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Tag: Low-income

  • The Role of Entrepreneurship in Low-Income Communities 

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    Entrepreneurship’s role in building community has always fascinated me. It seems almost paradoxical, given the myth of the solitary startup—with the lone, driven figure working at the kitchen table on countless late nights and early mornings. 

    In some cases, that community is composed primarily of entrepreneurs and their advocates. That support network provides vital nourishment for the startup journey. I saw that firsthand in June when thousands of entrepreneurs and their advocates gathered in Indianapolis from all over the world for the Global Entrepreneurship Network Congress. It was truly heartening to witness so many people across the globe come together for that shared purpose. 

    In other cases, the community is served by the entrepreneur, whose work attracts, galvanizes, and energizes local economic potential. I was reminded of that recently by the work of Majora Carter, and the profound insights it offers. 

    Carter is a real estate developer and urban revitalization strategy consultant, who grew up in New York City’s South Bronx and still lives there. A MacArthur Fellow, a Peabody Award-winning broadcaster, a lecturer at Princeton University, and an ambassador for Right to Start—the national nonprofit organization that I founded to champion entrepreneurship as a civic priority—Carter proves that you don’t have to leave low-income communities to succeed.

    Carter’s insights into urban revitalization are fueled by more than two decades of work in the South Bronx. She makes the fascinating point that in low-income communities, nonprofits provide only the services that philanthropy is willing to fund, while chain-store businesses typically sell their goods without encouraging residents to linger any longer than necessary. Both approaches are inherently limited—and limiting. 

    Entrepreneurship has the power to bring people together, to expand a shared sense of community. It provides the potential to build community wealth from the inside out, empowering local residents to be the architects of their own economic future.  

    You can see this firsthand at the Boogie Down Grind Café, which Carter founded on Hunts Point Avenue in the South Bronx. It’s designed to be a “third space”—a place that’s neither work nor home, where people can spend time in community. Neighbors can meet, share interests, and find common purpose.

    Just two blocks down the avenue, Carter acquired an abandoned railroad station for one dollar. It sits at the heart of Hunts Point, next to a subway stop (the “6” train to Manhattan) and a soon-to-open Metro-North commuter rail station (on the New Haven line to Grand Central Terminal). The train station was designed by Cass Gilbert, one of America’s first celebrity architects, whose work includes iconic early 20th-century buildings such as the Woolworth Building in New York City, then the tallest in the world, and the U.S. Supreme Court building in Washington, D.C. 

    Carter has transformed the train station into an event space called Bronxlandia that offers another third space—a place where neighbors and visitors can gather for concerts and community events. It also serves as a site for commercial photo shoots, while Carter seeks investors to fund the ongoing renovation of this stunning space. 

    Her challenge is that, even in New York City, it’s hard to convince policymakers that a low-income community can be lifted from within through entrepreneurship. The Department of City Planning recently studied four Bronx communities served by Metro-North stations on the New Haven line. They recommended rezoning three of the locations to enhance economic development, but excluded Hunts Point. Even experts in city planning couldn’t see the potential in a low-income community with rail links to Grand Central Terminal. 

    That’s why Right to Start has recently launched a national campaign—‘’America the Entrepreneurial”—to elevate understanding of the power of entrepreneurship. Not only does entrepreneurship generate nearly all net job growth, create community wealth, and reduce poverty—it builds community. And the beauty of it is this: Every town and city in America already has the culture and heritage needed to grow new businesses. The Boogie Down Grind Café and Bronxlandia are living examples.  

    And the benefits extend to every American, not just entrepreneurs. Every 1 percent increase in entrepreneurial activity in a state correlates with a 2 percent decline in poverty. Every new business per 100 people adds nearly $500 to average household income in a county, according to data from the GoDaddy Small Business Research Lab. 

    We simply need to see the potential. As we approach America’s 250th anniversary next year, we all need to see that potential—from sea to shining sea. We all must see America the Entrepreneurial. 

    The author is founder and CEO of Right to Start, the national nonprofit organization championing entrepreneurship as a civic priority. 

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    Victor W. Hwang

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  • Trump proposed cutting WIC for low-income families

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    The Trump administration said it found money to continue a food program for low-income families amid the government shutdown, but a Democratic lawmaker countered that it’s the president who ultimately wants to cut the Women, Infants and Children program.

    White House Press Secretary Karoline Leavitt wrote Oct. 7 on X that Democrats are “so cruel in their continual votes to shut down the government that they forced the WIC program for the most vulnerable women and children to run out this week.” Leavitt said the White House will transfer tariff revenue to cover WIC during the shutdown.

    U.S. Rep. James Clyburn, D-S.C, reshared Leavitt’s X post on Oct. 8 and wrote, “Trump’s budget called for a $300M cut to WIC. So yes, the White House *was* going to allow impoverished mothers and babies to go hungry.”

    Democrats and Republicans have blamed each other for the shutdown that began Oct. 1. It takes two to tango on the federal budget, and both sides are at an impasse; Republicans wanted to temporarily extend federal spending at current levels, while Democrats wanted Republicans to extend expiring subsidies for Affordable Care Act health care plans and to reverse Medicaid cuts that Trump signed into law this summer. 

    We asked the White House and the U.S. Agriculture Department, which oversees the WIC program, about Trump’s budget proposal for WIC. We received an automated response from the Agriculture Department about delayed response times related to staff furloughs because of the shutdown. The White House did not reply. 

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    The Special Supplemental Nutrition Program for Women, Infants, and Children, or WIC, provides healthy foods, nutrition education, breastfeeding support and referrals to health care providers and social services for low-income women, and infants and children up until they turn 5. The program serves about 6.9 million people.

    Trump’s budget proposal cuts WIC as part of larger spending cuts

    Congress ultimately approves federal spending, but the Trump administration, like every presidency before, can signal priorities with a wish list.

    Clyburn’s spokesperson pointed to the Agriculture Department’s 2026 budget summary, which drew from the president’s 2026 budget request. The budget includes $7.3 billion for WIC in 2026, a decrease from $7.597 billion in 2025, or a difference of about $291 million.

    Earlier this year, the Trump administration proposed cutting about $163 billion in non-defense discretionary spending for the next fiscal year while increasing spending for defense and the border. 

    Trump’s budget proposal also rolls back a WIC rule that allows participants to get additional money for fruits and vegetables through the “cash value benefit.”

    A left-leaning think tank and advocacy organization said the benefit would be rolled back from $26 a month to $10 per month for children, and from about $50 a month to $13 a month for adults.

    Lawmakers who set the budget prefer a different approach. The Senate-passed budget bill would increase WIC by $603 million, while the House Appropriations Committee bill was less generous, keeping it closer to 2024 levels. 

    Trump administration bails out WIC in the short term

    Lawmakers and WIC advocates warned that WIC could soon run out of money during the shutdown, although states had options to temporarily fill the gap.

    About one week into the shutdown, the White House said it will use tariff revenue to pay for WIC, providing about $300 million

    Chris Towner, a Committee for a Responsible Federal Budget expert, said it’s not clear whether the White House can use tariff revenue in this way.

    “The problem is not that there is insufficient money to pay WIC benefits; the problem is that WIC funding is appropriated by the bills that keep the government open, and since that appropriation has lapsed, the White House does not have Congress’s permission to spend that money,” Towner said.

    WIC benefits have continued during the shutdown, said Whitney Dawn Carlson, spokesperson for the National WIC Association. Some territorial and tribal agencies experienced temporary disruptions in WIC services, but they reopened. 

    Our ruling

    Clyburn said “Trump’s budget called for a $300 (million) cut” to the Women, Infants and Children program.

    Administration documents show that the administration’s proposed budget for WIC for the next year would cut $291 million for the program. In the short-term, the administration said it will use tariff revenues to allow WIC to continue during the shutdown, separate from Trump’s budget proposal.

    We rate this statement True.

    RELATED: Fact-checking political talking points about the 2025 government shutdown

    RELATED: Donald Trump says grocery, energy prices are down. It’s a mixed bag for consumers so far.

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  • How to Qualify for Low Income Housing: Eligibility Simplified

    How to Qualify for Low Income Housing: Eligibility Simplified

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    Low-income housing programs, like the Housing Choice Voucher Program (Section 8), offer rental assistance to those who meet specific income and eligibility criteria.

    I understand that navigating the application process can be daunting, which is why it’s important to know what’s required of you. These programs, primarily funded by the federal government, aim to provide affordable options to those in need.

    To begin your journey toward qualifying for low-income housing, you must first determine your eligibility, which typically revolves around your income, family size, and citizenship or eligible immigration status.

    Contacting your local public housing authority (PHA) is a smart move, as this agency can provide guidance through the process and inform you about the specific programs available in your area, like the options outlined by HUD’s Public Housing Program.

    Key Takeaways

    • Low-income housing programs, like Section 8 and Public Housing, offer crucial affordable housing options.
    • Eligibility is based on income limits, family size, and certain priority groups.
    • Engage with local Public Housing Authorities (PHAs) for application guidance.
    • Prepare the required documents and understand the application process thoroughly.
    • Expect long waiting lists due to high demand and limited supply.
    • Affordable housing aids in improving health, education, and employment outcomes for communities.

    Overview

    Low-income housing, often associated with programs like Section 8, provides rental assistance to eligible individuals and families with lower incomes. Eligibility criteria typically include income level, family status, and citizenship or immigration status. Various programs are designed to ensure that housing costs do not become prohibitive for those earning significantly less than the area’s median income.

    Importance of Affordable Housing

    Affordable housing is vital because it supports economic stability and community diversity. By providing access to housing that individuals and families can afford, you can see how it promotes better outcomes in health, education, and employment for community members.

    It enables individuals to allocate resources to other essential aspects of life, such as nutrition and healthcare, contributing to the overall well-being of a society.

    Eligibility Criteria

    Low income housing eligibility

    Source
    Percent of AMI
    Family
    of 1
    Family
    of 2
    Family
    of 3
    Family
    of 4
    Family
    of 5
    Family
    of 6
    Family
    of 7
    Family
    of 8
    10% $7,940 $9,070 $10,200 $11,300 $12,240 $13,150 $14,050 $14,960
    20% $15,880 $18,140 $20,400 $22,660 $24,480 $26,300 $28,100 $29,920
    30% $23,800 $27,200 $30,600 $34,000 $36,750 $39,450 $42,200 $44,900
    40% $31,760 $36,280 $40,800 $45,320 $48,960 $52,600 $56,200 $59,840
    50% $39,700 $45,350 $51,000 $56,650 $61,200 $65,750 $70,250 $74,800
    60% $47,640 $54,420 $61,200 $67,980 $73,440 $78,900 $84,300 $89,760
    65% $51,610 $58,955 $66,300 $73,645 $79,560 $85,475 $91,325 $97,240
    70% $55,580 $63,490 $71,400 $79,310 $85,680 $92,050 $98,350 $104,720
    80% $63,500 $72,550 $81,600 $90,650 $97,950 $105,200 $112,450 $119,700
    90% $71,460 $81,630 $91,800 $101,970 $110,160 $118,350 $126,450 $134,640
    Area Median Income $79,400 $90,700 $102,000 $113,300 $122,400 $131,500 $140,500 $149,600

    Income Limits

    Income limits are crucial in determining eligibility for low-income housing. Your income must not exceed certain thresholds defined by the Department of Housing and Urban Development (HUD). These limits vary by location and are calculated as percentages of the area median income (AMI). For instance, to be eligible for certain programs, You may need to have an income that is 50% below the AMI.

    Family Size Considerations

    The size of my family also affects my eligibility for low-income housing. Larger families may have higher income limits, allowing for a fair assessment of housing needs proportional to family size. This ensures that the income criteria accurately reflect the financial resources needed to support all members of my household.

    Priority Populations

    Certain populations are given priority in the allocation of low-income housing. This can include the elderly, people with disabilities families with young children, or a member who is pregnant. If I belong to one of these populations, I may thus be more likely to qualify for housing assistance and may be given preference in certain housing programs.

    Types of Low-Income Programs

    Housing assistance criteriaHousing assistance criteria

    Public housing provides affordable apartments for low-income families, the elderly, and persons with disabilities. Administered by local public housing agencies (PHAs), rents in these units are typically based on a percentage of the tenant’s income to ensure affordability. To join the program, interested individuals must contact a PHA in their state.

    Section 8 Choice Vouchers

    The Section 8 Housing Choice Voucher program empowers very low-income families to choose their housing while receiving governmental assistance to make it affordable according to HUD.gov. Tenants can use these vouchers to cover all or part of their rent in the private market, and the PHA directly pays the landlord the subsidized amount.

    Section 202 Supportive for the Elderly

    This program specifically caters to seniors, providing housing that not only is affordable but also offers the necessary supportive services to help elderly residents live independently. Housing under Section 202 has income-based rent and might include amenities like transportation and community dining, tailored to older adults’ needs.

    Application Process

    Income based housing requirementsIncome based housing requirements

    To apply for low-income housing, precision is crucial. I’ll guide you through collecting the necessary documentation, where to apply, and navigating the lottery system that often determines placement.

    Gathering Required Documents

    • Proof of income (such as pay stubs or tax returns)
    • Valid identification (like a driver’s license or passport)
    • Birth certificates for all family members
    • Social Security cards for each applicant

    I keep these documents organized and accessible, knowing that they are essential for a complete application.

    Where to Apply

    Public housing application processPublic housing application process

    Locate your local Public Housing Agency (PHA) to start the application process. Each agency has its own application process, but you can typically apply for a housing choice voucher online, by mail, or in person at the PHA office. It’s important to apply through the PHA serving the community to ensure my eligibility based on local income limits.

    Understanding the Lottery System

    Because demand often exceeds supply, many PHAs use a lottery system for their Section 8 voucher program as per the CSR Report. Once my application is in, I’m placed on a lottery or waiting list. It’s critical to know that being selected is not guaranteed, and wait times can vary considerably. If my name is chosen, the PHA will contact me with further instructions on how to proceed.

    Waiting List Management

    When applying for low-income housing, understanding how waiting list management works is as crucial as meeting the eligibility criteria. The waiting list itself is a critical part of the process that requires consistent attention and accurate estimation of potential wait times.

    Estimating Wait Times

    The length of the waiting list and the number of applicants play a significant role in determining how long you might wait before receiving assistance. You can get an idea of the timeframe by inquiring with the housing authority about the number of applicants ahead of you and the average wait time each year. Documentation, such as the PHOG Waiting List Chapter, can provide insights into how housing authorities manage these lists.

    Role of Public Housing Authorities

    Affordable housing qualificationsAffordable housing qualifications

    In my experience, Public Housing Authorities (PHAs) are key players in administering low-income housing programs. They serve as a bridge between the government’s housing aid and eligible residents, ensuring access to affordable homes.

    Navigating Through Local PHA

    Local PHAs have the responsibility of determining eligibility for programs like the Public Housing Program. I assess eligibility based on factors including annual gross income, whether applicants qualify as elderly, persons with disabilities, or as families, and their U.S. citizenship or eligible immigration status.

    To understand the application process, I work with individuals to ensure they meet these criteria. The process may vary between states, and sometimes, one may need to apply in person. Learning to navigate through your local PHA can be the first step toward securing assistance.

    PHA Resources and Assistance

    PHAs provide much more than just housing; they offer resources and support that aid residents in maintaining their homes. For instance, the Housing Choice Voucher Program Section 8 empowers very low-income families, the elderly, and the disabled to find decent in the private market. It’s my job to help residents understand the types of support available to them and how to apply for these programs effectively.

    Local PHAs, like the Memphis Housing Authority, receive federal aid to manage housing for low-income residents at affordable rents. They also provide technical and professional assistance in planning, developing, and managing these developments, ensuring residents receive quality housing.

    Tenant Responsibilities

    Subsidized housing criteriaSubsidized housing criteria

    As a tenant, I am aware that my ability to remain in low-income housing hinges on fulfilling specific obligations, of which the most crucial are adhering to my lease agreements and respecting the property rules set by my landlord or housing authority.

    Abiding by Lease Agreements

    I ensure that I read and understand my lease agreement thoroughly before signing. The lease is a legally binding document that stipulates my obligations, including rent payments, prompt reporting of maintenance issues, and proper notice before leaving the unit.

    Respecting Property Rules

    I recognize the importance of abiding by the property rules which may include guidelines on noise levels, pet ownership, waste disposal, and common area maintenance. These rules are in place to maintain a safe and clean living environment for all residents. 

    Appeals and Grievances

    Rental assistance qualificationsRental assistance qualifications

    When you face a denial from a low-income program, knowing the steps to challenge the decision is crucial. Each program provides a process for appeals and grievances to ensure fairness.

    Handling Denials

    If I receive a denial of admission from a housing program, I must receive a written notice specifying the reasons for the decision. This is a standard protocol required for all HUD and USDA housing programs. Importantly, under certain circumstances, I may be eligible to appeal this decision. For instance, on reviewing my denial from the Affordable Housing Online, if the denial was based on incorrect information, I have the right to request a correction and a subsequent review of my application.

    Filing for a Hearing

    In response to a denial, I have the option to file for a grievance hearing. This formal process allows me to present evidence and argue my case before a neutral party. The steps to initiate this process include requesting the hearing in writing within a specified deadline. The National Housing Law Project outlines that to prepare for the hearing, I can gather relevant documents, seek legal advice, and prepare to make a clear presentation of my case.

    Frequently Asked Questions

    What are the eligibility requirements for low-income housing assistance?

    Eligibility for low-income housing assistance is typically determined by income level, family size, and housing needs. My income must not exceed the income limits set by the Department of Housing and Urban Development (HUD), which are based on the median income in my area.

    How can I apply for a Section 8 housing voucher?

    To apply for a Section 8 housing voucher, you need to contact the local Public Housing Agency (PHA) and complete an application. Waiting lists can be long, so it’s important to apply as soon as possible.

    What documents do I need to submit for the Low-Income Housing Tax Credit program?

    For the Low-Income Housing Tax Credit program, you’re usually required to submit proof of income, tax returns, identification, and additional documentation to verify your eligibility. Check the application instructions provided by the housing property or manager for a specific list.

    Are there ways to receive immediate housing assistance in case of an emergency?

    Yes, immediate housing assistance might be available in an emergency such as job loss or disaster.

    How is the income limit for affordable housing determined in various states?

    Income limits for affordable housing are determined by HUD and vary by state and county. They are typically set at 50% to 80% of the median income for the area.

    What processes are involved in applying through my local Public Housing Agency?

    Applying through your local Public Housing Agency involves submitting an application with the required supporting documents, undergoing an eligibility review, and possibly being placed on a waiting list. You will then be contacted when a suitable housing option becomes available.

    Final Words

    Eligibility largely hinges on income, family size, and citizenship or eligible immigration status, with income limits set in relation to the Area Median Income (AMI).

    Applying through your local PHA is crucial for accessing programs tailored to your area’s needs, and understanding the system, including the potential use of a lottery for placement, is key to successfully securing affordable housing.

    The process underscores the importance of affordable housing in promoting economic stability, community diversity, and the well-being of individuals and families in need.

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    Teddy Hicks

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  • Trump Is Coming for Obamacare Again

    Trump Is Coming for Obamacare Again

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    Donald Trump’s renewed pledge on social media and in campaign rallies to repeal and replace the Affordable Care Act has put him on a collision course with a widening circle of Republican constituencies directly benefiting from the law.

    In 2017, when Trump and congressional Republicans tried and failed to repeal the ACA, also known as Obamacare, they faced the core contradiction that many of the law’s principal beneficiaries were people and institutions that favored the GOP. That list included lower-middle-income workers without college degrees, older adults in the final years before retirement, and rural communities.

    In the years since then, the number of people in each of those groups relying on the ACA has grown. More than 40 million Americans now receive health coverage through the law, about 50 percent more than the roughly 27 million the ACA covered during the repeal fight in 2017. In the intervening years, nine more states, most of them reliably Republican, have accepted the law’s federal funding to expand access to Medicaid for low-income working adults.

    “Republicans came very close to repealing and replacing the ACA in 2017, but that may have been their best window before the law had fully taken hold and so many people have benefited from it,” Larry Levitt, the executive vice president for health policy at KFF, a nonpartisan think tank that studies health-care issues, told me. “I think it gets harder and harder to repeal as more people benefit.”

    Trump’s repeated declarations over the past several weeks that he intends to finally repeal the ACA if reelected surprised many Republicans. Few GOP leaders have talked about uprooting the law since the party’s last effort failed, during Trump’s first year as president. At that point, Republicans controlled both chambers of Congress. But whereas the House, with Trump’s enthusiastic support, narrowly voted to rescind the law, the Senate narrowly rejected repeal. Three GOP senators blocked the repeal effort by voting no—including the late Senator John McCain, who dramatically doomed the proposal by signaling thumbs-down on the Senate floor. (Trump mocked McCain while calling the ACA “a catastrophe” as he campaigned in Iowa last weekend.)

    Republicans lost any further opportunity to repeal the law in the 2018 election when Democrats regained control of the House of Representatives. With the legislative route blocked, Trump instead pursued an array of regulatory and legal efforts to weaken the ACA during his final years in office. But since the 2017 vote, the GOP has never again held the unified control of the White House, the House, and the Senate required to launch a serious legislative repeal effort.

    If Republicans did win unified control of Congress and the White House next November, most health-care experts I spoke with agreed that Trump would follow through on his promises to again target the ACA. Leslie Dach, the founder of Protect Our Care, a liberal group that supports the law, says that he takes Trump’s pledge to pursue repeal seriously, “because he is still trying to overturn the legacy of John McCain, and it’s one of the few things he lost. He doesn’t like to be a loser.”

    Trump hasn’t specified his plan to replace the ACA. But whatever alternative Trump develops will inevitably face one of the main problems that confounded Republicans’ last attempt at repeal: Every plan they put forward raised costs and diminished access to care for core groups in their electoral coalition.

    That was apparent in the contrast between how the ACA and the GOP alternatives treated the individual insurance market. The ACA created exchanges where the uninsured could buy coverage, provided them with subsidies to help them afford it, and changed the rules about what kind of policies insurers could sell them. Key among those changes were provisions that barred insurers from denying coverage to people with preexisting health conditions, required them to offer a broad package of essential health benefits in all policies, and prevented them from charging older consumers more than three times the premiums of younger people.

    The common effect of all these and many other requirements was to require greater risk sharing in the insurance markets. The ACA made coverage in the individual insurance market more available and affordable for older and sicker consumers partly by requiring younger and healthier consumers to purchase more expensive and comprehensive plans than they might have bought before the law went into effect. That shift generated complaints from relatively younger and healthier consumers in the ACA’s early years as their premiums increased.

    Every alternative that Republicans proposed during the Trump years sought to lower premiums by unraveling the ACA provisions that required more sharing of risks and costs. For instance, the House GOP plan allowed insurers to charge seniors five times as much as young people, reduced the number of guaranteed essential benefits, and allowed states to exempt insurers from the requirement to cover all applicants with preexisting health conditions.

    One problem the GOP faced was that although this approach might have lowered premiums for the young and healthy (albeit while leaving them with less comprehensive coverage), it would have significantly raised costs and reduced access for the old or sick. “A lot of ‘repeal and replace’ was putting more cost back on people with health-care problems,” Linda Blumberg, an institute fellow at the Urban Institute’s Health Policy Center, told me. The Rand Corporation calculated that for individuals with modest incomes, the House GOP plan would have cut premiums for the majority of those under age 45 while raising them for virtually everyone older than 45. The Congressional Budget Office, in its assessment of the House-passed GOP bill, projected that it would nearly double the number of people without health insurance by 2026, and that the greatest coverage losses would happen “among older people with lower income.”

    As I wrote in 2017, the paradox was that the Republican plans would have hurt older working-age adults—a preponderantly GOP-leaning constituency—while lowering costs for younger generations that mostly vote Democratic. I called this inversion the “Trumpcare conundrum.”

    The congressional Republican alternatives to the ACA under Trump also uniformly made deep cuts to Medicaid, the joint state-federal health-care program for low-income people. But GOP constituencies were big winners as well in the ACA provisions that expanded eligibility for Medicaid.

    Until the ACA, Medicaid was generally available only to adults earning less than the federal poverty level. But the law provided states with generous federal financing to expand coverage to low-income individuals earning up to 138 percent of the poverty level. Particularly in interior states, research showed that many of those low-income workers covered under the Medicaid expansion were white people without a college degree, the cornerstone of the modern Republican electoral coalition.

    Another big beneficiary from the Medicaid expansion was rural communities, which have become more reliably Republican in the Trump years. Expanding access to Medicaid was especially important to rural places because studies have consistently found that more people in those areas than in metropolitan centers suffer from chronic health problems, while fewer obtain health insurance from their employer, and more lack insurance altogether.

    The increased number of people covered under Medicaid gave rural hospitals a lifeline by reducing the amount of uncompensated care they needed to provide for patients lacking insurance. “When you go out to the rural areas, frankly most hospital executives, like other business people, they tend to be pretty conservative,” Timothy McBride, a co-director of the Center for Advancing Health Services, Policy & Economics Research at Washington University in St. Louis, told me. “And they don’t like government intervention. But I would go to see these people and they would say, ‘I’m for Medicaid expansion,’ because they had to deal with the uninsured.”

    The Medicaid expansion also quickly became a crucial source of financing for addiction treatment in states ravaged through the 2010s by the opioid epidemic. Before the ACA, addiction treatment programs relied on “a little bit of block grant money here, a local voucher there, kind of out-of-pocket payments, and a little bit of spit and glue,” Brendan Saloner, a professor at the Johns Hopkins Bloomberg School of Public Health who studies addiction, told me. “Then Medicaid came along, and it provided a much more reliable and stable source of payment.”

    Since the 2017 legislative battle, the ACA’s impact on all these fronts has only deepened. Biden and congressional Democrats both increased the federal subsidies to buy insurance on the Obamacare exchanges and expanded eligibility to families further into the middle class. Largely as a result, the number of people obtaining insurance through the exchanges soared from about 10 million then to more than 15 million as of this past December.

    Similarly, a majority of the 31 states that had expanded Medicaid by 2017 were solidly Democratic-leaning. But the nine additional states that have broadened eligibility since then include seven that voted for Trump in 2016 and 2020.

    That has not only increased the total number of low-income workers covered through the Medicaid expansion (from about 16 million then to well over 24 million now), but also broadened the red-state constituency for the ACA. McBride estimates that the federal government has annually pumped $2 billion into the health-care system in Missouri alone since voters there approved a Medicaid expansion in 2020. The federal Department of Health and Human Services recently calculated that the likelihood of rural hospitals closing was more than twice as high in the states that have refused to expand Medicaid than in those that have. Simultaneously, the amount of funding that Medicaid provides for the treatment of substance abuse has at least doubled since 2014, allowing it to serve nearly 5 million people, according to calculations by Tami Mark, a distinguished fellow in behavioral health at RTI International, a nonprofit independent research institute.

    Even more fundamentally, Blumberg argues, the pandemic showed the ACA’s value as a safety net. Through either the exchanges or Medicaid, the law provided coverage to millions who lost their job, and insurance, during the crisis. “This law was critical in protecting us from unforeseen circumstances even beyond the value that people had seen in 2017,” she told me. “If we had not had that in place, we would have seen massive amounts of uninsurance and people who could not have accessed vaccines and could not have accessed medical care when they became sick.”

    For all of these reasons and more, Douglas Holtz-Eakin, the president of the American Action Forum, a conservative think tank, told me that he believes it’s a mistake for Trump and the GOP to seek repeal once again. Holtz-Eakin, a former director of the Congressional Budget Office, remains critical of the ACA, which he says has not done enough to improve the quality of coverage or control costs.

    But, he points out, during the Trump years, Republicans succeeded in repealing some of the law’s elements that they disliked most, including the tax penalty on uninsured people who did not buy coverage. “I don’t think we should be happy with the current system,” Holtz-Eakin told me. “But it’s not fruitful to try to roll the clock back to 2010.”

    Beyond the policy challenges of excising the ACA from the health-care system, the political landscape also appears less hospitable to a renewed repeal drive. In 2017, KFF polling found that the share of Americans who viewed the law favorably only slightly exceeded the share dubious of it; in the group’s most recent survey measuring attitudes toward the law, more than three-fifths of Americans expressed favorable views, while only slightly more than one-third viewed it negatively. Support for individual provisions in the law, such as the ban on denying coverage because of preexisting conditions or the requirement that insurers allow kids to stay on their parents’ plans through age 26, runs even higher in polls.

    Yet even with all these obstacles, Trump’s promise to seek repeal again virtually ensures another round of the ACA war next year if Republicans win unified control of the federal government. By historical standards, that’s a remarkable, even unprecedented, prospect. Though Barry Goldwater, the 1964 GOP nominee, had opposed the creation of Medicare, for instance, no Republican presidential nominee ever proposed to repeal it after Lyndon B. Johnson signed it into law in 1965.

    If Trump wins the nomination, by contrast, it would mark the fourth consecutive time the GOP nominee has run on ending the ACA. (Among Trump’s main competitors, Florida Governor Ron DeSantis has also promised to produce an alternative to the ACA, and Nikki Haley, who has spoken less definitively on the topic, might feel irresistible pressure to embrace repeal too.) Congressional Republicans may have been surprised that Trump committed them to charging up that hill again, but that doesn’t mean they would refuse his command to do so. “He wants to reverse a loss and take it off the books,” Dach told me. “And we’ve learned that that party follows him. It’s not like they are going to stand up against him, especially in the House. They will destroy the law if they can.”

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    Ronald Brownstein

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  • Trump’s Plan to Police Gender

    Trump’s Plan to Police Gender

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    After decades of gains in public acceptance, the LGBTQ community is confronting a climate in which political leaders are once again calling them weirdos and predators. Texas Governor Greg Abbott has directed the Department of Family and Protective Services to investigate the parents of transgender children; Governor Ron DeSantis has tried to purge Florida classrooms of books that acknowledge the reality that some people aren’t straight or cisgender; Missouri has imposed rules that limit access to gender-affirming care for trans people of all ages. Donald Trump is promising to nationalize such efforts. He doesn’t just want to surveil, miseducate, and repress children who are exploring their emerging identities. He wants to interfere in the private lives of millions of adults, revoking freedoms that any pluralistic society should protect.

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    During his 2016 campaign, Trump seemed to think that feigning sympathy for queer people was good PR. “I will do everything in my power to protect our LGBTQ citizens,” he promised. Then, while in office, he oversaw a broad rollback of LGBTQ protections, removing gender identity and sexuality from federal nondiscrimination provisions regarding health care, employment, and housing. His Defense Department restricted soldiers’ right to transition and banned trans people from enlisting; his State Department refused to issue visas to the same-sex domestic partners of diplomats. Yet when seeking reelection in 2020, Trump still made a show of throwing a Pride-themed rally.

    Now, recognizing that red-state voters have been energized by anti-queer demagoguery, he’s not even pretending to be tolerant. “These people are sick; they are deranged,” Trump said during a speech, amid a rant about transgender athletes in June. When the audience cheered at his mention of “transgender insanity,” he marveled, “It’s amazing how strongly people feel about that. You see, I’m talking about cutting taxes, people go like that.” He pantomimed weak applause. “But you mention transgender, everyone goes crazy.” The rhetoric has become a fixture of his rallies.

    Trump is now running on a 10-point “Plan to Protect Children From Left-Wing Gender Insanity.” Its aim is not simply to interfere with parents’ rights to shape their kids’ health and education in consultation with doctors and teachers; it’s to effectively end trans people’s existence in the eyes of the government. Trump will call on Congress to establish a national definition of gender as being strictly binary and immutable from birth. He also wants to use executive action to cease all federal “programs that promote the concept of sex and gender transition at any age.” If enacted, those measures could open the door to all sorts of administrative cruelties—making it impossible, for example, for someone to change their gender on their passport. Low-income trans adults could be blocked from using Medicaid to pay for treatment that doctors have deemed vital to their well-being.

    The Biden administration reinstated many of the protections Trump had eliminated, and the judiciary has thus far curbed the most extreme aspects of the conservative anti-trans agenda. In 2020, the Supreme Court ruled that, contrary to the assertions of Trump’s Justice Department, the Civil Rights Act protects LGBTQ people from employment discrimination. A federal judge issued a temporary restraining order preventing the investigations that Governor Abbott had ordered in Texas. But in a second term, Trump would surely seek to appoint more judges opposed to queer causes. He would also resume his first-term efforts to promote an interpretation of religious freedom that allows for unequal treatment of minorities. In May 2019, his Housing and Urban Development Department proposed a measure that would have permitted federally funded homeless shelters to turn away transgender individuals on the basis of religious freedom. A 2023 Supreme Court decision affirming a Christian graphic designer’s refusal to work with gay couples will invite more attempts to narrow the spaces and services to which queer people are guaranteed access.

    The social impact of Trump’s reelection would only further encourage such discrimination. He has long espoused old-fashioned ideas about what it means to look and act male and female. Now the leader of the Republican Party is using his platform to push the notion that people who depart from those ideas deserve punishment. As some Republicans have engaged in queer-bashing rhetoric in recent years—including the libel that queerness is pedophilia by another name—hate crimes motivated by gender identity and sexuality have risen, terrifying a population that was never able to take its safety for granted. Victims of violence have included people who were merely suspected of nonconformity, such as the 59-year-old woman in Indiana who was killed in 2023 by a neighbor who believed her to be “a man acting like a woman.”

    If Trump’s stoking of gender panic proves to be a winning national strategy, everyday deviation from outmoded and rigid norms could invite scorn or worse. And children will grow up in a more repressive and dangerous America than has existed in a long time.


    This article appears in the January/February 2024 print edition with the headline “Trump Will Stoke a Gender Panic.”

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    Spencer Kornhaber

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  • Black Success, White Backlash

    Black Success, White Backlash

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    For more than half a century, I have been studying the shifting relations between white and Black Americans. My first journal article, published in 1972, when I was a graduate student at the University of Chicago, was about Black political power in the industrial Midwest after the riots of the late 1960s. My own experience of race relations in America is even longer. I was born in the Mississippi Delta during World War II, in a cabin on what used to be a plantation, and then moved as a young boy to northern Indiana, where as a Black person in the early 1950s, I was constantly reminded of “my place,” and of the penalties for overstepping it. Seeing the image of Emmett Till’s dead body in Jet magazine in 1955 brought home vividly for my generation of Black kids that the consequences of failing to navigate carefully among white people could even be lethal.

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    For the past 16 years, I have been on the faculty of the sociology department at Yale, and in 2018 I was granted a Sterling Professorship, the highest academic rank the university bestows. I say this not to boast, but to illustrate that I have made my way from the bottom of American society to the top, from a sharecropper’s cabin to the pinnacle of the ivory tower. One might think that, as a decorated professor at an Ivy League university, I would have escaped the various indignities that being Black in traditionally white spaces exposes you to. And to be sure, I enjoy many of the privileges my white professional-class peers do. But the Black ghetto—a destitute and fearsome place in the popular imagination, though in reality it is home to legions of decent, hardworking families—remains so powerful that it attaches to all Black Americans, no matter where and how they live. Regardless of their wealth or professional status or years of law-abiding bourgeois decency, Black people simply cannot escape what I call the “iconic ghetto.”

    I know I haven’t. Some years ago, I spent two weeks in Wellfleet, Massachusetts, a pleasant Cape Cod town full of upper-middle-class white vacationers and working-class white year-rounders. On my daily jog one morning, a white man in a pickup truck stopped in the middle of the road, yelling and gesticulating. “Go home!” he shouted.

    Who was this man? Did he assume, because of my Black skin, that I was from the ghetto? Is that where he wanted me to “go home” to?

    This was not an isolated incident. When I jog through upscale white neighborhoods near my home in Connecticut, white people tense up—unless I wear my Yale or University of Pennsylvania sweatshirts. When my jogging outfit associates me with an Ivy League university, it identifies me as a certain kind of Black person: a less scary one who has passed inspection under the “white gaze.” Strangers with dark skin are suspect until they can prove their trustworthiness, which is hard to do in fleeting public interactions. For this reason, Black students attending universities near inner cities know to wear college apparel, in hopes of avoiding racial profiling by the police or others.

    I once accidentally ran a small social experiment about this. When I joined the Yale faculty in 2007, I bought about 20 university baseball caps to give to the young people at my family reunion that year. Later, my nieces and nephews reported to me that wearing the Yale insignia had transformed their casual interactions with white strangers: White people would now approach them to engage in friendly small talk.

    But sometimes these signifiers of professional status and educated-class propriety are not enough. This can be true even in the most rarefied spaces. When I was hired at Yale, the chair of the sociology department invited me for dinner at the Yale Club of New York City. Clad in a blue blazer, I got to the club early and decided to go up to the fourth-floor library to read The New York Times. When the elevator arrived, a crush of people was waiting to get on it, so I entered and moved to the back to make room for others. Everyone except me was white.

    As the car filled up, I politely asked a man of about 35, standing by the controls, to push the button for the library floor. He looked at me and—emboldened, I have to imagine, by drinks in the bar downstairs—said, “You can read?” The car fell silent. After a few tense moments, another man, seeking to defuse the tension, blurted, “I’ve never met a Yalie who couldn’t read.” All eyes turned to me. The car reached the fourth floor. I stepped off, held the door open, and turned back to the people in the elevator. “I’m not a Yalie,” I said. “I’m a new Yale professor.” And I went into the library to read the paper.

    I tell these stories—and I’ve told them before—not to fault any particular institution (I’ve treasured my time at Yale), but to illustrate my personal experience of a recurring cultural phenomenon: Throughout American history, every moment of significant Black advancement has been met by a white backlash. After the Civil War, under the aegis of Reconstruction, Black people for a time became professionals and congressmen. But when federal troops left the former Confederate states in 1877, white politicians in the South tried to reconstitute slavery with the long rule of Jim Crow. Even the Black people who migrated north to escape this new servitude found themselves relegated to shantytowns on the edges of cities, precursors to the modern Black ghetto.

    All of this reinforced what slavery had originally established: the Black body’s place at the bottom of the social order. This racist positioning became institutionalized in innumerable ways, and it persists today.

    I want to emphasize that across the decades, many white Americans have encouraged racial equality, albeit sometimes under duress. In response to the riots of the 1960s, the federal government—led by the former segregationist Lyndon B. Johnson—passed far-reaching legislation that finally extended the full rights of citizenship to Black people, while targeting segregation. These legislative reforms—and, especially, affirmative action, which was implemented via LBJ’s executive order in 1965—combined with years of economic expansion to produce a long period of what I call “racial incorporation,” which substantially elevated the income of many Black people and brought them into previously white spaces. Yes, a lot of affirmative-action efforts stopped at mere tokenism. Even so, many of these “tokens” managed to succeed, and the result is the largest Black middle class in American history.

    Over the past 50 years, according to a study by the Pew Research Center, the proportion of Black people who are low-income (less than $52,000 a year for a household of three) has fallen seven points, from 48 to 41 percent. The proportion who are middle-income ($52,000 to $156,000 a year) has risen by one point, to 47 percent. The proportion who are high-income (more than $156,000 a year) has risen the most dramatically, from 5 to 12 percent. Overall, Black poverty remains egregiously disproportionate to that of white and Asian Americans. But fewer Black Americans are poor than 50 years ago, and more than twice as many are rich. Substantial numbers now attend the best schools, pursue professions of their choosing, and occupy positions of power and prestige. Affirmative action worked.

    But that very success has inflamed the inevitable white backlash. Notably, the only racial group more likely to be low-income now than 50 years ago is whites—and the only group less likely to be low-income is Blacks.

    For some white people displaced from their jobs by globalization and deindustrialization, the successful Black person with a good job is the embodiment of what’s wrong with America. The spectacle of Black doctors, CEOs, and college professors “out of their place” creates an uncomfortable dissonance, which white people deal with by mentally relegating successful Black people to the ghetto. That Black man who drives a new Lexus and sends his children to private school—he must be a drug kingpin, right?

    In predominantly white professional spaces, this racial anxiety appears in subtler ways. Black people are all too familiar with a particular kind of interaction, in the guise of a casual watercooler conversation, the gist of which is a sort of interrogation: “Where did you come from?”; “How did you get here?”; and “Are you qualified to be here?” (The presumptive answer to the last question is clearly no; Black skin, evoking for white people the iconic ghetto, confers an automatic deficit of credibility.)

    Black newcomers must signal quickly and clearly that they belong. Sometimes this requires something as simple as showing a company ID that white people are not asked for. Other times, a more elaborate dance is required, a performance in which the worker must demonstrate their propriety, their distance from the ghetto. This can involve dressing more formally than the job requires, speaking in a self-consciously educated way, and evincing a placid demeanor, especially in moments of disagreement.

    As part of my ethnographic research, I once embedded in a major financial-services corporation in Philadelphia, where I spent six months observing and interviewing workers. One Black employee I spoke with, a senior vice president, said that people of color who wanted to climb the management ladder must wear the right “uniform” and work hard to perform respectability. “They’re never going to envision you as being a white male,” he told me, “but if you can dress the same and look a certain way and drive a conservative car and whatever else, they’ll say, ‘This guy has a similar attitude, similar values [to we white people]. He’s a team player.’ If you don’t dress with the uniform, obviously you’re on the wrong team.”

    This need to constantly perform respectability for white people is a psychological drain, leaving Black people spent and demoralized. They typically keep this demoralization hidden from their white co-workers because they feel that they need to show they are not whiners. Having to pay a “Black tax” as they move through white areas deepens this demoralization. This tax is levied on people of color in nice restaurants and other public places, or simply while driving, when the fear of a lethal encounter with the police must always be in mind. The existential danger this kind of encounter poses is what necessitates “The Talk” that Black parents—fearful every time their kids go out the door that they might not come back alive—give to their children. The psychological effects of all of this accumulate gradually, sapping the spirit and engendering cynicism.

    Even the most exalted members of the Black elite must live in two worlds. They understand the white elite’s mores and values, and embody them to a substantial extent—but they typically remain keenly conscious of their Blackness. They socialize with both white and Black people of their own professional standing, but also members of the Black middle and working classes with whom they feel more kinship, meeting them at the barbershop, in church, or at gatherings of long-standing friendship groups. The two worlds seldom overlap. This calls to mind W. E. B. Du Bois’ “double consciousness”—a term he used for the first time in this publication, in 1897—referring to the dual cultural mindsets that successful African Americans must simultaneously inhabit.

    For middle-class Black people, a certain fluidity—abetted by family connections—enables them to feel a connection with those at the lower reaches of society. But that connection comes with a risk of contagion; they fear that, meritocratic status notwithstanding, they may be dragged down by their association with the hood.

    When I worked at the University of Pennsylvania, some friends of mine and I mentored at-risk youth in West Philadelphia.

    One of these kids, Kevin Robinson, who goes by KAYR (pronounced “K.R.”), grew up with six siblings in a single-parent household on public assistance. Two of his sisters got pregnant as teenagers, and for a while the whole family was homeless. But he did well in high school and was accepted to Bowdoin College, where he was one of five African Americans in a class of 440. He was then accepted to Dartmouth’s Tuck School of Business, where he was one of 10 or so African Americans in an M.B.A. class of roughly 180. He got into the analyst-training program at Goldman Sachs, where his cohort of 300 had five African Americans. And from there he ended up at a hedge fund, where he was the lone Black employee.

    What’s striking about Robinson’s accomplishments is not just the steepness of his rise or the scantness of Black peers as he climbed, but the extent of cultural assimilation he felt he needed to achieve in order to fit in. He trimmed his Afro. He did a pre-college program before starting Bowdoin, where he had sushi for the first time and learned how to play tennis and golf. “Let me look at how these people live; let me see how they operate,” he recalls saying to himself. He decided to start reading The New Yorker and Time magazine, as they did, and to watch 60 Minutes. “I wanted people to see me more as their peer versus … someone from the hood. I wanted them to see me as, like, ‘Hey, look, he’s just another middle-class Black kid.’ ” When he was about to start at Goldman Sachs, a Latina woman who was mentoring him there told him not to wear a silver watch or prominent jewelry: “ ‘KAYR, go get a Timex with a black leather band. Keep it very simple … Fit in.’ ” My friends and I had given him similar advice earlier on.

    All of this worked; he thrived professionally. Yet even as he occupied elite precincts of wealth and achievement, he was continually getting pulled back to support family in the ghetto, where he felt the need to code-switch, speaking and eating the ways his family did so as not to insult them.

    The year he entered Bowdoin, one of his younger brothers was sent to prison for attempted murder, and a sister who had four children was shot in the face and died. Over the years he would pay for school supplies for his nieces and nephews, and for multiple family funerals—all while keeping his family background a secret from his professional colleagues. Even so, he would get subjected to the standard indignities—being asked to show ID when his white peers were not; enduring the (sometimes obliviously) racist comments from colleagues (“You don’t act like a regular Black”). He would report egregious offenses to HR but would usually just let things go, for fear that developing a reputation as a “race guy” would restrict his professional advancement.

    Robinson’s is a remarkable success story. He is 40 now; he owns a property-management company and is a multimillionaire. But his experience makes clear that no matter what professional or financial heights you ascend to, if you are Black, you can never escape the iconic ghetto, and sometimes not even the actual one.

    The most egregious intrusion of a Black person into white space was the election (and reelection) of Barack Obama as president. A Black man in the White House! For some white people, this was intolerable. Birthers, led by Donald Trump, said he was ineligible for the presidency, claiming falsely that he had been born in Kenya. The white backlash intensified; Republicans opposed Obama with more than the standard amount of partisan vigor. In 2013, at the beginning of Obama’s second term, the Supreme Court gutted the Voting Rights Act, which had protected the franchise for 50 years. Encouraged by this opening, Alabama, Mississippi, North Carolina, and Texas moved forward with voter-suppression laws, setting a course that other states are now following. And this year, the Supreme Court outlawed affirmative action in college admissions. I want to tell a story that illustrates the social gains this puts at risk.

    Many years ago, when I was a professor at Penn, my father came to visit me. Walking around campus, we bumped into various colleagues and students of mine, most of them white, who greeted us warmly. He watched me interact with my secretary and other department administrators. Afterward, Dad and I went back to my house to drink beer and listen to Muddy Waters.

    “So you’re teaching at that white school?” he said.

    “Yeah.”

    “You work with white people. And you teach white students.”

    “Yeah, but they actually come in all colors,” I responded. I got his point, though.

    “Well, let me ask you one thing,” he said, furrowing his brow.

    “What’s that, Dad?”

    “Do they respect you?”

    After thinking about his question a bit, I said, “Well, some do. And some don’t. But you know, Dad, it is hard to tell which is which sometimes.”

    “Oh, I see,” he said.

    He didn’t disbelieve me; it was just that what he’d witnessed on campus was at odds with his experience of the typical Black-white interaction, where the subordinate status of the Black person was automatically assumed by the white one. Growing up in the South, my dad understood that white people simply did not respect Black people. Observing the respectful treatment I received from my students and colleagues, my father had a hard time believing his own eyes. Could race relations have changed so much, so fast?

    They had—in large part because of what affirmative action, and the general processes of racial incorporation and Black economic improvement, had wrought. In the 1960s, the only Black people at the financial-services firm I studied would have been janitors, night watchmen, elevator operators, or secretaries; 30 years later, affirmative action had helped populate the firm with Black executives. Each beneficiary of affirmative action, each member of the growing Black middle class, helped normalize the presence of Black people in professional and other historically white spaces. All of this diminished, in some incremental way, the power of the symbolic ghetto to hold back people of color.

    Too many people forget, if ever they knew it, what a profound cultural shift affirmative action effected. And they overlook affirmative action’s crucial role in forestalling social unrest.

    Some years ago, I was invited to the College of the Atlantic, a small school in Maine, to give the commencement address. As I stood at the sink in the men’s room before the event, checking the mirror to make sure all my academic regalia was properly arrayed, an older white man came up to me and said, with no preamble, “What do you think of affirmative action?”

    “I think it’s a form of reparations,” I said.

    “Well, I think they need to be educated first,” he said, and then walked out.

    I was so provoked by this that I scrambled back to my hotel room and rewrote my speech. I’d already been planning to talk about the benefits of affirmative action, but I sharpened and expanded my case, explaining that it not only had lifted many Black people out of the ghetto, but had been a weapon in the Cold War, when unaligned countries and former colonies were trying to decide which superpower to follow. Back then, Democrats and some Republicans were united in believing that affirmative action, by demonstrating the country’s commitment to racial justice and equality, helped project American greatness to the world.

    Beyond that, I said to this almost entirely white audience, affirmative action had helped keep the racial unrest of the ’60s from flaring up again. When the kin—the mothers, fathers, cousins, nephews, sons, daughters, baby mamas, uncles, aunts—of ghetto residents secure middle-class livelihoods, those ghetto relatives hear about it. This gives the young people who live there a modicum of hope that they might do the same. Hope takes the edge off distress and desperation; it lessens the incentives for people to loot and burn. What opponents of affirmative action fail to understand is that without a ladder of upward mobility for Black Americans, and a general sense that justice will prevail, a powerful nurturer of social concord gets lost.

    Yes, continuing to expand the Black professional and middle classes will lead to more instances of “the dance,” and the loaded interrogations, and the other awkward moments and indignities that people of color experience in white spaces. But the greater the number of affluent, successful Black people in such places, the faster this awkwardness will diminish, and the less power the recurrent waves of white reaction will have to set people of color back. I would like to believe that future generations of Black Americans will someday find themselves as pleasantly surprised as my dad once was by the new levels of racial respect and equality they discover.


    This article appears in the November 2023 print edition with the headline “Black Success, White Backlash.”

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    Elijah Anderson

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  • It’s the Best Time in History to Have a Migraine

    It’s the Best Time in History to Have a Migraine

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    Here is a straightforward, clinical description of a migraine: intense throbbing headache, nausea, vomiting, and sensitivity to light and noise, lasting for hours or days.

    And here is a fuller, more honest picture: an intense, throbbing sense of annoyance as the pain around my eye blooms. Wondering what the trigger was this time. Popping my beloved Excedrin—a combination of acetaminophen, aspirin, and caffeine—and hoping it has a chance to percolate in my system before I start vomiting. There’s the drawing of the curtains, the curling up in bed, the dash to the toilet to puke my guts out. I am not a religious person, but during my worst migraines, I have whimpered at the universe, my hands jammed into the side of my skull, and begged it for relief.

    That probably sounds melodramatic, but listen: Migraines are miserable. They’re miserable for about 40 million Americans, most of them women, though the precise symptoms and their severity vary across sufferers. For about a quarter, myself included, the onset is sometimes preceded by an aura, a short-lived phase that can include blind spots, tingling, numbness, and language problems. (These can resemble stroke symptoms, and you should seek immediate medical care if you experience them and don’t have a history of migraines.) Many experience a final phase known as the “migraine hangover,” which consists of fatigue, trouble concentrating, and dizziness after the worst pain has passed.

    These days, migraine sufferers are caught in a bit of a paradox. In some ways, their situation looks bright (but, please, not too bright): More treatments are available now than ever before—though still no cure—and researchers are learning more about what triggers a migraine, with occasionally surprising results. “It’s a really exciting time in headache medicine,” Mia Minen, a neurologist and the chief of headache research at NYU Langone, told me.

    And yet the enthusiasm within the medical community doesn’t seem to align with conditions on the ground (which, by the way, is a nice, cool place to press your cheek during an attack). Migraine sufferers cancel plans and feel guilty about it. They struggle to parent. They call in sick, and if they can’t, they move through the work day like zombies. In a 2019 survey, about 30 percent of participants with episodic migraines—attacks that occur on fewer than 15 days a month—said that the disorder had negatively affected their careers. About 58 percent with chronic migraines—attacks that occur more often than that—said the same.

    Migraines are still misunderstood, including by the people who deal with them. “We still don’t have a full understanding of exactly what causes migraine, and why some people suffer more than others do,” Elizabeth Loder, a headache clinician at Brigham and Women’s Hospital in Boston and a neurology professor at Harvard Medical School, told me. Despite scientific progress, awareness campaigns, and frequent reminders that migraines are a neurological disorder and not “just headaches,” too often, they’re not treated with the medical care they require. Yes, it’s the best time in history to have migraines. It just doesn’t feel that way.


    Humans have had migraines probably for as long as we’ve had brains. As the historian Katherine Foxhall argues in her 2019 book, Migraine: A History, “much evidence suggests migraine had been taken seriously in both medical and lay literature throughout the classical, medieval, and early modern periods as a serious disorder requiring prompt and sustained treatment.” It was only in the 18th century, when medical professionals lumped migraines in with other “nervous disorders” such as hysteria, that they “came to be seen as characteristic of sensitivity, femininity, overwork, and moral and personal failure.” The association persisted, Stephen Silberstein, the director of the headache center at Thomas Jefferson University, told me. When Silberstein began his training in the 1960s, “nobody talked about migraine in medical school,” he told me. Physicians still believed that migraines were “the disorder of neurotic women.”

    The first drug treatments for migraines appeared in the 1920s, and they were discovered somewhat by accident: Doctors found that ergotamine, a drug used to stimulate contractions in childbirth and control postpartum bleeding, also sometimes relieved migraines. (It could also cause pain, muscle weakness, and, in high enough doses, gangrene; some later studies have found that it’s little better than placebo.) The drug constricted blood vessels in the brain, so doctors assumed that migraine was a vascular disorder, the symptoms brought on by changes in blood flow and inflamed vessels. In the 1960s, a physician studying the effectiveness of a heart medication noticed that one of his participants experienced migraine attacks less frequently than he used to; a decade later, the FDA approved that class of drug, called beta-blockers, as a preventative treatment. (In the decades since their approval, studies have found that beta-blockers helped about a quarter of participants reduce their monthly migraine days by half, compared with 4 percent of people taking a placebo.)

    Things changed in the 1990s, when triptans, a new class of drugs made specifically for migraines, became available. Triptans were often more effective and faster at easing migraine pain than earlier drugs, though the effects didn’t last as long. Around the same time, genetic studies revealed that migraines are often hereditary. Meanwhile, new brain-imaging technology allowed researchers to observe migraines in real time. It showed that, although blood vessels could become inflamed during an attack and contribute to pain, migraine isn’t strictly a vascular disorder. The chaos comes from within the nervous system: Scientists’ best understanding is that the trigeminal nerve, which provides sensation in the face, becomes stimulated, which triggers cells in the brain to release neurotransmitters that produce headache pain. How exactly the nerve gets perturbed remains unclear.

    The past few years of migraine medicine have felt like the ’90s all over again. In 2018, the FDA approved a monthly injection that prevents migraines by regulating CGRP, a neurotransmitter that’s known to spike during attacks. For 40 percent of people with chronic migraines participating in one clinical trial, the treatment cut their monthly migraine days in half. Similar remedies followed; Lady Gaga, a longtime migraine sufferer, appeared in a commercial this summer to endorse Pfizer’s CGRP-blocking pill, and the company’s CEO launched a migraine-awareness campaign earlier this month. Solid evidence has emerged that cognitive behavioral therapy and relaxation techniques tailored to migraine can be helpful as part of a larger treatment plan. The FDA has cleared several wearable devices designed to curb migraines by delivering mild electric stimulation. Last year, the agency decided to speed up the development of a device that deploys gentle puffs of air into a user’s ears.

    Researchers are still, to this day, making progress on identifying migraine triggers. Experts agree on many common triggers, such as skipping meals, getting too little sleep, getting too much sleep, stress, the comedown from stress, and hormone changes linked to menstruation or menopause. They’re also realizing that some long-held beliefs about triggers might be entirely wrong. MSG, for example, probably doesn’t induce migraines; changes in air pressure don’t do so as often as many people who have migraines seem to think.

    Some supposed triggers might actually be signs of an oncoming migraine. The majority of migraine sufferers experience something called the premonitory phase, which can last for several hours or days before headache pain sets in and has its own set of symptoms, including food cravings. We migraine sufferers are frequently advised to steer clear of chocolate, but if you’re craving a Snickers bar, the migraine may already be coming whether or not you eat it. “When you get a headache, you blame it on the chocolate—even though the migraine made you eat the chocolate,” Silberstein said. “I always tell people, if they think they’re getting a migraine, eat a bar of chocolate … It’s more likely to do good than harm.”


    Silberstein’s advice sounded like absolute blasphemy to me. Virtually every migraine FAQ page in existence had led me to believe that chocolate is a ruthless trigger. Maybe I shouldn’t have been relying on general guidelines on the internet, even though they came from reputable medical institutions. But I had turned to the internet because I didn’t think my migraines necessitated a visit to a specialist. According to the American Migraine Foundation, the majority of people who have migraines never consult a doctor to receive proper diagnosis and treatment.

    Recent surveys have shown that people are reluctant to see a professional for a variety of reasons: They think their migraine isn’t bad enough, they worry that their symptoms won’t be taken seriously, or they can’t afford the care. The hot new preventative medications in particular “are extremely expensive, putting them out of reach of some of the people who might benefit the most,” Loder said. In 2018, when the much-heralded CGRP blocker hit the market, the journalist Libby Watson, a longtime migraine patient herself, interviewed migraine sufferers who described themselves as low-income, and found that most of them hadn’t heard of the new drug at all.

    Even if you can get them, the treatments don’t guarantee relief. One recent study showed that triptans might not relieve pain—or might not be tolerable—for up to 40 percent of migraine patients. Experts are still trying to figure out why the same treatment might work wonderfully for one person, and not at all for another, Minen said. Some patients find that drugs eventually stop working for them, or that they come with side effects bad enough to discourage continued use, such as dizziness and still more nausea.

    These problems remain unsolved in part because of a dearth of research. Like other conditions that mostly afflict women, migraines receive “much less funding in proportion to the burden they exert on the U.S. population,” Nature’s Kerri Smith reported in May. And many doctors are unaware of the research that exists: A 2021 study of non-migraine physicians found that 43 percent had “poor knowledge” of the condition’s symptoms and management, and just 21 percent were aware of targeted treatments. Specialists tend to have a much better knowledge base, but good luck seeing one: America has too few headache doctors, and there are significantly fewer of them in rural areas.

    Many migraine sufferers rely on over-the-counter pain relievers, myself included. Years ago, my primary-care physician prescribed me a triptan nasal spray. It produced a terrible aftertaste and worsened the throbbing in my head, and I gave up on it after only a couple of uses. Back to Excedrin I went, not realizing—until reporting this story—that nonprescription medications can cause even more attacks if you overuse them. Some people get by on home remedies that the journalist Katy Schneider, who battles migraines herself, has described as a “medicine cabinet of curiosities”; one person she interviewed shotguns an ice-cold Coke when she feels the symptoms coming on.

    When triptans and tricks fail, some people try to prevent migraines by avoiding triggers. Don’t stay up too late or sleep in. Don’t drink red wine. Put down that Snickers. This strategy of avoidance “interferes with the quality of their life in many cases,” Loder said, and probably doesn’t stop the attacks. And drawing associations is a futile exercise because most migraines are brought on by more than one trigger, Minen said. People can end up internalizing the 18th-century idea that migraines are a personal failure rather than a disease—and migraine FAQs perpetuate that myth by advising patients to live an ascetic life.

    The misconceptions surrounding migraine, combined with its invisibility, make the disorder easy to stigmatize. The authors of a 2021 review found that, compared with epilepsy, a neurological disorder with a physical manifestation, “people with chronic migraine are viewed as less trustworthy, less likely to try their hardest, and more likely to malinger.” Perhaps as a result, many feel pressure to grind through it. Migraines are estimated to account for 16 percent of presenteeism—being on the job but not operating at full capacity—in the American workforce.

    Before reporting this story, I had never thought to call my migraines a neurological disorder, let alone a “debilitating” one, as Minen and other experts do. Migraines were just this thing that I’ve lived with for more than a decade, and had accepted as an unfortunate part of my existence. Just my Excedrin and me, together forever, barreling through the wasted days. The attacks began in my late teens, around the same time that my childhood epilepsy mysteriously vanished. I never got an explanation for my seizures, despite years of daily medication and countless EEGs. A neurologist once told me that the two might be related, but he couldn’t say for sure; research has shown that people who have epilepsy are more likely to experience migraines. And so I assumed that I just had a slightly broken brain, prone to electrochemical misfiring.

    All of the experts I spoke with were politely horrified when I told them about my migraines and how I manage them. I promised them that I’d make an appointment with a specialist. Before we got off the phone, Silberstein gave me a tip. “Put a cold pack on your neck and then a heating pad, 15 minutes alternating,” he said. “It’ll take the migraine away.” He told me that researchers are developing a device that does this, but the old-fashioned way can be effective too. At this point, my cabinet of curiosities is falling apart, its hinges squeaking from overuse. I’m already rethinking my entire migraine life, so I may as well try this too.

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    Marina Koren

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  • Long COVID Is Being Erased—Again

    Long COVID Is Being Erased—Again

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    Updated at 6:29 p.m. ET on April 21, 2023

    Charlie McCone has been struggling with the symptoms of long COVID since he was first infected, in March 2020. Most of the time, he is stuck on his couch or in his bed, unable to stand for more than 10 minutes without fatigue, shortness of breath, and other symptoms flaring up. But when I spoke with him on the phone, he seemed cogent and lively. “I can appear completely fine for two hours a day,” he said. No one sees him in the other 22.  He can leave the house to go to medical appointments, but normally struggles to walk around the block. He can work at his computer for an hour a day. “It’s hell, but I have no choice,” he said. Like many long-haulers, McCone is duct-taping himself together to live a life—and few see the tape.

    McCone knows 12 people in his pre-pandemic circles who now also have long COVID, most of whom confided in him only because “I’ve posted about this for three years, multiple times a week, on Instagram, and they’ve seen me as a resource,” he said. Some are unwilling to go public, because they fear the stigma and disbelief that have dogged long COVID. “People see very little benefit in talking about this condition publicly,” he told me. “They’ll try to hide it for as long as possible.”

    I’ve heard similar sentiments from many of the dozens of long-haulers I’ve talked with, and the hundreds more I’ve heard from, since first reporting on long COVID in June 2020. Almost every aspect of long COVID serves to mask its reality from public view. Its bewilderingly diverse symptoms are hard to see and measure. At its worst, it can leave people bed- or housebound, disconnected from the world. And although milder cases allow patients to appear normal on some days, they extract their price later, in private. For these reasons, many people don’t realize just how sick millions of Americans are—and the invisibility created by long COVID’s symptoms is being quickly compounded by our attitude toward them.

    Most Americans simply aren’t thinking about COVID with the same acuity they once did; the White House long ago zeroed in on hospitalizations and deaths as the measures to worry most about. And what was once outright denial of long COVID’s existence has morphed into something subtler: a creeping conviction, seeded by academics and journalists and now common on social media, that long COVID is less common and severe than it has been portrayed—a tragedy for a small group of very sick people, but not a cause for societal concern. This line of thinking points to the absence of disability claims, the inconsistency of biochemical signatures, and the relatively small proportion of severe cases as evidence that long COVID has been overblown. “There’s a shift from ‘Is it real?’ to ‘It is real, but …,’” Lekshmi Santhosh, the medical director of a long-COVID clinic at UC San Francisco, told me.

    Yet long COVID is a substantial and ongoing crisis—one that affects millions of people. However inconvenient that fact might be to the current “mission accomplished” rhetoric, the accumulated evidence, alongside the experience of long haulers, makes it clear that the coronavirus is still exacting a heavy societal toll.


    As it stands, 11 percent of adults who’ve had COVID are currently experiencing symptoms that have lasted for at least three months, according to data collected by the Census Bureau and the CDC through the national Household Pulse Survey. That equates to more than 15 million long-haulers, or 6 percent of the U.S. adult population. And yet, “I run into people daily who say, ‘I don’t know anyone with long COVID,’” says Priya Duggal, an epidemiologist and a co-lead of the Johns Hopkins COVID Long Study. The implication is that the large survey numbers cannot be correct; given how many people have had COVID, we’d surely know if one in 10 of our contacts was persistently unwell.

    But many factors make that unlikely. Information about COVID’s acute symptoms was plastered across our public spaces, but there was never an equivalent emphasis that even mild infections can lead to lasting and mercurial symptoms; as such, some people who have long COVID don’t even know what they have. This may be especially true for the low-income, rural, and minority groups that have borne the greatest risks of infection. Lisa McCorkell, a long-hauler who is part of the Patient-Led Research Collaborative, recently attended a virtual meeting of Bay Area community leaders, and “when I described what it is, some people in the chat said, ‘I just realized I might have it.’”

    Admitting that you could have a life-altering and long-lasting condition, even to yourself, involves a seismic shift in identity, which some people are understandably loath to make. “Everyone I know got Omicron and got over it, so I really didn’t want to concede that I didn’t survive this successfully,” Jennifer Senior, a friend and fellow staff writer at The Atlantic, who has written about her experience with long COVID, told me. Duggal mentioned an acquaintance who, after a COVID reinfection, can no longer walk the quarter mile to pick her kids up from school, or cook them dinner. But she has turned down Duggal’s offer of an appointment; instead, she is moving across the country for a fresh start. “That is common: I won’t call it ‘long COVID’; I’ll just change everything in my life,” Duggal told me. People who accept the condition privately may still be silent about it publicly. “Disability is often a secret we keep,” Laura Mauldin, a sociologist who studies disability, told me. One in four Americans has a disability; one in 10 has diabetes; two in five have at least two chronic diseases. In a society where health issues are treated with intense privacy, these prevalence statistics, like the one-in-10 figure for long COVID, might also intuitively feel like overestimates.

    Some long-haulers are scared to disclose their condition. They might feel ashamed for still being sick, or wary about hearing from yet another loved one or medical professional that there’s nothing wrong with them. Many long-haulers worry that they’ll be perceived as weak or needy, that their friends will stop seeing them, or that employers will treat them unfairly. Such fears are well founded: A British survey of almost 1,000 long-haulers found that 63 percent experienced overt discrimination because of their illness at least “sometimes,” and 34 percent sometimes regretted telling people that they have long COVID. “So many people in my life have reached out and said, ‘I’m experiencing this,’ but they’re not telling the rest of our friends,” McCorkell said.

    Imagine that you interact with 50 people on a regular basis, all of whom got COVID. If 10 percent are long-haulers, that’s five people who are persistently sick. Some might not know what long COVID is or might be unwilling to confront it. The others might have every reason to hide their story. “Numbers like 10 percent are not going to naturally present themselves in front of you,” McCone told me. Instead, “you’ll hear from 45 people that they are completely fine.”

    Illustration by Paul Spella / The Atlantic; Getty

    The same factors that stop people from being public about their condition—ignorance, denial, or concerns about stigma—also make them less likely to file for disability benefits. And that process is, to put it mildly, not easy. Applicants need thorough medical documentation; many long-haulers struggle to find doctors who believe their symptoms are real. Even with the right documents, applicants must hack their way through bureaucratic overgrowth, likely while fighting fatigue or brain fog. For these reasons, attempting to measure long COVID through disability claims is a profoundly flawed exercise. Even if people manage to apply, they face an average wait time of seven months and a two-in-three denial rate. McCone took six weeks to put an application together, and, despite having a lawyer and extensive medical documentation, was denied after one day. McCorkell knows many first-wavers—people who’ve had long COVID since March 2020—“who are just getting their approvals now.”

    An alternative source of data comes from the Census Bureau’s Current Population Survey, which simply asks working-age Americans if they have any of six forms of disability. Using that data, Richard Deitz, an economics-research adviser at the Federal Reserve Bank of New York, calculated that about 1.7 million more people now say they do than in mid-2020, reversing a years-long decline. These numbers are lower than expected if one in 10 people who gets COVID really does become a long-hauler, but the survey doesn’t directly capture many of the condition’s most common symptoms, such as fatigue, neurological problems beyond brain fog, and post-exertional malaise, where a patient’s symptoms get dramatically worse after physical or mental exertion. About 900,000 of the newly disabled people are also still working. David Putrino, who leads a long-COVID rehabilitation clinic at Mount Sinai, told me that many of his patients are refused the accommodations required under the Americans With Disabilities Act. Their employers won’t allow them to work remotely or reduce their hours, because, he said, “you look at them and don’t see an obvious disability.”


    Long COVID can also seem bafflingly invisible when people look at it with the wrong tools. For example, a 2022 study by National Institutes of Health researchers compared 104 long-haulers with 85 short-term COVID patients and 120 healthy people and found no differences in measures of heart or lung capacities, cognitive tests, or levels of common biomarkers—bloodstream chemicals that might indicate health problems. This study has been repeatedly used as evidence that long COVID might be fictitious or psychosomatic, but in an accompanying editorial, Aluko Hope, the medical director of Oregon Health and Science University’s long-COVID program, noted that the study exactly mirrors what long-haulers commonly experience: They undergo extensive testing that turns up little and are told, “Everything is normal and nothing is wrong.”

    The better explanation, Putrino told me, is that “cookie-cutter testing” doesn’t work—a problem that long COVID shares with other neglected complex illnesses, such as myalgic encephalomyelitis/chronic-fatigue syndrome and dysautonomia. For example, the NIH study didn’t consider post-exertional malaise, a cardinal symptom of both ME/CFS and long COVID; measuring it requires performing cardiopulmonary tests on two successive days. Most long-haulers also show spiking heart rates when asked to simply stand against a wall for 10 minutes—a sign of problems with their autonomic nervous system. “These things are there if you know where to look,” Putrino told me. “You need to listen to your patients, hear where the virus is affecting them, and test accordingly.”

    Contrary to popular belief, researchers have learned a huge amount about the biochemical basis of long COVID, and have identified several potential biomarkers for the disease. But because long COVID is likely a cluster of overlapping conditions, there might never be a singular blood test that “will tell you if you have long COVID 100 percent of the time,” Putrino said. The best way to grasp the scale of the condition, then, is still to ask people about their symptoms.

    Large attempts to do this have been relatively consistent in their findings: The U.S. Household Pulse Survey estimates that one in 10 people who’ve had COVID currently have long COVID; a large Dutch study put that figure at one in eight. The former study also estimated that 6 percent of American adults are long-haulers; a similar British survey by the Office for National Statistics estimated that 3 percent of the general population is. These cases vary widely in severity, and about one in five long-haulers is barely affected by their symptoms—but the remaining majority very much is. Another one in four long-haulers (or 4 million Americans) has symptoms that severely limit their daily activities. The others might, at best, wake every day feeling as if they haven’t had any rest, or feel trapped in an endless hangover. They might work or socialize when their tidal symptoms ebb, but only by making big compromises: “If I work a full day, I can’t also then make dinner or parent without significant suffering,” JD Davids, who has both long COVID and ME/CFS, told me.

    Some people do recover. A widely cited Israeli study of 1.9 million people used electronic medical records to show that most lingering COVID symptoms “are resolved within a year from diagnosis,” but such data fail to capture the many long-haulers who give up on the medical system precisely because they aren’t getting better or are done with being disbelieved. Other studies that track groups of long-haulers over time have found less rosy results. A French one found that 85 percent of people who had symptoms two months after their infection were still symptomatic after a year. A Scottish team found that 42 percent of its patients had only partially recovered at 18 months, and 6 percent had not recovered at all. The United Kingdom’s national survey shows that 69 percent of people with long COVID have been dealing with symptoms for at least a year, and 41 percent for at least two.

    The most recent data from the U.S. and the U.K. show that the total number of long-haulers has decreased over the past six months, which certainly suggests that people recover in appreciable numbers. But there’s a catch: In the U.K., the number of people who have been sick for more than a year, or who are severely limited by their illness, has gone up. A persistent pool of people is still being pummeled by symptoms—and new long-haulers are still joining the pool. This influx should be slower than ever, because Omicron variants seem to carry a lower risk of triggering long COVID, while vaccines and the drug Paxlovid can lower that risk even further. But though the odds against getting long COVID are now better, more people are taking a gamble, because preventive precautions have been all but abandoned.

    Even if prevalence estimates were a tenth as big, that would still mean more than 1 million Americans are dealing with a chronic illness that they didn’t have three years ago. “When long COVID first came on the scene, everyone told us that once we have the prevalence numbers, we can do something about it,” McCorkell told me. “We got those numbers. Now people say, ‘Well, we don’t believe them. Try again.’”


    To a degree, I sympathize with some of the skepticism regarding long COVID, because the condition challenges our typical sense of what counts as solid evidence. Blood tests, electronic medical records, and disability claims all feel like rigorous lines of objective data. Their limitations become obvious only when you consider what the average long-hauler goes through—and those details are often cast aside because they are “anecdotal” and, by implication, unreliable. This attitude is backwards: The patients’ stories are the ground truth against which all other data must be understood. Gaps between the data and the stories don’t immediately invalidate the latter; they just as likely show the holes in the former.

    Laura Mauldin, the disability sociologist, argues that the U.S. is primed to discount those experiences because the country’s values—exceptionalism, strength, self-reliance—have created what she calls the myth of the able-bodied public. “We cannot accept that our bodies are fallible, or that disability is utterly ordinary and expected,” she told me. “We go to great pains to pretend as though that is not the case.” If we believe that a disabling illness like long COVID is rare or mild, “we protect ourselves from having to look at it.” And looking away is that much easier because chronic illnesses like long COVID are more likely to affect women—“who are more likely to have their symptoms attributed to psychological problems,” Mauldin said—and because the American emphasis on work ethic devalues people who can’t work as much or as hard as their peers.

    Other aspects of long COVID make it hard to grasp. Like other similar, neglected chronic illnesses, it defies a simplistic model of infectious disease in which a pathogen causes a predictable set of easily defined symptoms that alleviate when the bug is destroyed. It challenges our belief in our institutions, because truly contending with what long-haulers go through means acknowledging how poorly the health-care system treats chronically ill patients, how inaccessible social support is to them, and how many callous indignities they suffer at the hands of even those closest to them. Long COVID is a mirror on our society, and the image it reflects is deeply unflattering.

    Most of all, long COVID is a huge impediment to the normalization of COVID. It’s an insistent indicator that the pandemic is not actually over; that policies allowing the coronavirus to spread freely still carry a cost; that improvements such as better indoor ventilation are still wanting; that the public emergency may have been lifted but an emergency still exists; and that millions cannot return to pre-pandemic life. “Everyone wants to say goodbye to COVID,” Duggal told me, “and if long COVID keeps existing and people keep talking about it, COVID doesn’t go away.” The people who still live with COVID are being ignored so that everyone else can live with ignoring it.


    This article originally misstated the name of the bank where Richard Deitz works.

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    Ed Yong

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  • Why Congress Doesn’t Work

    Why Congress Doesn’t Work

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    Control of the House of Representatives could teeter precariously for years as each party consolidates its dominance over mirror-image demographic strongholds.

    That’s the clearest conclusion of a new analysis of the demographic and economic characteristics of all 435 congressional districts, conducted by the Equity Research Institute at the University of Southern California in conjunction with The Atlantic.

    Based on census data, the analysis finds that Democrats now hold a commanding edge over the GOP in seats where the share of residents who are nonwhite, the share of white adults with a college degree, or both, are higher than the level in the nation overall. But Republicans hold a lopsided lead in the districts where the share of racial minorities and whites with at least a four-year college degree are both lower than the national level—and that is the largest single bloc of districts in the House.

    This demographic divide has produced a near-partisan stalemate, with Republicans in the new Congress holding the same narrow 222-seat majority that Democrats had in the last one. Both sides will struggle to build a much bigger majority without demonstrating more capacity to win seats whose demographic and economic profile has mostly favored the other. “The coalitions are quite stretched to their limits, so there is just not a lot of space for expansion,” says Lee Drutman, a senior fellow in the political-reform program at New America.

    The widening chasm between the characteristics of the districts held by each party has left the House not only closely divided, but also deeply divided.

    Through the late 20th and early 21st centuries, substantial overlap remained between the kinds of districts each party held. In those years, large numbers of Democrats still represented mostly white, low-income rural and small-town districts with few college graduates, and a cohort of Republicans held well-educated, affluent suburban districts. That overlap didn’t prevent the House from growing more partisan and confrontational, but it did temper that trend, because the small-town “blue dog” Democrats and suburban “gypsy moth” Republicans were often the members open to working across party lines.

    Now the parties represent districts more consistently divided along lines of demography, economic status, and geography, which makes finding common ground difficult. The parties’ intensifying separation “is a recipe for polarization,” Manuel Pastor, a sociology professor at USC and the director of the Equity Research Institute, told me.

    To understand the social and economic characteristics of the House seats held by each party, Jeffer Giang and Justin Scoggins of the Equity Research Institute analyzed five-year summary results through 2020 from the Census Bureau’s American Community Survey.

    The analysis revealed that along every key economic and demographic dimension, the two parties are now sorted to the extreme in the House districts they represent. “These people are coming to Washington not from different districts, but frankly different planets,” says former Representative Steve Israel, who chaired the Democratic Congressional Campaign Committee.

    Among the key distinctions:

    *More than three-fifths of House Democrats hold districts where the share of the nonwhite population exceeds the national level of 40 percent. Four-fifths of House Republicans hold districts in which the minority share of the population is below the national level.

    *Nearly three-fourths of House Democrats represent districts where the share of white adults with a college degree exceeds the national level of 36 percent. More than three-fourths of Republicans hold districts where the share of white college graduates trails the national level.

    *Just over three-fifths of House Democrats hold districts where the share of immigrants exceeds the national level of 14 percent; well over four-fifths of House Republicans hold districts with fewer immigrants than average.

    *Perhaps most strikingly, three-fifths of Democrats now hold districts where the median income exceeds the national level of nearly $65,000; more than two-thirds of Republicans hold districts where the median income falls beneath the national level.

    Sorting congressional districts by racial diversity and education produces the “four quadrants of Congress”: districts with high levels of racial diversity and white education (“hi-hi” districts), districts with high levels of racial diversity and low levels of white education (“hi-lo districts”), districts with low levels of diversity and high levels of white education (“lo-hi districts”), and districts with low levels of diversity and white education (“lo-lo districts”). (The analysis focuses on the education level among whites, and not the entire population, because education is a more significant difference in the political behavior of white voters than of minority groups.)

    Looking at the House through that lens shows that the GOP has become enormously dependent on one type of seat: the “lo-lo” districts revolving around white voters without a college degree. Republicans hold 142 districts in that category (making up nearly two-thirds of the party’s House seats), compared with just 21 for Democrats.

    The intense Republican reliance on this single type of mostly white, blue-collar district helps explain why the energy in the party over recent years has shifted from the small-government arguments that drove the GOP in the Reagan era toward the unremitting culture-war focus pursued by Donald Trump and Florida Governor Ron DeSantis. Many of the most militantly conservative House Republicans represent these “lo-lo” districts—a list that includes Marjorie Taylor Greene of Georgia, Lauren Boebert of Colorado, Matt Gaetz of Florida, Ralph Norman of South Carolina, and Scott Perry of Pennsylvania.

    “The right accuses the left of identity politics, when the analysis of this data suggests that identity politics has become the core of the Republican Party,” Pastor told me.

    House Democrats are not nearly as reliant on seats from any one of the four quadrants. Apart from the lo-lo districts, they lead the GOP in the other three groupings. Democrats hold a narrow 37–30 lead over Republicans in the seats with high levels of diversity and few white college graduates (the “hi-lo” districts). These seats include many prominent Democrats representing predominantly minority areas, including Jim Clyburn of South Carolina, Terri Sewell of Alabama, and Ruben Gallego of Arizona. At the same time, these districts have been a source of growth for Republicans: The current Democratic lead of seven seats is way down from the party’s 28-seat advantage in 2009.

    Democrats hold a more comfortable 57–35 edge in the “lo-hi” districts with fewer minorities and a higher share of white adults with college degrees than average. These are the mostly white-collar districts represented by leading suburban Democrats, many of them moderates, such as Angie Craig of Minnesota, Seth Moulton of Massachusetts, Sharice Davids of Kansas, and Mikie Sherrill of New Jersey. A large share of the House Republicans considered more moderate also represent districts in this bloc.

    The core of Democratic strength in the House is the “hi-hi” districts that combine elevated levels of both racial minorities and college-educated whites. Democrats hold 98 of the 113 House seats in this category. Many of the party’s most visible members represent seats fitting this description, including former Speaker Nancy Pelosi; the current House Democratic leader, Hakeem Jeffries; former House Intelligence Committee chair Adam Schiff; and Alexandria Ocasio-Cortez. These are also the strongholds for Democrats representing what Pastor calls the places where “diversity is increasing the most”: inner suburbs in major metropolitan areas. Among the members representing those sorts of constituencies are Lucy McBath of Georgia, Abigail Spanberger of Virginia, and Ro Khanna and Zoe Lofgren of California.

    Though Democrats are not as dependent on any single quadrant as Republicans are on the low-diversity, low-education districts, each party over the past decade has been forced to retreat into its demographic citadel. As Drutman notes, that’s the result of a succession of wave elections that has culled many of the members from each side who had earlier survived in districts demographically and economically trending toward the other.

    The first victims were the so-called blue-dog Democrats, who had held on to “lo-lo” districts long after they flipped to mostly backing Republican presidential candidates. Those Democrats from rural and small-town areas, many of them in the South, had started declining in the ’90s. Still, as late as 2009, during the first Congress of Barack Obama’s presidency, Republicans held only 20 more seats than Democrats did in the “lo-lo” quadrant. Democrats from those districts composed almost as large a share of the total party caucus in that Congress as did members from the “hi-hi” districts.

    But the 2010 Tea Party landslide virtually exterminated the blue dogs. After that election, the GOP edge in the lo-lo districts exploded to 90 seats; it reached 125 seats after redistricting and further GOP gains in the 2014 election. Today the districts low in diversity and white-education levels account for just one in 10 of all House Democratic seats, and the “hi-hi” seats make up nearly half. The seats low in diversity and high in white education (about one-fourth) and those high in diversity and low in white education (about one-sixth), provide the remainder.

    For House Republicans, losses in the 2018 midterms represented the demographic bookend to their blue-collar, small-town gains in 2010. In 2018, Democrats, powered by white-collar antipathy toward Trump, swept away a long list of House Republicans who had held on to well-educated suburban districts that had been trending away from the GOP at the presidential level since Bill Clinton’s era.

    Today, districts with a higher share of white college graduates than the nation overall account for less than one-fourth of all GOP seats, down from one-third in 2009. The heavily blue-collar “lo-lo” districts have grown from just over half of the GOP conference in 2009 to their current level of nearly two-thirds. (The share of Republicans in seats with more minorities and fewer white college graduates than average has remained constant since 2009, at about one in seven.)

    Each party is pushing an economic agenda that collides with the immediate economic interests of a large portion of its voters. “The party leadership has not caught up with the coalitions,” says former Representative Tom Davis, who served as chair of the National Republican Congressional Committee.

    For years, some progressives have feared that Democrats would back away from a populist economic agenda if the party grew more reliant on affluent voters. That shift has certainly occurred, with Democrats now holding 128 of the 198 House districts where the median income exceeds the national level. But the party has continued to advocate for a redistributionist economic agenda that seeks higher taxes on upper-income adults to fund expanded social programs for working-class families, as proposed in President Joe Biden’s latest budget. The one concession to the new coalition reality is that Democrats now seek to exempt from higher taxes families earning up to $400,000—a level that earlier generations of Democrats probably would have considered much too high.

    Republicans face more dissonance between their reconfigured coalition and their agenda. Though the GOP holds 152 of the 237 districts where the median income trails the national level, the party continues to champion big cuts in domestic social programs that benefit low-income families while pushing tax cuts that mostly flow toward the wealthy and corporations. As former Democratic Representative David Price, now a visiting fellow at Duke University’s Sanford School of Public Policy, says, there “is a pretty profound disconnect” between the GOP’s economic agenda and “the economic deprivation and what you would think would be a pretty clear set of needs” of the districts the party represents.

    Each of these seeming contradictions underscores how cultural affinity has displaced economic interest as the most powerful glue binding each side’s coalition. Republicans like Davis lament that their party can no longer win culturally liberal suburban voters by warning that Democrats will raise their taxes; Democrats like Price express frustration that their party can’t win culturally conservative rural voters by portraying Republicans as threats to Social Security and Medicare.

    The advantage for Republicans in this new alignment is that there are still many more seats where whites exceed their share of the national population than seats with more minorities than average. Likewise, the number of seats with fewer white college graduates than the nation overall exceeds the number with more.

    That probably gives Republicans a slight advantage in the struggle for House control over the next few years. Of the 22 House seats that the nonpartisan Cook Political Report currently rates as toss-ups or leaning toward the other party in 2024, for instance, 14 have fewer minorities than average and 12 have fewer white college graduates. “On the wedge issues, a lot of the swing districts look a little bit more like Republican districts than Democratic districts,” says Drutman, whose own recent analysis of House districts used an academic polling project to assess attitudes in all 435 seats.

    But as Pastor points out, Republicans are growing more dependent on those heavily white and non-college-educated districts as society overall is growing more diverse and better educated, especially in younger generations. “It’s hard to see how the Republicans can grow their coalition,” Pastor told me, with the militant culture-war messages they are using “to cement their current coalition.”

    Davis, the former NRCC chair, also worries that the GOP is relying too much on squeezing bigger margins from shrinking groups. The way out of that trap, he argues, is for Republicans to continue advancing from the beachheads they have established in recent years among more culturally conservative voters of color, especially Latino men.

    But Republicans may struggle to make sufficient gains with those voters to significantly shift the balance of power in the House: Though the party last year improved among Latinos in Florida, the results in Arizona, Nevada, and even Texas showed the GOP still facing substantial barriers. The Trump-era GOP also continues to face towering resistance in well-educated areas, which limits any potential recovery there: In 2020, Biden, stunningly, carried more than four-fifths of the House districts where the share of college-educated white adults exceeds the national level. Conversely, despite Biden’s emphasis on delivering tangible economic benefits to working families, Democrats still faced enormous deficits with blue-collar white voters in the midterms. With many of its most vulnerable members defending such working-class terrain, Democrats could lose even more of those seats in 2024.

    Constrained by these offsetting dynamics, neither party appears well positioned to break into a clear lead in the House. The two sides look more likely to remain trapped in a grinding form of electoral trench warfare in which they control competing bands of districts that are almost equal in number, but utterly antithetical in their demographic, economic, and ideological profile.

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    Ronald Brownstein

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  • The Age of Vaccine Pessimism

    The Age of Vaccine Pessimism

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    The world has just seen the largest vaccination campaign in history. At least 13 billion COVID shots have been administered—more injections, by a sweeping margin, than there are human beings on the Earth. In the U.S. alone, millions of lives have been saved by a rollout of extraordinary scope. More than three-fifths of the population elected to receive the medicine even before it got its full approval from the FDA.

    Yet the legacy of this achievement appears to be in doubt. Just look at where the country is right now. In Florida, the governor—a likely Republican presidential candidate—openly pursues the politics of vaccine resistance and denial. In Ohio, kids are getting measles. In New York, polio is back. A football player nearly died on national TV, and fears about vaccines fanned across the internet. Vaccinologists, pediatricians, and public-health experts routinely warn that confidence is wavering for every kind of immunization, and worry that it may collapse in years to come.

    In other words, America is mired in a paradoxical and pessimistic moment. “We’ve just had a national vaccination campaign that has exceeded almost all previous efforts in a dramatic fashion,” says Noel Brewer, a psychologist at the University of North Carolina who has been studying decision making about vaccines for more than 20 years, “and people are talking about vaccination as if there’s something fundamentally wrong.”

    It’s more than talk. Americans are arguing, Americans are worrying, Americans are obsessing over vaccines; and that fixation has produced its own, pathological anxiety. To fret about the state of public trust is rational: When vaccine adherence wobbles, lives are put in peril; in the midst of a pandemic, the mortal risk is even greater. More than 60 million Americans haven’t gotten a single COVID shot, and a few thousand deaths are attributed to the disease every week. But the scale of this concern—the measure of our instability—may be distorted by the heights to which we’ve climbed. Evidence that the nation has arrived at the brink of collapse does not hold up to scrutiny. No one knows where vaccination rates are really heading, and the coming crash is more an idea—a projection, even—than a certainty. The future of vaccination in America may be no worse than its recent past. In the end, it might be better.

    The first alarms about a widespread vaccination crisis—the first suggestions that a leeriness of COVID shots had “spread its tentacles into other diseases”—were raised by clinicians. Megha Shah, a pediatrician with the Los Angeles public-health department, told me that she began to worry in the spring of 2021, while volunteering at a medical center. Two years earlier, she recalled, working there had been uneventful. She’d meet with parents—mostly from low-income Latino families—to discuss the standard vaccination schedule: Okay, here’s what we’re recommending for your child. This protects against this; that protects against that. The parents would ask a couple of questions, and she’d answer them. The child would be immunized, almost every time.

    But in the middle of the COVID-vaccine rollout, she found that those conversations were playing out differently. “Oh, I’m just not sure,” she said some parents told her. Or, “I need to talk this over with my partner.” She saw families refuse, flat-out, to give their infants routine shots. “It just was very, very surprising,” Shah said. “I mean, questions are good. We want parents to be engaged and informed decision makers.” But it seemed to her—and her colleagues too—that healthy “engagement” had gone sour.

    Last year, she and her colleagues took a closer look. For a study published in Pediatrics, they drew on national survey data collected from April 2020 through early 2022, of parents’ attitudes toward standard childhood vaccines. In some respects, the results looked good: Parents endorsed the importance and effectiveness of these vaccines at a high and stable rate throughout the pandemic—in the vicinity of 91 percent. But over the same period, concerns about potential harms marched upward. In April 2020, about 25 percent of those surveyed agreed that vaccines “have many known harmful side effects” and “may lead to illness or death”; by the end of the year, that number had increased to 30 percent, and then to nearly 35 percent the following June. “Parents still seemed very confident overall in the benefits of vaccinations,” Shah told me, “but there was a huge jump over the course of the pandemic about the safety.”

    Those results jibed with a theory that has now been invoked so many times, it reads as common knowledge: “Perhaps this was a spillover effect,” Shah said, “from all of the vaccine misinformation that was circling during the pandemic.” That effect—the spreading tentacles of doubt—can be seen around the world, says Heidi Larson, a professor at the London School of Hygiene & Tropical Medicine who has studied attitudes toward vaccination across Europe since the start of the coronavirus pandemic. “The public-health community was assuming that COVID would be a great boon to public confidence in vaccines, but it hasn’t worked out that way. The trend has been actually a negative knock-on effect,” Larson told me. In a troubling alignment, even anti-vaccine activists now endorse the notion of hesitancy spillover, calling it a “wonderful silver lining” to the pandemic.

    But hold on a minute. Here in the U.S., it’s certainly true that vaccine worries have been broadcast and rebroadcast, at ever greater volumes, through a clamorous network of influencers and politicians. This campaign of hesitancy is growing more open and insistent by the day, and the consequences can be atrocious: Americans with false beliefs about vaccines are falling sick and dying stubborn and alone. But even as these anecdotes accrue, misinformation’s greater sway—the extent to which it shapes Americans’ behavior toward vaccines for COVID, measles, or the flu—remains murky, if not altogether undetectable. The best numbers to go on in this country, drawn from polls of people’s attitudes about vaccines and official vaccination surveys from the CDC, don’t hint at any comprehensive change. When concerning blips and mini-trends arise—shifts in parents’ attitudes, as seen in Shah’s research, or drops in local rates of children getting immunized—they’re set against a landscape with a flat horizon.

    It’s not a pretty view, for that: The U.S. lags five points behind the average wealthy country in its rate of people fully vaccinated against COVID, and two points behind in its vaccination rate for measles. And even blips can translate into many thousands of at-risk kids, Shah pointed out. Yet one might still be grateful for the sameness overall. A seedbed of resistance to the COVID shots, disproportionately Republican, was already present near the start of the pandemic, and hasn’t seemed to thrive despite two years’ worth of fertilizer runoff from Fox News and other outlets spewing doubt. In August 2020, the Harris Poll’s weekly COVID-19 tracker found that 15 percent of American adults said they were “not at all likely” to get the vaccine when it finally became available. In August 2022, Harris reported that 17 percent weren’t planning to be immunized. Other long-running surveys have found similar results. In September 2020, Kaiser Family Foundation’s vaccine monitor pegged the rate of refusal at 20 percent. In December 2022, it was … still 20 percent.

    The most recent uptake numbers from the CDC suggest that children born in 2018 and 2019 (who would have been babies or toddlers when COVID first appeared) had higher vaccination rates by age 2 than children born in 2016 and 2017. Some of these kids did miss out on shots amid the pandemic’s early lapses in routine medical care, but they quickly caught up. Another, more alarming batch of data from the CDC shows that measles-mumps-rubella coverage among the nation’s kindergartners has dropped for two years in a row, down from 95.2 to 93.5 percent, and is now lower than it’s been since at least 2013. Still, the proportion of kids who get exempted from school vaccine requirements for medical or philosophical reasons has hardly changed at all, and the headline-grabbing “slide” in rates appears instead to be at least in part a product of “provisional enrollments”—i.e., children who missed some vaccinations (perhaps in early 2020) and were allowed to enter school while they caught up. If there really is a wave of newly red-pilled, anti-vaxxer parents, then going by these data, they’re nowhere to be seen.

    Some public-health disasters hit like hurricanes; others spread like rust. “We may not have a full picture yet,” Shah told me, referring to the latest evidence from the CDC on where vaccination rates are heading. “My gut and my clinical experience tell me that it’s too soon to say.”

    Other experts share that view. Robert Bednarczyk, an epidemiologist at Emory University, has been estimating the susceptibility of U.S. children to measles outbreaks since 2016. National immunization surveys have not shown substantial drops in coverage for 2020 and 2021, he told me, “but there is a large caveat to this. These surveys have a lag time.” Any children from the CDC’s data set who were born in 2018, he noted, would have gotten most of their vaccines before the pandemic started, during their first year of life. The same problem applies to teens. The government’s latest stats for adolescents—which looked as good as ever in 2021—capture many who would have gotten all their shots pre-COVID. Until more data are released, researchers still won’t know whether or how far kids’ vaccination rates have really dipped during the 2020s.

    The time delay is just one potential problem. Parents who are suspicious of vaccines, and angry at the government for encouraging their use, may be less willing to participate in CDC surveys, Daniel Salmon, the director of the Institute for Vaccine Safety at Johns Hopkins Bloomberg School of Public Health, told me. “Having studied this for 25 years, I would be surprised if we don’t see a substantial COVID effect on childhood vaccines,” he said. “These data are a little bit reassuring, that it’s not, like, an oh-my-god huge effect. But we need more time and more data to really know the answer.”

    Uncertainty doesn’t have to be a source of terror, though. Early uptake data already provide some signs of a “vaccine-hesitancy spillover effect” happening in reverse, UNC’s Brewer told me, driving more enthusiasm, not less, for getting different kinds of shots. Just look at how the push to dose the nation with half a billion COVID shots goosed the rates of grown-ups getting flu shots: For decades now, our public-health establishment has pushed for better influenza coverage, even as the rate for older Americans was stuck at roughly 65 percent. Then COVID came along and, voilà, senior citizens’ flu-shot coverage jumped to 75 percent—higher than it ever was before. This all fits with a familiar idea in the field, Brewer said, that going in for any one vaccine makes you much more likely to get another in the future. “There does seem to be a sort of positive spillover,” he said, “probably because the forces that led to previous vaccinations are still mostly in place.”

    Even some of the scariest signals we’ve seen so far—reports that anti-vaccine sentiment is clearly on the rise—can seem ambiguous, depending on one’s breadth of view. Consider the finding from Heidi Larson’s group, that vaccine confidence has declined across the whole of the European Union throughout the pandemic, according to surveys taken in 2020 and 2022. The same report says that attitudes have now returned to where they were in 2018 and that confidence in the MMR vaccine, in particular, remains higher than it was four years ago. Given that the 2020 surveys were conducted mostly in March, at the very onset of the first pandemic lockdowns, they might have captured a temporary spike of interest in vaccines. After all, vaccines can seem more useful when you’re terrified of death.

    In other words, America may truly have experienced a recent drop in vaccine confidence—but from an inflated and unsustainable high. That could help explain other recent findings too, including Shah’s. “You need to take the long view,” says Douglas Opel, a pediatric bioethicist at Seattle Children’s Hospital who has been studying the ups and downs of vaccine hesitancy for more than a decade. For a paper published last July, he and colleagues looked at vaccine attitudes among 4,562 parents from late 2019 to the end of 2020. They found that the parents grew more enthusiastic about childhood immunizations when the pandemic started, but their feelings later returned to baseline.

    Larson told me that a “transient COVID effect” may well explain some of what her team has found, but said it was very unlikely to account in full for the worrying trend. In any case, she told me, “we shouldn’t assume this and should instead make an extra effort to continue to build confidence.”

    No crunching of the numbers can excuse the spread of vaccine misinformation, or suggest that those who peddle it are anything but a hateful scourge on individuals and a threat to public health. But you can’t simply ignore the fact that, as far as we can see, all the gnashing about vaccines’ supposed risks simply hasn’t changed a lot of people’s minds. It certainly hasn’t caused a steep and sudden rise in vaccine refusal. The idea that we’re in the midst of some new vaccine-hesitancy contagion is based as much on vibes as proven fact.

    The problem is, bad vibes can leave us prone to misinterpretation. Take the recent measles outbreak in Ohio: It’s alarming, but not so relevant to recent trends in vaccination, despite many claims to that effect. More than one-quarter of the affected children were too young to have been eligible for the MMR vaccine, while others were old enough to have missed their first shot by 2020, before any hesitancy “spillover” could have taken place. And at least a meaningful proportion of the affected families, from the state’s Democratic-leaning Somali American community, wouldn’t seem to represent the GOP’s white, unvaccinated constituency.

    The stark politicization of the COVID shots can be misread too. Despite the 30-point gap between Democrats and Republicans in COVID vaccination rates, those rates are much, much higher—for members of both parties—than they’ve ever been for flu shots. And interparty differences in flu-shot uptake seem to be long-standing. A preprint study from Minttu Rönn, a researcher at the Harvard T. H. Chan School of Public Health, and colleagues found a broadening divide in coverage between Democratic- and Republican-voting states, based on data going back to 2010. But this may not be a bad thing. Rönn doesn’t think the change arises from a loss of trust among Republicans; rather, she told me, it looks to be related to rising flu-shot coverage overall, with proportionally greater gains in Democratic-leaning areas. (That difference could be the result of local attitudes, ease of access, or insurance coverage, she said.) In other words, red states aren’t necessarily falling behind on vaccination. Blue states are surging forward.

    Optimism here may seem perverse. COVID booster uptake is absurdly low right now, even for the elderly. The politicization of vaccines (whenever it began) certainly isn’t letting up. Given what would happen if trust in vaccination really did collapse, perhaps it makes more sense to err on the side of freaking out. As Larson said, every effort should be taken to build confidence, no matter what.

    But the truth of what we know right now ought to be important too. Maybe it’s okay to feel okay. Maybe there’s value in maintaining calm and taking stock of what we’ve accomplished or what we’ve maintained in the face of all these efforts to confuse us. At the risk of trying way too hard to find some solace in disturbing facts, here’s another case in point. Remember Shah’s results, that parents’ concerns about the health effects of childhood vaccines have steadily gone up throughout the pandemic, even as their belief in vaccines’ benefits stayed high? That increase wasn’t clearly more pronounced in any specific group. Belief that vaccination can result in illness or death went up across the board for men and women in the survey, for young and old, for Black and white alike. It rose among Republicans and also Democrats—in just about the same proportions. If America’s parents have been getting more attuned to potential risks from vaccination, we’re doing it together.

    I’m in that number too. As a scientist by training and a science journalist by trade, I’ve been reporting and editing stories about vaccination for years. Still, I’ve never thought so hard about the topic, and in such critical detail, as I have since 2021. At no point in my life has vaccination been this pervasive, perplexing, and important. When it came time to get my children COVID shots, I learned everything I could about potential risks and benefits. I looked at data on the incidence of myocarditis, I considered very rare but deadly outcomes, and I weighed the efficacy of different shots against their measured side effects. These investigations did not arise from distrust of authority, podcast propaganda, or a belief in microchips so small they fit inside of a syringe. I wasn’t fearful; I was curious. I had questions, and I got answers—and now every member of my family has gotten their shots.

    We’ve all been forced by circumstance to think in different ways about our health. Before the pandemic, Larson told me, most people simply didn’t have to pay attention to vaccines. Parents with young children, sure, but everybody else? “I think they probably said, Yeah, vaccines are important. Yeah, they’re safe enough,” she said. But now the stakes are raised across the population. “I mean, there are these groups around the world where you’re like, ‘why do they care about vaccines?’ And it’s because of COVID.”

    The emergence of so many groups with newfound interest in vaccines could end up being dangerous, of course—in the same way that newly minted drivers are a menace on the road. “A lot of people went online asking questions about vaccines,” Larson told me, in a tone that made it sound as though online were a synonym for “straight to hell.” But sometimes asking questions gets you useful information, and sometimes useful information leads to wise decisions. Debates about vaccines may be louder than they’ve ever been before, but that doesn’t mean that vaccination rates are bound to fall.

    Even if the situation isn’t getting that much worse, the country might still be left to wallow in its status quo. Yes, more than 200 million Americans have been fully immunized against COVID—and more than 100 million haven’t. “This has been a problem for a long time,” Daniel Salmon told me. “It was already ‘a crisis in confidence’ a dozen years ago. We don’t see a free fall—that’s somewhat reassuring—but that’s very different from saying that we’re good to go.”

    The fact of this crisis, however long it’s been around, will never matter more than its effects. After all, “confidence” itself is not the only factor, or even the most important one, that determines who gets shots. “Generally speaking, access to vaccination is a much bigger driver than what people think and feel,” Noel Brewer told me. Early in the pandemic, lots of parents wanted to vaccinate their kids and simply couldn’t. Now many of them can. But obstacles persist, and their effects aren’t evenly distributed. According to the CDC, toddlers’ vaccination rates are somewhat lower among those who live in poverty, or reside in rural areas, or don’t identify as white or Asian. Since the pandemic started, these gaps in opportunity appear to have increased. A grand and tragic spillover of people’s vaccination doubts—the anti-vaxxers’ hoped-for “silver lining” to the pandemic—may or may not come. In the meantime, though, there are other problems to address.

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    Daniel Engber

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  • Thanksgiving’s Most Underrated Food

    Thanksgiving’s Most Underrated Food

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    Since the start of 2022, I’ve consumed more than my body weight in sweet potatoes. The average American eats closer to the equivalent of one (1) fry a day, but for the past decade, I’ve had at least half a pound of the roots at almost every dinner. I travel with sweet potatoes more reliably than I travel with my spouse. All I need in order to chow down is a microwave and something to cushion my hands against the heat.

    Tomorrow, Americans will finally put sweet potatoes in the spotlight—and still not appreciate all that they’re worth. Families across the country will smother the roots with sugar and butter beneath a crunchy marshmallow crust. This classic casserole may be the only serving of sweet potatoes some people have all year—which is a travesty in terms of both quantity and (sorry) preparation style. Sweet potatoes deserve so much more than what Thanksgiving serves them. And maybe they’d get it, if they weren’t so misunderstood.

    For starters, sweet potatoes are not potatoes or yams. Each belongs to a distinct family of plants. And although potatoes and yams are technically tubers, a riff on a plant stem, sweet potatoes are a modified root. The common name doesn’t exactly help, which is why many experts want to change it from sweet potato to … sweetpotato. Even in grocery stores, confusion abounds. A small part of Lauren Eserman-Campbell, a geneticist and sweet-potato expert at the Atlanta Botanical Garden, dies every time she spots a can of Bruce’s Yams.

    Mostly, the sweet potatoes in American markets resemble Bruce’s (Not) Yams: orange-fleshed, brown-skinned, sugary, moist. But the plant’s true range is much more diverse. The outside comes in earthy umbers, ruddy reds and purples, and sandy beiges; the interior can be cream, buttercup yellow, cantaloupe, lilac, even a shade of violet that verges on black. Some are rather watery; others are almost as dry and starchy as bread. Not all of them are even perceptibly sweet. And thanks to the plant’s zany genetics—six copies of each of 15 chromosomes—nearly every combo of color, texture, taste, shape, and sugar and water content can spring out of a cross between, say, a dryish, veiny purple and a moist, smooth-skinned orange. Craig Yencho, a sweet-potato breeder and geneticist at North Carolina State University, told me that, given enough time, “I could find a sweet potato that would be enjoyable to just about any consumer.”

    The common misconception that potatoes are fattening and devoid of nutrition (slander!) might make some people assume the same or worse of sweet potatoes. But that couldn’t be further from the truth. Pit their nutritional profile against other staple crops, such as rice, wheat, and corn—all of which command a larger share of the world market—and, in many respects, “sweet potato is on top,” says Samuel Acheampong, a geneticist at the University of Cape Coast, in Ghana. The orange-fleshed varieties, in particular, come chock-full of iron, zinc, and beta-carotene, a precursor to vitamin A; the purples are rich in cancer-fighting anthocyanins. Even sweet-potato leaves are a powerhouse, packed with folate and a surprising amount of protein. Also, they’re delicious stir-fried.

    Sweet potatoes tend to get America’s attention only in November, but they’re hardy, flexible, and ubiquitous enough to be an anytime, anywhere kind of food. They’ve taken root on every continent, save for Antarctica; they’ve been rocketed into space. Acre for acre, sweet potatoes also yield edible crop far more efficiently than many other plants do, “and that is really important in families where they don’t have enough quality food,” says Robert Mwanga, a sweet-potato geneticist based in Uganda, where some locals eat the roots at nearly every meal. In Kenya, sweet potatoes have sustained communities when other crops have failed. Among some populations, the roots have earned an apt moniker: cilera abana, protector of the children.

    But even among scientists, sweet potatoes get, if not a bad rap, at least an underwhelming one. “It’s a tiny community, and there’s not a lot of funding,” Eserman-Campbell told me. “I went to a sweet-potato breeders’ meeting one time, and I just thought there would be more people there.” It doesn’t help that the plants can be a bit of a genetic pain, Mwanga told me. Their many copied chromosomes make breeding tricky, and new sweet-potato varieties can be propagated only by clonal cuttings. Among consumers, the sweet potato has also struggled to shed its reputation as a poor person’s food, turned to in times of famine or war and culturally linked to rural, low-income farmers.

    People in the Western world are catching on—especially now that nutritionists so often tout sweet potatoes as a superfood, says Ana Rita Simões, a taxonomist at Kew Gardens, in London. In the past decade, demand for Yencho’s sweet potatoes has tripled, maybe quintupled; “I have never seen a crop take off like that,” he said.

    Culinarily, though, Americans are still batting in the sweet potato’s minor leagues. The big hitter remains the Thanksgiving casserole—a dish Acheampong likes but remains a bit mystified by. “You guys add a lot of sugar,” he told me, which is amusing, considering that the orange-fleshed varieties are already plenty sweet. Plus, the casserole is (gasp) under the thumb of Big Confection: Its invention was commissioned as part of a ploy to sell more marshmallows. It’s sugar all the way down.

    I am not here to yuck anyone’s yam; I celebrate any dish that features sweet potatoes. More preferable, though, would be casting these wonderful roots in a starring role. In other parts of the world, sweet-potato recipes run the gamut from sugary to savory, from appetizer to main to dessert. They’re pureed, stir-fried, noodle-fied; they’re blended into soups, beverages, and pastries. They’ve even found their way into booze. Imagine how they could dress our Thanksgiving tables: sweet potatoes roasted; sweet potatoes grilled; sweet potatofurkey—I mean, why the heck not.

    Or perhaps there is a more modest proposal to be made: Enjoy the roots all on their own. Yencho, like me, is a purist; he likes his sweet potatoes plain, baked until soft, no condiments necessary. They just don’t need anything else.

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    Katherine J. Wu

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  • The Pandemic’s Legacy Is Already Clear

    The Pandemic’s Legacy Is Already Clear

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    Recently, after a week in which 2,789 Americans died of COVID-19, President Joe Biden proclaimed that “the pandemic is over.” Anthony Fauci described the controversy around the proclamation as a matter of “semantics,” but the facts we are living with can speak for themselves. COVID still kills roughly as many Americans every week as died on 9/11. It is on track to kill at least 100,000 a year—triple the typical toll of the flu. Despite gross undercounting, more than 50,000 infections are being recorded every day. The CDC estimates that 19 million adults have long COVID. Things have undoubtedly improved since the peak of the crisis, but calling the pandemic “over” is like calling a fight “finished” because your opponent is punching you in the ribs instead of the face.

    American leaders and pundits have been trying to call an end to the pandemic since its beginning, only to be faced with new surges or variants. This mindset not only compromises the nation’s ability to manage COVID, but also leaves it vulnerable to other outbreaks. Future pandemics aren’t hypothetical; they’re inevitable and imminent. New infectious diseases have regularly emerged throughout recent decades, and climate change is quickening the pace of such events. As rising temperatures force animals to relocate, species that have never coexisted will meet, allowing the viruses within them to find new hosts—humans included. Dealing with all of this again is a matter of when, not if.

    In 2018, I wrote an article in The Atlantic warning that the U.S. was not prepared for a pandemic. That diagnosis remains unchanged; if anything, I was too optimistic. America was ranked as the world’s most prepared country in 2019—and, bafflingly, again in 2021—but accounts for 16 percent of global COVID deaths despite having just 4 percent of the global population. It spends more on medical care than any other wealthy country, but its hospitals were nonetheless overwhelmed. It helped create vaccines in record time, but is 67th in the world in full vaccinations. (This trend cannot solely be attributed to political division; even the most heavily vaccinated blue state—Rhode Island—still lags behind 21 nations.) America experienced the largest life-expectancy decline of any wealthy country in 2020 and, unlike its peers, continued declining in 2021. If it had fared as well as just the average peer nation, 1.1 million people who died last year—a third of all American deaths—would still be alive.

    America’s superlatively poor performance cannot solely be blamed on either the Trump or Biden administrations, although both have made egregious errors. Rather, the new coronavirus exploited the country’s many failing systems: its overstuffed prisons and understaffed nursing homes; its chronically underfunded public-health system; its reliance on convoluted supply chains and a just-in-time economy; its for-profit health-care system, whose workers were already burned out; its decades-long project of unweaving social safety nets; and its legacy of racism and segregation that had already left Black and Indigenous communities and other communities of color disproportionately burdened with health problems. Even in the pre-COVID years, the U.S. was still losing about 626,000 people more than expected for a nation of its size and resources. COVID simply toppled an edifice whose foundations were already rotten.

    In furiously racing to rebuild on this same foundation, America sets itself up to collapse once more. Experience is reputedly the best teacher, and yet the U.S. repeated mistakes from the early pandemic when faced with the Delta and Omicron variants. It got early global access to vaccines, and nonetheless lost almost half a million people after all adults became eligible for the shots. It has struggled to control monkeypox—a slower-spreading virus for which there is already a vaccine. Its right-wing legislators have passed laws and rulings that curtail the possibility of important public-health measures like quarantines and vaccine mandates. It has made none of the broad changes that would protect its population against future pathogens, such as better ventilation or universal paid sick leave. Its choices virtually guarantee that everything that’s happened in the past three years will happen again.


    The U.S. will continue to struggle against infectious diseases in part because some of its most deeply held values are antithetical to the task of besting a virus. Since its founding, the country has prized a strain of rugged individualism that prioritizes individual freedom and valorizes self-reliance. According to this ethos, people are responsible for their own well-being, physical and moral strength are equated, social vulnerability results from personal weakness rather than policy failure, and handouts or advice from the government are unwelcome. Such ideals are disastrous when handling a pandemic, for two major reasons.

    First, diseases spread. Each person’s choices inextricably affect their community, and the threat to the collective always exceeds that to the individual. The original Omicron variant, for example, posed slightly less risk to each infected person than the variants that preceded it, but spread so quickly that it inundated hospitals, greatly magnifying COVID’s societal costs. To handle such threats, collective action is necessary. Governments need policies, such as vaccine requirements or, yes, mask mandates, that protect the health of entire populations, while individuals have to consider their contribution to everyone else’s risk alongside their own personal stakes. And yet, since the spring of 2021, pundits have mocked people who continue to think this way for being irrational and overcautious, and government officials have consistently framed COVID as a matter of personal responsibility.

    Second, a person’s circumstances always constrain their choices. Low-income and minority groups find it harder to avoid infections or isolate when sick because they’re more likely to live in crowded homes and hold hourly-wage jobs without paid leave or the option to work remotely. Places such as prisons and nursing homes, whose residents have little autonomy, became hot spots for the worst outbreaks. Treating a pandemic as an individualist free-for-all ignores how difficult it is for many Americans to protect themselves. It also leaves people with vulnerabilities that last across successive pathogens: The groups that suffered most during the H1N1 influenza pandemic of 2009 were the same ones that took the brunt of COVID, a decade later.

    America’s individualist bent has also shaped its entire health-care system, which ties health to wealth and employment. That system is organized around treating sick people at great and wasteful expense, instead of preventing communities from falling sick in the first place. The latter is the remit of public health rather than medicine, and has long been underfunded and undervalued. Even the CDC—the nation’s top public-health agency—changed its guidelines in February to prioritize hospitalizations over cases, implicitly tolerating infections as long as hospitals are stable. But such a strategy practically ensures that emergency rooms will be overwhelmed by a fast-spreading virus; that, consequently, health-care workers will quit; and that waves of chronically ill long-haulers who are disabled by their infections will seek care and receive nothing. All of that has happened and will happen again. America’s pandemic individualism means that it’s your job to protect yourself from infection; if you get sick, your treatment may be unaffordable, and if you don’t get better, you will struggle to find help, or even anyone who believes you.


    In the late 19th century, many scholars realized that epidemics were social problems, whose spread and toll are influenced by poverty, inequality, overcrowding, hazardous working conditions, poor sanitation, and political negligence. But after the advent of germ theory, this social model was displaced by a biomedical and militaristic one, in which diseases were simple battles between hosts and pathogens, playing out within individual bodies. This paradigm conveniently allowed people to ignore the social context of disease. Instead of tackling intractable social problems, scientists focused on fighting microscopic enemies with drugs, vaccines, and other products of scientific research—an approach that sat easily with America’s abiding fixation on technology as a panacea.

    The allure of biomedical panaceas is still strong. For more than a year, the Biden administration and its advisers have reassured Americans that, with vaccines and antivirals, “we have the tools” to control the pandemic. These tools are indeed effective, but their efficacy is limited if people can’t access them or don’t want to, and if the government doesn’t create policies that shift that dynamic. A profoundly unequal society was always going to struggle with access: People with low incomes, food insecurity, eviction risk, and no health insurance struggled to make or attend vaccine appointments, even after shots were widely available. A profoundly mistrustful society was always going to struggle with hesitancy, made worse by political polarization and rampantly spreading misinformation. The result is that just 72 percent of Americans have completed their initial course of shots and just half have gotten the first of the boosters necessary to protect against current variants. At the same time, almost all other protections have been stripped away, and COVID funding is evaporating. And yet the White House’s recent pandemic-preparedness strategy still focuses heavily on biomedical magic bullets, paying scant attention to the social conditions that could turn those bullets into duds.

    Technological solutions also tend to rise into society’s penthouses, while epidemics seep into its cracks. Cures, vaccines, and diagnostics first go to people with power, wealth, and education, who then move on, leaving the communities most affected by diseases to continue shouldering their burden. This dynamic explains why the same health inequities linger across the decades even as pathogens come and go, and why the U.S. has now normalized an appalling level of COVID death and disability. Such suffering is concentrated among elderly, immunocompromised, working-class, and minority communities—groups that are underrepresented among political decision makers and the media, who get to declare the pandemic over. Even when inequities are highlighted, knowledge seems to suppress action: In one study, white Americans felt less empathy for vulnerable communities and were less supportive of safety precautions after learning about COVID’s racial disparities. This attitude is self-destructive and limits the advantage that even the most privileged Americans enjoy. Measures that would flatten social inequities, such as universal health care and better ventilation, would benefit everyone—and their absence harms everyone, too. In 2021, young white Americans died at lower rates than Black and Indigenous Americans, but still at three times the rate of their counterparts in other wealthy countries.

    By failing to address its social weaknesses, the U.S. accumulates more of them. An estimated 9 million Americans have lost close loved ones to COVID; about 10 percent will likely experience prolonged grief, which the country’s meager mental-health services will struggle to address. Because of brain fog, fatigue, and other debilitating symptoms, long COVID is keeping the equivalent of 2 million to 4 million Americans out of work; between lost earnings and increased medical costs, it could cost the economy $2.6 trillion a year. The exodus of health-care workers, especially experienced veterans, has left hospitals with a shortfall of staff and know-how. Levels of trust—one of the most important predictors of a country’s success at controlling COVID—have fallen, making pandemic interventions harder to deploy, while creating fertile ground in which misinformation can germinate. This is the cost of accepting the unacceptable: an even weaker foundation that the next disease will assail.


    In the spring of 2020, I wrote that the pandemic would last for years, and that the U.S. would need long-term strategies to control it. But America’s leaders consistently acted as if they were fighting a skirmish rather than a siege, lifting protective measures too early, and then reenacting them too slowly. They have skirted the responsibility of articulating what it would actually look like for the pandemic to be over, which has meant that whenever citizens managed to flatten the curve, the time they bought was wasted. Endemicity was equated with inaction rather than active management. This attitude removed any incentive or will to make the sort of long-term changes that would curtail the current disaster and prevent future ones. And so America has little chance of effectively countering the inevitable pandemics of the future; it cannot even focus on the one that’s ongoing.

    If change happens, it will likely occur slowly and from the ground up. In the vein of ACT UP—the extraordinarily successful activist group that changed the world’s approach to AIDS—grassroots organizations of longhaulers, grievers, immunocompromised people, and others disproportionately harmed by the pandemic have formed, creating the kind of vocal constituency that public health has long lacked.

    More pandemics will happen, and the U.S. has spectacularly failed to contain the current one. But it cannot afford the luxury of nihilism. It still has time to address its bedrocks of individualism and inequality, to create a health system that effectively prevents sickness instead of merely struggling to treat it, and to enact policies that rightfully prioritize the needs of disabled and vulnerable communities. Such changes seem unrealistic given the relentless disappointments of the past three years, but substantial social progress always seems unfeasible until it is actually achieved. Normal led to this. It is not too late to fashion a better normal.

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    Ed Yong

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