited, because of the speed with which companies can manufacture doses. But given the hostility from Kennedy and his team, finding support for that kind of development just got a lot harder.

“If today we were to have a flu pandemic emerge, we could probably only produce enough vaccine with our current technologies to vaccinate about 20 percent of the world in the first year,” Osterholm told me. But “mRNA technology would offer us the opportunity to greatly scale that up, such that within the year we could probably have enough vaccine to vaccinate the world. That would be the difference between those scenarios—millions and millions of lives lost.”

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DONALD TRUMP, STEPHEN MILLER, and the rest of the MAGA faithful want you to believe their crusade against immigration will make America a happier, healthier place.

A new research paper suggests they are dead wrong.

The paper finds that higher immigration literally saves lives—and suggests that, by extension, lower immigration costs lives.

The reason is health care for the elderly. The paper finds that when a community attracts more immigrants, seniors are less likely to end up in health care institutions and, ultimately, less likely to die. It also shows that influxes of immigrants mean influxes of health care workers—both high-skilled (doctors, nurses, etc.) and low-skilled (home health aides, nursing home staff, etc.).

The arrival of those low-skilled workers in particular could be important, the researchers who wrote the paper say. When there are more of these care workers around, seniors and people with disabilities are more likely to live at home rather than in assisted-living facilities, nursing homes, and other congregant settings. And for those who do end up in such facilities, the staffing levels there are likely to be higher. Overall, the paper finds, allowing immigration to go up by about 325,000 people a year—an increase of more than 25 percent over the current legal limit—would reduce deaths by 5,000 annually.

Of course, more immigration is not exactly in vogue with the current administration, which is trying to block new immigrants and expel many who are already here. But just as the new study shows that it’s possible to model how more immigrants will lead to fewer people dying, it’s also possible to model the inverse: how fewer immigrants will lead to

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