IT HAS BEEN SIX MONTHS since Donald Trump and congressional Republicans refused to renew temporary, enhanced subsidies for the Affordable Care Act, causing premiums to jump for more than 20 million Americans. And at first, it seemed like things might not work out so badly, all things considered.

In January, the administration reported that initial signups were down by just 1.5 million. That would represent a relatively modest fall in a program that serves more than ten times that number, even if it was the largest year-to-year decline on record.

But since then, a handful of states have released their enrollment numbers. Based on that data—and ongoing survey information—several independent analyses have all come to basically the same conclusion: Enrollment is likely to fall by several million more.1

It will be a few weeks (at least) before the federal government releases final coverage statistics and we learn just how many millions of Americans have dropped their insurance coverage because of the canceled subsidies.2 Meanwhile, though, it’s worth remembering that the people dropping insurance aren’t the only ones feeling the pain. The expiring of the subsidies is also hitting many millions of people still getting insurance through the program who are now paying more for their coverage or who have shifted into skimpier plans that, though cheaper on a month-to-month basis, leave them exposed to higher out-of-pocket costs.

This is precisely what Democrats (and a handful of Republicans) warned would happen in the final months of last year, when there was a debate over whether to extend the subsidies. And in theory that argument could still carry the day. Trump and the Republicans could still decide to appropriate the money and offer the assistance retroactively. It’s been done before, and it could potentially bring the GOP some political relief heading into the midterms, given how big an issue affordability is shaping up to be.

But nobody thinks that is going to happen. Trump and the Republicans have signaled clearly they intend to stick by their decision and defend it, mostly by denying the harm it’s causing. Yes, enrollment is falling. But, they say, that’s mostly because they’ve culled from the program “phantom enrollees” who either gave deceptive information to qualify for financial assistance or were signed up without their knowledge by unscrupulous agents and brokers.

This argument fits seamlessly into one of the administration’s favorite narratives—that social welfare programs have exploded in cost and scope because of fraud, and that aggressively thinning enrollment in these programs is necessary to preserve them for the truly needy. “If you care about the ACA, then you’ll want us to take the fraud out,” Mehmet Oz, the Trump administration official who oversees federal insurance programs, said at a White House briefing earlier this month.

Oz is right that anybody who cares about the Affordable Care Act should support efforts at eliminating fraud. He’s also right that fraud has been a problem. But the available evidence suggests it was a lot less pervasive than Republicans claim—and that it could have been addressed in a way that would have allowed the extra financial assistance to stay in place.

Republicans have used a bazooka to kill an ant colony. And now they want you to believe that the smoldering crater is a figment of your imagination.

ONE PLACE YOU CAN REALLY SEE the impact of the expiring subsidies is Georgia, one of the states where hard numbers are now available. As of April, enrollment in the state’s marketplace had fallen by one-third, according to data the CurrentGA and Georgia Recorder obtained via public-records request.

That comes as no surprise to Linda Williamson, an insurance broker in Atlanta. Most of her clients saw their premiums go up by hundreds of dollars a month, Williamson told me in a phone interview, and many have responded by switching into plans with higher out-of-pocket costs because they came with lower monthly payments. Still others are dropping their Affordable Care Act insurance altogether, Williamson said, with many opting instead for alternative forms of coverage like indemnity plans that have limited benefits.

That last part is an especially revealing window into what’s really happening. The problem with indemnity plans is that they typically pay fixed amounts per medical service, even if the provider charges more, and they stop paying altogether when the bills exceed a fixed threshold—anywhere from $250,000 to a million dollars for the policies Williamson sells.

The costs from a catastrophic medical event can easily exceed that, as Williamson knows personally: About twenty years ago, she had to refinance her house and borrow from retirement funds to pay off more than $100,000 in medical bills following a car accident and (separately) a bilateral pulmonary embolism that hit in her early forties.

The other catch with indemnity and short-term plans is that they usually entail what’s known as “medical underwriting,” which means that insurers will charge higher premiums—or deny coverage altogether—to anyone with pre-existing conditions. Williams told me she’s already had one client get approved for an indemnity plan only to have the coverage rescinded a few weeks later because the insurer went through the client’s records following a hospital visit and determined it was related to a past medical episode.

“They investigated and decided retroactively she never would have qualified for the policy, dissolved her policy, and left her with the medical bills,” Williamson said. “There’s nothing she could do, nothing she could qualify for. She’s paying out of pocket now, until we can get to January 1 and next year’s open enrollment, to get her back into an ACA plan.”

Stories like that used to be a lot more common in the days before the Affordable Care Act, when insurers selling individual coverage routinely subjected buyers to medical underwriting, as well as those retroactive reviews that frequently lead to rescissions like the one Williamson described to me. Putting a stop to those practices was one of the big motivating reasons to pass “Obamacare” in the first place. Now those practices are creeping back into the world of health insurance, at least for people for whom Affordable Care Act coverage has become too expensive.

It’s part of a larger story of backsliding on the Affordable Care Act’s progress just now coming into view—a story that affects middle- and upper-middle-income workers and small business owners, like the type Williamson tends to advise, as well as lower-income workers for whom even seemingly small premium increases of $20 or $30 a month strain budgets.

“What we’re hearing from our [enrollment counselors] is that a lot of these people are working multiple jobs, didn’t have health insurance until a few years ago when the extra credits got them into the ACA marketplaces, and now they’re going back to being uninsured” Whitney Griggs, director of health policy at Georgians for a Healthy Future, told me. “We have also heard about folks who are trying to pay that first premium and just could not keep up that cadence, and dropping their coverage.”

TRUMP ADMINISTRATION OFFICIALS have been preparing to explain away declining Affordable Care Act enrollment at least as far back as March, when Oz told NBC News “the fact that we have 23 million makes me think we have too many participants in the ACA—it’s too high of a number.”

The reason, the celebrity doctor claimed, was that millions of enrollees had either lied about their incomes to qualify for big subsidies or had been signed up under false pretenses by unscrupulous brokers and agents. To back up this explanation, officials like Oz frequently cite data showing that a little more than one-third of enrollees filed zero claims last year—proving, they say, that millions of people on the program are there unwittingly, and in some cases illegitimately.

This claim dates back to last year’s debate over whether to extend the subsidies. And it remains as flimsy as it was then. Lots of relatively healthy people don’t file insurance claims in a given twelve-month period. And by design, the Affordable Care Act marketplaces include lots of people getting coverage for just a few months—say, when they are between jobs. Adjust for that and some other relevant facts, as Brookings Institution economist and former Obama administration official Matthew Fiedler has in a set of calculations, and the percentage of enrollees making no claims lines up nicely with the percentage who do so in employer plans, which nobody would suggest are prone to enrollment fraud.

To support their argument about fraudulent enrollment, Oz and other officials have drawn heavily on reports by the Paragon Health Institute, a right-leaning think tank, which argue that the Biden administration’s efforts to grease the wheels for enrollment enabled fraud on a mass scale. “Obamacare enrollment over the last few years has been inflated by improper and phantom enrollees, and those enrollees are expensive to the taxpayer,” Brian Blase, a veteran of Trump’s first administration who is Paragon’s founder and president, told the Washington Post earlier this month.

Nobody disputes that the Affordable Care Act marketplaces attracted some agents and brokers who enrolled people using unethical, possibly illegal methods—like signing up people or switching their plans without permission—to get commissions. And it seems likely that Biden administration efforts to ease enrollment, undertaken in the name of expanding coverage, made fraud easier to pull off. But the scale of that problem is what’s in dispute. The estimate in a recent Paragon report that there are more than 6 million improper or fraudulent enrollees rests on some assumptions that are highly contestable—and, in fact, have been strenuously contested.3

One part of the Paragon report nobody contests is that improper enrollment is skewed geographically. There’s a lot of it in states like Florida and Texas where people enroll through the federal website, HealthCare.gov, and relatively little in states like Massachusetts and California that run their own marketplaces. Among those who can vouch for that is Jessica Altman, executive director of Covered California. “We have no evidence of systematic fraud at Covered California at all,” she told me in a recent interview.

But as Altman also noted, this strongly suggests the fraud problem isn’t mainly a byproduct of the extra subsidies—which, after all, were available in states like hers as well. Rather, it reflects some differences in the ways the online marketplaces operate. Probably the biggest is that states like California never gave agents and brokers the kind of direct enrollment access that the federal government has allowed on HealthCare.gov—a feature of the website, by the way, that was put in place not by Biden’s team but by Trump’s back in 2018.

Changes to protect HealthCare.gov from fraud are underway, some of them dating back to the Biden administration and others being put in place today. Time will tell how effective they are. But the lapsing of subsidies is raising costs for people now, even in states like California that avoided the Florida-like fraud problems.4

“We have a lot of evidence that these are real people—people who are telling us their stories, who are calling us, trying to make impossible decisions, and ultimately choosing to drop their coverage,” Altman said.5

THE HIGHER INCIDENCE of (possibly) fraudulent enrollment in states like Florida and Texas likely isn’t simply a function of their reliance on HealthCare.gov. There’s also the fact that ten of the fifty states—all Republican-led—have not expanded Medicaid to cover all legal residents with incomes below or just above the poverty line, as the Affordable Care Act’s architects envisioned all states doing before the Supreme Court in 2012 effectively made expansion optional.

The reason is a wrinkle in the way the law’s subsidies work. Because the Affordable Care Act’s authors assumed the lowest-income Americans would get coverage through Medicaid, they restricted subsidized marketplace coverage to people with incomes above the poverty line.

That has created a “coverage gap,” mostly in the South, among poor people who have no Medicaid but make too little money to get Affordable Care Act subsidies. It’s safe to assume—as critics of the program, like Paragon’s scholars, have argued—that some of those people are lying about their incomes, saying they make more than they really do, to qualify for subsidies. They may be doing so on their own, or under coaching from agents and brokers.

It’s certainly possible to argue that this violates the letter of the law, and that it’s driving up costs for the federal government. But it’s difficult to take seriously pleas for fiscal rectitude from an administration lighting far bigger sums on fire every week with its war in Iran. It’s even tougher to swallow arguments about integrity from the most nakedly corrupt presidential administration in history.

It’s also worth pausing to think about who this particular group of supposed Affordable Care Act fraudsters are.

Yes, they have qualified for subsidized private coverage illegitimately by overstating how much money they expected to make in a year. But they would already have government-backed insurance—in the form of Medicaid—if they didn’t live in states where the likes of Ron DeSantis and Greg Abbott and their GOP allies are in charge.

And that’s not to mention the fact that these are extremely poor people, many of them with multiple jobs and unpredictable incomes. Some probably overstated their incomes inadvertently—especially because, as KFF executive vice president Larry Levitt told me, ”the ACA has enormously complicated eligibility rules . . . plenty of people get tripped up by those complexities.”

But fewer people getting coverage through public programs is the outcome Trump and his supporters have long said they wanted. That is why they have been trying to get rid of the Affordable Care Act ever since it became law. And while they haven’t succeeded, they’ve managed to weaken it—as more than 20 million Americans are now discovering.

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THE TRUMP ADMINISTRATION published a piece of brazenly dishonest propaganda last week.

Actually, I’m not even sure “brazenly” does it justice.

Because while misinformation from Trump is nothing new, this most recent case involves a very important debate around health care coverage for some of the most vulnerable people in America—and because it risks sullying the reputation of the highly respected office that published it.

The propaganda came in the form of a Department of Health and Human Services report about coming changes to Medicaid, the insurance program that pays medical bills for more than 70 million mostly low-income Americans and legal residents. As you probably remember, last year Trump and the Republican Congress imposed a “work requirement” on certain Medicaid recipients, as part of a broader set of cuts that will reduce projected spending by roughly $1 trillion over ten years.

As many as 10 million people a year could become uninsured by 2034, with a little more than half of the losses from the work requirements, according to the Congressional Budget Office. And the cuts as a whole appear to be highly unpopular—in part, because they reinforce the perception of Trump and the Republicans as indifferent to the needs of Americans struggling with health care bills. That’s not a great image to carry into the midterms.

The administration’s report purports to provide a winning counterargument. It says that the changes to Medicaid will have a positive effect, because they “could reduce poverty by as much as 1.6 to 2.9 million people.”

Wow! A win-win!

But wait, you might wonder. If all those millions of people are going to lose health insurance—a loss that is widely understood to cause medical and financial hardship—how is it possible that millions are simultaneously going to emerge from poverty?

The answer is that it is almost certainly not possible. The administration’s claim is hot, steaming garbage, intellectually speaking. And so is the report behind it.

You don’t have to take my word for this. Chloe East and Adrianna McIntyre, two highly respected policy scholars from the University of Colorado Boulder and Harvard University respectively, have published a thorough debunking at the “Can We Still Govern” Substack.1 And Richard G. Frank and Sherry Glied, widely cited health economists from Harvard and New York University, have written a (not yet published) critique of their own that they have shared with me.

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In today’s newsletter, I’m going to walk you through the administration’s logic, such that it is, by drawing on those two analyses as well as phone interviews with Glied, McIntyre, and University of Michigan professor Tom Buchmueller, another top-notch health economist.

Don’t let all the Ph.D.s and fancypants institutional affiliations worry you. This explanation won’t be particularly technical. It will require no regressions.

That’s actually part of what makes the report so remarkable. The logical flaws are basic, the kind of stuff that would get you marked down in an undergraduate class. But the report came from the office of the Assistant Secretary for Planning and Evaluation, which traditionally serves as a sort of in-house think tank for HHS.

That office is supposed to be a source of reliable, dispassionate analysis. And while it has always promoted the priorities of whatever administration is in power—Buchmueller, Frank, and Glied all did stints there under Democrats—it has a reputation for producing intellectually defensible material.

This report doesn’t live up to that standard. And it’s emblematic of what’s been happening elsewhere in the federal government, as the Trump administration has purged veteran, senior leaders and in some cases large numbers of lower-ranking career analysts as well. The HHS planning and evaluation office is a perfect example: It lost two-thirds of its staff during the DOGE purges last year, going from about 150 to fewer than 50 employees, according to STAT News.

The result across government agencies has been predictably shoddy work, like with this January’s thinly referenced HHS report supposedly showing the United States childhood vaccine schedule was an international outlier—or last August’s highly selective reading of climate research by the Environmental Protection Agency, allegedly demonstrating that warming temperatures did not endanger human health.

This assault on the integrity of government information threatens to do more than skew political debates. It undermines a key pillar of a functioning democracy.

But more on that in a moment. Let’s talk about this report first.

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A PRETTY BIG JOLT just hit one of this year’s most critical Senate races. And I don’t mean the one in Maine.

On Friday, Michigan’s chapter of the United Auto Workers announced it was endorsing Abdul El-Sayed’s bid to become the Democratic nominee for the state’s open Senate seat. El-Sayed is the former public health director for Detroit and Wayne County, a Bernie Sanders–backed progressive whose campaign mantra is “money out of politics, money in your pocket, Medicare for All.” The union in its announcement signaled that all three parts of the slogan resonated.1

The endorsement means El-Sayed can count on phone banking, mailers, and other forms of organizing from a union that—with more than 300,000 members in Michigan—is the state’s largest. It also means that same support won’t be there for his two rivals, state Senator Mallory McMorrow and U.S. Representative Haley Stevens.

The blow to the Stevens campaign seems especially noteworthy, given how much her candidacy is tied up with manufacturing in general and the auto industry in particular. She first came to national attention while working for the Obama administration’s task force that in 2009 saved General Motors and Chrysler—and, most likely, the jobs of countless UAW members. On the campaign trail, she has portrayed herself as the best friend of labor, the strongest champion for Michigan’s economy, and the logical heir to Gary Peters, the popular Democratic incumbent whose retirement has created the vacancy she wants to fill.

That’s hardly the only case for her candidacy, or for McMorrow’s. An argument for both—sometimes implied by the candidates themselves, often stated explicitly by their supporters—is that they are more electable in a purple state that is practically essential to the hopes for a Democratic Senate majority. The idea here is that El-Sayed will have a much harder time winning over moderate-minded voters who would never even think of pulling the lever for somebody who embraces the likes of Hasan Piker. Already, GOP strategists are attacking El-Sayed as “fringe” and “radical.”

It would be a mistake to assume the UAW endorsement will simply give El-Sayed the inroads with working-class voters to counterbalance any loss he might suffer with moderates. The union is not as synonymous with the hard-hat crowd as it once was, thanks to an influx of graduate students and other members of the professional class whose politics skew reliably to the left on a variety of issues. That includes Middle East policy, which has been as divisive for Democrats in Michigan as in any state—and on which Stevens has struggled to defend her history of strong support for Israel (and her backing by AIPAC).

But plenty of Michigan UAW members are still in manufacturing.2 And to local leaders like Chad Fabbro, the financial secretary of UAW Local 598 and cohost of a weekly podcast on politics called “Unapologetic Americans,” it’s not hard to imagine why the kind of factory workers who frequently disdain “the left” might still find El-Sayed appealing.

“It’s based on people being frustrated with the party, blaming a lot of shortcomings on the current leadership,” Fabbro told me when we spoke Friday, after the endorsement came out. “They just don’t have a lot of faith on what was done, what worked in the past. They think the rules have changed, so the way we play the game has got to change too.”

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It’s hard to know exactly how prevalent this mentality really is, either inside or outside the UAW.3 But it picks up an underappreciated way the candidates are different—one that is less about where they each sit on the traditional ideological spectrum and more about how they imagine change happening in Washington.

It’s a difference that became most apparent to me over the last two weeks, when I had a chance to interview all three of them. We spoke by video, each for about thirty minutes. Going in, my primary goal was to suss out what the candidates actually believed on key domestic policy questions that might come up if they were in the Senate—like why they have all said they would support the federal government taking a more active role in helping families to raise kids, or under what circumstances (if any) they thought it was alright to approve spending even if it meant running higher deficits in the near term.4

You can decide for yourself what you think of their answers. Excerpts of their interviews are intercut here:

And you can watch the full interviews here: Haley Stevens, Mallory McMorrow, Abdul El-Sayed.

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ALL THREE CANDIDATES gave relatively forthright answers, at least by the standards of American politics. And they all showed they could wonk out on their favorite topics (even if I wouldn’t stipulate to all of their claims).

But the more I listened to them, the less I thought about the positions they were taking and the more I thought about their very different conceptions of how to operate in office—in particular, the extent they imagine themselves trying to overturn the system, rather than working within it.

With El-Sayed, pretty much every answer he gave involved some kind of broader critique of the political debate, and the false choices he said it created. You can’t talk about how to help the auto industry, he told me, without recognizing the way executives and shareholders prioritize short-term gain over investments. And you can’t talk about fiscal policy, he said, without pointing out the way demands for balancing budgets apply only to social expenditures and not tax cuts.

This is also his approach to his signature cause: his calls to create a Medicare for All system in which a government health plan would largely displace private insurance.

During the campaign, El-Sayed has said that people who want to keep employer or union health care plans should get to do so. His rivals, meanwhile, have said they want to create a “public option”—that is, a government plan into which people could enroll voluntarily. When I asked whether those two were really so different, he said they were conceding too much ground to the insurance industry. A public option wouldn’t give Americans the kind of security they’d get from Medicare for All, he said, because it would be grafted onto the existing system.

“If you’re for a public option, you actually don’t want to guarantee shit,” El-Sayed said.

McMorrow rejected the suggestion that a public option wouldn’t provide meaningful security, telling me it would create “a universal standard that ensures that we are not leaving anybody outside of having health care” while introducing “real competition in the marketplace.” And she was just as emphatic about why lawmakers need to recognize the real-world political constraints on action—which, in health care reform, include not just the overwhelming power of the private health care industry but also the fear of change among people who already have coverage.

As proof of the difficulties, McMorrow cited a failed attempt to create a version of Medicare for All in Vermont, even though it is arguably the most politically progressive state in the country. Then she talked about hearing from constituents who were struggling with medical bills now—and who, she said, “cannot afford to wait for a single-payer option [like Medicare for All] that may be too large of a hurdle.”

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That emphasis on talking about policy within the frame of what seems politically possible extended beyond health care. When I asked her to list initiatives for young families she would try to promote, McMorrow mentioned creating a national version of Rx Kids, a Michigan program that gives direct cash payments to new parents that she supported in the state Senate. She also talked about enacting a national law to guarantee paid leave, versions of which already exist in more than a dozen states.

“Eight years in the legislature has taught me a lot,” said McMorrow. “You need to build coalitions. You need to move the ball forward constantly.”

Building coalitions and moving the ball forward is also the way Stevens talks about getting things done. But with Stevens, pretty much every answer she gave me started with a bill she had sponsored in the House (like the Unearth America’s Future Act, which would invest in domestic mineral development) or a constituent she had met (like Jimmy from the Iron Workers local who, she said, is worried about data centers).

And when we got to discussing how she’d make complicated policy tradeoffs—like weighing whether to bring back Biden-era car-emissions standards that Trump has repealed—Stevens’s solution always involved sitting down with the interested parties and finding some kind of path forward. “It depends on where our suppliers are, where our Big Three is, where our auto industry, and, of course, the environmental groups that I work with,” she said.

This is the essence of the case for the Stevens candidacy: She will listen to every constituent group, go back to Washington to craft a workable bill, and then push to get it through Congress. It’s not the most glamorous conception of politics. And insofar as working alongside interest groups often means winning their support and taking their donations, it’s high on the list of her qualities that critics find objectionable.

But there’s no question the approach can be productive. The Center for Effective Lawmaking has recognized Stevens as the most effective member of Michigan’s Democratic delegation, precisely because of her ability to build partnerships and play legislative small ball.

It also happens to be the way Peters has approached his tenure in the Senate, just as it was for Debbie Stabenow, who served four terms before retiring after the 2024 election. They are both beloved old-school pols with records of delivering tangible benefits for their communities.

This approach could still work for Stevens, as well. One lost endorsement, even from the UAW, isn’t going to make or break anybody’s candidacy in this campaign. There’s still plenty of campaigning to go before the August 4 primary, and more than enough undecided voters to swing this three-way race in her direction—or in McMorrow’s, for that matter.5

But if the UAW’s backing of El-Sayed says anything, it’s that some significant portion of Democratic voters want something different from the kind of methodical bill-writing, coalition-building politician the party has elected in the past—a feeling that, as Fabbro put it, that “the worker bee isn’t working for us anymore.” Just how large that portion is could end up determining the Democratic nominee.

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IT IS NOT EASY TO OVERWHELM CANCER SCIENTISTS, a world-weary bunch who are constantly dealing with setbacks in their experiments—and, all too frequently, deaths among their patients. But it happened on Sunday morning, inside a darkened Chicago convention hall, when Harvard-based researcher Brian Wolpin announced the results of clinical trials for a drug called daraxonrasib.

Wolpin spoke in a monotone, addressing fellow oncologists from around the world. Above him and around the room, on a set of projection screens, a seemingly simple line graph revealed something extraordinary: Daraxonrasib had nearly doubled survival time for pancreatic cancer patients who’d already been through a preliminary round of chemotherapy.

As Wolpin read off the numbers, a few members of the audience clapped, then a few more, and then they started standing until eventually most of the room was on its feet. “It was sustained,” Adam Feuerstein, the veteran biotech correspondent from STAT, tweeted about the reaction. “I’ve never seen anything like it in the middle of a talk.”

The news made headlines across the country, and it’s easy to see why. Pancreatic cancer took more than 50,000 American lives last year, according to estimates, making it the nation’s third-deadliest cancer. Until now, it has stubbornly resisted the kinds of treatment advances that have allowed patients with several other cancers to live a lot longer, and in some cases “beat” their cancers altogether.

That’s still a long way off for pancreatic cancer, because this new drug is not a cure. That near-doubling of survival time means that the patients already past the first phase of treatment survived for another 13.2 months on average when they got daraxonrasib, as opposed to 6.7 months if they went on the secondary chemo drugs typically administered at that point. And those who do benefit from the new drug will have to live with side effects, including intense rashes and serious gastrointestinal problems—a subject that former Nebraska Senator Ben Sasse, who is now on daraxonrasib, has discussed frequently during interviews about his battle with the disease.

But overall the side effects are less severe than they are for the existing alternative of more chemotherapy. It is among the reasons Sasse has called daraxonrasib a “miracle drug.” More importantly, the findings by Wolpin and other scientists show it’s possible to treat a cancer once considered “undruggable.” Researchers in the future may be able to stretch pancreatic cancer survival rates even more—by, among other things, deploying daraxonrasib as an initial treatment rather than a follow-up to chemo.

“That’s where, if this really has the possibility of either totally suppressing or—you know, God willing—even curing this, that would be a huge, huge breakthrough,” Ezekiel Emanuel, the oncologist who is now vice provost for global initiatives at the University of Pennsylvania, told me in an interview.

The “if” from Emanuel’s interview—which you can watch above—is an important caveat. Plenty of similarly promising cancer breakthroughs have, with further study and development, proved disappointing.

But plenty have panned out, too. In fact, one of the more oddly underappreciated stories of modern history is the steady, very real progress against cancer: The five-year survival rate for all cancers combined reached 70 percent for the first time last year, up from about 50 percent in the 1970s, according to the American Cancer Society.

Behind these advances are decades of scientific research, which brings us to a bittersweet asterisk to the pancreatic cancer announcement: The news comes right as the foundation for that progress—consistent research funding from the federal government—is being undermined by the Trump administration.

IN THE LAST SIXTEEN MONTHS, Trump and his lieutenants have repeatedly ordered agencies to hold back promised funding for scientific research, alter the grantmaking process behind that research, and at times freeze out whole research institutions. Many of those institutions, like Harvard, are among the most widely respected, most productive universities in the world, accounting for a wildly disproportionate share of global medical innovation.

And there may be more trouble coming.

The administration last month formally proposed to change the way the government scrutinizes funding applications. Under the new system, a grant that had passed through the scientific peer-review process that agencies have long used would then have to get approval from political appointees, who would ensure funding decisions “align” with administration priorities. Critics fear that could mean anything from nixing studies that focus on gender or racial differentials (as Elon Musk’s DOGE did to many government grants that they claimed sounded like DEI) to favoring studies carried out in red states or those likely to boost drug-development efforts from biotech companies friendly to Trump.

It’s impossible to be definitive about what impact this broad attack on research is having or will have. Scientific discovery is a process that plays out over many years and sometimes decades, and the damage is likely to show up as an absence of innovation. That’s awfully hard to measure.

But it’s possible to get some sense of what’s at stake by looking at recent breakthroughs, to see what role federal funding played in making them possible. Daraxonrasib turns out to be a pretty good case study.

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BRIAN WOLPIN KNOWS as well as anybody how helpless clinicians have felt when trying to treat pancreatic cancer. He remembers seeing cases in the mid-2000s, when he was fresh out of his oncology residency and in his first years at the Dana-Farber Cancer Institute, one of the world-class academic hospitals clustered down the street from Fenway Park in Boston.

“I think I saw several patients that first year of fellowship who had pancreatic cancer, and they all died in like three months,” Wolpin told me in an interview via Zoom. “I just couldn’t believe it. You come to Boston, Harvard, Dana-Farber—it’s like a mecca of medicine. It’s not supposed to happen here, right? You’re supposed to have figured this out.”

But scientists weren’t anywhere close. The five-year survival rate for pancreatic cancer back then was around 7 percent, by far the lowest among more common cancers. A big reason for that is pancreatic cancer is typically a stealth killer, growing inside the organ and then spreading before it finally causes symptoms that trigger testing and diagnosis. It was only in relatively rare cases—such as when physicians diagnosed the cancer early, sometimes by accident— that traditional treatments including chemotherapy offered hope of long-term survival.

But chemotherapy is not the only way doctors can treat tumors. One of the big advances of the past quarter-century has been the development of what’s known as targeted therapies. These treatments seek out the mutations that cause cancerous cells, typically binding with them in ways that interfere with or simply halt the process that causes these cells to grow uncontrollably. Targeted therapies have dramatically improved both symptoms and survival for some people with breast, lung, and blood cancers.

An essential element in any targeted therapy is knowing the right target to hit. And scientists knew about a likely pancreatic cancer target long before Wolpin started his research.

Back in the 1980s, scientists discovered a mutation in something called the KRAS gene that accounts for the vast majority of pancreatic cancer cases. The gene has what is basically an on/off switch for cell growth. Sometimes, a mistake in the code has a “catastrophic” effect, as science writer Ruxandra Teslo explained recently in the “Works in Progress” Substack: The mutation locks KRAS “permanently in the ‘on’ position. Cells receive a continuous, unrelenting instruction to proliferate.”

But the KRAS mutation turned out to have a “slippery” surface: Scientists couldn’t find the biochemical crevices or protrusions that in other kinds of cancers allow targeted therapies to bind. “To get the drug to stick, there has to be some divot for it to stick into, and this was just a fully round ball and everything bounced off of it,” Wolpin said.

Soon private capital that had poured into the field dried up, as the whole enterprise acquired an air of futility—not just for investors, but for potential investigators as well.

“Most people told me not to do pancreatic cancer, because it was too hard—and if that was your career, you had a high likelihood of failure,” Wolpin said. In a particularly cruel twist, the cancer’s speedy lethality made it tough to learn from human subjects. They weren’t living long enough to generate research findings.

“We didn’t know that much, honestly, and there weren’t that many people working on it,” Wolpin said.

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TWO SETS OF DISCOVERIES over the last two decades changed that. One was the development of mouse models, by researchers at MIT and Dana-Farber, that allowed scientists to study the tumors more thoroughly. Another was the discovery of one small pocket on the KRAS surface, from researchers at Vanderbilt and the University of California-San Francisco—and in particular, UCSF professor Kevan Shokat—that proved it was possible to bind chemicals to KRAS after all.

“He found things that would stick to it,” Wolpin said of Shokat. “Even though the class of drugs that came out of that initially were not very relevant to pancreatic cancer per se, the concept that you could do that was definitely a turning point.”

One of the scientists who took notice was Nobel Prize-winning physician and researcher Harold Varmus, then head of the National Cancer Institute, who saw the possibility of a breakthrough but realized that private investors spooked by past failures wouldn’t invest. He launched something called the RAS initiative, a research project based out of the Frederick National Laboratory that funded studies all across the world.1

“The RAS initiative helped push people to think, ‘We’ve got to go back, we’ve got to do this, we can’t just throw up our hands,’” Wolpin said. And it was in the flurry of research that followed that he and counterparts at other institutions—like Eileen O’Reilly at Memorial Sloan Kettering, and Zev Wainberg at UCLA—conducted new studies, eventually partnering with Revolution Medicines, the biotech company that developed and is now producing daraxonrasib.2

Money for the RAS Initiative came out of the budget of the National Cancer Institute, which is a federal agency. The Frederick National Laboratory is a federal facility. The labs at Dana-Farber, MIT, Memorial Sloan Kettering, UCLA, Vanderbilt—all benefited from sustained, generous federal funding, as did labs at countless other institutions that have been contributing research ever since the initial identification of KRAS back in the 1980s.

“All of the biology that was understood about RAS, that RAS is important, that RAS causes cancer when it’s mutated, how RAS works, the fact that RAS is present in so many pancreatic cancers—all that comes from the academic research that went before it,” Wolpin said. “Much of that is federally funded.”

It would be a serious mistake to say that federal funding was singularly responsible for the development of daraxonrasib. Revolution Medicines did the essential work that pharmaceutical companies always do—namely, taking the insights from scientific research and turning them into safe, effective drugs. That required (among other things) running extensive and expensive trials, a point made to me not just by Wolpin but also by Catharine Young, a senior fellow at the Harvard School of Public Health.

“They did it with private capital, and they deserve that credit,” Young, who served as assistant director for policy for the Biden administration’s Cancer Moonshot project, told me in an interview.

“But,” she added, “we simply wouldn’t be here today if not for that very defined and impactful federal funding. It was critical, absolutely critical.”

THE TRUMP ADMINISTRATION’S ATTEMPTS to cut or interfere with that kind of federal funding have not been entirely successful.

They’ve run into opposition from Congress, where support for research remains bipartisan and where appropriators refused to approve the kind of big cuts Trump proposed in his budget last year. They’ve also run into opposition from the courts, which have ruled that some of the actions the administration has taken to limit or cut off funding violates the laws chartering agencies like the National Institutes of Health, of which the National Cancer Institute is part.

But other Trump administration actions that reduced funding have survived legal scrutiny. And now the administration is pushing this new proposal that would leave funding decisions in the hands of political appointees who quite possibly have no scientific backgrounds. That’s alarming even to scientists like Emanuel who have called for reforming federal grant-making, in order to (for example) shift money over to younger researchers who may think up newer approaches to old questions.

“Politicization of science and research is not the reform [of government funding mechanisms] needed,” Emanuel said.

And while it’s always possible policies will change, because the administration proposing those policies has a change of heart or—eventually—another administration takes over, real damage has already been done.

“I think we are going to start missing key pieces of research, because of the withdrawal of support for scientific research and the ecosystem,” Young said. “That will be invisible to us for many, many years, but it will be the patients ultimately that are affected by it, because they are the ones that will not have these—in some cases—amazing breakthroughs twenty or thirty years from now.”

Wolpin told me patients are also the ones on his mind. And while he declined to comment on the ongoing political debate specifically, he mentioned to me that at the end of his plenary session—the one where he spoke in a monotone in front of those basic, but amazing, lines on a graph—the moderator asked him to make a closing statement.

“I hadn’t expected that, so I just said I felt like this was all a call to science,” Wolpin told me. “This shows you that [the breakthrough on pancreatic cancer] didn’t come out of the blue. It’s decades of investment that got us here. Decades of investment in science.”

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DOCTORS AROUND THE COUNTRY are baffled, disturbed, and in some cases aghast at the Trump administration’s plan for Americans who get Ebola overseas—in particular, the decision not to bring these patients back home, to one of the facilities that the federal government created precisely for this purpose.

And if you want to know why these medical professionals are upset, ask infectious disease physician Tara Palmore.

Palmore knows better than most what Ebola care looks like in the American facilities, because she provided it during the 2014 outbreak. Although most of the cases were in West Africa, nearly a dozen infected Americans got treatment in the United States, including one who ended up at a facility inside the National Institutes of Health Clinical Center in Bethesda, Maryland.1

That is where Palmore was working at the time. And in a phone interview on Thursday, she described the unit to me—how the surfaces are all nonporous, lest they absorb infected bodily fluids that can’t be fully wiped away, and how there’s extra space for medical equipment, because staff have to bring machines to the patient rather than the other way around.

Another distinguishing feature of the unit, Palmore said, is the sealing of every wall, door, and window seam. It’s part of a system to maintain negative pressure, so that air is circulated only through special filters—a system that patients and staff cannot see but can sometimes hear, because of the high-powered fans. “It can be a little loud in there,” Palmore said.

For her and her colleagues, though, a bigger issue was

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A PROMINENT, DEMOCRATIC-ALLIED THINK TANK is releasing a new report on how to make health care more affordable, and it targets for-profit companies in a way that says a lot about how the politics of the issue are shifting.

The report comes from the Searchlight Institute, which sees itself as a source of ideas that can deliver progress while appealing to voters who might not identify as progressive or liberal. But the report’s core recommendations seem perfectly compatible with the priorities of progressives. They include blocking the formation of hospital monopolies, limiting the role of private equity in health care, and stopping insurance companies from denying coverage arbitrarily.1

It’s easy to imagine somebody like Bernie Sanders or AOC embracing these kinds of policies—and using some of the same language Searchlight leaders are invoking as they pitch their plan.

“I think people are tired of being jerked around by big corporations that don’t have their interests at heart,” David Bowen, a Searchlight senior fellow and principal author of the report, told me in an interview.

The report lands in the middle of a broad conversation now taking place among Democrats and their advisers, in the hopes of forging some kind of consensus on health care reform so they are ready to act whenever the political opportunity presents itself. The Searchlight report, which the organization planned to publish and circulate Tuesday evening, will actually be the second one the group has issued this month. The first came out a little less than two weeks ago, when the organization formally called for free primary care.

The month prior, the left-leaning Center for American Progress published a health care agenda that included a call to regulate hospital prices. And that’s on top of the more ambitious overhauls that many Democrats have been floating for years, like progressive proposals for a “Medicare for All” system, that very much remain part of the debate.

But the CAP and Searchlight proposals are notable because of those groups’ many ties to party leaders. And although the plans are different in their particulars and in their framing, both focus on the ways hospital monopolies have raised prices, just as both seek to curb the power of insurance companies to deny treatments.

The common element here is the contempt for corporations and conglomerates who seem to be putting shareholder profits before the best interests of their patients. There are good reasons both groups have landed there, and those reasons start with all the evidence that for-profit health care companies really are having some pernicious effects.

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ONE OF THE BIGGEST HEALTH CARE SCANDALS in recent history was about a private equity firm that started acquiring hospitals in 2010, and within a few years had created the largest for-profit hospital chain in America. It was called Steward Health Care.

The original idea had been to rescue some nonprofit hospitals that had been struggling financially by bringing in smarter management and finding economic efficiencies. But Steward racked up billions of dollars in debt. By 2024, it was beset by widespread reports that it was not paying its bills, forcing the closure of some facilities while leaving others short of staff and crucial supplies.

Among the unsettling stories that journalistic and government investigations eventually produced was an allegation—which Steward strenuously denied—that supply issues had led directly to the death of a Massachusetts woman after childbirth. Doctors had wanted to perform a procedure to stop bleeding in her liver, according to reporting in the Boston Globe, but staff said they were unable to do so because a supplier had repossessed the required equipment.

Steward would go on to declare bankruptcy, and there’s still ongoing litigation involving various parties associated with the company. But things worked out okay for the private equity firm and its shareholders, who together made hundreds of millions of dollars.

The Steward story is an extreme example of what is now a well-chronicled phenomenon: Private equity gobbling up hospitals, physician practices, nursing homes, and other providers to build giant health systems. The promise is always the same: that the integration and consolidation will yield efficiencies. And research has found evidence of that happening . . . sometimes. But multiple studies have also linked private equity acquisition to closures, cuts and higher mortality rates.

“Medicine and private equity stand at the crossroads of an irreconcilable conflict,” John E. McDonough, a Harvard health policy professor and author of a forthcoming book called America’s Wrong Turn, told me this week. “To hold public trust, medicine must embrace the value of patients first. Private equity is all about maximizing shareholder value.”

Like the other researchers I interviewed, McDonough did not know about the Searchlight plan when we spoke. But it’s not hard to see the intellectual overlap between his point and the group’s proposals.

Searchlight calls for curbing private equity’s influence—and preventing more sagas like that of Steward—by giving the Federal Trade Commission more power to review acquisitions in advance and to reject those that don’t serve the interests of the community. A stronger FTC is also the cornerstone of Searchlight’s efforts to stop the formation of hospital monopolies, which multiple studies have found lead to higher prices without corresponding improvement in quality or access.

Another big piece of the Searchlight proposal calls for creating a “charter of consumer rights” that would limit how long insurance companies could take reviewing treatment recommendations, and prohibit reviews altogether for certain routine procedures. Here again the Searchlight proposal is drawing on academic research—in this case, evidence that insurance companies are using the review process, called “prior authorization,” in ways that delay or deny necessary care rather than simply reduce unnecessary or wasteful treatments.

“There is overprescribing in the U.S. [but]. . . . the problem is that prior authorization has extended to areas of prescribing where there is not evidence of abuse,” Miranda Yaver, a University of Pittsburgh health policy professor, told me this week. Yaver, author of a new book called Coverage Denied, cited insulin and certain cancer drugs as examples of treatments for which prior authorization makes no sense, because patients clearly need them and will suffer harm without them.

Bowen said he believes the problems of prior authorization are tied to the problems of market concentration, in that both are symptoms of a health system where government isn’t doing enough to check the power of for-profit companies.

“I think U.S. policy has been hamstrung by the legal construct in which it works—it is less driven by the ultimate goal, which is what’s good for patients,” Bowen said. “It’s good for patients not to pay artificially high prices because a given hospital has achieved dominance in a particular area. It’s good for patients not to have what Miranda Yaver calls ‘rationing by inconvenience’ on the insurance side, where they just put up so many rules in place because they can.”

WHETHER THE SPECIFIC PROPOSALS in the Searchlight report would deliver what the group promises—i.e., cheaper, more reliable health care—is a complex question of its own.

Health policy is all about tradeoffs. And it’s possible, for example, that breaking up big health systems would deter coordination among primary care physicians and specialists. That could lead to more duplicative treatment and unnecessary care, or too little emphasis on prevention, any of which could drive up costs or drive down quality.

And that assumes the steps Searchlight is outlining would have any significant impact at all. Bowen says inspiration for the group’s anti-monopoly efforts came from health care systems abroad, where—as he described it—“countries have a broader, and more consumer-protective approach to monopolies.” But it’s impossible to know how well the Searchlight proposals will work without more information—like precisely under what circumstances the FTC would intervene—that’s not available at this early stage of policy development, when think tanks are issuing six-page memos rather than fifty-page white papers.

“Antitrust enforcement—blocking potentially harmful mergers—will stop things from getting worse,” Zack Cooper, a Yale economist who has done much of the groundbreaking work on hospital market concentration, told me. “The challenge, however, is that after two decades of consolidation, a large portion of hospital markets are already concentrated. So unless we’re talking about breaking up health systems . . . more enforcement will not prospectively lower spending.”

At its best, a proposal like Searchlight’s could provide building blocks for bigger reforms, while helping to get health care costs under control and sparing patients from some of the insurance company hassles they face now. At its worst, it could draw attention away from more promising policy alternatives, including efforts to pass more sweeping reforms (like “Medicare for All”) that plenty in the party would prefer to pursue.

Figuring out which description better applies to Searchlight’s agenda is precisely the sort of debate Democrats and their allies should be having. And the time to have it is now, because if they wait until they have power it will be too late.

“People ask when did the work on the ACA start, and the answer is that it really started years before,” said Bowen, who as a senior committee staffer and adviser to former Massachusetts Senator Edward Kennedy was part of the effort to write and pass the Affordable Care Act. “That’s when you start getting policies out and saying what can we do. And there are a bunch of different ones out there, a bunch of good ideas, and you spend the time pressure testing them and figuring out what makes sense in the context of what you have.”

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AN OUTBREAK OF EBOLA in Africa. Global health authorities scrambling to catch up. And Donald Trump pushing for aggressive travel restrictions at the border.

That’s how things unfolded in 2014, during the historic West African epidemic that eventually killed more than 11,000 people. And that’s how things are unfolding now, with a new Ebola outbreak in Central Africa that already, going by caseload numbers, appears to be the third-worst ever recorded.

But last time around, Trump was a political agitator, leading a chorus of critics screaming that the administration then in power—i.e., Barack Obama’s—wasn’t doing enough to seal off Americans from the rest of the world. Now Trump is the president. And the U.S. response has changed accordingly.

The most obvious contrast is the one the Trump administration created on Monday, when it announced a ban on non-American travelers coming from the two affected countries, the Democratic Republic of the Congo (DRC) and Uganda, as well as from nearby South Sudan. Back in 2014, the Obama administration rejected more aggressive travel restrictions on the theory they would undermine the international response and actually make it tougher to contain the disease.1 Increased screening at airports and border crossings, the Obama administration argued, would protect Americans.2

But the travel bans aren’t the only difference between now and then, nor the most important one. After a slow start, the Obama administration poured personnel and materiel into the affected countries, while helping to coordinate the global response. It was, as officials said at the time, a “whole-of-government” effort, with the United States Agency for International Development (USAID) playing a big role because it possessed the knowledge and contacts necessary to make public health efforts work on the ground.

USAID isn’t part of the American effort this time. Trump and his then-adviser Elon Musk effectively killed the agency last year. And according to almost everything I have seen and heard, including several advocates and scientists I interviewed over the past forty-eight hours to gauge how seriously we should be taking this outbreak, the withdrawal of so much American assistance

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DONALD TRUMP ON MONDAY hosted a forty-minute Oval Office event focusing on maternal health, and mostly it got attention because he seemed to nod off in the middle of it.

But the president and his invited guests also got some news coverage for the intended message, which was about a series of initiatives like reducing the cost of some fertility drugs, and launching an informational website called Moms.gov. These are supposed to demonstrate, as one attendee put it, that “President Trump wants to make America the best place to have a baby.”

That’s a laudable goal, though it would require an awful lot of policy work.

Both the maternal and infant mortality rates in the United States are the highest among economically advanced countries, according to analyses by the Commonwealth Fund. And when UNICEF last year rated several dozen nations for child well-being, the scores for the United States were terrible, way behind the world leaders: the Netherlands, Denmark, and France.

Those facts may come as a shock to anyone used to hearing about those other countries as socialist hellholes. But spend time in the countries of Northern and Western Europe and you’ll see all the ways people living there benefit from universal health care, cash support for newborns, guaranteed paid leave for new parents, and heavily subsidized childcare.

Several U.S. presidents have tried to replicate versions of those supports here, piece by piece. And some have made real headway.

Today, millions of young children and their mothers have health insurance because of Barack Obama and the Affordable Care Act. Child poverty fell dramatically—if, alas, temporarily—thanks to Joe Biden and the income support measures that he signed into law as part of his pandemic-relief efforts. Lyndon Johnson’s Great Society is the reason so many millions of low-income families can enroll in Medicaid and Head Start. Richard Nixon got behind a substantial increase in food assistance for young families.

Trump is well on his way to creating his own legacy when it comes to maternal and child well-being. But it’s not the kind his predecessors left. Whatever the modest contributions of the initiatives he was touting in the Oval Office last week—and “modest” is a generous description—they aren’t the real story about what the president has done for young families with children.

No, the real story is about what Trump has done to young families with children, by downsizing or undermining some of the most important programs on which many of them rely. And because it’s a big, sprawling tale that involves several programs—not to mention wonky policy details—it may be easiest to follow the way it would affect a typical family as it grows.

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So you’re having a baby. . .

If you care about improving maternal and child health, the place to start is with prenatal care.

Research makes a strong case that women who get proper care in pregnancy are less likely to develop gestational diabetes, high blood pressure, and other health problems. They are also less likely to give birth to low-birthweight babies, which is a big risk factor for all kinds of poor child health outcomes—up to and including death in infancy.

Exactly how big an impact prenatal care has is the subject of ongoing debate, because the subject is tough to study. The same goes for how much health outcomes for pregnant women and newborns truly depend on insurance status per se. But there’s plenty of evidence that people with insurance are better off in other ways, including financially. People who have coverage are less likely to fall behind on rent, or to run up debt.

For most of the last decade, the United States has been making steady progress at getting people insurance thanks to the Affordable Care Act’s creation (under Obama) and then its expansion (under Biden). The one interruption was during Trump’s first term, when progress stalled for a few years. But that was just a preview of what’s happening now, thanks primarily to the $1 trillion taken out of Medicaid over the next decade as part of Trump’s “One Big, Beautiful Bill.”

Trump and the Republicans have defended their cuts by saying (among other things) that they are merely targeting waste—and that the whole point is to preserve the program for people like pregnant women who really need it. They have also noted that pregnant women are, by definition, not subject to the law’s controversial work requirements.

But there’s good reason to think that the cuts will end up affecting pregnant women anyway, partly because the financial pressure the cuts place on states will force them to scale back outreach or special services that target the most at-risk parents. That’s in addition to the fact that, historically, work requirements have reduced enrollment by ensnaring people in paperwork, so that even people who qualify for exemptions end up without insurance anyway.

“With the punishing amount of administrative burden that’s on state Medicaid agencies, it could take three, four months to sort that out,” Sarah Gordon, co-director of the Boston University Medicaid Policy Lab, told the New York Times after the cuts became law last year. And three or four months out of a nine-month pregnancy can make a big difference.1

So you just had a baby. . .

Nutrition is another big factor in prenatal health, as it is for postnatal health—and especially for young children. At least in theory, improving nutrition is supposed to be a priority for this administration. Health and Human Services Secretary Robert F. Kennedy Jr. talks about it all the time!

But the focus for Kennedy has been ultraprocessed foods and artificial dyes. A far more important issue for many pregnant women and their soon-to-be-born children is whether they can simply pay their grocery bills. And like access to health care, that too is becoming a lot more expensive because of historic cuts to food assistance Trump and Republicans have enacted, including many that impose new paperwork requirements that in theory are there to stop fraud.

Those cuts are also part of the One Big, Beautiful Bill. But unlike the Medicaid cuts, they are already having a visible and substantial effect. Enrollment in SNAP, the Supplemental Nutrition Assistance Program, has fallen by more than 10 percent since a year ago, according to newly released federal figures. That works out to more than 4 million people, with nearly 700,000 losing benefits in just the latest month captured by the data.

Enrollment has already plunged by nearly 50 percent in Arizona, where—as a recent ProPublica article reported—implementation appears to be farthest along.

“We’re seeing people being denied when they can’t provide the additional documentation the state is requiring, stuck in backlogs because the state doesn’t have the capacity to process the additional paperwork, being denied because they can’t get through on overloaded phone lines for required interviews,” Katie Bergh, senior policy analyst at the Center on Budget and Policy Priorities, told me recently.

Not all of the current enrollment decline is because of the Republican cuts. Some of it is a reversion to pre-COVID pandemic levels, following the expiration of rules that Biden put in place to ease enrollment. But there’s plenty of evidence that the cuts are a big factor, according to Georgetown University economist Diane Schanzenbach, just as there’s plenty of evidence that they will end up hurting women and children.

“The research backs up what you and I would think of as common sense,” Schanzenbach, coauthor of a groundbreaking paper on the subject, told me in an interview. “If you have enough resources to get the food that they need as they’re growing up, they grow up to be both healthier and more academically inclined, so they’re more likely to finish high school and get a job.”

And it’s not just the food-assistance cuts already in law that could affect infants. It’s the cuts that could still become law in the future. Trump’s budget for 2027 calls for reducing spending on an initiative that covers produce for people in the Women, Infants, and Children (WIC) food program.2

“WIC is targeted at the youngest children, when their brains are developing,” Schanzenbach said. “I’m just kind of speechless to think about cuts there.”

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So now you have a young child. . .

The evidence linking health insurance and nutrition to the well-being of young children is, if anything, stronger than it is for pregnant women. “The literature shows that expanding Medicaid to kids increases use of preventive care, reduces mortality—and pays itself back by age 30 in increased tax collections,” Jonathan Gruber, the MIT economist whose CV includes foundational research on the impact of Medicaid, told me via text.

But it’s not just health insurance and food that families need for their kids. They also need childcare—or, at least, support for parents who stay at home. Not so long ago, Trump seemed to recognize that. During his first term, he talked frequently about the importance of paid leave and childcare, hosting White House events where his daughter and then-close adviser Ivanka Trump helped to preside.

But that was then. This time around he’s barely mentioned the subject, except the time a few weeks ago when—in the midst of justifying the cost of the war in Iran—he said “We’re fighting wars, we can’t take care of daycare.”

And while he and the Republican Congress haven’t reduced spending on early childhood programs the way they have health and food assistance, the Trump administration has repeatedly disrupted funding streams for both the federal subsidized childcare program (which states operate) and the Head Start program (which the federal government operates directly).3

It has done so through a combination of executive actions—like slashing the Health and Human Services staff that oversees grants, slowing the distribution of money to providers that operate on paper-thin margins. And just this past week it finalized new rules for subsidized childcare that could make financial survival for providers even more precarious, by paying them based on day-to-day attendance rather than enrollment.4

Here, too, there’s ample reason to believe that reducing childcare support will have adverse effects on children, especially among the low-income children for whom a nurturing program—or a more intensive Head Start program—might equip them with the tools to succeed in school and at work much later in life.5

That’s not to say these and other supports for mothers and children always work well. Sometimes there really is fraud. And many times the programs could simply be more efficient. All of this matters given that a real tradeoff of these programs is their cost: Creating anything that approached a European-level welfare state would require a bigger tax base, including—almost certainly—finding a way to get more revenue from the middle class.

“It’s certainly not the case that every single program is going to have the beneficial effects we hope it’s going to have—that’s one reason we need to do careful research,” Harold Pollack, a widely respected and cited University of Chicago poverty scholar, told me.

But Pollack was quick to add that “we know that when it comes to health care for children generally, educational inputs for children, for those we’ve got a good evidence base showing they’ll be beneficial.”

Making America a great place to raise kids is an admirable goal. But it requires more than a PR summit. It requires adding rather than taking away resources—not to mention the commitment of a president who cares enough about the subject to stay awake.

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ROBERT F. KENNEDY JR. HAS TAKEN A SERIES of very public political blows in the last few weeks, the kind that might have humbled a less determined figure.

The anti-vaccine crusader had to fall in line last month when Donald Trump appointed a conventionally qualified, vaccine-supporting candidate to lead the CDC. Then Kennedy had to do it all over again a few weeks later when Trump withdrew the nomination of Casey Means, a fellow MAHA warrior, whom the administration had put forward to serve as surgeon general.

As if losing that potential ally wasn’t bad enough, Kennedy had to watch Trump choose a replacement who generally supports vaccination—and who on at least two occasions publicly criticized Kennedy for his efforts to roll back vaccine requirements for children. Kennedy praised the choice anyway, saying he “looked forward to partnering with her.”

And that’s on top of some other embarrassing setbacks, like Trump’s executive order supporting the production of glyphosate, a controversial herbicide Kennedy had spent years attacking as an alleged carcinogen. It was one of several recent Trump decisions that left Kennedy’s MAHA followers absolutely livid. But Kennedy offered his fans no support, instead issuing a statement describing Trump’s order as a necessary—if unfortunate—concession to farmers who rely on glyphosate to protect their crops.

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The backstory here is no great secret. Ever since last fall, Trump advisers have been warning privately—and sometimes publicly, via published polling memos—that Kennedy’s vaccine rhetoric was alienating voters. They have called on him to stop talking about vaccines and stick to his message on healthier eating, which is a lot more popular.

They have also taken firmer control over what’s happening at the Department of Health and Human Services, by elevating a now-trusted deputy, Chris Klomp, to become the department’s chief counselor. His arrival has coincided with the exodus of outspoken vaccine skeptics like the Louisiana doctor who had been serving as deputy director at the CDC, and who had described the United States potentially losing measles elimination status as the “cost of doing business.”

The latest RFK-damaging departure happened on Tuesday, when embattled FDA Commissioner Marty Makary resigned. Makary had become the fulcrum for several ongoing and overlapping controversies, but on issues of common interest he is—er, was—a Kennedy ally.

In Washington—especially Trump’s Washington—these sorts of ritual humiliations are frequently the prelude to leaving an administration, voluntarily or otherwise. And who knows, maybe Kennedy will soon join Pam Bondi, Lori Chavez-DeRemer, and Kristi Noem among the ranks of former Trump cabinet members.

But Kennedy is still at HHS, pursuing an agenda that hints at why his partnership with Trump might yet endure: However much their political imperatives may be clashing, the two men still hold some of the same fundamental grievances.

Two recent developments highlight how Trump and Kennedy’s anti-scientist and anti-elite animus binds them to one another, and to the MAGA/MAHA movement that thrust them into power.

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IT SOUNDS LIKE the premise of a horror film.

A small ship is making its way across the South Atlantic, ferrying roughly 150 tourists to explore remote lands and glimpse rare birds, when an older man suddenly develops fever and a cough—and dies. Symptoms quickly appear in a half dozen more passengers and crew, including the ship’s doctor, and soon the death count is up to three. Testing reveals they’ve been stricken with an animal-borne virus that can infect humans, but that in most forms does not jump from person to person.

By this point, more than 30 passengers have already disembarked and scattered across a dozen countries, setting off a mad scramble by health authorities to find and isolate them. Meanwhile, the rest are still on the boat—also isolated, and under the watchful eyes of newly arrived medical staff observing to see who else will develop this disease for which there is no cure.

If you’ve been following the headlines, you know this isn’t fiction. It’s the story of a hantavirus outbreak aboard MV Hondius, an expedition vessel that set sail from Argentina in April. And the good news—yes, there’s good news—is that this tale isn’t likely to have a horror-film ending, at least on a mass scale.

The form of hantavirus known to be transmissible among humans is thought to spread for a relatively short period as symptoms appear, and through close-up contact.1 That’s very different from, for example, COVID, which was airborne and which people could spread before they even realized they had the virus. With hantavirus, contact tracing has a better chance of catching up to people who might have been exposed—most of whom, in turn, are unlikely to contract the disease.2

“We have contained this in the past and I’m very confident it’s going to be contained again,” Katelyn Jetelina, a former CDC consultant who founded and writes for the newsletter Your Local Epidemiologist, told me in an interview. “To the average person, your risk is essentially nil.”

But if you talk to people who work in public health, you will pick up a clear level of concern. And it’s not simply because the spread of any lethal virus is, quite rightly, a reason for them to be vigilant.

They know that Donald Trump has spent much of his second presidency waging an all-out assault on America’s global health infrastructure—by downsizing or eliminating existing agencies and programs, and transforming them in ways that make them instruments of other goals like extracting mineral rights or ending DEI. This assault has also included withdrawing from the World Health Organization, and from global health cooperation more generally.

That has left the federal government without some of the tools, systems, and personnel it has deployed in the past. The result is a federal response to outbreaks that is weaker overall, and could falter in the face of a more serious threat.

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HANTAVIRUS IS A DISEASE CARRIED mainly by rodents. Estimates suggest it infects tens of thousands of people worldwide each year, which sounds like a lot until you remember more than eight billion people live on this planet.

The majority of cases come from Europe and Asia, where the common strains can cause renal failure. The versions in the Americas usually cause respiratory problems, and are more likely to kill. What these variants have in common is that transmission for the majority of observed strains takes place through one method: Somebody inhales particles of rodent excrement that have accumulated in dust or are floating in the air.

That is why the few cases3 that pop up in the United States frequently come from people who didn’t wear masks while cleaning out old attics or basements, or from people who were living in places that turned out to have rodent infestations. This is what officials believe killed the wife of actor Gene Hackman last year (leaving the ailing Hackman without a caretaker).

One of the few versions of hantavirus known to be capable of transmission among people is the Andes strain, so called because of its prevalence in South America. And that is likely how the virus made its way onto Hondius in April. The first passenger to die had been visiting Argentina with his wife, observing birds, in some cases going to sites with large rodent populations. Reportedly one of the stops was right near a landfill.

He got sick shortly after the boat left Argentina, likely infecting his wife and possibly the doctor, both of whom would have had the kind of close contact necessary for human-to-human transmission.4 The wife ended up disembarking during a stopover at Saint Helena, the remote island about 1,200 miles west of the Angolan coast, and flying to South Africa. She had planned to return home to the Netherlands, via a flight on KLM, but the airline says the crew determined she was too sick to fly and removed her. She died one day later.

The woman was not the only one to get off the boat in Saint Helena. Between thirty and forty other passengers did as well. (There are conflicting reports of the precise number.) One of the most urgent tasks for health authorities has been to find all of these people, and anybody who might have come into close contact with them.

But the news so far has been reassuring. A KLM flight attendant who had been in contact with the woman has tested negative for hantavirus. Nobody on the ship has developed symptoms since May 1, according to the most recent WHO update. And there have been reports that passengers and crew are handling the ordeal well—even taking part in deck-side activities, albeit with social distancing—as the ship makes its way to the Canary Islands for a carefully controlled evacuation that Spanish authorities have said they plan to oversee on Sunday.

Maybe the best news of all has come from genetic testing, which confirmed that the pathogen is the Andes strain with no unusual mutations that would allow it to spread more easily or quickly than what researchers have seen in the past.

“The [genetic] sequence has been published, posted publicly, and it looks like the sequences that are known from Argentina,” Tara Palmore, an infectious-disease specialist and epidemiologist who spent more than two decades at the National Institutes of Health, told me.

That is why public health authorities are treating the outbreak as something they can handle. They will watch for any new information that suggests something about the virus has changed, but they aren’t sounding alarm bells—and on a personal level, they aren’t stocking up on quarantine supplies either.

“It’s probably going to burn itself out,” Jeanne Marrazzo, an internationally recognized physician who now leads the Infectious Diseases Society of America, told me on the phone. “These things that are sustained by individual chains of probable close contact, with a limited duration of infectivity, there’s an end in sight. With COVID, there was no end in sight. It became pandemic, and now it’s endemic. That’s how I would draw the distinction.”

THE ABILITY TO ASSESS this hantavirus outbreak so quickly is testimony to the sophisticated international infrastructure now in place for disease surveillance and response. And that infrastructure didn’t appear out of thin air. It was constructed over time, with much of the essential money, leadership, and expertise coming from the United States.

The worry now—for Marrazzo and so many of her counterparts here and abroad—is that the infrastructure is losing American support, thanks to Trump.

Consider the testing that pinpointed the hantavirus strain this month. It took place in South Africa, which has cutting-edge research facilities full of world-class virologists. And a big reason for that is years of investment from the President’s Emergency Plan for AIDS Relief, the wildly successful 2003 George W. Bush initiative to fight HIV.

PEPFAR was among the programs that Trump hit with a stop-work order shortly after taking office, temporarily freezing funds and disrupting activities with little notice. And although the administration subsequently restored some funding, it continues to restrict the program in multiple ways—including a dramatic reduction in aid to South Africa, which Trump has (along with former adviser and South Africa native Elon Musk) alleged is undertaking a campaign of “genocide” against white farmers.

“It is the work that was done setting up infrastructure through PEPFAR to do genetic sequencing of HIV that is now paying off, in being able to do genetic screens, sequencing of viruses like this [hantavirus],” Carlos del Rio, another internationally recognized scientist who is a professor of medicine and public health at Emory University, told reporters during a briefing last week. “I worry that, as we disinvest in global health, we’re losing our capacity—our global capacity—to deal with diseases.”

And this isn’t happening just in South Africa. The Trump administration has been dialing back on global health assistance to all countries—sometimes by refusing to spend appropriated money, sometimes by making assistance conditional on countries agreeing to U.S. demands, like ceding mineral rights.

“There’s so many ways that this is so crazy,” Emily Bass, a longtime journalist, expert, and activist on global health who is also a consultant to Physicians for Human Rights, told me. “Through PEPFAR and through our support for labs, if there was a new disease outbreak—if there was a new anything—we knew about it immediately because we were working alongside people. And we were paying for the GeneXpert machines that were diagnosing and sequencing whatever the respiratory virus was, and so we had access at a level few people even realize.”5

And that’s just one way the Trump administration yanked funds from biothreat programs. Another was the defunding of a fifty-nation disease surveillance and response network that physician and author Atul Gawande once described as a “global immune system,” because it gave the United States a way to spot new outbreaks—and backstop or help direct local responses—just as they were emerging.

Gawande helped to set up this network while he was the assistant administrator for global health at USAID, the international aid agency that Trump effectively dismantled early last year. “There are parts of that network that they have re-funded,” Gawande told me on the phone last week, “but the network, the surveillance system, the advancement towards strengthening a comprehensive system of detection and response and prevention—that’s all gone.”

TRUMP ADMINISTRATION OFFICIALS have said that these and other changes will not interfere with their ability to monitor global health threats or protect American lives. And it’s not as if the United States has completely turned its back on the world. Officials at the WHO say they’ve been in communication with U.S. counterparts during the hantavirus outbreak—exchanging information and expertise, while cooperating on matters like how to evacuate and repatriate American passengers from the boat.

But because Trump had the U.S. officially withdraw from the WHO, these sorts of communications must take place quietly and often through backchannels—an approach that public health experts told me is slower and clunkier, and can mean key information never gets conveyed. And to the extent international communication takes place informally, it’s going to depend more heavily on existing relationships. Those inevitably deteriorate when the administration is laying off or purging leaders at agencies like the CDC—which, by the way, has gone eight months without a permanent director.

One visible sign of that, Marrazzo told me, is the agency’s slow public response to the hantavirus outbreak.

The CDC hasn’t “had a press briefing, we haven’t heard anybody talk about mobilizing investigators across the world who are already working on potential treatments,” Marrazzo said. She added that it wasn’t until Wednesday evening that Jay Battacharya—the NIH head who is overseeing the CDC while the director’s post remains vacant—posted a tweet announcing that the CDC was monitoring the situation and working with international officials.

When we spoke, Marrazzo mentioned she had recently realized the Health Action Network—an online tool for alerting health care providers around the country of possible health threats—had nothing on its website about hantavirus. “My jaw dropped,” Marrazzo said.

That was Thursday morning. A note finally posted late Friday.

As always with Trump, it’s an open question what’s driving the changes he has unleashed. Is it a deliberate effort to reshape global health agencies, policies, and priorities? An expression of grievances against institutions like the WHO, which he continues to think sabotaged him during the COVID-19 epidemic? Sheer indifference to how government works? All of these things?

But it seems pretty clear he thinks about global health the same way he thinks about other global issues: As a contest for supremacy among self-interested nations, rather than as an opportunity for cooperation. The problem for Trump—and, more important, for all Americans—is that deadly pathogens frequently cannot be stopped without truly global efforts. And the next one might pose a much bigger threat than hantavirus.

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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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Boston
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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