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  • How Bad Are America’s COVID-Vaccination Rates?

    How Bad Are America’s COVID-Vaccination Rates?

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    Relatively speaking, 2023 has been the least dramatic year of COVID living to date. It kicked off with the mildest pandemic winter on record, followed by more than seven months of quietude. Before hospitalizations started to climb toward their September mini-spike, the country was in “the longest period we’ve had without a peak during the entire pandemic,” Shaun Truelove, an infectious-disease modeler at Johns Hopkins University, told me. So maybe it’s no surprise that, after a year of feeling normalish, most American adults simply aren’t that worried about getting seriously sick this coming winter.

    They also are not particularly eager to get this year’s COVID shot. According to a recent CDC survey, just 7 percent of adults and 2 percent of kids have received the fall’s updated shot, as of October 14; at least another 25 percent intends to nab a shot for themselves or their children but haven’t yet. And even those lackluster stats could be an overestimate, because they’re drawn from the National Immunization Surveys, which is done by phone and so reflects the answers of people willing to take federal surveyors’ calls. Separate data collected by the CDC, current as of October 24, suggest that only 12 million Americans—less than 4 percent of the population—have gotten the new vaccine, according to Dave Daigle, the associate director for communications at the CDC’s Center for Global Health.

    CDC Director Mandy Cohen still seems optimistic that the country will come close to the uptake rates of last autumn, when 17 percent of Americans received the updated bivalent vaccine. But for that to happen, Americans would have to maintain or exceed their current immunization clip—which Gregory Poland, a vaccine expert at Mayo Clinic, told me he isn’t betting on. (Already, he’s worried about the possible dampening effect of new data suggesting that getting flu and COVID shots simultaneously might slightly elevate the risk of stroke for older people.) As things stand, the United States could be heading into the winter with the fewest people recently vaccinated against COVID-19 since the end of 2020, when most people didn’t yet have the option to sign up at all.

    This winter is highly unlikely to reprise that first one, when most of the population had no immunity, tests and good antivirals were scarce, and hospitals were overrun. It’s more likely to be an encore of this most recent winter, with its relative calm. But that’s not necessarily a comfort. If that winter was a kind of uncontrolled experiment in the damage COVID could do when unchecked, this one could codify that experiment into a too-complacent routine that cements our tolerance for suffering—and leaves us vulnerable to more.

    To be fair, this year’s COVID vaccines have much been harder to get. With the end of the public-health emergency, the private sector is handling most distribution—a transition that’s made for a more uneven, chaotic rollout. In the weeks after the updated shot was cleared for use, many pharmacies were forced to cancel vaccination appointments or turn people away because of inadequate supply. At one point, Jacinda Abdul-Mutakabbir, an infectious-disease pharmacist at UC San Diego, who’s been running COVID and flu vaccination in her local community, was emailing her county’s office three times a week, trying to get vaccine vials. Even when vaccines have been available, many people have been dismayed to find they need to pay out of pocket for the cost. (Most people, regardless of insurance status, are supposed to be able to receive a free COVID-19 vaccine.)

    [Read: Fall’s vaccine routine didn’t have to be this hard]

    The vaccine is now easier to find, in many places; insurance companies, too, seem to be fixing the kinks in compensation. But Abdul-Mutakabbir told me she worries that many of the people who were initially turned away may simply never come back. “You lose that window of opportunity,” she told me. Even people who haven’t gotten their autumn shot may be hesitating to try if they expect access to be difficult, as the emergency physician Jeremy Faust points out in his Inside Medicine newsletter.

    Plus, because the rollout started later this year than in 2022, many people ended up infected before they could get vaccinated and may now be holding off on the shot—or skipping it entirely. And some Americans have simply decided against getting the shot. The CDC reported that 38 percent don’t plan to vaccinate themselves or their children; earlier this fall, more than half of respondents in a Kaiser Family Foundation poll said they probably or definitely wouldn’t be signing up themselves or their kids. More than 40 percent of those polled by KFF remain doubtful, too, that COVID shots are safe—dwarfing the numbers of people worried about flu shots, and even about RSV shots, which are newer than their COVID counterparts.

    The consequences of low COVID-vaccine uptake are hard to parse. This year, like last year, most Americans have been vaccinated, infected, or both, many of them quite recently. COVID’s average severity has, for many months, been at a relatively consistent low. The last catastrophic SARS-CoV-2 variant—one immune-evasive enough to spark a massive wave of sickness, death, and long COVID—arrived two years ago. Barring another feat of viral evolution, perhaps these dynamics have reached something like a stable state, Justin Lessler, an infectious-disease modeler at the University of North Carolina at Chapel Hill, told me. So maybe the most likely scenario is a close repeat of last winter: a rise in hospitalizations and deaths that’s ultimately far more muted than any earlier in the outbreak. And the COVID-19 Scenario Modeling Hub, which Lessler co-leads alongside Truelove and a large cohort of other researchers, projects that “next year will look a lot like this year, whatever this year ends up looking like,” Lessler said.

    But predictability is distinct from peace. COVID has still been producing roughly twice the annual mortality that flu does; roughly 17,000 people are being hospitalized for the disease each week. SARS-CoV-2 infections also still carry a risk, far higher than flu’s, of debilitating some people for years. “And I do think we’re going to experience a winter increase,” Truelove told me. Even if this year’s COVID-vaccine uptake were to climb above 30 percent, models suggest that January hospitalizations could rival numbers from early 2023. Go much lower than that, and several scenarios point to outcomes being worse.

    Based on the limited data available, at least one trend is mildly encouraging: Adults 75 and older, the age demographic most vulnerable to COVID and that stands to benefit most from annual shots, also have the highest vaccine uptake so far, at about 20 percent. At the same time, Katelyn Jetelina, the epidemiologist who writes the popular Your Local Epidemiologist newsletter, points out that CDC data suggest that only 8 percent of nursing-home residents are up to date on their COVID shots. “That is what keeps me up at night,” Jetelina told me. Early National Immunization Surveys data also suggest that uptake is lagging among other groups that might fare less well against COVID—among them, rural populations, Hispanic people, American Indians and Alaskan Natives, the uninsured, and people living below the poverty line.

    Last winter was widely considered to be a bullet dodged, and the reactions to the coming months may be similar: At least it’s no longer that bad. Since the winter of Omicron, the country has been living with lower vaccine uptake while experiencing lower COVID peaks. But those lower peaks shouldn’t undermine the importance of vaccines. Infection-induced immunity, past vaccinations, improvements in treatments, and other factors have combined to make COVID look like a gentler disease. Add more recent vaccination to that mix, and many of those gains would likely be enhanced, keeping immunity levels up without the risks of illness or passing the virus to someone else.

    [Read: The one thing everyone should know about fall COVID vaccines]

    As relatively “okay” as this past year-plus has been, it could have been better. Missed vaccinations still translate into more days spent suffering, more chronic illnesses, more total lives lost—an enormous burden to put on an already stressed health-care system, Jetelina told me. For the flu, more Americans act as if they understand this relationship: This year, as of November 1, nearly 25 percent of American adults, and more than 20 percent of American kids, have gotten their fall flu shot. Most of the experts I spoke with would be surprised to see such rates for COVID vaccines even at the end of this rollout.

    If last winter was a preview of future COVID winters, our behaviors, too, could predict the patterns we’ll follow going forward. We may not be slammed with the next terrible variant this year, or the next, or the next. When one does arrive, though, as chances are it will, the precedent we’re setting now may leave us particularly unprepared. At that point, people may be years out from their most recent COVID shot; whole swaths of babies and toddlers may have yet to receive their first dose. Some of us may still have some immunity from recent infections, sure—but it won’t be the same as dosing up right before respiratory-virus season with protection that’s both reliable and safe. Systems once poised to deliver COVID vaccines en masse may struggle to meet demand. Or maybe the public will be slow to react to the new emergency at all. Our choices now “will be self-reinforcing,” Poland told me. We still won’t be doomed to repeat our first full COVID winter. But we may get closer than anyone cares to endure.

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    Katherine J. Wu

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  • Why Politics Has Become So Stressful

    Why Politics Has Become So Stressful

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    No matter which party wins control of the House and Senate next month, the results are virtually certain to reinforce the paradox powering the nation’s steadily mounting political tension.

    American politics today may be both more rigid and more unstable than at any other time since at least the Civil War. A politics that is rigid and unstable sounds like a contradiction in terms. But the system’s instability is a direct result of its rigidity. Because so many voters—and so many states—are reliably locked down for one side or the other, even the slightest shifts among the few voters and few states that are truly up for grabs can tilt the balance of power. The consequence is a politics in which neither party can sustain a durable advantage over the other, and political direction for a country of 330 million people is decided by a tiny sliver of voters in about half a dozen states—maybe a few hundred thousand people in all.

    These twin forces largely explain why so many Americans now find politics so stressful. People across the country nervously parse the choices of distant voters in a handful of states to see which party will control the federal government. The balance always remains so wobbly that a momentary mood swing in just a few subdivisions outside Atlanta, Phoenix, or Philadelphia can determine whether Democrats are empowered to pass a new law codifying a national right to abortion, or Republicans are positioned to impose a national ban. Everything is always at stake—and nothing seems to break the deadlock.

    Just how few states determine which side prevails? Probably no more than eight, and arguably as few as six. The list of genuine swing states extends no further than Arizona, Georgia, Nevada, Michigan, Pennsylvania, and Wisconsin, with New Hampshire and North Carolina plausibly added to that roster, though at the federal level the former measurably leans toward Democrats and the latter toward Republicans. The parties still dream of occasional statewide wins in other places—say, Colorado or Minnesota for Republicans and Ohio or Florida for Democrats—but they know that such victories will require unusual circumstances and candidates.

    This small band of true swing states holds the balance of power between the massive red and blue blocks that are, as I’ve written, behaving as if they constitute different nations. Five states in this small group effectively decided the last presidential election by shifting from Donald Trump in 2016 to Joe Biden in 2020: Arizona, Georgia, Michigan, Pennsylvania, and Wisconsin. Almost all of the highly competitive Senate races that will determine control of the chamber this year are unfolding in one of those eight most competitive states, too. Partisans who obsessively checked the poll results from those few states in 2020 have found themselves in a political Groundhog Day, scanning the FiveThirtyEight election-outcome probabilities on pretty much the same places two years later. Two years from now, in the 2024 presidential contest, they are almost guaranteed to be fixated on the same states again.

    What’s more, the balance of power within those few swing states is also precarious; the outcome of elections teeters on microscopic shifts in turnout and/or voter preferences. Biden won the five states he flipped from 2016 by only a combined 279,265 votes, and more than half of that total came in Michigan alone. Few observers would be surprised if almost all of this year’s major Senate contests across the swing states come down to photo finishes.

    In a new book on the 2020 election, The Bitter End, three prominent political scientists describe modern American politics as “calcified,” meaning that the majority of voters are firmly locked into support for one party based primarily on their views about cultural and demographic change. But the UCLA political scientist Lynn Vavreck, one of the co-authors, says that equating “calcification” with “stability” is a mistake. “Being stuck, or calcified, doesn’t mean we are stuck with one outcome,” she told me. “It means that because of that rough partisan parity, we are stuck on the knife’s edge. Anything is tipping these outcomes.”

    The best evidence is that the modern Democratic electoral coalition is at least somewhat larger than the GOP’s. Democrats have won the popular vote in seven of the past eight presidential elections, something no party has done since the formation of the modern party system in 1828. But the Democratic edge hasn’t been decisive enough to overcome the party’s inability to compete in large swaths of the country. Nor can Democrats overcome the structural advantages provided to the GOP by its dominance of smaller, preponderantly white and mostly Christian interior states, whose influence is magnified in the Electoral College and the Senate.

    Barring a major surprise, next month’s election seems guaranteed to extend the longest period in American history when neither party has been able to establish a lasting advantage over the other.

    If Democrats lose the House or Senate, or both, it will mark the fifth consecutive time that a president went into a midterm with unified control of Congress and the White House and then lost it. (That happened to Bill Clinton in 1994, George W. Bush in 2006, Barack Obama in 2010, and Trump in 2018.) No president since Jimmy Carter in 1978 has successfully defended unified control of government through a midterm election. Since 1968, in fact, either party has held unified control in Washington for just 16 of 54 years. In the 72 years before that (from 1896 to 1968), one party or the other held unified control for 58 years.

    This isn’t the first extended period of political instability for the U.S. One party or the other managed just eight years of unified control in the tumultuous two decades before the Civil War. The era from 1877 to 1896 may have been the period most like today: The two sides managed just six years of unified control over those two decades, and never for more than two years at a time. Divided government was also the rule through the 1950s. But none of these earlier periods of instability persisted remotely as long as today’s.

    All of the earlier periods without a dominant party were notable for the lack of clear differentiation between the sides. In the decades before the Civil War, for instance, the need to mollify northern and southern wings prevented either the Whigs or the Democrats from taking a clear position in opposition to the spread of slavery.

    Now it’s the gulf between the parties that largely explains their standoff. In their current ideological configurations, neither side can consistently win enough states to sustain an advantage. Democrats dominate the coastal states most integrated into the 21st-century Information Age economy; the heartland states centered on the 20th-century powerhouse industries of manufacturing, energy extraction, and agriculture are a sea of Republican red. Neither side has managed more than idiosyncratic incursions into the other’s terrain (like Republican Glenn Youngkin’s 2021 gubernatorial win in Virginia and Democrat Joe Manchin’s three Senate wins in West Virginia).

    Generational and demographic change may strengthen Democrats over time, but as long as attitudes about American identity remain the principal dividing line in our politics, Vavreck, like many others, doesn’t see either side breaking out of today’s trench warfare. And she expects that identity-centered division—what I’ve called the collision between the Republican “coalition of restoration” and the Democratic “coalition of transformation”—to remain the central focus of our politics for years. “This is the dimension of conflict we are fighting on for the foreseeable future,” she said. “COVID didn’t dislodge it; the murder of George Floyd didn’t dislodge it; the Capitol insurrection didn’t dislodge it.”

    One way to measure how dug in we’ve become is to look at the consistency of presidential-election results over time. Forty states, or four-fifths of the total, have voted the same way in each of the four presidential elections since 2008: 20 for the Democratic nominees, 20 for the Republicans. That’s a modern peak for consistency. Thirty-four states voted the same way in the four presidential elections from 1992 through 2004. In the four elections from 1976 through 1988, only 25 did. Even in the four consecutive elections won by Franklin D. Roosevelt from 1932 through 1944, only about two-thirds of the states voted the same way each time.

    What’s especially relevant for next month’s election is a corollary trend. Not only are more states reliably voting the same way for president; they are also, to a greater extent than earlier, aligning their votes in congressional elections with their preferences for the White House. Republicans hold just one of the 40 Senate seats in the 20 states that have voted Democratic in at least the past four presidential elections (Susan Collins in Maine), and Democrats hold just two of 40 in the four-time Republican states (Manchin in West Virginia and Jon Tester in Montana). Republicans this year might capture a Senate seat in Nevada—a state on the Democratic list—and solidly Republican Utah, of all places, looks reasonably competitive, but otherwise the November results are unlikely to change those numbers.

    With each side realistically contesting Senate seats in so few states, it’s no wonder, as I’ve written, that the parties are much less likely than in the past to accumulate comfortable Senate majorities—and thus much more likely to quickly lose control of the upper chamber after winning it. Neither side has held the Senate majority for more than eight consecutive years since 1980, a span unprecedented in American history.

    The fact that control of Congress appears within reach for both sides in virtually every election, as it does again this year, heightens the sense of urgency and intensity around each campaign. So does the awareness that, because the parties have become so polarized in their goals, each shift in control can produce enormous changes in policy, no matter how wispy the change in voter attitudes that precipitated it. “The difference in policy now between the group that has 51 percent and the group that has 49 percent is so enormous because of the polarization and divergence of the two parties,” the longtime GOP pollster Whit Ayres told me. Such big change resting on such small shifts, Ayres added, “is not healthy for democracy.”

    Trump’s emergence has further raised the stakes over control of Congress and the White House. Many independent students of democracy and authoritarianism believe that if restored to unified control over government, Trump—and the many Republicans embracing his discredited fraud claims—will seek to tilt the electoral rules in a way that makes it more difficult to again remove him from power. A similar dynamic is already evident in the 21 red states that responded to Trump’s 2020 defeat by passing laws making voting more difficult. “If the Republican Party manages to get control one way or another, including both legal and illegal things, and rig the system a little bit more, we could have a period of more continuity [in unified control of Washington] but it would be minority government,” the political scientist Thomas Mann, a co-author of a seminal 2012 book on congressional polarization, It’s Even Worse Than It Looks, told me.

    Which is to say that you can likely add the future of American democracy to the list of issues that will soon be decided by a relative handful of voters in the handful of states at the tipping point of our internal cold war.

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    Ronald Brownstein

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