Detroit, Michigan
ABDUL EL-SAYED HAS BEEN RUNNING to become Michigan’s Democratic Senate nominee for more than fifteen months. And if there’s been one constant over that period it’s been his promotion of “Medicare for All” as a way to make sure all Michiganders—and all Americans—have access to affordable, quality health care.

It’s a big focus of his stump speech, something he usually raises right at the beginning. It’s all over his campaign signage. And it’s the only specific policy promise in his three-part campaign slogan, which he and supporters invoke constantly:

Money out of politics. Money in your pockets. Medicare for All.

Medicare for All—a proposed version of universal health care that would have the government cover everybody directly, mostly doing away with private health insurance—has been part of the policy conversation among Democrats since the 1940s, when Harry Truman proposed a national health plan that included a prototypical version of the idea.

In the last few decades, partly as a nod to real-world political constraints, Democrats have leaned more toward hybrid plans with both private and public insurance as the surest path to universal coverage. That approach gave us the Affordable Care Act in 2010, which alongside Medicare and Medicaid—and with some financial reinforcements put in place during the Biden administration—reduced the uninsured rate to a record low.1 It’s as close as America has ever come to a place where health care is a right, not a privilege.

But even then, millions of Americans didn’t have insurance or couldn’t cover their out-of-pocket costs. And that was before Donald Trump and the Republicans started hacking away at the existing programs, exposing even more people to crushing medical bills. Partly in reaction to those realities—and partly thanks to high-profile advocacy by the likes of Senator Bernie Sanders, the Vermont democratic socialist—over the last decade or so the idea of a full reset through Medicare for All has gotten increasing attention from the Democratic faithful.

On Tuesday, those sorts of voters in Michigan will get a chance to weigh in on this debate when they decide between El-Sayed, who is a former public health director in Detroit and Wayne County, and Haley Stevens, who is a four-term House Democrat. Stevens is from the wing of the party that prefers to work within and around existing arrangements, whether that means trying to repair the damage from Trump or creating a new, optional public insurance program for people who want an alternative to private coverage.

For voters here who care about health care, weighing the two candidates means considering the different policy paths they recommend, including the merits of Medicare for All itself. But it also means pondering something that hasn’t gotten as much attention: exactly what kind of senator El-Sayed and Stevens would each likely turn out to be, and what history teaches us about how their distinct styles would play out in the current political landscape.

IT WOULD BE DIFFICULT to overstate how central health care is to El-Sayed’s identity.

The political origin story he tells involves his journey through medical school when, while working in a New York City hospital, he saw the difference between the lavish attention to wealthy patients on the top floor and the shabby treatment that the destitute got down in the emergency room. One of his staple campaign lines is that the life expectancy in the country of his parents, Egypt, is roughly the same as it is in parts of Detroit.

He says it convinced him to focus on public health rather than the practice of medicine—which, in turn, drew him to Medicare for All. “In public health, we’re always in this position where we’re underfunded and underinvested-in,” El-Sayed told me during a phone interview Saturday, while driving between campaign stops. “That’s because our current health care system sucks so much money into the care part of things rather than the prevention part of things.”

A few years ago, El-Sayed collaborated with a physician-researcher on Medicare for All: A Citizen’s Guide, a book that briefly explains how America’s health care system evolved, then sketches out the broad outlines of a Medicare for All system, including benefits and financing.2

The pitch El-Sayed makes in his speeches and appearances doesn’t get into the policy weeds; it is more like a general pitch for the idea of universal coverage, which is something that takes a variety of forms abroad. Many countries’ systems include significant roles for private insurance, and some have considerable out-of-pocket spending. At the same time, even the hybrid systems of countries like France or the Netherlands have more in common with the single-payer systems of Canada, Taiwan, and Sweden than they do with the American patchwork.

One way to think about Medicare for All—and to evaluate El-Sayed’s support for it—is to imagine, as a thought experiment, what it would be like to transplant one of those systems here. You’d have to account for all kinds of cultural differences, including among medical practitioners, that can have profound effects on the economics of health care. You’d also have to account for the transition, which may be the hardest part of the equation because health care represents one-sixth of the economy and even modest changes would entail massive disruption.

Spend any time with the numbers and you’ll discover Medicare for All, like all health care systems, including America’s status quo, would require making difficult tradeoffs. Throw in the political obstacles to any kind of substantial health care reform—a list that includes the power of monied interests, the skewed representation of the Senate, and the public’s fear of change3—and the chances of actually enacting Medicare for All anytime soon is slim at best, even if El-Sayed gets to the Senate.

Some people act like the only way to support universal coverage as a goal is to support Medicare for All, as if anyone who doesn’t back Medicare for All isn’t truly committed to universal coverage. That would surprise the likes of Ted Kennedy, the legendary Massachusetts Democratic senator who was the patron saint of universal coverage while he was alive, yet was a key orchestrator of multiple compromises including early work on the legislation that became the Affordable Care Act.4

El-Sayed hasn’t done anything to dispel this notion, and probably reinforced it by dismissing narrower proposals like one Democratic-aligned think tank’s call to make primary care free. But in our phone interview he said he understands the technical challenges and would, if elected, seek to help Democratic colleagues work through them.

He also said he understands the political challenge, which is why he routinely refers to Medicare for All as a “Mount Everest” to be scaled in stages. “I’ve been very clear that I want to get to Medicare for All, and I also believe that we’ve got to take a pathway there. To me, as long as it reduces the power of the health care corporations, expands health care, and does so publicly, I’m for it, and would be glad to work with likeminded partners on that path.”

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FOR A MODEL OF WHAT this might look like in practice, you need look no further than Sanders, who is not just Medicare for All’s most visible champion but also El-Sayed’s, having endorsed both his 2018 gubernatorial bid and now his Senate run. The Vermont senator played a key role in shaping the prescription drug reforms that Democrats passed and Biden signed in 2022.

Sanders’s harping on persistently high health care costs during the 2016 presidential primaries frustrated Democrats who were preparing to defend the Affordable Care Act against possible repeal, and back in 2009 he held off supporting the law until the final stages of Senate debate. But he came around to yes, as the Obama White House and Senate leaders knew he would, with his one big ask being an $11 billion investment in community clinics entirely consistent with the law’s spirit. And in 2017, once the repeal effort got underway, Sanders proved an enthusiastic and effective defender of the law.

Another Sanders accomplishment was a landmark 2014 reform of veterans health services. That was a bipartisan effort, one that he negotiated with the late John McCain, and it’s an open question how much interest El-Sayed would show in such deal-making, or how much capacity he has for it. It requires EQ as much as IQ, and not disparaging adversaries in the way he has treated Stevens multiple times—most recently just this week, when he described the four-time election winner as the “least capable candidate in America.”

Stevens in many ways illustrates the opposite archetype. She has a proven record of bipartisanship. In fact, that’s been the main thrust of her campaign: that she’s a workhorse who gets stuff done, winning recognition as an effective legislator precisely because she makes deals on legislation targeting particular needs or groups of constituents.

Health care is not as central an issue for Stevens’s campaign or her public identity as it is for El-Sayed. (To be fair, you could say that of most politicians. In Stevens’s case, industrial policy is her thing, and she’ll hold forth on it for hours if you let her.) If Sanders is a prototype of who El-Sayed might be, a more likely role model for Stevens would be Debbie Stabenow, who represented Michigan in the Senate from 2001 to 2025.

Stabenow, who has endorsed Stevens, also focused on issues other than health care. But she did leave her mark in a few spots. One of those was the treatment of mental illness; over the course of years, she built a bipartisan coalition for legislation that now funds mental health clinics around the country, in a way that appears to be providing much-needed care while easing the burden on local law enforcement.

Other than that, Stabenow supported whatever health care measures Democratic leaders promoted. Most likely Stevens would too, because that’s how she’s conducted herself in the House whenever health votes came up. That includes the 2022 law giving the federal government power to negotiate some drug prices in Medicare. Stevens voted yes, notwithstanding some (relatively small) campaign donations from drug companies she has taken over the years.

Insofar as the Democrats stay on the path they’ve been on—using the policy architecture now in place to finally get to universal coverage—Stevens as senator figures to be another lawmaker helping that journey along. And she would come to office with legislative experience, something one of her key backers told me gave her an advantage over El-Sayed.

“She’s the only person that actually passed legislation,” Coleman Young II, president pro tem of the Detroit City Council, told me during a joint appearance with Stevens on Saturday. “If we were talking about who could be the best public health director, we’d be in trouble. We’re campaigning for who’s going to be the best United States senator. This is a legislative position, and Haley Stevens has the record.”

WHAT STEVENS WOULD CLEARLY not do as a senator is try to push the boundaries of debate over health care in the way that El-Sayed would. He has said repeatedly that if he is elected, he would try to use his platform to build support for his agenda—including Medicare for All—to national audiences, to the point of visiting other states where lawmakers might not be with his program.

Stevens has suggested that makes El-Sayed more interested in making headlines than making progress. And there was a time, certainly, when that kind of advocacy would look to fellow members of the Senate like grandstanding, making it difficult to accumulate power and negotiate—and, eventually, to pass laws that could benefit constituents.

But lawmaking in 2026 is different from, say, 2016 or 2006. More now than ever before, attention is political currency. In the hands of somebody committed to a cause like Medicare for All, it can change the agenda, sometimes substantially. The proof is Sanders, whose persistent advocacy for Medicare for All—even when he was the only nationally recognizable figure pushing for it—is a big reason it’s a central part of the conversation among Democrats.

In that sense, the main impact of electing El-Sayed would be adding to that chorus another, younger version of Sanders—somebody who would push the whole caucus in the direction of expanding health care access, and who could inherit the Medicare for All movement whenever Sanders, now 84, decides to hang up his democratic socialist spurs. And it is safe to assume that merely electing El-Sayed would have a galvanizing effect on the national debate, by challenging old conceptions of what’s politically possible in a swing state campaign.

But first El-Sayed would have to win the general election, while running in a state far less hospitable to his politics than Vermont has been for Sanders. And it doesn’t take a ton of imagination to see how difficult that could be.

Just for starters, El-Sayed would have to overcome an onslaught of negative advertising even more overwhelming than the one he’s facing now. And this time it would feature the sort of attacks fellow Democrats would never make but Republicans make all the time. Example: El-Sayed has said undocumented workers should get coverage if they pay taxes. The position is highly defensible as a substantive proposition but highly difficult to defend politically.

El-Sayed, never lacking in confidence, thinks he can win this fight. And he is well equipped to do that—especially in a campaign against presumptive GOP nominee Mike Rogers, a former GOP House member who took money from pharmaceutical companies and has a long record of supporting Republican bills to take health care away from people.

El-Sayed could leverage his background as a doctor and epidemiologist who has literally spent years helping people to get health care. And unlike Stevens, he could present himself as somebody who has never taken money from corporate PACs. Those are all powerful rhetorical tools, especially in the hands of a communicator as deft as El-Sayed.

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ELECTABILITY IS A TOUGH THING TO PREDICT. Its consequences aren’t. Just look at the recent history of health policy debates.

One more Democratic senator in 2009 would have given the Affordable Care Act’s architects leverage to pass a more generous bill, one that got closer to delivering what Medicare for All would. And in 2021, one more Democratic senator would have allowed leaders to muscle through a program for home health care they had to drop, to expand the universe of drugs subject to government price negotiation, or to fund more years of the temporary Obamacare subsidies Republicans have since allowed to lapse.

By contrast, with one fewer Democratic senator in 2017, the Affordable Care Act probably wouldn’t have survived repeal. And with one fewer Democratic senator in 2009, it might not have become law at all.

There are countless more examples like that on other issues, all highlighting the same essential reality that is true on health care. The effect of nominating El-Sayed instead of Stevens as nominee would be substantial—for better or worse, depending on your perspective. But it would be small relative to the impact of putting up a losing candidate in the general election. For health care especially, the cost of turning Michigan’s Senate seat red could be catastrophic.

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‘Bring better ideas.’

Excerpts from an interview with Abdul El-Sayed on August 1, 2026, lightly edited for clarity.

JONATHAN COHN: One of the things I want to do is predict for people—on health care—what you would be like in the Senate. And I was thinking back to when we had a video interview a few months ago, when I asked you whom you thought of as role models. You mentioned Bernie Sanders and Elizabeth Warren. Looking at them, are they a pretty good preview of how you would like to operate in the Senate?

ABDUL EL-SAYED: And I mentioned a third, Senator Chris Van Hollen. Yes. I think our work is about getting the nuts and bolts of the policy right, making the moral and political argument, and then working to line up the votes because you’ve moved the ground underneath the U.S. Senate and public policy. I want to be able to do my part on all three of them, working alongside colleagues who’ve been thinking about this and doing this work for a long time. I think about Senator Sanders, of course, and Congresswoman [Pramila] Jayapal and Senator Warren, and then many others. I hope that folks can rely on me to be a bona fide policy student, somebody who’s taking what I’ve learned as a researcher and an expert to build that into public policy. And then also an advocate on the ground, to use the broader public conversation around what all of us can believe in and should fight for when it comes to health care. And then working alongside somebody like a Senator Van Hollen to say, okay, how do we start to think about building the coalition for this in the Senate, to line up the votes that we need to get it done.

COHN: You look back at Bernie Sanders, he obviously is talking constantly about Medicare for All. But he also did a big bipartisan veterans bill with John McCain. And he worked on the prescription drug price negotiation. Do you imagine yourself being someone who would work on things like this that are not Medicare for All, and really put your muscle into them?

EL-SAYED: For sure. I’ve been very clear that I want to get to Medicare for All, and I also believe that we’ve got to take a pathway there. To me, as long as it reduces the power of the health care corporations, expands health care, and does so publicly, I’m for it, and would be glad to work with likeminded partners on that path. I think the mistake is sometimes to say, ‘Okay, we’ve made these changes and therefore we’re good to go. We’re not good to go until we have Medicare for All. But you know on the pathway—the steps along the way—I’ll be working hard with my colleagues to try to get those things done too. . . . When it comes to making the VA whole, when it comes to funding our investment in affordable prescription drugs, when it comes to our investment in medical science, you’re going to see me right at the forefront.

COHN: You’ve talked a lot about how you want to be going into other districts and states, making the case for Medicare for All, and other priorities too. Does that include fellow Democrats? Would you go to a Democratic district or state if you feel like a senator is pulling in a different direction?

EL-SAYED: I think we have a responsibility to fight for the things we need and deserve. In the end, politics is about a competition of ideas. I think you lose that competition if you’re not willing to take your ideas and present them to a broader public, and I think it’s important for voters to have an alternative to somebody who’s corporate bought. Now, that means beating Republicans big time. But it also means standing up within our own party, like I’m doing in this primary, when it is the power of corporations buying our own party against the will of the broader public. . . . I’m focused on the best interests of the people of Michigan. And to achieve the things I need for the people of Michigan, it’s going to be really important that we have the kind of movement inside the U.S. Senate to be able to pass the legislation that is in service of people here in my state. So the question is: Am I afraid of what colleagues might think of my advancing my ideas? I tell them: Bring better ideas.

COHN: I know some people are worried you’re more excited about attacking Democrats and fighting out a factional war in the party, rather than beating Republicans.

EL-SAYED: Give me thirteen weeks and ask them if they think that after I’ve dispatched Mike Rogers.

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Detroit, Michigan
ABDUL EL-SAYED STOOD AT THE EDGE of a picnic pavilion in Detroit’s largest urban park on Sunday, making his case for why he is the Democratic Senate candidate best positioned to help the city’s voters.

El-Sayed, who is locked in a tight contest with four-term House Democrat Haley Stevens, is a doctor and epidemiologist who has served as public health director for Detroit and then (separately) its surrounding county. He reminded the crowd that in those two positions he supplied kids with free eyeglasses so they could see in school, went after polluters whose emissions were causing asthma, and spearheaded an effort to remove lead from water pipes that were slowly poisoning several city neighborhoods.

“I have been showing up for Detroit since I first stepped into the city as its health director back in 2015,” said El-Sayed, “and I intend to show up for Detroit every single day when I walk into the Capitol as your next U.S. Senator.”

The gathering in Rouge Park was one of several “Knock Out the Vote” events El-Sayed has held in these final two weeks before the August 4 primary. Judging by the cheers and scattered “amens,” it was a success. But it was also hard not to notice the complexion of the group. It was

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Detroit, Michigan
ANOTHER JOLT JUST HIT the highest-profile Democratic Senate primary in the country: Big Gretch entered the conversation.

That’s the affectionate nickname for Gretchen Whitmer, the two-term Democratic governor who is by most reckonings the most popular statewide elected official in Michigan. On Friday, she announced that she was endorsing Haley Stevens, the four-term House Democrat who has been running in a tightly contested, increasingly bitter campaign against former Detroit and Wayne County public health director Abdul El-Sayed.

Whitmer made the announcement in a video—and then in person about three hours later, during a campaign event at a Teamsters union hall in Detroit, where she said “Michiganders need a fighter in Washington.” Never once in either case did she mention El-Sayed. But she alluded to him indirectly during the speech when she said the top priority for Democratic voters was keeping the open Senate seat—now occupied by Gary Peters, who is not seeking re-election—in the party’s hands.1

“Democrats cannot take back the Senate without winning the state of Michigan,” Whitmer said, as a crowd of about a hundred supporters cheered. “We don’t hold this seat, we can’t fight back against Medicaid cuts. We can’t fight back against tariffs, against skyrocketing gas and grocery prices. We can’t fight back against the chaos and division and political gamesmanship that have consumed our country for too long.”

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That argument cut right to the heart of the question that for many Michigan Democrats is the most important: Which candidate has the best chance of winning? Supporters of Stevens have said she’s the one, citing her record of winning in swing districts and the difficulties El-Sayed would have defending a left-wing platform in a closely divided state. El-Sayed’s backers counter that his populist message actually speaks to many conservatives, while Stevens’s support from wealthy outside groups ties her to an establishment that infuriates voters across the ideological spectrum.

Whitmer at the Friday appearance didn’t have to spell out which side of the argument she finds compelling. But she did drop a reminder of why she has some authority to speak on the matter—as “someone who won statewide twice,” pausing and drawing out that last word for emphasis, and holding up two fingers for effect.

Just how seriously Michigan voters will take this advice is a separate question. Endorsements certainly don’t have the power they did in the old days. Just ask the editors of the Detroit Free Press, whose compelling endorsement of the campaign’s third candidate, state Sen. Mallory McMorrow, appeared exactly six days before she dropped out of the race.

Meanwhile, more than 690,000 Michiganders have already voted via mail or absentee ballot, according to official figures.2 And Whitmer’s reputation has recently taken a hit thanks to in-state controversies over her support for data-center construction and her veto of several budget amendments. The former has pissed off progressives, environmentalists, and local activists. The latter has pissed off longtime Whitmer allies in the state legislature and key interest groups like labor.

But there are still plenty of reasons to think Whitmer’s endorsement will matter, maybe quite a lot.

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THE TRUMP ADMINISTRATION is contemplating radical and potentially destructive changes to one of America’s most famous anti-poverty programs, according to several people familiar with internal administration deliberations and one with direct knowledge of them.

The program is Head Start, which provides free, specially enhanced childcare to more than 700,000 low-income preschoolers, toddlers, and infants. It operates through the Department of Health and Human Services—where, sources have told me, officials have drafted a regulation that would eliminate most of the rules for how individual Head Start providers operate. Under this draft regulation, HHS would then introduce new rules designed to align Head Start with MAGA priorities and the right’s crusade to shrink government.

One of the most important changes under consideration, the sources said, would be a new prohibition on enrolling children if they don’t have at least one parent who is either a U.S. citizen, a U.S. national, or a “qualifying” immigrant. Notably, that prohibition would apply to all children, regardless of their own immigration status, meaning the rule could—and almost surely would—deny public benefits to some children who are full citizens. Blocking full citizens from getting public benefits in this way would be unprecedented, according to legal experts I consulted.1

Many of the other changes under consideration would affect the program’s quality and safety standards in equally dramatic ways, the sources told me. One example: The regulation, as drafted, would eliminate the existing minimum requirements on instructor-to-child ratios, leaving the matter to states. That’s a big deal, because a hallmark of Head Start is its nationally uniform rules designed to make sure programs in all states meet the special needs of children growing up in low-income conditions.

The Office of Management and Budget website states that it is currently reviewing a proposed HHS regulation designed “to reduce and streamline Head Start regulatory requirements, to align Head Start standards with state and local systems and reduce burden on Head Start programs.” The Trump administration isn’t commenting on it and my sources cautioned that they do not know whether officials have already made changes to the draft. But nobody would be surprised to see this administration formally propose some version of these regulations.

The Trump administration spent much of last year battering Head Start with funding restrictions and disruptions. It also took a run at restricting enrollment based on immigration status, failing only because federal judges halted the initiative. The administration is currently in the middle of a separate effort to rescind yet another Head Start rule, this one a Biden-era initiative designed to boost instructor pay. And that’s to say nothing of the fact that the administration last year had reportedly planned to call for Head Start’s elimination, as part of its 2026 budget proposal, before backing off in the face of political pressure.

There is, to be clear, nothing inherently unreasonable about a presidential administration scrutinizing Head Start, or making some changes on its own authority. A serious, worthwhile debate about the program’s effectiveness has been going on for decades, with even fierce Head Start advocates in favor of some reforms.

But the changes now under consideration don’t sound like an effort to address Head Start’s weaknesses with some carefully considered modifications. Rather, they sound like an attempt to abandon parts of the program’s basic mandate, which Head Start has pursued for the better part of six decades and which was first put in place by its founders.

ONE OF THOSE FOUNDERS was Lyndon Johnson. During the 1964 State of the Union address, with the country still in mourning following John Kennedy’s assassination, Johnson dedicated himself to a mission that JFK had first discussed: a “war on poverty” that would seek “not only to relieve the symptom of poverty, but to cure it and, above all, to prevent it.”

Kids were a focus of this effort in part because of a new scientific development: Researchers were firmly establishing how deprivation early in life put impoverished children at a severe, lingering disadvantage in school. By the time these kids got to kindergarten, researchers were demonstrating, they had learning and knowledge deficits on everything from language to problem-solving that in many cases were simply too big to make up.

Sargent Shriver, whom Johnson had empowered to lead the war on poverty, convened a panel of psychologists, pediatricians, and other experts to develop a policy that could equip these children with the skills they would need to keep up with their peers and to succeed later in life. The result was Head Start, which the Johnson administration launched as an eight-week summertime pilot and later—working with Congress—expanded into a full-time, year-round program.

“Head Start embodied the vision of the Great Society,” Princeton historian Julian Zelizer told me, “building on the New Deal [promise of providing] . . . support to Americans so that there was a basic social safety net from the vicissitudes of capitalism—particularly for children and elderly Americans.”

From the get-go, Head Start had a few guiding principles. One of the most important held that instructors should be trained in the science of early-childhood education and lead classrooms in ways that would be consistent with the latest findings on how best to teach children at different ages or in different socioeconomic circumstances.

But the program’s architects knew the formula wouldn’t do any good without intermediaries committed to using it faithfully. And they did not trust state-level officials, especially those in places where Jim Crow laws remained in place. That was a big reason why Shriver and his team opted to bypass state governments altogether. Money would flow from Washington directly to individual programs and organizations, or to local governments and school systems that chose to offer programs. In exchange for the funding, anybody running a Head Start program would agree to abide by rules that the federal government set.

“At the time it was created, the southern states were not providing services to black children,” Olivia Golden, who served as HHS assistant secretary for children and families during the Clinton administration, told me. “Head Start has always been at its core about the idea that we’re at our best as a country when everybody has a chance to thrive.”

The program’s rules have evolved over time, sometimes because administrations have wanted to tweak how the program operates and sometimes because administrations have been implementing laws that overhauled the program substantially. That’s what happened after 2007, when Congress passed legislation designed to tie the program more clearly to school readiness by—for example—upping the requirements for teacher credentials and putting in place new systems to monitor how individual programs were performing.

That legislation was negotiated by a Republican president (George W. Bush) and a Democratic senator (Ted Kennedy), and got through Congress with overwhelming majorities. It was a sign of the program’s enduring popularity and of the commitment, across ideological lines, to the basic goal of helping children who need it the most.

That commitment extended to Head Start’s longstanding policy of not checking immigration status, even though a decade earlier the 1996 welfare reform law had made it difficult for immigrants (even some legal ones) to get public benefits.

The theory for exempting Head Start from those rules was that its purpose was to promote child welfare and community well-being, not to provide financial assistance. There was also concern that aggressive documentation requirements might discourage some immigrant families from enrolling their kids, even if those children were eligible.

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THAT BIPARTISAN POLITICAL SUPPORT notwithstanding, Head Start’s performance over the years has provoked lots of debate.

Critics point to studies that found gains in reading and math scores made by Head Start enrollees frequently faded after a few years. Supporters have responded by highlighting studies showing long-term gains like lower rates of delinquency and teen pregnancy, and a higher propensity to graduate high school.

An exhaustive literature review from this past February concluded that the best available evidence suggests Head Start helps children who face the biggest disadvantages, though it acknowledged lots of variability from program to program—and lots of uncertainty because some of the gains are simply hard to measure.

The debate will continue as researchers continue to study the program, which is as it should be. In the meantime, a presidential administration skeptical about the efficacy of regulation and the wisdom of regulators would be well within its rights to propose and pursue modifications to the program in ways that loosened some of the rules now in place.

But what the Trump administration has in mind would go far beyond that. One source told me that the regulation under consideration would effectively eliminate whole sections of the rules, including some spelling out how to make sure children with disabilities have access to the program.

“These proposed standards would fundamentally transform Head Start beyond recognition, removing the characteristics that make it so much more than an early-education program,” the person familiar with deliberations told me.

But even as the draft regulation would clear out all of those rules tied to instruction, quality, and safety, it would add those new requirements to restrict enrollment based on immigration status. That would put a much bigger burden on families, who would have to come up with documentation, as well as on providers, who would have to check it.

“I think the best evidence is that, actually, this isn’t about trying to have fewer rules,” Golden said. “This is about trying to change the rules, in ways that are generally not consistent with the Head Start Act or Head Start values.”

Mark Greenberg, a former HHS official who is now a scholar in residence at Brookings, put it a bit more bluntly. “This is not an administration that is reflecting a broad and consistent commitment to flexibility in federally assisted programs,” he told me in an interview. “It is one that uses language about flexibility when its goal is to eliminate protections and standards.”

This doesn’t appear to be what Congress wanted when it last reauthorized the program back in 2007, Greenberg went on to note. And it’s probably not what Congress wants now, which is almost certainly why administration officials are thinking about using executive authority to make these changes rather than trying to pass legislation, and presumably why they are doing it quietly rather than shining a spotlight on it.

They might yet decide against it. And if they do go ahead, the courts might stop them, as they have before.2 But the fact that a draft proposal has gone this far already says a lot about their determination to undermine Head Start, and their contempt for the spirit behind it.

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“EXPLOSIVE DIARRHEA” IS NOT A PHRASE YOU WANT to be hearing in your household, let alone on the national news. But it is happening a lot these days, thanks to an outbreak of a parasitic infection called cyclospora that has already sickened thousands of people across the country.

So far the largest number is in Michigan, my home state. But it’s not simply a Michigan problem: More than thirty states have recorded cases. And although officials have said they think contaminated lettuce might be the culprit, or one of the culprits, as of Wednesday morning they still were not sure.

That last part has raised a lot of questions about how federal public health agencies are handling the outbreak, given their weakened condition following all of the funding cuts, layoffs, and leadership purges by the Trump administration.

But those aren’t the only questions on people’s minds. There are practical questions too: What is this disease? How do you get it? What can you do to not get it? And what should you do if you get it?

To answer those sorts of questions—including some submitted by readers of The Bulwark—I turned to Katelyn Jetelina, an epidemiologist and data scientist who consults with organizations like the CDC but is probably best known as the founder and writer of the Your Local Epidemiologist newsletter.

Jetelina knows the relevant science. She is also gifted at explaining it to non-scientists. That is no small thing, especially in a time when government agencies have lost their veteran leaders and the public’s trust.

A lightly edited transcript of our conversation follows.

JONATHAN COHN: Katelyn, thanks for joining us. Don’t take this the wrong way, but as soon as I heard the phrase “explosive diarrhea,” you were the first name that came to mind.

KATELYN JETELINA: What an honor. What an honor. Yeah, you guys just keep calling me with these random bug things that keep happening at really high rates nowadays, huh?

COHN: Yes, it is not always the best thing to see you on our camera. But all joking aside, let’s start with the basics. What is cyclospora? How does it make you sick and what does it do to your body?

JETELINA: Cyclospora is a microscopic, really, small single-celled parasite. And the interesting thing about this parasite is humans are the only known host. So every contamination event traces back to—and I know this is disgusting—human waste or fecal matter, somewhere along the train, and usually in water.

There are two ways a food source gets contaminated. One is at the farm level, from poor field sanitation. It could be workers without adequate bathroom access, or contaminated irrigation water. Or contamination can happen during processing, usually through contaminated water at the packing or washing stage.

We don’t know which one it is yet. I hope we get answers soon. But it does trace back to human fecal matter hitting our produce, and then us eating it and making us sick.

COHN: And when you get sick, what happens?

JETELINA: So it’s watery, explosive diarrhea. It is not fun. And partly it’s not fun because you get cramping and bloating and fatigue, and appetite loss and sometimes low fever.

But this bugger can drag out for weeks. There was this poor soul in a Nepal outbreak, they went 107 days with these symptoms. It comes and goes, you feel like you’re getting better and then it’ll come back for a few days.

Thankfully it’s rarely fatal. There are no deaths reported with this outbreak. The real danger is dehydration from weeks of diarrhea. And it’s usually hardest hit for the most vulnerable—we’re talking pregnant women, kids, older adults, immunocompromised.

With really severe cases among high-risk groups, it can be treated with antibiotics. But that is usually the last move. Usually you just wait it out.

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COHN: This gets to one of our reader questions who said their son was having watery diarrhea for a couple of days and wanted to know, at what point do you seek help for this?

JETELINA: Dehydration is the biggest concern. And so a few days should be okay as long as they can suck on ice cubes. But always check with your clinical care team. They’ll tell you when to come in.

We usually know it’s cyclospora compared to another disease that causes diarrhea because it lasts so long. And so if you’re high risk, don’t tough it out. If you’re pregnant, immunocompromised, go to the doctor, call them.

All of us that are healthy can probably last it out for a few days. But it’s always great to connect with the care team.

COHN: We’re going to talk in a minute about what the government should be doing to detect and prevent the disease, but I want to stay on the individual level for right now. People listening to this, they’ll be thinking, I don’t want to get sick. What is some general advice for how we should be conducting ourselves, to try to avoid this?

JETELINA: Unfortunately we don’t know the source yet. It’s delayed. I don’t know why we don’t know the source. I wish we had more answers, but we don’t.

What we know from past outbreaks in the United States is that cyclospora is usually on produce with lots of grooves and bumps and folds, because the parasite finds those folds and hides in the nooks and crannies. And so it’s typically on lettuce. So right now I’m avoiding bagged or boxed salads…

COHN: You mean like the bags you get in the store?

JETELINA: Yes, those pre-made ones that make my life easier at dinner. I’m not buying those, because that’s usually a big culprit. Whole heads of lettuce that you can wash and cut yourself are probably a safer bet.

COHN: I read somewhere that raspberries are a good one to avoid, which broke my heart because I love raspberries this time of year. Is that right?

JETELINA: That’s right. If you think about raspberries, they have tons of those grooves and the parasite can just stick in there.

Things you can peel are usually good. Oranges or bananas are great. Or things that you can really wash thoroughly, like a cucumber. Or definitely anything you can cook.

COHN: So this gets to a couple of reader questions. I’m gonna throw them at you real quick and you know you can give me some answers. So Natalie said, does it matter if I’m washing them in hot water? Should I be using soap to wash my produce?

JETELINA: That’s a good question. Washing helps, but it won’t fully remove the parasite because—again—it clings and hides in these nooks and crannies.

Cooking is the better bet. And in order to cook it, you have to cook the spinach leaf or whatever to hit a temperature of 158 degrees [Fahrenheit]. Once you hit that, it completely kills the parasite and so you’re good.

Freezing doesn’t really work as well. Microwaves also don’t work as well because the temperature is so inconsistent. What you see in studies is at least 45 seconds [in the microwave], but even 45 seconds doesn’t kill [it] all.

So really the best bet is putting it on your stove. I know you can’t put your bagged salad on a stove. That doesn’t sound very great. So for me at least that means just avoiding it.

COHN: One question we got from a lot of readers, including Martha and Connie, was about buying produce from a local farm stand rather than a store? Is that safer? Can you trust that?

JETELINA: I’m seeing that question a lot too. I think it’s a great question. The problem is that cyclospora lives in the soil or contaminated water sources. So local produce could be contaminated as well. We just don’t know how this started.

If this started at a processing plant, sure, those local farms are much more safe. But if it actually started at a source of farm water contamination, it could still be infected. . . .

COHN: This is now considered the largest outbreak [of cyclospora] in recent history. Is there any reason to think the disease is a worse outbreak for some reason? Do we know? Do we think we’re maybe detecting it?

JETELINA: We have spikes every year around this time. Every year we have about 3,000 to 4,000 cases in total. Right now we have about more than 3,000 cases for this particular outbreak. So this is definitely a big outbreak. It is not something we really expected.

The question of why is a really good question. And I’ll be honest, I don’t think we know yet.

It could be that it was just spreading undetected for a long time, and now we’re catching a lot of cases. And we’re going to get more cases the more that people are asking questions, and the knowledge base is increasing. More people are gonna be testing, more physicians are gonna be willing to use the test, and the numbers are going to balloon.

Unfortunately, the only way to really stop an outbreak like this is to take the source out from distribution. And we can only do that over time—that certain lettuce from that farm just stops getting circulated, or we do find a specific thing that’s then pulled from the market.

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COHN: Alright, let’s talk about policy. You have written—we both have written—about cuts to the public health infrastructure of this country under the Trump administration. That includes a scaling back of some of the data tracking for cyclospora, as I understand it. Now, you’ve written about this and you seemed skeptical that it was actually part of the story here. Could you talk about that for a second?

JETELINA: A lot of people are pointing their fingers to this program that was cut called FoodNet, that was cut last September. The reason I’m very skeptical about that is that FoodNet was never used for outbreak detection or response. It was used more to detect trends in the background that researchers use for studying this parasite—or other other bugs—over time.

There was an impact in cutting that, don’t get me wrong. But I don’t think that there’s a direct link to this outbreak.

What I do think is happening is not rocket science. If you cut public health funding, you cut our force. You have a lack of transparency. You have no centralized communication efforts. . . .

We have siloed health systems, and these teams are chronically underfunded, especially parasite teams. And you know, this work is very laborious.

And local public health departments are being pulled in a billion directions right now. We have the highest number of measles cases in thirty years. We’re dealing with Ebola and people traveling from places with Ebola. We have a really high whooping cough rate. We have the World Cup. We have so much going on.

I think the bottom line is that, if the American public wants a public health system and one that works, then the United States has to pay for it and support it. And what we’ve seen over the past eighteen months is the decimation of it instead.

COHN: You do epidemiology, you’ve been part of these efforts. A lot of this damage has been done. When you lose people, when you lay off people, you can’t just snap your fingers and flip a switch. How long do you think it’s going to take us to rebuild this kind of infrastructure just to get back to where we were before these cuts?

JETELINA: You’re not going to like my answer. I think it’s gonna be at least ten to twenty years. I think we are going to go backwards. We are going to go backwards before we go forward again. I think the biggest question is how backwards do we go? And what sense of urgency is met with it.

These systems have been destroyed and it’s not like the status quo was great before. We have lost a lot of historical knowledge. We’re losing a lot of scientific research and funding right now.

And it’s not like a subscription where you can turn on and turn off. We need these pipelines of brilliant scientists. We need these surveillance systems. We also need to reimagine how these systems work, so we can all do better in the future as well. So it’s going to take a while.

Which means you may be calling me more to join The Bulwark during outbreaks. But this is what those of us in public health expected would happen. I am not surprised this is the state of affairs now.

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THE SUPREME COURT on the next-to-last day of its term ended the commonsense principle that officials serving on independent regulatory commissions can be protected from being fired for nothing more than a policy disagreement. As many legal commentators have noted, in overturning the 91-year-old precedent Humphrey’s Executor, the Court endangered the independence of such agencies as the FTC, the NLRB, the CPSC, and the EEOC—to name just a few from which Trump has fired commissioners or board members.

But the death of independent agencies should not be considered a fait accompli. The Court’s ruling in Trump v. Slaughter just turned a wonky bill focused on the structure of crypto markets into a live test case for whether Congress will let one party’s White House—present or future—singlehandedly control how every industry in the United States is regulated.

Let’s start with some background: Since the nineteenth century, Congress has provided the leadership of federal regulatory agencies—now roughly two dozen of them—with for-cause removal protections, preventing the president from firing officials except in cases of inefficiency, neglect, and malfeasance in office. Such removal protections reflected lawmakers’ belief that the nation’s problems could be solved by, as the Court explained in Humphrey’s Executor in 1935, the “trained judgment” of experts acting with “entire impartiality” rather than loyalty to the White House and its partisan allies.

In addition to removal protections, Congress frequently structured these regulatory agencies in such a way that no more than a bare majority of their membership would come from any one political party. These partisan-balance requirements were intended to ensure that the agencies would yield better-reasoned, more moderate policy through deliberation, negotiation, and consensus-building; the presence of the minority commissioners would serve as a built-in monitoring system to alert the public if the majority swung too far in any one direction.

By a 6–3 vote, the Court declared in Trump v. Slaughter that for-cause removal protections are “contrary to the separation of powers enshrined in the Constitution.” In doing so, the Court also made partisan-balance requirements a practical dead letter, since a commissioner of a party opposite the president’s can be removed if she votes against the president’s wishes—as Rebecca Slaughter was when President Trump removed her from the Federal Trade Commission.

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Quorums as a solution

Slaughter need not be the last word on bipartisan policymaking. Although the Court has ruled that the president must be permitted to remove board members and commissioners at will, Congress is still permitted to structure agencies in ways that disincentivize firings.

One partial solution worth pursuing would be to emphasize and clarify independent agencies’ quorum rules, requiring that bipartisan slates of commissioners are seated before agencies take any actions. As sketched out in a new Stanford Law Review article by University of Minnesota Law School professor Nicholas R. Bednar and myself, commissions’ quorum requirements could be structured such that members from both the Democratic and Republican parties must be in office and must not be recused before the agency may advance any action. Such quorums would ensure that even if members of the minority party are not successful in persuading their colleagues of their policy proposals, they are at least in the room when decisions are being made.

This is not to relitigate Slaughter or to try to restore removal protections the Court just took off the table—that fight is over. Rather, it is to propose a narrow speed-bump into the president’s decision-making. The president may certainly fire commissioners as the Supreme Court has permitted, but doing so in a way that breaks the quorum will simply prevent the agency from acting until the Senate confirms replacements. It is a structural guardrail, not a personnel mandate, and it survives the Court’s reasoning because it never depends on anyone’s job being protected, and thus cannot be said to infringe on the powers the Constitution grants to the president.

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The time to try quorums is now

A first test of this quorum proposal could come via the CLARITY Act, an important bill Congress is considering that would regulate the sale and trading of digital commodities, enable tokenized real-world assets, and create a binding classification for determining which assets are commodities and which are securities. These are foundational rules for a multi-trillion-dollar asset class that will determine how capital is raised, held, and transferred.

Yet the CLARITY Act’s enactment would not be the end of the lawmaking process. The bill assigns to the Commodity Futures Trading Commission (CFTC) and the Securities and Exchange Commission (SEC)—two independent agencies that Congress structured to be bipartisan—responsibility for promulgating a number of crucial regulations that will make or break digital asset markets.

The CLARITY Act has already passed the House and is poised to come to a vote in the Senate within the next few weeks. Legislators should use it as a test case to determine whether agency independence can still exist in light of Slaughter. Senators should refuse to vote to give these commissions authority over hotly contested issues without amending the bill to ensure that the commissions are subject to quorum requirements mandating the presence of both Democratic and Republican commissioners.

Politics and policy are in independence’s favor

Lawmakers understandably may be afraid to make this move, having watched the huge sums of money the crypto industry has been pouring into politics—some $170 million during the 2024 election cycle and already another $189 million to date in the current midterm cycle. It’s not hard to imagine some political squeamishness. But there are still reasons for legislators from both parties to push for quorum requirements in the CLARITY Act.

First, the desire for bipartisan regulatory agencies is not simply a Democratic wish. The Republican chairman of the committee overseeing the CFTC has acknowledged “the importance of having Democrats and Republicans on the Commission.” Although Democrats would be the beneficiaries of quorum requirements today, Republicans would be the beneficiaries under future Democratic administrations.

Second, Republican control of the White House and Democrats’ minority position represent strengths in this context, because Republicans will bear the blame if the CLARITY Act fails. To be enacted, the bill will presumably need seven Democratic Senate votes and White House support, creating a possible stalemate if the White House refuses to preserve the SEC’s and CFTC’s bipartisan nature as Congress intended them. Republicans could in theory pass the bill without Democratic support—the Senate majority can change the filibuster with a simple majority and pass the bill on partisan lines whenever it chooses—although that seems highly unlikely here. The best bet would be for Republicans to join with Democrats in backing a bill that preserves bipartisan policymaking; uniting behind such a bill, it would not be difficult to override a presidential veto.

Third, the crypto industry will not campaign against legislators who support a clear, durable legal framework for digital assets, albeit with quorum requirements. The industry has little incentive to spend against legislators genuinely pushing for a workable bill.

Although the Supreme Court has made its decision, Congress need not let the six justices have the last word on whether agency independence is permitted to exist. Tightening quorum requirements for independent regulatory agencies is not a perfect solution. But it’s a step worth taking. Legislators who oppose volatile, episodic regulation driven by who happens to control an agency at any given moment should use the CLARITY Act as an opportunity to preserve, at least in a limited way, bipartisan, independent agencies while articulating a blueprint for reforming other commissions in the future.

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Todd Phillips is a consultant and most recently taught law as a professor at Georgia State University. His research focuses on financial regulation and administrative law. He has published in the Stanford Law Review and the Yale Journal on Regulation.

Royal Oak, Michigan
MALLORY MCMORROW SEEMED LIKE an impressively strong candidate back in April 2025, when she became the first major Democrat to declare she was running for Michigan’s open U.S. Senate seat.

At the time, Democrats around the country were reeling from Donald Trump’s election and the governing blitzkrieg of his first months back in office. Up stepped McMorrow, a (then-)38-year-old state senator in her second term,1 who announced her candidacy with a video touting her ability to win in red-leaning districts and her record of pushing back against MAGA—most famously, in a 2022 floor speech defending LGBTQ rights that went viral and established her as one of the party’s most effective young communicators.

The announcement video stressed McMorrow’s ability to get results in the state legislature, while making clear she was fed up with her own party’s impotence. One day later, she fleshed out her vision when she sat down with me at a coffee shop in Royal Oak, the northern Detroit suburb with a hipster vibe that she calls home.

She talked about her ideas for addressing the high cost of health care, housing, and childcare, weaving in her firsthand experiences as a millennial parent of a kindergartner. She gave a detailed critique of Trump policies on tariffs, tying it to her knowledge of Michigan’s auto industry. And she vented, as she had in her video, about Democratic leaders cowering back in Washington.

“There’s a lot of power that you still have if you’re just willing to push back and raise your voice,” McMorrow said. “But that requires leadership that understands how to engage with voters in a way that treats them as more than a number—not just a voter, not just a donor.”

McMorrow’s position seemed just as strong after she drew her opponents: Abdul El-Sayed, a Bernie Sanders-endorsed progressive who had served as public health director in Detroit, and Haley Stevens, a four-term House Democrat with close ties to party leaders in Washington. Each was formidable in their own ways, but McMorrow had the makings of a Goldilocks candidate who could rally both progressives and moderates, winning over those eager to shake up the establishment and those not quite ready to ditch it.

It hasn’t worked out that way. On Sunday, with polls showing her well behind both rivals and the August 4 primary less than a month away, McMorrow formally suspended her campaign. In a video to go with the announcement, she dedicated herself to electing Democrats in November, including the eventual Senate nominee.

Who that will be is anybody’s guess. McMorrow had been under pressure to withdraw from Stevens supporters and members of the Democratic establishment, reportedly including Gary Peters, the retiring senator whose seat she was seeking. Their theory was that Stevens would get most of the McMorrow vote. But El-Sayed’s team has been touting a poll suggesting he’ll get more. And while it’s an internal poll, winning even a significant minority of McMorrow’s backers could be enough to secure him the nomination.

Plenty of Democratic primary voters in Michigan are just starting to pay attention, making the outcome especially hard to predict right now. But it’s not too early to ask why McMorrow’s campaign failed to live up to those initial, lofty expectations. And while there’s no single, definitive answer, it’s possible to come up with explanatory theories that fit the available facts—including an explanation that says

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Blast from the Past

Back in the long-ago days of 2009, when Barack Obama and the Democrats were in the middle of their grueling fight to pass what would eventually become the Affordable Care Act, they adopted a proposal under which doctors who sat down to discuss end-of-life planning with patients could bill Medicare for the time.

It was a bipartisan, seemingly innocuous, plan. The idea was to make these conversations easier to arrange, so that people would have more agency over how they spend their final days. Then a conservative commentator named Elizabeth McCaughey discovered the provision in the legislative text.1 And all hell broke loose.

McCaughey went on Rush Limbaugh’s show and insisted the provision would “absolutely require” doctors to meet with patients, advising them on how to “decline nutrition, how to decline being hydrated, how to go into hospice care . . . all to do what’s in society’s best interest or in your family’s best interest and cut your life short.” She went on to write a New York Post column called “Deadly Doctors” in which she claimed Obama health care adviser Ezekiel Emanuel, who supported the idea, wanted to ration care for people with Parkinson’s, cerebral palsy, and other disabilities.

The swipe at Emanuel, an oncologist and bioethicist who had been writing about how to help the kind of families he had seen as a practitioner, was as egregious as the description of the provision was dishonest. But McCaughey’s argument took on a life of its own in the right-wing universe, especially after former GOP vice presidential candidate Sarah Palin got involved and started talking about how the legislation was allegedly proposing to create “death panels.”2 Eventually Democrats removed the end-of-life provision entirely. But the smear campaign had a lasting impact. Polling from the research organization KFF found that in 2010, when the Affordable Care Act became law, four in ten Americans still believed it had death panels.3

I am writing about that history now because death panels are back—only this time, it’s not coming from the Democrats. It’s coming from Donald Trump and his top health care advisers.

A new regulatory proposal from the Trump administration,

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A LOUISIANA MAN WALKED OUT of a hospital this week, functionally cured from a debilitating disease that until very recently was mostly incurable. In so doing, he offered a genuinely heartwarming case study in what modern medicine can now achieve—and a genuinely worrisome reminder of what Donald Trump’s attacks on science could now destroy.

I’m here to tell you about both.

Let’s start with the medical miracle and the man who benefitted from it. His name is Daniel Cressy. He is one of more than 100,000 Americans who suffer from sickle cell disease, a congenital disorder in which the body produces misshapen, sickle-shaped red blood cells. These cells stiffen and become sticky, and can clog smaller vessels in ways that restrict blood supply to parts of the body. Sickle cell disease causes the weakness and fatigue common to all kinds of anemia. It also causes recurring bouts of pain that require hospitalization because of their severity

“Think about the tightest rubber band ever on any part of your body,” Cressy told me in a phone interview on Friday, describing the episodes that during his childhood sometimes sent him to the hospital once a month.1 “And think about that rubber band just going super tight, then relaxing, then going super tight again, then relaxing—just constantly pulsating with pressure, and you can’t do anything about it.”

Fatigue and pain aren’t sickle cell disease’s only effects. The disease strains organs throughout the body, including kidneys, the liver and (especially) the spleen. It also weakens the immune system, rendering people more prone to severe infection, while increasing the risk of cardiovascular crises. “Stroke was probably my biggest concern,” Cressy, who is just 23, told me.

The underlying cause of sickle cell disease is a single genetic mutation, which in turn causes the blood-producing stem cells inside bone marrow to churn out those mis-formed, sickle- or crescent-shaped red blood cells instead of the normal, puffy discs. Until a few years ago, the only cure was a bone marrow transplant that, in effect, imported into the body the blood-making capacity of an unafflicted person. And it worked only in rare cases, in part because finding donors whose bone marrow was a close enough match was so difficult.

All of that changed in the early 2010s

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Palm Beach County, Florida
ONE OF THE BIGGEST IMMIGRATION STORIES in America right now is actually a story about America’s senior citizens and the refugees who care for them—and how those arrangements could be shattered, maybe within days if Donald Trump gets his way.

At issue is special protected status for more than 300,000 Haitian refugees whom Trump has wanted to expel ever since he became president the first time. Lower federal courts have blocked those efforts. But now the Supreme Court has the case. It is expected to issue some kind of ruling before it adjourns for the summer, likely late this week or early next.

Among those watching closely to see what happens are Maryse Balthazar, a home health care aide, and Esther Binbaum, a 96-year-old mother and grandmother for whom Maryse cares. Maryse came to the United States with her family in 2010—right around the time a devastating earthquake destroyed Haiti’s infrastructure, plunging the already troubled country further into a state of chaos, poverty, and danger.

The federal government responded as it has to such disasters in the past: It gave hundreds of thousands of Haitians fleeing their destroyed homes permission to stay and to work in the United States legally. But that was when Barack Obama was the president. Now it’s Trump, whose hostility to Haitians was clear even before he infamously (and absurdly) suggested during the 2024 campaign that Haitian refugees in Ohio were eating their neighbors’ dogs and cats.

The reality is that the vast majority of those hundreds of thousands of Haitians are not just law-abiding, hard-working, tax-paying residents. They are also filling essential roles in society, especially in the “care economy” where they make up a disproportionate share of nursing home staff and home health aides.

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Nobody knows the value of that more than people like Esther. I recently got a chance to sit down with her and Maryse, whom readers of The Breakdown may recognize from a previous edition. As we sat in loungers on a screened porch, while a slowly rotating ceiling fan nudged the sticky Florida air, Esther talked about how close she’d grown to Maryse—and her bewilderment that Trump’s anti-immigration efforts would be so blind to the human costs.

“I’d be very sad, very sad for her and for her kids, and for the whole situation,” Esther told me, “and of course I’d be very sad to lose her.”

Whether that all comes to pass depends most immediately on how the Supreme Court weighs a series of interlocking legal arguments. They include a last-minute appeal based on recently discovered internal administration communications that—according to lawyers for the Haitians—proves the administration didn’t follow the law when trying to revoke the Haitians’ “temporary protected status.”

And then there is the possibility of congressional action, especially if the Court sides with the Trump administration. A House bill from Massachusetts Democrat Ayanna Pressley has passed, thanks to support from a handful of Republicans. Now it is sitting in the Senate, where Republican support has yet to materialize.

All the while, Maryse and Esther wait for some resolution. “We’re always worried about it,” Esther said.

“She’s so worried, she dreams about it,” added Maryse.

THE LEGAL CONTROVERSY before the Supreme Court is actually two separate cases, one involving Syrian refugees and one involving Haitians. But the basis for both is a dispute over how a program called “Temporary Protected Status” is supposed to work.

TPS comes from a 1990 immigration overhaul that passed with strong bipartisan support and was signed into law by George H.W. Bush. The TPS provisions in effect codified what had already been a common practice, carried out previously on executive authority alone. It allowed foreign nationals to remain in the United States if armed conflict, natural disaster, or other “extraordinary and temporary conditions” made it unsafe for them to return.

“It has to do with the conditions at home, as opposed to the individual circumstances,” Margo Schlanger, a University of Michigan law professor whose expertise spans civil rights and immigration, explained to me in a phone interview. “It could be based on a civil war or an earthquake . . . extraordinary conditions that are dangerous for the people in a home country, so that they are not forced to go home where they’ll die.”

TPS applicants must go through security vetting and regular check-ins with immigration officials. “No matter what they are saying about people with TPS here, if you don’t follow the law and stay out of trouble, you can’t get it,” Maryse told me. TPS does not provide a pathway to citizenship, although people here on protected status can apply for legal papers if they would qualify for citizenship under normal circumstances.

Most importantly, TPS beneficiaries can get official government documentation like a driver’s license, and they can work. Over the years, Haitians in particular have gravitated to the care industry, partly because the work is in perpetually high demand and does not require extensive training. But there’s another element as well, as Tessa Petit, executive director of the Florida Immigration Council, reminded me this week.

“Being able to take care of an aging person is actually a blessing,” Petit said. “It’s in our culture, we take care of those who came here before us.”

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Back in Haiti, Maryse had been a broadcast journalist, with a resume that included working with non-profits and traveling abroad. Once she was in the United States with her family, and had obtained protected status, she sought out a job in media. “I was looking for work everywhere, because I’m not the kind of person to just sit around,” she told me. “I applied everywhere. Nobody was hiring.”

That’s when her sister invited her to visit in Georgia, and urged her to do what so many other refugees had—train as a certified nursing assistant, and find work in caregiving. “She said, ‘I know you’re a professional, but you have to start somewhere,’” Maryse recalled. When she heard about a job in South Florida, she moved her family there—and ended up caring for Esther’s brother, Michael, a World War II veteran who she said had flown dozens of missions over Europe.

Now Maryse is caring for Esther, a Long Island native who, as she puts it, “fell apart” physically, as evidenced by the metal walker that was at Esther’s side while we spoke. Despite being mentally sharp—even by the standards of somebody twenty years younger—she counts on Maryse to help with some of life’s basic tasks.

But in their conversation, they mostly talked about how they play games together, how Maryse troubleshoots Esther’s iPad and all the other technology she uses now—and how, as Esther put it, “we are more like friends than employer-employee, I hope, at least that’s the way I feel about it.”

“She’s right,” Maryse said, nodding with a smile.

“Everybody loves Maryse,” Esther said.

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Haitian health care workers are all over the United States. But they have an especially large presence in places like South Florida, where the Haitian diaspora has congregated. That helps explain why one of the most outspoken advocates for saving protected status for Haitians has been Miami Archbishop Thomas Wenski, whose responsibilities include overseeing Catholic Health Services, one of the area’s major suppliers of in-home care.

“If you take these people, take the jobs away from these people, it’s going to have a very harmful effect on the institutions themselves for continuing to meet their standards and quality of care,” Wenski told me in a phone interview. “The removal of 300,000 Haitians would not only constitute a real disaster for them, but it would also be an economic disaster for the broader community.”

It could be a medical disaster as well. The ripple effects of fewer care workers would be more seniors and people with disabilities going into facilities rather than staying at home, and fewer staff at these facilities. That, in turn, could cause thousands of premature deaths every year, according to a study that three nationally recognized scholars published in February.

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It’s not clear how much these possibilities have weighed on the minds of the Trump administration, if at all. In fact, it’s not clear any serious contemplation took place when then-Secretary of Homeland Security Kristi Noem issued a series of orders designed to end TPS for Haitians.

That deliberation—or lack thereof—is the linchpin of the lawsuits against Trump’s orders. While the law gives the secretary of homeland security authority to extend or end protected status, it also requires consultation with other relevant government agencies. Lawyers representing the Haitian refugees have used public statements from top administration officials, along with internal documents they have obtained, to show Noem had only minimal contact with the State Department, and that it took place after some of her initial orders.

The lawyers for the refugees have cited Trump’s own rhetoric, as well—especially his calls for fewer immigrants from places like Somalia and Haiti, and more from places like Sweden and South Africa (or, more precisely, from its white population). That’s evidence of racial animus, the lawyers say, which would be more proof that the decision to revoke protected status was pre-ordained and, maybe, illegal.

The Trump administration maintains that Noem actually did check with other agencies, at least enough to meet the standards of the law. But in its filings, government lawyers have leaned mostly on a broader argument about presidential power: that immigration law, as written, doesn’t allow the courts to second guess the president or his administration on whether a group gets this particular kind of protected status.

The refugees’ case was strong enough to win over two federal district judges, who blocked Noem’s order while the lawsuits themselves proceeded. And evidently the case was strong enough to persuade judges at the D.C. Circuit Court of Appeals, because they refused to intervene. But it’s not clear how the case will fare at the Supreme Court, which heard oral arguments in April. The justices back then sounded sympathetic to the administration’s viewpoint, though it was hard to be sure, with Chief Justice John Roberts and Justice Amy Coney Barrett asking tough questions of both sides.

A potentially important twist in the case came last week, when lawyers for the refugees submitted a last-minute filing asking the Court to dismiss the case (and thus leave the blockage of the order in place). The basis was new internal administration communications the lawyers had obtained through legal discovery in the lawsuits. The communications appear to show administration officials in 2025 acknowledging they had not gotten State Department input prior to a Noem directive, contrary to what the administration has claimed during the legal proceedings.

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Whether the Supreme Court will consider that information—or whether the level of consultation even matters to a majority of the justices—is anybody’s guess.

In the meantime, Petti told me immigration advocacy organizations are preparing for the worst. That includes setting up mutual aid networks to feed and house refugees who might lose their working status right away, but not face immediate deportation—and would be waiting to see if Congress moves on a reprieve.

It could happen. Advocates are focusing their efforts on states that would feel the impact most acutely, starting with Florida, where the two GOP senators—Rick Scott and Ashley Moody—have yet to take a public position. (Neither senator responded to a request for comment.) That’s a sign they feel the cross pressures of a national party where even the appearance of leniency on immigration is toxic, and a community that is already anxious over what losing workers like Maryse would mean.

That pressure is significant—because, while people like Maryse can’t vote in the United States, people like Esther can.

“If they only got rid of the bad people, then okay,” Esther said, shrugging. “But to have everybody looking over their back every day, worried about their kids going to school . . . it’s just terrible, it’s terrible. It’s not the country I grew up with.”

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Miami Beach, Florida
THE DEMOLITION CREW ARRIVED late in the afternoon. The crowd came not long after that—to watch and to protest and to mourn the dismantling of a beloved landmark.

It was a Sunday night last October. The site was a crosswalk with pastel-colored bricks that officials had installed back in 2018. Its purpose had been to celebrate the LGBTQ community’s contributions to the culture and prosperity of Miami Beach—and to recognize the difficult, still-ongoing campaign for equality in America.

But that was before Ron DeSantis became Florida’s governor and launched a campaign against “woke” ideology that targeted pretty much anything with a rainbow or the letters LGBTQ attached. He had made a lot of headway, and by last summer his administration was ordering the statewide removal of rainbow crosswalks, including one in Orlando outside the site of the 2016 Pulse nightclub massacre. The directive covered any street art with political or social messaging—ostensibly for the sake of traffic safety, though almost nobody believed it given evidence that brightly colored crosswalks actually reduced accidents in pedestrian areas.

Miami Beach officials had tried to save their crosswalk tribute by appealing to the state Department of Transportation for a reprieve. When the last of those bids failed, on a Friday, community leaders knew destruction was imminent. But they had not expected the backhoes and crews with jackhammers to show up within forty-eight hours, or just how hard the scene would hit.

“The night that they tore out the crosswalk, it was like witnessing carnage, an act of violence,” city commissioner Tanya Bhatt told me this week, as we stood at the site. “There was the Miami breeze going off the ocean,” she recalled, “and people were stopping and watching and filming and crying.” But while her first instinct was to give everyone a “mom hug,” she and fellow community leaders quickly turned their attention to next steps: “We were all talking, part of this group saying it was not okay and that we couldn’t just let this happen.”

They didn’t. And about six months later, Bhatt was with those other leaders at the opening of a new tribute to the LGBTQ community, practically in the same location as the original. It even uses the same brightly colored bricks, which city officials had made a point of retaining. But this marker is on the sidewalk, not in the street, putting it beyond the reach of Florida’s Department of Transportation—and the Republican governor in charge of it.

“They can move the bricks,” Miami-Dade Mayor Daniella Levine Cava said at the ceremony, “but they cannot erase us.”

For a community of LGBTQ Floridians that has faced a years-long and at times highly effective political assault, restoring a singular piece of artistic expression may seem like the tiniest of victories. But sometimes symbolic victories matter. DeSantis after all wasn’t simply pulling colored bricks out of the pavement. He was taking away public recognition from a group that for most of human history has had to hide its identity. And if there is one place where that kind of effort seems particularly unconscionable, it’s Miami Beach.

MIAMI BEACH’S IDENTITY as a refuge for the LGBTQ community traces as far back as the early twentieth century, not long after industrialist Henry Flagler’s railroad first made South Florida a destination for northern tourists escaping the cold.

This was an era when homosexuality was simply not discussed, let alone accepted in polite society. It was also a time when being openly gay meant inviting arrest for deviancy, and when violence against members of the LGBTQ community—even lethal violence—was rarely met with public outrage.

Miami Beach was different. With its constant churn of people and cultures, including from abroad, it gained a reputation as a place where it was a bit more acceptable to stray from society’s conventions—a community where, as historian Julio Capo Jr. put it, “the confines of the real world, including the boundaries around gender and sexual expression, could loosen.”

Half a century later, Miami Beach played a central role in the birth of the modern gay rights movement—staging what is considered by some the nation’s first Pride celebration, and enacting through surrounding Dade County one of the nation’s first anti-discrimination laws for LGBTQ residents.1 It was at the 1972 Democratic convention, held in Miami Beach, that activists first pushed for an official party plank recognizing the importance of civil rights for the gay community.

These advances didn’t come easily. Dade’s anti-discrimination ordinance sparked a backlash led by the anti-LGBTQ activist Anita Bryant. Her “Save Our Children” campaign, which focused on the supposed menace of gay teachers in the schools, succeeded in getting the law off the books and helped establish a model for anti-LGBTQ efforts nationwide.

But by that point, Miami Beach was seeing a different sort of transformation: an economic one. A group of developers and preservationists led by a New York designer named Leonard Horowitz had obtained historical status for the city’s aging art deco buildings. They renovated the buildings and applied their now-signature pastel schemes—all while turning the area into a mecca for wealthy transplants like the designer Gianni Versace.

Versace was gay, as was Horowitz, whose family had shunned him after he came out of the closet. Plenty of other newcomers were gay too, most of them drawn to a place that, like in the 1930s, would let them be who they were and love whom they loved.2

“The whole resurgence of Miami Beach was due to the artists and photographers coming here, staying, and then bringing the arts and culture community with them,” Bhatt said. “The nightclubs and music, photography studios, model agencies, art installations—Miami Beach is built on the shoulders of the queer community.”

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In 2016, a year after the Supreme Court’s Obergefell decision and Florida’s first same-sex marriages, Miami Beach officials decided it was time to recognize how much the LGBTQ community had achieved—not just nationally, but locally as well. They opened a design competition and picked as their location the intersection of Ocean Drive and 12th Street, the unofficial center of local LGBTQ life, where a painted rainbow sidewalk they’d approved years before kept fading from weather and street traffic.

Adriana Savino, a Venezuela-born architect whose specialty is design for public spaces, came up with the winning entry: Paving bricks in the pastel colors Horowitz had brought to Miami Beach, laid down in a pattern evocative of art deco style. They would cover and connect three street corners (the fourth side of the intersection fronts a park and the beach) so as to resemble a rainbow—a symbol of particular importance to Savino, whose gay brother had died just a few years before.

THE OFFICIAL UNVEILING was in November 2018—as it happens, just days after DeSantis won his first election for governor. He spent his first two years focusing on tax cuts and conservative education reforms, which was conventional Republican fare in those days. But starting around 2021, with his eye on the 2024 Republican presidential nomination, he turned into one of the nation’s most prominent anti-woke crusaders, pushing for (among other things) a statute restricting mere references to sexuality in schoolrooms in what critics derided as a “Don’t Say Gay” law.

In this and his other pursuits, DeSantis discovered the soft political underbelly of the broader campaign for LGBTQ equality. He focused on issues like transgender athletes and gender-affirming care for minors, about which even many people broadly supportive of equality had qualms. All along, DeSantis and his allies insisted they were not out to undo civil rights for the gay community—that, instead, they were simply maintaining the government’s neutrality, and protecting children from harm.

The DeSantis administration made a similar argument when it issued its directive to eliminate crosswalk messages: that it was merely preventing the state from endorsing political or social messaging. But however defensible in theory, that position rang hollow from a governor who enthusiastically signed a bill renaming a street after Rush Limbaugh and is now expected to do the same for a bill naming another road after Charlie Kirk.3

Other items in the DeSantis agenda contained similar contradictions. He insisted he was only out to protect children, even as he crusaded to cut off transgender care for adults. He swore he wasn’t anti-gay, even though he tried to defund a program that financed life-saving care for HIV patients. (He backed down when many of his fellow Republicans, responding to public outrage, thought that was going too far.)

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“They start by saying they’re just deeply worried about girls’ sports, and before you know it, they’re introducing resolutions to oppose marriage equality in state legislatures across the country,” Brandon Wolf, a survivor of the Pulse massacre who is now senior director of communications strategy for the advocacy group Equality Florida, told me in a phone interview. “They believe that there’s only one right way to be a man, only one right way to be a woman, only one right way to build a family, only one right way to love and to live your life.”

In all of these efforts, DeSantis was following the same national anti-woke agenda that Donald Trump’s administration would adopt once he returned to the White House. “One of the things we say around here is that Florida has been living Project 2025 since 2023,” Joe Saunders, Equality Florida senior political director, told me. The crosswalk order was a perfect example of the national and state levels of this right-wing movement working in tandem: The DeSantis order came shortly after Sean Duffy, Trump’s transportation secretary, warned states to remove political and cultural street art from federally funded roadways or risk losing money from Washington.

That was one reason Miami Beach leaders like Bhatt knew that any replacement for the demolished crosswalk had to be beyond the reach of both Washington and Tallahassee. And after kicking around a few possibilities, including a sculpture that would go elsewhere in the city, Savino came up with the idea of simply recreating the crosswalk on the sidewalk, right next to the Ocean and 12th intersection.

“We thought the location was important, because of that intersection—the Palace [a famed gay nightclub] was in that corner, and that’s where the original crosswalk was,” Savino told me in an interview. “We thought it was more impactful if we basically just mirrored the image, creating a gateway to the park and maintaining the symbolic importance of Ocean Drive.”

It was an easy sell politically, with unanimous backing from the city commission—something that Alex Fernandez, the commission’s only openly gay member commissioner, later hailed as a show of solidarity. “When the State forcibly removed this crosswalk,” Fernandez said in a prepared statement, “it was our straight allies on the Miami Beach City Commission who ensured our gay community would not be pushed into the shadows.”

At that point, the only challenge was the timing. Commissioners wanted the installation in place for its world-famous Pride celebration, which attracts more than 100,000 visitors annually and is held in April rather than the traditional June in order to avoid the worst of the Florida heat.

They got the job done and, at the ceremony, talked about the one big change designers had made. The old markers had angled corners, because it was meant to be a literal crosswalk. The new one had no such constraints, so the designers used material from some of the broken pavers to round the corners, making it look more like an authentic rainbow.

But it wasn’t just the aesthetics that had changed. It was the sense of purpose too. The 2018 tribute had been created at a time when the LGBTQ community felt confident—maybe a little too confident—about the place it had secured in American society. “The last one, I think a lot of people took it for granted,” Bhatt told me. “For this one, we fought back, we made it permanent. And we are very much aware now that we are all collectively fighting for our lives again.”

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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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