People who live in red states are in more financial distress than those living in blue states, according to a recent WalletHub study.
Texas ranked at No. 1 on the study’s Top 10 financially distressed states, with Texan residents having the ninth-lowest average credit score in the country in Q1 in 2025. The state also had the third-highest number of accounts in forbearance or with deferred payments per person, as well as the seventh-highest share of people with these distressed accounts at 7.1%.
Florida (No. 2) and Louisiana (No. 3) followed closely behind Texas, with South Carolina’s placement on the list not too far off.
“Measuring the share of residents in financial distress is a good way to take the pulse of a state and see whether people are generally thriving or having trouble making ends meet,” said Chip Lupo, WalletHub analyst. “When you combine data about people delaying payments with other metrics like bankruptcy filings and credit score changes, it paints a good picture of the overall economic trends of a state.”
WalletHub defines a financially distressed account as one that is in forbearance or has its payments deferred.
To determine the most financially distressed states, WalletHub compared 50 states across nine key metrics in six categories, including credit score, people with accounts in distress, average number of accounts in distress, change in number of bankruptcy filings (March 2025 vs. 2024), “debt” Search Interest Index, and “loans” Search Interest Index. The study then determined the weighted average across all metrics to calculate an overall score for each state, using the resulting scores to rank-order the states.
Data used to create the study’s rankings were collected as of June 17, 2025, from the Administrative Office of the U.S. Courts, TransUnion, Google Trends and WalletHub database.
South Carolina ranked No. 5 when it comes to the most financially distressed states in the country, with an overall score of 56.49. This score is comprised of the following data:
Credit score rank: 30
People with accounts in distress rank: 2
Average number of accounts in distress rank: 4
Change in bankruptcy filings March 2025 vs. March 2024 rank 34
“Debt” Search Interest Index rank: 22
“Loans” Search Interest Index rank: 5
In WalletHub’s study, blue states scored an overall average rank of 32.95, while red states scored 20.94. The majority of financially distressed states in the study’s Top 10 are red states:
The Trump administration’s cuts to Centers for Disease Control and Prevention funding for state and local health departments had vastly uneven effects depending on the political leanings of a state, according to a KFF Health News analysis. Democratic-led states and select blue-leaning cities fought back in court and saw money for public health efforts restored — while GOP-led states sustained big losses.
The Department of Health and Human Services in late March canceled nearly 700 Centers for Disease Control and Prevention grants nationwide — together worth about $11 billion. Awarded during the covid-19 pandemic, they supported efforts to vaccinate people, reduce health disparities among demographic groups, upgrade antiquated systems for detecting infectious disease outbreaks, and hire community health workers.
Initially, grant cancellations hit blue and red states roughly evenly. Four of the five jurisdictions with the largest number of terminated grants were led by Democrats: California, the District of Columbia, Illinois, and Massachusetts.
But after attorneys general and governors from about two dozen blue states sued in federal court and won an injunction, the balance flipped. Of the five states with the most canceled grants, four are led by Republicans: Texas, Georgia, Oklahoma, and Ohio.
In blue states, nearly 80% of the CDC grant cuts have been restored, compared with fewer than 5% in red states, according to the KFF Health News analysis. Grant amounts reported in an HHS database known as the Tracking Accountability in Government Grants System, or TAGGS, often don’t match what states confirmed. Instead, this analysis focused on the number of grants.
The divide is an example of the polarization that permeates health care issues, in which access to safety-net health programs, abortion rights, and the ability of public health officials to respond to disease threats diverge significantly depending on the political party in power.
In an emailed statement, HHS spokesperson Andrew Nixon said the agency “is committed to protecting the health of every American, regardless of politics or geography. These funds were provided in response to the COVID pandemic, which is long over. We will continue working with states to strengthen public health infrastructure and ensure communities have the tools they need to respond to outbreaks and keep people safe.”
The money in question wasn’t spent solely on covid-related activities, public health experts say; it was also used to bolster public health infrastructure and help contain many types of viruses and diseases, including the flu, measles, and RSV, or respiratory syncytial virus.
“It really supported infrastructure across the board, particularly in how states respond to public health threats,” said Susan Kansagra, chief medical officer of the Association of State and Territorial Health Officials.
The Trump cutbacks came as the U.S. recorded its largest measles outbreak in over three decades and 266 pediatric deaths during the most recent flu season — the highest reported outside of a pandemic since 2004. Public health departments canceled vaccine clinics, laid off staff, and put contracts on hold, health officials said in interviews.
After its funding cuts were blocked in court, California retained every grant the Trump administration attempted to claw back, while Texas remains the state with the most grants terminated, with at least 30. As the CDC slashed grants in Texas, its measles outbreak spread across the U.S. and Mexico, sickening at least 4,500 people and killing at least 16.
Colorado, which joined the lawsuit, had 11 grant terminations at first, but then 10 were retained. Meanwhile, its neighboring states that didn’t sue — Wyoming, Utah, Kansas, Nebraska, and Oklahoma — collectively lost 55 grants, with none retained.
In Jackson, Ohio, a half-dozen community health workers came to work one day in March to find the Trump administration had canceled their grant five months early, leaving the Jackson County Health Department half a million dollars short — and them without jobs.
“I had to lay off three employees in a single day, and I haven’t had to do that before. We don’t have those people doing outreach in Jackson County anymore,” Health Commissioner Kevin Aston said.
At one point, he said, the funding helped 11 Appalachian Ohio counties. Now it supports one.
Marsha Radabaugh, one employee who was reassigned, has scaled back her community health efforts: She’d been helping serve hot meals to homeless people and realized that many clients couldn’t read or write, so she brought forms for services such as Medicaid and the Supplemental Nutrition Assistance Program to their encampment in a local park and helped fill them out.
“We would find them rehab places. We’d get out hygiene kits, blankets, tents, zero-degree sleeping bags, things like that,” she said. As a counselor, she’d also remind people “that they’re cared for, that they’re worthy of being a human — because, a lot of the time, they’re not treated that way.”
Sasha Johnson, who led the community health worker program, said people like Radabaugh “were basically a walking human 411,” offering aid to those in need.
Radabaugh also partnered with a food bank to deliver meals to homebound residents.
Aston said the abrupt way they lost the funds — which meant the county unexpectedly had to pay unemployment for more people — could have ruined the health district financially. Canceling funding midcycle, he said, “was really scary.”
HHS Secretary Robert F. Kennedy Jr., a longtime anti-vaccine activist and promoter of vaccine misinformation, has called the CDC a “cesspool of corruption.” At HHS, he has taken steps to undermine vaccination in the U.S. and abroad.
Federal CDC funding accounts for more than half of state and local health department budgets, according to KFF, a health information nonprofit that includes KFF Health News. States that President Donald Trump won in the 2024 election received a higher share of the $15 billion the CDC allocated in fiscal 2023 than those that Democrat Kamala Harris won, according to KFF.
The Trump administration’s nationwide CDC grant terminations reflect this. More than half were in states that Trump won in 2024, totaling at least 370 terminations before the court action, according to KFF Health News’ analysis.
The Columbus, Ohio, health department had received $6.2 million in CDC grants, but roughly half of it — $3 million — disappeared with the Trump cuts. The city laid off 11 people who worked on investigating infectious disease outbreaks in such places as schools and nursing homes, Columbus Health Commissioner Mysheika Roberts said.
She also said the city had planned to buy a new electronic health record system for easier access to patients’ hospital records — which could improve disease detection and provide better treatment for those infected — but that was put on ice.
“We’ve never had a grant midcycle just get pulled from us for no reason,” Roberts said. “This sense of uncertainty is stressful.”
Columbus did not receive its money directly from the CDC. Rather, the state gave the city some funds it received from the federal government. Ohio, led by Republican Gov. Mike DeWine and a Republican attorney general, did not sue to block the funding cuts.
Columbus sued the federal government in April to keep its money, along with other Democratic-led municipalities in Republican-governed states: Harris County, Texas, home to Houston; the Metropolitan Government of Nashville and Davidson County in Tennessee; and Kansas City, Missouri. A federal judge in June blocked those cuts.
As of mid-August, Columbus was awaiting the funds. Roberts said the city won’t rehire staff because the federal funding was expected to end in December.
Joe Grogan, a senior scholar at the University of Southern California’s Schaeffer Institute and former director of the White House Domestic Policy Council in Trump’s first term, said state and local agencies “are not entitled” to the federal money, which was awarded “to deal with an emergency” that has ended.
“We were throwing money out the door the last five years,” Grogan said of the federal government. “I don’t understand why there would ever be a controversy in unspent covid money coming back.”
Ken Gordon, Ohio Department of Health spokesperson, wrote in an email that the $250 million in grants lost had helped with, among other things, upgrading the disease reporting system and boosting public health laboratory testing.
Some of the canceled HHS funding wasn’t slated to end for years, including four grants to strengthen public health in Indian Country, a grant to a Minnesota nonprofit focused on reducing substance use disorders, and a few to universities about occupational safety, HIV, tuberculosis, and more.
Brent Ewig, chief policy and government relations officer for the Association of Immunization Managers, said the cuts were “the predictable result of ‘boom, bust, panic, neglect’ funding” for public health.
The association represents 64 state, local, and territorial immunization programs, which Ewig said will be less prepared to respond to disease outbreaks, including measles.
“The system is blinking red,” Ewig said.
Methodology
KFF Health News’ analysis of Centers for Disease Control and Prevention grants sought to answer four questions: 1) How many grants have been terminated in the U.S. under the Trump administration since March? 2) Which states saw the most grants cut? 3) What were the grants for? and 4) Did the grant terminations affect blue, red, and purple states differently? This follows a similar analysis by KFF Health News for an article on nationwide NIH grant terminations.
Our primary data source was a Department of Health and Human Services website showing grant terminations. We compared an initial list of grant terminations from April 3 with one from July 11 to determine how many grants had been restored. The USAspending.gov database helped us track grants by state.
To classify states politically, we followed the same steps from our April coverage of National Institutes of Health grant terminations. States were “blue” if Democrats had complete control of the state government or if the majority of voters favored Democratic presidential candidates in the last three elections (2016, 2020, 2024). “Red” states were classified similarly with respect to the Republican Party. “Purple” states had politically split state governments and/or were generally considered to be presidential election battleground states. The result was 25 red states, 17 blue states, and eight purple states. The District of Columbia was classified as blue using similar methods.
This analysis does not account for potential grant reinstatements in local jurisdictions where the funds were awarded indirectly rather than directly from the CDC; it accounts only for the recipients’ location, and excludes grants terminated from Compacts of Free Association states and other foreign entities that received grants directly from the CDC. At least 40 CDC grants were terminated that were meant for global health efforts or assisting public health activities in other nations following the Trump administration’s order for the CDC to withdraw support for the World Health Organization.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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Henry Larweh, Rachana Pradhan, Rae Ellen Bichell and KFF Health News
The best way to understand last week’s unusual debate between Governors Gavin Newsom of California and Ron DeSantis of Florida is to think of them less as representatives of different political parties than as ambassadors from different countries.
Thursday night’s debate on Fox News probably won’t much change the arc of either man’s career. DeSantis is still losing altitude in the 2024 GOP presidential race, and Newsom still faces years of auditioning before Democratic leaders and voters for a possible 2028 presidential-nomination run.
What the debate did reveal was how wide a chasm has opened between red and blue states. The governors spent the session wrangling over the relative merits of two utterly divergent models for organizing government and society. It was something like watching an argument over whether the liberal government in France or the conservative government in England produces better outcomes for its people.
“The way the debate will be heard is the nationals of each country cheering their guy on,” Michael Podhorzer, a progressive political strategist and a former political director for the AFL-CIO, told me.
The sharp disagreements between the governors pointed toward a future of widening separation between red and blue blocs whose differences are growing so profound that Podhorzer has argued the sections should be understood as fundamentally different nations.
As Podhorzer and other analysts have noted, this accelerating separation marks a fundamental reversal from the generally centralizing trends in American life through the late 20th century. Beginning with the New Deal investments under Franklin D. Roosevelt (such as agricultural price supports, the Tennessee Valley Authority, and Social Security), and continuing with massive expenditures on defense, infrastructure, and the social safety net after World War II (including Medicare, Medicaid, and federal aid for K–12 and higher education), federal spending for decades tended to narrow the income gaps between the southern states at the core of red America and the rest of the country.
After World War II, in a dynamic that legal scholars call the rights revolution, the federal government nationalized more civil rights and liberties and limited the ability of states to constrain those rights. Through Supreme Court and congressional actions that unfolded over more than half a century, Washington struck down state-sponsored segregation and racial barriers to voting across the South, and invalidated a procession of state restrictions on abortion, contraception, interracial marriage, and same-sex relationships, among other things.
But both big unifying trends reshaping the economy and the rules of social life have stalled and are moving in the opposite direction. Podhorzer has calculated that the convergence in per capita income between the South and other regions plateaued in 1980 and then started widening again around 2008. And, as I’ve written, the axis of Republican-controlled state governments, the GOP-appointed majority on the Supreme Court, and Republican senators wielding the filibuster are actively reversing the rights revolution that raised the floor of personal freedoms guaranteed in all 50 states.
On issues including voting, LGBTQ rights, classroom censorship, book bans, public protest, and, most prominent, access to abortion, red states are imposing restrictions that are universally rejected in blue states. As Newsom argued in an interview with me a few hours before he went onstage, “This assault on our rights and the weaponization of grievance” is designed to “bring us back to … the pre-1960s world” in which people’s rights depended on their zip code. Under DeSantis, Florida has been a leader in that process, creating policies, such as limits on classroom discussion of sexual orientation and gender identity, widely emulated across other red states.
Thursday night’s debate revolved around the differences between Florida and California, though the Fox moderator Sean Hannity hardly presented an accurate picture of the comparison. Both states have their successes and failures. But Hannity focused his questions entirely on measures that favor Florida (such as unemployment rate, violent-crime rate, and homelessness numbers) while ignoring all the contrasts that favor California (which has a much higher median income, far fewer residents without health insurance, and, according to the CDC, much lower rates of teen birth, infant mortality, and death from firearms, as well as a longer life expectancy). Hannity essentially joined in a tag team with DeSantis to frame the debate in terms familiar to his Fox audience that blue states are a chaotic hellhole of crime and “woke” liberalism; when Newsom pushed back against that characterization, or challenged DeSantis’s approach, Hannity often cut him off or steered the conversation in a different direction.
The narrow focus on California and Florida made sense in a debate between their two governors. But those comparisons can obscure the bigger story, which is the expanding divergence between all the states in the red and blue sections.
Podhorzer has documented that gap in an array of revealing measures. He divides the nation between states in which Republicans or Democrats usually hold unified control of the governorship and state legislature, and those in which control of state government is usually divided or frequently changes hands. That classification system yields 27 red states, 17 blue states (plus the District of Columbia), and six purple states. By these definitions, the red states account for just under half the population and the blue states just below two-fifths, while the blue states contribute slightly more of the nation’s GDP.
Podhorzer’s data show that on many key measures, blue states as a group are producing far better outcomes than the red states.
In new results provided exclusively to The Atlantic, Podhorzer calculates that the economic output per capita and the median family income are both now 27 percent higher in the blue section than in the red, while the share of children in poverty is 27 percent higher in the red states. The share of people without health insurance is more than 80 percent higher in the red states than in the blue, as are the rates of teen pregnancy and maternal death in childbirth. The homicide rate across the red states is more than one-third higher than in the blue, and the rate of death from firearms is nearly double in the red. Average life expectancy at birth is now about two and a half years higher in the blue states. On most of these measures, the purple states fall between red and blue.
(Podhorzer also groups the states by their voting behavior in federal elections, which results in 24 red-leaning states, 18 blue ones, and eight purple states. But the comparisons between the two big sections don’t change much under that definition.)
On most of these measures, Podhorzer calculates, the gap between the red and blue states has widened over the past 15 years. He attributes the expansion mostly to the kind of policy differences that DeSantis and Newsom debated. The difference in health outcomes, for instance, is rooted in disparities such as the continuing refusal of 10 red states, including Florida, to expand Medicaid eligibility under the Affordable Care Act (which every blue state has done). As other economic analysts have noted, with their higher concentrations of college graduates, blue states—and the large blue metropolitan areas of red states—are benefiting the most from the nation’s transition into an information-age economy.
As DeSantis and Hannity did in the debate, defenders of the red-state approach point to other measures. Housing costs are typically much lower in red states than in blue, as are taxes. Those are probably the central reasons many of the blue states, despite their stronger results on many important yardsticks, are stagnant or shrinking in population, while several of the red states, especially those across the Sun Belt, have been adding middle-income families. Lower housing costs are also one reason homelessness is less of a problem in red states than in blue metros, especially along the West Coast.
But the relative superiority of either model is probably less important to the nation’s future than the widening separation, and growing antagonism, between them that was displayed so vividly in the debate.
Most experts I spoke with agree that there is now no single difference between the red and blue sections as great as the gulf during most of the 20th century between the states with and without Jim Crow racial segregation, much less the 19th-century distance between the slave and free states.
But the number of issues dividing the states is reaching a historic peak, many of those same experts agree. Although civil rights and racial equity have made up the most important dividing line between the states for most of U.S. history, “the way in which these issues line up today—on everything from abortion to library books to the question of how much power states ought to have over their local governments … I think there’s not been since the founding such a far-reaching debate,” Donald Kettl, a former dean of the University of Maryland’s School of Public Policy, told me.
To Kettl, the new wave of restrictive social legislation spreading across red states challenges the traditional idea that local variation benefits the country by allowing states to function as the fabled “laboratories of democracy.” “It strikes me as being incredibly dangerous,” Kettl said. “The good old arguments about the laboratories of democracy is that individual states would try different ideas, find out what works, and throw out the ones that didn’t work. We are not talking about that at all. We are talking about an effort to push a particular agenda and to push it as far as possible.”
David Cole, the ACLU’s national legal director, likewise sees the erosion of a national floor of civil rights and liberties as the most ominous element of the widening red-blue separation. “We are supposed to be one nation, committed to a common set of fundamental rights,” Cole told me in an email. “But we have increasingly become two nations, with substantial rights protections for some, and robust repression for others. Federalism was designed to allow for some play in the joints, some variations among states—but not on the fundamental constitutional rights to which we are all entitled as human beings and U.S. residents.”
It’s not clear that in the near term anything will close the space between red and blue states. Neither party has many realistic chances to win power in states that now prefer the other side. And particularly in red states, the dominance of the conservative media ecosystem makes it difficult for Democrats even to present their arguments, as the debate demonstrated.
In the interview a few hours before he went onstage, Newsom told me that the principal reason he accepted the debate was not so much to rebut DeSantis as to reach Fox viewers. “I want to make the case in their filter bubble,” he told me. “We’ve got to get into their platforms.” Though the forum allowed Newsom to assert some positive facts about President Joe Biden’s record rarely heard on the network, any progress in reaching Fox viewers was likely blunted by Hannity’s framing of every issue as proof of the superiority of red over blue. After the debate, Newsom’s aides said they believed he had achieved his mission of evangelizing to Fox’s audience. But in the end, the evening may have validated Barack Obama’s lament during his presidency that it was virtually impossible for Democrats to communicate with red-state voters except through the negative filter that conservative media build around them.
Podhorzer is among those skeptical that anything will reverse this process of separation in the foreseeable future. He views the late-20th-century trend toward convergence as the anomaly; “the default position” through most of American history has been for the states we now consider the red bloc to pursue very different visions of moral order, economic progress, and the role of government than those we now label as blue. To Podhorzer, the disagreements on display at the DeSantis-Newsom debate were just the modern manifestation of the deep divisions between the free and slave states, or the Union and the Confederacy.
In the 2024 presidential race, Biden and the leading Republican candidates have each endorsed new national laws that would reverse our separation by imposing the dominant laws in one section on the other. Biden and other Democrats are backing federal bills to restore a national floor of abortion, LGBTQ, and voting rights in every state; Republicans in turn want to impose red-state restrictions on all those issues in blue states.
Podhorzer believes that the differences between the states have hardened to the point where setting common national rules on these issues in either direction has become extremely risky. “Any compromise on any of these big issues,” he told me, “means half the country will see a loss in some aspect of what they like about the way they live.” From his perspective, courting that backlash might be worth the effort to restore core civil rights, such as access to abortion, nationally. But he warns that no one should underestimate the potential for fierce red-state resistance to such an effort, extending even to violence.
It won’t be easy for either side to pass legislation nationalizing the social- and civil-liberties regime in their section; at the least, it would require them to not only hold unified control of the White House and Congress but also end the Senate filibuster, which remains an uncertain proposition. The more likely trajectory is for red and blue states to continue careening away from each other along the pathways that Newsom and DeSantis so passionately defended last week. “Without some major disruption, this cycle” of separation “hasn’t played itself out fully,” Podhorzer told me, in a view echoed by the other experts I spoke with. “There are hurricane-force winds in that direction.” Thursday’s gusty debate between these two ambitious governors only hinted at how hard those gales may blow in the years ahead.
When the Supreme Court overturned Roe v. Wade, Diana Greene Foster made a painful prediction: She estimated that one in four women who wanted an abortion wouldn’t be able to get one. Foster, a demographer at UC San Francisco, told me that she’d based her expectation on her knowledge of how abortion rates decline when women lose insurance coverage or have to travel long distances after clinics close.
And she was well aware of what this statistic meant. She’d spent 10 years following 1,000 women recruited from clinic waiting rooms. Some got an abortion, but others were turned away. The “turnaways” were more likely to suffer serious health consequences, live in poverty, and stay in contact with violent partners. With nearly 1 million abortions performed in America each year, Foster worried that hundreds of thousands of women would be forced to continue unwanted pregnancies. “Having a baby before they’re ready kind of knocks people off their life course,” she told me.
But now, more than a year removed from the Dobbs v. Jackson Women’s Health Organization decision, Foster has revised her estimate. After seeing early reports of women traveling across state lines and ordering pills online, she now estimates that about 5 percent of women who want an abortion cannot get one. Indeed, two recent reports show that although Dobbs upended abortion access in America, many women have nevertheless found ways to end their pregnancy. A study by the Guttmacher Institute, a research group that supports abortion rights, signals that national abortion rates have not meaningfully fallen since 2020. Instead, they seem to have gone up a bit. A reportreleased this week by the Society of Family Planning, another pro-abortion-rights group, shows that an increase in abortions in states that allow the procedure more than offset the post-Dobbs drop-off in states that closed down clinics.
Some of this increase may be a result of trends that predate Dobbs: Abortion rates in the U.S. have been going up since 2017. But the reports suggest that the increase may also be due to travel by women who live in red states and the expanded access to abortion that many blue states enacted after the ruling. Still, it is not yet clear exactly how much each of these factors is contributing to the observed increase—and how many women who want an abortion are still unable to get one.
Alison Norris, a co-chair of the Society of Family Planning study, told me that she fears that the public will “become complacent” if they see the likely increase in abortion rates and believe that everyone has access. “Feeling like the problem isn’t really that big of a deal because the numbers seem to have returned to what they were pre-Dobbs is a misunderstanding of the data,” she said.
It seems illogical that more than a dozen states would ban abortion and national rates would hardly change. But even as red states have choked off access, blue states have widened it. And the data show that women have flooded the remaining clinics and ordered abortion pills from pharmacies that ship across the country. More than half of all abortions are done using medication, a pattern that began even before the Dobbs decision.
“It just doesn’t work to make abortion illegal,” Linda Prine, a doctor at Mount Sinai Hospital, told me. “There may be some people who are having babies that they didn’t want to have, but when you shift resources all over the place, and all kinds of other avenues open up, there’s also people who are getting abortions that might not have gotten them otherwise.”
With mail-order abortion pills, “it’s this weird moment where abortion might, ironically, be more available than it’s ever been,” Rachel Rebouché, an expert in abortion law and the dean of the Temple University Beasley School of Law, told me.
The Guttmacher Institute sampled abortion clinics to estimate the change in abortion counts between the first halves of 2020 and 2023. Areas surrounding states with post-Roe bans saw their abortion numbers surge over that period of time. In Colorado, which is near South Dakota, a state with a ban, abortions increased by about 89 percent, compared with an 8 percent rise in the prior three-year period. New Mexico saw abortions climb by 220 percent. (For comparison, before Dobbs, the state recorded a 27 percent hike from 2017 to 2020.) Even states in solidly blue regions saw their abortion rates grow over the three-year interval from 2020 to 2023: Guttmacher estimates that California’s abortion clinics provided 16 percent more abortions, and New York’s about 18 percent more.
Some shifts predated the court’s intervention. After a decades-long decline, abortions began ticking upward around 2017. In 2020, they increased by 8 percent compared with 2017. The researchers I spoke with for this story told me that they couldn’t point to a decisive cause for the shift that started six years ago; they suggested rising child-care costs and Trump-era cuts to Medicaid coverage as possible factors. But the rise in abortion rates reflects a broader change: Women seem to want fewer children than they used to. Caitlin Myers, a professor at Middlebury College, told me that abortion rates might have increased even more if the Court hadn’t reversed Roe. “It looks like more people just want abortions than did a few years ago,” she said. “What we don’t know is, would they have gone up even more if there weren’t people trapped in Texas or Louisiana?”
One of the most significant factors in maintaining post-Roe abortion access dates from the latter half of 2021. As the coronavirus pandemic clobbered the health-care system, the FDA suspended its requirement that women pick up abortion medications in person. A few months later, it made the switch permanent. The timing was opportune: People became accustomed to receiving all of their medical care through virtual appointments at the same time that they could get abortion pills delivered to their doorstep, Rebouché told me. People no longer have to travel to a clinic and cross anti-abortion picket lines. But access to mifepristone, one of the most commonly used drugs for medication abortions, is under threat. After an anti-abortion group challenged the FDA’s approval of the drug, a federal court instated regulations that would require women to visit a doctor three times to get the pills, making access much more difficult. The Supreme Court is weighing whether to hear an appeal, and has frozen the 2021 rules in place while it decides.
But paradoxically, several of the factors that may have contributed to the rise in abortion rates seem to have sprung directly from the Dobbs decision. In the year since the ruling, sixblue states have enacted laws that allow practitioners to ship abortion pills anywhere, even to deep-red Texas. Although these laws haven’t yet been litigated to test whether they’re truly impenetrable, doctors have relied on them to mail medication across the country. Aid Access, an online service that operates outside the formal health-care system, receives requests for about 6,500 abortion pills a month. (The pills cost $150, but Aid Access sends them for free to people who can’t pay.) Demand for Aid Access pills in states that ban or restrict medication abortion has mushroomed since the Dobbs decision, rising from an average of about 82 requests per day before Dobbs to 214 after. The Guttmacher report doesn’t count abortions that take place in this legally fuzzy space, suggesting that actual abortion figures could be higher.
As the Supreme Court revoked the constitutional right to an abortion and turned the issue back to the states, it also hardened the resolve of abortion-rights supporters. In the five months after Roe fell, the National Network of Abortion Funds received four times the money from donations than it got in all of 2020. People often donate as states encroach on abortion rights. In many cases, they bankrolled people’s travel out of ban states. Community networks also gained experience in shuttling people out of state to get abortions. “There’s definitely been innovation in the face of abortion bans,” Abigail Aiken, who documents abortions that occur outside of the formal health-care system, told me.
Some researchers believe that the Dobbs decision has actually convinced more women to get abortions. Abortion-rights advocacy groups have erected highway billboards that promise Abortion is ok. Public opinion has tilted in favor of abortion rights. Ushma Upadhyay, a professor at UC San Francisco, told me that California’s rising abortion rates cannot all be due to people traveling from states that ban abortion. “It’s also got to be an increase among Californians,” she said. “It’s just a lot of attention, destigmatization, and funding that has been made available. Even before Dobbs, there was a lot of unmet need for abortion in this country.”
Abortion used to be a topic that was “talked about in the shadows,” Greer Donley, an expert in abortion law and a professor at the University of Pittsburgh, told me. “Dobbs kind of blew that up.” Still, she believes that it’s unlikely that people are getting significantly more abortions simply because of changes within blue states. Just as obstacles don’t seem to have stopped people from seeking abortions, efforts that moderately expand access are unlikely to lead people to get an abortion, she said.
The people I spoke with emphasized that even though overall abortion rates might be going up, not everyone who wants the procedure can get it. People who don’t speak English or Spanish, who don’t have internet access, or who are in jail still have trouble getting abortions. “What I foresee is a bunch of Black women being stuck pregnant who didn’t want to be pregnant, in a state where it’s incredibly dangerous to be Black and pregnant,” Laurie Bertram Roberts, a founder of the Mississippi Reproductive Freedom Fund, told me.
Bertram Roberts’s fund used to provide travel stipends of up to $250. Now women need three times that. Most people travel from Mississippi to a clinic in Carbondale, Illinois. The trip takes two days—48 hours that women must take off work and find child care for. “If you are in the middle of Texas, and you have to travel to Illinois, even if funds covered all the costs, to say that abortion is more accessible for that person seems callous and wrong,” Donley told me.
Many women spend weeks waiting for an abortion. “It is excruciating to be carrying a pregnancy that one knows they’re planning to end,” Upadhyay said. And although studies show that abortion pills are safe, women who take them can bleed for up to three weeks, and they may worry that they’ll be prosecuted if they seek help at a hospital. Only two states—Nevada and South Carolina—explicitly criminalize women who give themselves an abortion (and few women have been charged under the laws), but the legislation contributes to a climate of fear.
More than a year out from the Dobbs decision, the grainy picture of abortion access is coming into focus. With the benefit of distance, the story seems not to be solely one of diminished access, widespread surveillance, and forced births, as the ruling’s opponents had warned. For most Americans, abortion might be more accessible than it’s ever been. But for another, more vulnerable group, abortion is a far-off privilege. “If I lived in my birth state—I was born in Minnesota—my work would be one hundred times easier,” Bertram Roberts told me, later adding, “I think about that a lot, about how the two states that bookend my life are so different.”
Officially, abortion had nothing to do with the constitutional amendment that Ohio voters rejected today. The word appeared nowhere on the ballot, and no abortion laws will change as a result of the outcome.
Practically and politically, however, the defeat of the ballot initiative known as Issue 1 was all about abortion, giving reproductive-rights advocates the latest in a series of victories in the year since the Supreme Court overturned Roe v. Wade. Fearing the passage of an abortion-rights amendment in November, Republicans in Ohio asked voters to approve a proposal that would raise the threshold for enacting a change to the state constitution, which currently requires a simple majority vote. The measure on the ballot today would have lifted the threshold to 60 percent.
Ohio voters, turning out in unusually large numbers for a summertime special election, declined. Their decision was a rare victory for Democrats in a state that Republicans have dominated, and it suggests that abortion remains a strong motivator for voters heading into next year’s presidential election. The Ohio results could spur abortion-rights advocates to ramp up their efforts to circumvent Republican-controlled state legislatures by placing the issue directly before voters. They have reason to feel good about their chances: Since the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization, statewide abortion-rights ballot measures have been undefeated, winning in blue states such as Vermont and California as well as in red states such as Kansas and Kentucky.
In Kansas last summer, an 18-point victory by the abortion-rights side stunned members of both parties in a socially conservative state. By the final day of voting in Ohio, however, the defeat of Issue 1 could no longer be called a surprise. For weeks, Democrats who had become accustomed to disappointment in Ohio watched early-voting numbers soar in the state’s large urban and suburban counties. If Republicans had hoped to catch voters napping by scheduling the election for the dog days of August, they miscalculated. As I traveled the state recently, I saw Vote No signs in front yards and outside churches in areas far from major cities, and progressive organizers told me that volunteers were signing up to knock on doors at levels unheard of for a summer campaign. The opposition extended to some independent and Republican voters, who saw the proposal as taking away their rights. “It’s this ‘Don’t tread on me’ moment where voters are being activated,” says Catherine Turcer, the executive director of Common Cause Ohio, a good-government advocacy group that helped lead the effort to defeat the amendment.
Opponents of Issue 1 assembled a bipartisan coalition that included two former Republican governors. They focused their message broadly, appealing to voters to “protect majority rule” and stop a brazen power grab by the legislature. But the special election’s obvious link to this fall’s abortion referendum in Ohio drove people to the polls, particularly women and younger voters. “Voters don’t spend a lot of time thinking about the Ohio constitution. They probably don’t spend a ton of time thinking about voting rights,” Turcer told me. But, she said, “the attempt to dilute voter power so that it would impact a vote on reproductive rights made it really concrete, and that was important.”
Voters in South Dakota and Arkansas last year rejected similar GOP-driven efforts to make ballot initiatives harder to pass. But Ohio’s status as a large former swing state that has turned red over the past decade posed a unique test for Democrats who are desperate to revive their party in the state. “We’ve been beat in Ohio a lot,” Dennis Willard, a longtime party operative in the state who served as the lead spokesperson for the No campaign, told me. That Republicans tried to pass this amendment, he said, “is a testament to them believing that they’re invincible and that we cannot beat them.”
The defeat of Issue 1 likely clears the way for voters this fall to guarantee abortion access in Ohio, and it will keep open an avenue for progressives to enshrine, with a simple majority vote, other policies in the state constitution—including marijuana legalization and a higher minimum wage—that they could not get through a legislature controlled by Republicans. Democrats, including Willard, are eying an amendment to curb the gerrymandering that has helped the GOP lock in their majorities. They also hope that tonight’s victory will put Ohio back on the political map. “Us winning sends a message to the rest of the country that Ohio has possibilities,” Willard said. “And winning in November demonstrates to people that you can’t write Ohio off anymore.”
For the moment, though, the GOP is in little danger of losing its hold on the state. It controls supermajorities in both chambers of the legislature; the Republican governor, Mike DeWine, trounced his Democratic opponent by 25 points last year to win a second term. One Ohio Republican, speaking anonymously before today’s election, told me that the defeat of Issue 1 and the expected passage of the reproductive-rights amendment in November could actually help the party next year, because voters might no longer believe that abortion access is in danger in the state. (The GOP performed better last year in blue states such as New York and California, where abortion rights were not under serious threat.)
Republicans in Ohio, and in other states where similar ballot measures have flopped, are now confronting the limits of their power and the point at which voters will rebel. Will they be chastened and recalibrate, or will they continue to push the boundaries? It’s a question the proponents of Issue 1 did not want to contemplate before the votes confirming their defeat were counted. Their critics, however, are doubtful that Republicans will shift their strategy. “It’s unlikely that they will stop right away,” Turcer said. “It will take a number of defeats before they’re likely to understand that voters do not want to be taken advantage of.”
Across multiple fronts, Democrats and their allies are stiffening their resistance to a surge of Republican-led book bans.
President Joe Biden and Vice President Kamala Harris in the past month have conspicuously escalated their denunciations of the book bans proliferating in schools across the country, explicitly linking them to restrictions on abortion and voting rights to make the case that “MAGA extremists” are threatening Americans’ “personal freedom,” as Biden said in the recent video announcing his campaign for a second term.
Last week, Illinois became the first Democratic-controlled state to pass legislation designed to discourage local school districts from banning books. And a prominent grassroots progressive group today will announce a new national campaign to organize mothers against the conservative drive to remove books and censor curriculum under the banner of protecting “parents’ rights.”
“We are not going to let the mantle of parents’ rights be hijacked by such an extreme minority,” Katie Paris, the founder of the group, Red Wine and Blue, told me.
These efforts are emerging as red states have passed a wave of new laws restricting how classroom teachers can talk about race, gender, and sexual orientation, as well as measures making it easier for critics to pressure schools to remove books from classrooms and libraries. Partly in response to those new statutes, the number of banned books has jumped by about 30 percent in the first half of the current school year as compared with last, according to a recent compilation by PEN America, a free-speech group founded by notable authors.
To the frustration of some local activists opposing these measures in state legislatures or school boards, the Biden administration has largely kept its distance from these fights. Nor did Democrats, while they controlled Congress, mount any sustained resistance to the educational constraints spreading across the red states.
But the events of the past few weeks suggest that this debate has clearly reached a turning point. From grassroots organizers like Paris to political advisers for Biden, more Democrats see book bans as the weak link in the GOP’s claim that it is upholding “parents’ rights” through measures such as restrictions on curriculum or legislation targeting transgender minors. A national CBS poll released on Monday found overwhelming opposition among Americans to banning books that discuss race or criticize U.S. history. “There is something about this idea of book banning that really makes people stop and say, ‘I may be uncomfortable with some of this transitional treatment kids are getting, and I don’t know how I feel about pronouns, but I do not want them banning books,’” says Guy Molyneux, a Democratic pollster.
The conservative call to uphold parents’ rights in education has intensified since Republican Governor Glenn Youngkin in 2021 unexpectedly won the governorship in blue-leaning Virginia partly behind that theme. In the aftermath of long COVID-related shutdowns across many school districts, Youngkin’s victory showed that “Republicans really did tap into an energy there” by talking about ways of “giving parents more of a choice in education,” Patrick Brown, a fellow at the conservative Ethics and Public Policy Center who specializes in family issues, told me.
But as the parents’-rights crusade moved through Republican-controlled states, it quickly expanded well beyond academic concerns to encompass long-standing conservative complaints that liberal teachers were allegedly indoctrinating kids through “woke” lessons.
New red-state laws passed in response to those arguments have moved the fight over book banning from a retail to a wholesale level. Previously, most book bans were initiated by lone parents, even if they were working with national conservative groups such as Moms for Liberty, who objected to administrators or school boards in individual districts. But the new statutes have “supercharged” the book-banning process, in PEN’s phrase, by empowering critics to simultaneously demand the removal of more books in more places.Five red states—Florida, Texas, Missouri, South Carolina, and Utah—have now become the epicenter of book-banning efforts, the study concluded.
Biden and his administration were not entirely silent as these policies proliferated. He was clear and consistent in denouncing the initial “Don’t Say Gay” law that Florida Governor Ron DeSantis passed to bar discussion of sexual orientation and gender identity in early grades. But that was the exception. Even during the 2022 campaign, when Biden regularly framed Republicans as a threat to voting and abortion rights, he did not highlight red-state book bans and curriculum censorship. Apart from abortion and voting, his inclination has been to focus his public communications less on culture-war disputes than on delivering kitchen-table benefits to working families. Nor had Education Secretary Miguel Cardona done much to elevate these issues either. “We have not seen a lot of visibility” from the Education Department, says Nadine Farid Johnson, PEN’s managing director for Washington.
The administration’s relative disengagement from the classroom wars, and the limited attention from national progressive groups, left many grassroots activists feeling “isolated,” Paris said. Revida Rahman, a co-founder of One WillCo, an organization that advocates for students of color in affluent and predominantly white Williamson County, south of Nashville, told me that the group has often felt at a disadvantage trying to respond to conservative parents working with national right-leaning groups to demand changes in curriculum or bans on books with racial or LGBTQ themes. “What we are fighting is a well-funded and well-oiled machine,” she told me, “and we don’t have the same capacity.”
Pushback from Democrats and their allies, though, is now coalescing. Earlier this month, the Freedom to Learn initiative, a coalition organized mostly by Black educators, held a series of events, many on college campuses, protesting restrictions on curriculum and books. The Red Wine and Blue group is looking to organize a systematic grassroots response. Founded in 2019, the organization has about 500,000 mostly suburban mothers in its network and paid organizers in five states. The group has already provided training for local activists to oppose curriculum censorship and book bans, and today it is launching the Freedom to Parent 21st Century Kids project, a more sweeping counter to conservative parents’-rights groups. The project will include virtual training sessions for activists, programs in which participants can talk with transgender kids and their parents, and efforts to highlight banned books. “We want to equip parents to talk about this stuff,” Paris told me. “It’s moms learning from moms who already faced this in their community.”
Illinois opened another front in this debate with its first-in-the-nation bill to discourage book banning. The legislation will withhold state grants from school districts unless they adopt explicit policies to prohibit banning books in response to partisan or ideological pressure. Democratic Governor J. B. Pritzker has indicated that he will sign the bill.
Potentially the most consequential shift has come from the Biden administration. The president signaled a new approach in his late-April announcement video, when he cited book bans as evidence for his accusation that Republicans in the Donald Trump era are targeting Americans’ “personal freedom.” That was, “by far, the most we have seen on” book bans from Biden, Farid Johnson told me.
One senior adviser close to Biden told me that the connection of book bans to those more frequent presidential targets of abortion and democracy was no accident. “There is a basic American pushback when people are told what they can and cannot do,” said the adviser, who asked for anonymity while discussing campaign strategy. “Voters,” the adviser said, “don’t like to be told, ‘You can’t make a decision about your own life when it comes to your health care; you can’t make a decision about what book to read.’ I think book bans fit in that broader context.”
Biden may sharpen that attack as soon as Saturday, when he delivers the commencement address at Howard University. Meanwhile, Vice President Harris has already previewed how the administration may flesh out this argument. In her own speech at Howard last month, she cited book bans and curriculum censorship as components of a red-state social regime that the GOP will try to impose nationwide if it wins the White House in 2024. In passing these laws, Republicans are not just “impacting the people” of Florida or Texas, she said. “What we are witnessing—and be clear about this—is there is a national agenda that’s at play … Don’t think it’s not a national agenda when they start banning books.”
The Education Department has also edged into the fray. When the recent release of national test scores showed a decline in students’ performance on history, Cardona, the education secretary, issued a statement declaring that “banning history books and censoring educators … does our students a disservice and will move America in the wrong direction.”
His statement came months after the department’s Office of Civil Rights launched an investigation that could shape the next stages of this struggle. The office is probing whether a Texas school district that sweepingly removed LGBTQ-themed books from its shelves has violated federal civil-rights laws. The department has not revealed anything about the investigation’s status, but PEN’s Farid Johnson said if it concludes that the removals violated federal law, other districts might be deterred from banning books.
The politics of the parents’-rights debate are complex. Republicans are confident that their interconnected initiatives related to education and young people can win back suburban voters, especially mothers, who have rejected the party in the Trump era. Polling, including surveys done by Democratic pollsters last year for the American Federation of Teachers, has consistently found majority national support for some individual planks in the GOP agenda, including the prohibitions on discussing sexual orientation in early grades.
Brown said he believes that at the national level, the battle over book bans is likely to end in a “stalemate.” That’s not only, he argued, because each side can point to examples of extreme behavior by the other in defending or removing individual books, but also because views on what’s acceptable for kids vary so much from place to place. “We shouldn’t expect a national consensus on what book is appropriate for a 13-year-old to be reading, because that’s going to be different among different parents in different communities,” Brown told me.
Yet as the awakening Democratic resistance suggests, many in the party are confident that voters will find the whole of the GOP agenda less attractive than the sum of its parts. In that 2022 polling for the teachers’ union, a significant majority of adults said they worry less that kids are being taught values their parents don’t like than that culture-war fights are diverting schools from their real mission of educating students. Paris said the most common complaint she hears from women drawn to her group is that the conservative activists proclaiming parents’ rights are curtailing the freedoms of other parents by trying to dictate what materials all students can access. “What you’ll have women in our communities say all the time is ‘If you don’t want your kid to read a book, that’s fine, but you don’t get to decide for me and my family,’” she told me.
The White House, the senior official told me, believes that after the Supreme Court last year rescinded the right to abortion, many voters are uncertain and uneasy about what rights or liberties Republicans may target next. “There is a fear about Where does it stop?,” the official said, andbook bans powerfully crystallize that concern. Trump and DeSantis, who’s expected to join the GOP race, have both indicated that they intend to aggressively advance the conservative parents’-rights agenda of attacks on instruction they deem “woke” and books they consider indecent. Biden and other Democrats, after months of hesitation, are stepping onto the field against them. The library looms as the next big confrontation in the culture war.
The red-state drive to reverse the rights revolution of the past six decades continues to intensify, triggering confrontations involving every level of government.
In rapid succession, Republican-controlled states are applying unprecedented tactics to shift social policy sharply to the right, not only within their borders but across the nation. Just last Thursday, the GOP-controlled Tennessee House of Representatives voted to expel two young Black Democratic representatives, and Texas’s Republican governor, Greg Abbott, on Saturday moved to nullify the verdict of a jury in liberal Travis County. In between, last Friday, a single Republican-appointed federal judge, acting on a case brought by a conservative legal group and 23 Republican state attorneys general, issued a decision that would impose a nationwide ban on mifepristone, the principal drug used in medication abortions.
All of these actions are coming as red states, continuing an upsurge that began in 2021, push forward a torrent of bills restricting abortion, LGBTQ, and voting rights; loosening controls on gun ownership; censoring classroom discussion of race, gender, and sexual orientation; and preempting the authority of their Democratic-leaning metropolitan cities and counties.
This flood of legislation has started to erase the long-term trend of Congress and federal courts steadily nationalizing more rights and reducing the freedom of states to constrict them—what legal scholars have called the “rights revolution.” Now, across all these different arenas and more, the United States is hurtling back toward a pre-1960s world in which citizens’ basic rights and liberties vary much more depending on where they live.
“We are in the middle of an existential crisis for the future of our burgeoning multicultural, multiethnic democracy,” and the extreme events unfolding in Tennessee and other states “are the early manifestations of an abandonment of democratic norms,” Janai Nelson, the president and director-counsel of the Legal Defense Fund, wrote to me in an email.
The past week’s events in Tennessee and Texas, and the federal court case on mifepristone, extend strategies that red states have employed since 2020 to influence national policy. But these latest moves show Republicans taking those strategies to new extremes. Together these developments underscore how aggressively red states are maneuvering to block the federal government and their own largest metropolitan areas from resisting their systematic attempt to carve out what I’ve called a “nation within a nation,” operating with its own constraints on civil rights and liberties.
“It shows there really is no limit, no institution that is quote-unquote ‘sacred’ enough not to try to use to their advantage,” Marissa Roy, the legal team lead for the Local Solutions Support Center, a group opposing the broad range of state preemption efforts, told me.
This multipronged offensive from red states seeks to reverse one of the most powerful currents in modern American life. Since the 1960s, on issues including the legalization of abortion and same-sex marriage and the banning of discrimination on grounds of race or gender, the Supreme Court, Congress, and federal agencies have broadened the circle of rights guaranteed nationwide and reduced the ability of states to limit those rights.
Over the past decade, Republican-controlled states have stepped up their efforts to reverse that arrow and restore their freedom to impose their own restrictions on rights and liberties. Nelson sees this red-state drive as continuing the “cycle of progress and retrenchment” on racial equity through American history that stretches back to Reconstruction and the southern resistance that eventually produced Jim Crow segregation. “The current pendulum swing is occurring both in reaction to changing politics and changing demographics, making the arc of that swing that much higher toward extremism,” she told me.
The vote in the Tennessee House of Representatives, for instance, marked a new level in the long-term struggle between red states and blue cities. In most red states, Republicans control the governorship and/or state legislature primarily through their dominance of predominantly white non-urban areas. Over the past decade, those red-state Republicans have grown more aggressive about using that statewide power to preempt the authority of, and override decisions by, their largest cities and counties, which are typically more racially diverse and Democratic-leaning.
These preemption bills have removed authority from local governments over policy areas including minimum wage, COVID masking requirements, environmental rules, and even plastic-bag-recycling mandates. Legislatures have accompanied many of these bills with other measures, such as extreme gerrymanders, meant to dilute the political clout of their state’s population centers and shift influence toward exurban and rural areas where Republicans are strongest. In Tennessee, for example, the legislature voted to arbitrarily cut the size of the Nashville Metropolitan Council in half, a decision that a state court blocked this week. Many of the bills that red states have passed since 2020 making it harder to vote have specifically barred techniques used by large counties to encourage participation, such as drop boxes or mobile voting vans.
Republicans who control the Tennessee House took this attack on urban political power to a new peak with their vote to expel the two Black Democratic representatives, Justin Pearson and Justin Jones, who represent Memphis and Nashville, respectively. Though local officials in each city quickly moved this week to reappoint the two men, the GOP majority sent an ominous signal in its initial vote to remove them. The expulsions went beyond making structural changes to diminish the power of big-city residents, to entirely erasing those voters’ decision on whom they wanted to represent them in the legislature. Conservative legislatures and governors “have become so emboldened [in believing] that they can tread on local democracy,” Roy said, “that they are going all out and perhaps destroying the institution altogether.”
One of the most aggressive areas of red-state preemption this year has been in moves to seize control of policing and prosecutorial powers in Democratic-leaning cities and counties, which typically have large minority populations. In Georgia, for instance, both chambers of the GOP-controlled state legislature have passed bills creating a new oversight board that would be directed by state officials and have the power to recommend removal of county prosecutors. In Mississippi, both GOP-controlled chambers have approved legislation to expand state authority over policing and the courts in Jackson, the state capital,a city more than 80 percent Black. The Republican governor in each state is expected to sign the bills.
Tennessee legislators passed a bill in their last session increasing state authority to override local prosecutors. This week they went further. Although it didn’t attract nearly the attention of the expulsion vote, the Tennessee House Criminal Justice Committee on Tuesday approved a bill to eradicate an independent board to investigate police misconduct that Nashville residents had voted to create in a 2018 referendum.
In 2019, the GOP legislature had already stripped the Nashville Community Oversight Board of the subpoena power that was included in the local referendum establishing it. The new legislation approved this week, which is also advancing in the State Senate, would replace the board and instead require that citizen complaints about police behavior in Nashville and other cities be directed to the internal-affairs offices of their police departments. The legislation is moving forward just weeks after five former police officers were indicted in Memphis for beating a Black man named Tyre Nichols to death. “You would think that while the Tyre Nichols case is going on … that we would be really wanting more oversight, not less,” Jill Fitcheard, the executive director of the Nashville oversight board, told me. Coming so soon after the vote to expel the two Black members, the attempt to eradicate the oversight board, she said, represents “another attack on democracy in Nashville.”
Texas has joined this procession with bills backed by Governor Abbott and Lieutenant Governor Dan Patrick advancing in both legislative chambers to make it easier for state officials to remove local prosecutors who resist bringing cases on priorities for the GOP majority, such as the measures banning abortion or gender-affirming care for transgender minors.
But Abbott last Saturday introduced an explosive new element into the red-state push to preempt local law-enforcement authority. In a statement, Abbott directed the Texas Board of Pardons and Parole to fast-track consideration of a pardon for a U.S. Army sergeant convicted just one day earlier of killing a Black Lives Matter protester in 2020. Abbott, who had faced criticism from conservative media for not intervening in the case, promised to approve the pardon, and criticized the Democratic district attorney who brought the case and the jury that decided it in Travis County, an overwhelmingly blue county centered on Austin.
Although many Republicans are seeking ways to constrain law-enforcement officials in blue counties, Abbott’s move would invalidate a decision by a jury in such a Democratic-leaning area. And whereas the preemption legislation in Texas and elsewhere targets prosecutors because of the cases they won’t prosecute, Abbott is looking to override a local prosecutor because of a case he did prosecute.
Gerry Morris, a former president of the National Association of Criminal Defense Lawyers now practicing in Austin, told me that Abbott’s move was especially chilling because it came before any of the normal legal appeals to a conviction had begun. Morris said he can think of no precedent for a Texas governor intervening so peremptorily to effectively overturn a jury verdict. “I guess it means if you are going to kill somebody in Texas,” Morris said, “you need to make sure it’s somebody Governor Abbott thinks ought to be killed; because if that’s the case, then he’ll pardon you.”
The past week’s third dramatic escalation came from District Judge Matthew Kacsmaryk, an appointee of former President Donald Trump with ties to the social-conservative movement. Kacsmaryk’s ruling overturning the FDA’s approval in 2000 of mifepristone was in one sense unprecedented. “Never has a court actually overturned an FDA scientific decision in approving a drug on the grounds that [the] FDA got it wrong,” William Schultz, a former deputy commissioner of the Food and Drug Administration, said on a press call Monday.
But in another sense, the case merely extended what’s become a routine strategy in the red states’ drive to set their own rules. Nearly two dozen Republican state attorneys general joined the lawsuit in support of the effort to ban mifepristone. That continued a steady procession of cases brought by Republican-controlled states to hobble the exercise of federal authority, or to erase rights that had previously been guaranteed nationwide.
The most consequential example of this trend is the case involving a Mississippi abortion law that the Republican-appointed Supreme Court majority used to overturn Roe v. Wade last summer. But shifting coalitions of GOP state attorneys general have also sued to block environmental regulations proposed by President Joe Biden, and to prevent him from changing Trump-administration immigration-enforcement policies or acting to protect LGBTQ people under federal antidiscrimination laws. Red states “have been very interested in opposing virtually every rule or guidance that would provide nondiscrimination protection to LGBTQ people,” says Sarah Warbelow, the legal director for the Human Rights Campaign.
All of these legal and political struggles raise the same underlying question: Can Democrats and their allies defend the national baseline of civil rights and liberties America has built since the 1960s?
Democrats have found themselves stymied in efforts to restore those rights through legislation: While Democrats held unified control of Congress during Biden’s first years, the House passed bills that would largely override the red-state moves and restore a set of national rules on abortion, voting, and LGBTQ rights. But in each case, they could not overcome a Republican-led Senate filibuster.
The Biden administration and civil-rights groups are pursuing lawsuits against many of the red-state rights rollbacks. But numerous legal experts remain skeptical that the conservative U.S. Supreme Court majority will reverse many of the red-state actions. The third tool available to Democrats is federal executive-branch action, such as the Title IX regulations the Education Department proposed last week that would invalidate the blanket bans against transgender girls participating in school sports that virtually all the red states have now approved. Yet federal regulations that attempt to counter the red-state actions may prompt resistance from that conservative Supreme Court majority.
And even as Democrats search for strategies to preserve a common baseline of rights, they face the prospect that Republicans may seek to nationalize the restrictive red-state social regime. Congressional Republicans have introduced bills to write into federal law almost all of the red-state moves, such as abortion bans and prohibitions on classroom discussion of sexual orientation or participation in school sports by transgender girls. Several 2024 GOP presidential candidates are starting to offer similar proposals.
The past week has seen Republicans reach a new extreme in their effort to build a nation within a nation across the red states. But the next time the GOP achieves unified control of Congress and the White House, even this may seem like the beginning of an attempt to impose on blue states the rollback of rights and liberties that continues to burn unabated through red America.
President Joe Biden is following a strategy of asymmetrical warfare as the 2024 presidential race takes shape.
Through the early maneuvering, the leading Republican candidates, particularly former President Donald Trump and Florida Governor Ron DeSantis are trying to ignite a procession of culture-war firefights against what DeSantis calls “the woke mind virus.”
With the exception of abortion rights, Biden, by contrast, is working to downplay or defuse almost all cultural issues. Instead Biden is targeting his communication with the public almost exclusively on delivering tangible economic benefits to working-class families, such as lower costs for insulin, the protection of Social Security and Medicare, and the creation of more manufacturing jobs.
While the leading Republican presidential contenders are effectively asking voters “Who shares your values?” or, in the harshest versions, “Who shares your resentments?,” Biden wants voters to ask “Who is on your side?”
The distinction is not absolute. Trump, DeSantis, and the other Republicans circling the 2024 race argue that Biden’s spending programs have triggered inflation, and insist that lower taxes, budget cuts, and more domestic energy production would spur more growth. And in addition to their unwavering defense of abortion rights, Biden and his aides have also occasionally criticized some of the other Republican cultural initiatives, such as DeSantis’s “Don’t Say Gay” bill banning discussion of sexual orientation in early grades.
But the difference in emphasis is real, and the contrast illuminates the core of Biden’s vision about how to sustain a national majority for Democrats. He’s betting that the non-college-educated workers, especially those who are white, who constitute the principal audience for the Republican cultural offensive will prove less receptive to those divisive messages if they feel more economically secure.
“We need to reforge that identity as the party that gives a damn about people who feel forgotten, who have really tough lives right now,” says the Democratic strategist Mike Lux, who recently released a study of political attitudes in mostly blue-collar, midsize “factory towns” across the Midwest. “That’s the central mission. And that’s why I think Biden is right to be focusing on those economic issues first.”
But other Democrats worry that Biden’s economy-first approach risks allowing Republicans such as DeSantis to define themselves as championing parents while advancing an agenda that civil-rights advocates believe promotes exclusion and bigotry. They also fear that Biden’s reluctance to engage more directly with Republicans over the rollback of rights raging through red states risks dispiriting the core Democratic constituencies, including Black Americans and the LGBTQ community, that face the most direct consequences from restrictions on how teachers and professors can talk about race or bans on gender-affirming care for minors. These Democrats have grown even more uneasy as Biden lately has moved toward Republican positions on immigration (with new restrictions on asylum seekers) and crime (by indicating that he would not block congressional efforts to reverse a reform-oriented overhaul of Washington, D.C.’s criminal code.)
“Not engaging in culture wars does not mean that Democrats win: It means that we forfeit,” says Terrance Woodbury, chief executive officer and founding partner of HIT Strategies, a Democratic consulting firm that focuses on young and minority voters. The group’s polling, Woodbury told me, shows that “not only do Democratic voters expect Democratic leaders to do more to advance social and racial justice” but that “they will punish Democrats that do not.”
My conversations with Democrats familiar with White House thinking, however, suggest that Biden and those around him don’t share that perspective. In that inner circle, I’m told, the dominant view is that the best way to respond to the culture-war onslaught from Republicans is to engage with it as little as possible. Those around Biden do not believe that the positions Republicans are adopting on questions such as classroom censorship, book bans, LGBTQ rights, and allowing people to carry firearms without a permit, much less restricting or banning abortion, will prove popular with voters beyond the core conservative states.
More fundamentally, Biden’s circle believes that voters don’t want to be subjected to fights about such polarizing cultural issues and would prefer that elected officials focus more on daily economic concerns such as inflation, jobs, and health care. Those around Biden largely share the view expressed by the Democratic pollster Guy Molyneux, who studied public attitudes about key GOP educational proposals in two national surveys last year. “People don’t really want either side of these culture wars to win; they want to just stop having these culture wars,” Molyneux told me. “They really see a lot of this as a diversion.” A national survey released this week by Navigator, a Democratic polling consortium, supports Molyneux’s point: When asked to identify their top priorities in education, far more voters cited reducing gun violence and ensuring that kids learn skills that will help them succeed than picked “preventing them from being exposed to woke ideas about race and gender.”
Biden hasn’t completely sidestepped the culture wars. After mostly avoiding the issue earlier in his presidency, he’s been relentless in his defense of abortion rights since the Supreme Court overturned Roe v. Wade last summer. (Earlier this year, Vice President Kamala Harris commemorated what would have been the 50th anniversary of Roe with a speech in Tallahassee, Florida, where she targeted DeSantis’s signing of legislation banning abortion there after 15 weeks.) When DeSantis signed the “Don’t Say Gay” bill last year, the White House also criticized him. And most recently in Selma, Alabama, Biden has also issued tough criticisms of the red-state laws erecting new hurdles to voting.
The emphasis was very different in marquee appearances last weekend from Trump and DeSantis. Trump, in his long monologue on Saturday at CPAC, accused Biden of exacerbating inflation and promised to pursue an all-out trade war with China. But those comments came deep into a nearly two-hour speech in which Trump blurred the boundary between calling on his supporters to engage in a culture war and an actual civil war, when he promised to be their “retribution” against elites and “woke tyranny.”
When DeSantis spoke at the Ronald Reagan Presidential Library, northwest of Los Angeles, last Sunday, he delivered more of an economic message, attributing Florida’s robust population growth in part to its low taxes and low spending. But he drew a much more passionate reaction from his audience later when he denounced the “woke mind virus,” recounted his stand during the coronavirus pandemic against “the biomedical security state,” and pledged to “empower parents” against the educational establishment. DeSantis received his only standing ovation when he declared that schools “should not be teaching a second grader that they can choose their gender.”
To some extent, the heavy reliance by Trump and DeSantis on these cultural confrontations reflects their belief that GOP primary voters are much more energized now by social rather than economic issues. Yet it also represents the widespread GOP belief that distaste for liberal positions on cultural issues remains an insuperable barrier for Democrats with most working-class voters, including a growing number of Latino men. “Blue-collar voters don’t separate cultural concerns from economic fears,” the GOP strategist Brad Todd, a co-author of The Great Revolt, told me in an email. “They think big global companies are in cahoots with the left on culture, and they don’t put pocketbook concerns ahead of way-of-life concerns.”
Todd thinks Biden’s attempt to define himself mostly around economic rather than cultural commitments represents his desire “to jump in a time machine and go back to the Democratic Party of the ’80s.” Indeed, Biden, who was first elected to the Senate in 1972, came of age politically in an era when Republicans repeatedly used racially infused “wedge issues” to pry away working-class white voters who had mostly supported Democrats on economic grounds over the previous generation. Some Democrats see Biden’s recent moves to adopt more right-leaning policies on immigration and crime as a resurgence of that era’s widespread Democratic belief that the party needed to neutralize cultural issues, typically by conceding ground to conservative positions.
Like others I spoke with, Jenifer Fernandez Ancona, the vice president and chief strategy officer at Way to Win, believes that focusing primarily on economic issues makes sense for Biden now, but that he will eventually be forced to address the GOP’s cultural arguments more directly. Sublimating those issues, she argues, isn’t sustainable, because it is “hurting the very people” Democrats now rely on to win and because the Republican cultural arguments, left unaddressed, could prove very persuasive to not only working-class white voters but also Hispanic and even Black men. Ultimately, Fernandez said, Biden and other Democrats must link the two fronts by convincing working-class voters that Republicans are picking cultural fights to distract them from an economic agenda that mostly benefits the rich. “We have to put to bed this idea [that] we can have an economic message that doesn’t address the racial grievance and fear of change that is at the center of all this culture-war stuff,” argued Fernandez, whose group funds candidates and organizations focused on building a multiracial electoral coalition.
The debate among Democrats ultimately comes down to whether Biden is skillfully controlling the electoral battlefield or trying to resurrect a coalition that no longer exists (centered on working-class families) at the expense of dividing or demoralizing the coalition the party actually relies on today (revolving around young people, college-educated white voters, and racial minority voters). Several Democratic strategists told me that one obvious challenge with Biden’s trying to define the election around the question of which party can deliver the best economic results for working-class families is that polls throughout his presidency have found that more Americans would pick the GOP. “People still think that Trump economics was better for them than Biden or Obama economics,” Celinda Lake, who served as one of Biden’s lead campaign pollsters in 2020, told me.
To Lake, that’s an argument for Biden’s strategy of stressing kitchen-table concerns, because she believes the party cannot win unless it narrows the GOP advantage on the economy. But other Democrats believe today’s party is less likely to persuade a national majority that it is better than Republicans for their finances than it is to convince them that the Trump-era GOP constitutes a threat to their rights, values, and democracy itself. Biden’s response to the Republican initiatives censoring teachers, rolling back abortion access, and threatening LGBTQ rights “simply cannot be ‘more jobs,’” Woodbury said. “If Democrats insist on fighting exclusively on economic terms, every poll in America shows they will lose.”
The next front is rapidly emerging in the struggle between supporters and opponents of legal abortion, and that escalating conflict is increasing the chances that the issue will shape the 2024 election as it did last November’s midterm contest.
President Joe Biden triggered the new confrontation with a flurry of recent moves to expand access to the drugs used in medication abortions, which now account for more than half of all abortions performed in the United States. Medication abortion involves two drugs: mifepristone followed by misoprostol (which is also used to prevent stomach ulcers). Although abortion opponents question the drugs’ safety, multiple scientific studies have found few serious adverse effects beyond headache or cramping.
Federal regulation of the use and distribution of these drugs by agencies including the FDA and the United States Postal Service has long been overshadowed in the abortion debate by the battles over Supreme Court nominations and federal legislation to ban or authorize abortion nationwide. But with a conservative majority now entrenched in the Court, and little chance that Congress will pass national legislation in either direction any time soon, abortion supporters and opponents are focusing more attention on executive-branch actions that influence the availability of the pills.
“The reality of abortion care has been changing very, very rapidly, and now the politics are catching up with it,” Celinda Lake, a Democratic pollster who served as one of Biden’s advisers in 2020, told me.
Tens of thousands of anti-abortion activists will descend on Washington today for their annual March for Life—the first since the Supreme Court last summer overturned Roe v. Wade, the 1973 decision that established a nationwide right to abortion. The activists will cheer the swift moves by some two dozen Republican-controlled states to ban or severely restrict abortion since the Court struck down Roe.
But even as abortion opponents celebrate, they are growing more frustrated about the increased reliance on the drugs, which are now used in 54 percent of U.S. abortions—up dramatically from less than one-third less than a decade ago, according to the Guttmacher Institute, a research group that supports abortion rights. “With the overturning of Roe, [with] COVID, and with President Biden’s loosening of the restrictions on these [drugs] … there is a new frontier that everyone is pivoting to,” Rebecca Parma, the legislative director for Texas Right to Life, a prominent anti-abortion group, told me.
George W. Bush and Donald Trump, the two Republicans who have held the presidency since the drugs were first approved under Democratic President Bill Clinton, in 2000, took virtually no steps to limit their availability. But conservative activists are already signaling that they will press the Republican presidential candidates in 2024 for more forceful action.
“Our job is to make sure … this becomes an issue that any GOP candidate will have to answer and address,” Kristan Hawkins, the president of the anti-abortion group Students for Life of America, told me. “No one can be ambivalent again; it will simply not be an option.”
The challenge for Republicans is that the 2022 midterm elections sent an unmistakable signal of resistance to further abortion restrictions in almost all of the key swing states that tipped the 2020 presidential election and are likely to decide the 2024 contest. “Would you really want to be Ron DeSantis or Donald Trump running in a close election saying, ‘I’m going to ban all abortion pills in Michigan or Pennsylvania’ right now?” says Mary Ziegler, a law professor at UC Davis, who has written extensively on the history of the abortion debate.
Sunday is the 50th anniversary of the original Roe decision, and the Biden administration will mark the occasion with a defiant pro-abortion-rights speech from Vice President Kamala Harris in Florida, where GOP Governor DeSantis, a likely 2024 presidential contender, signed a 15-week abortion ban last April.
White House officials see access to abortion medication as “the next battlefront” in the larger struggle over the procedure, Jennifer Klein, the director of the White House Gender Policy Council, told me. She said she expects Republicans to mount more sweeping efforts to restrict access to the drugs than they did during the Bush or Trump presidencies. “The reason you’ve seen both Democratic and Republican administrations ensure access to medication abortions is because this is the FDA following their evidence-based scientific judgment,” she said. “So what I think is different now is you are seeing some pretty extreme actions as the next way to double down on taking away reproductive health and reproductive rights.”
Federal regulation of the abortion drugs has followed a consistent pattern, with Democratic presidents moving to expand access and Republican presidents mostly accepting those actions.
During the 2000 presidential campaign, for instance, George W. Bush called the Clinton administration’s initial approval of mifepristone “wrong” and said he worried it would lead to more abortions. But over Bush’s two terms, his three FDA commissioners ignored a citizen petition from conservative groups to revoke approval for the drug. Under Barack Obama, the FDA formalized relatively onerous rules for the use of mifepristone. Physicians had to obtain a special certification to prescribe the drug, women had to meet with their doctor once before receiving it and twice after, and it could be used only within the first seven weeks of pregnancy.
The FDA loosened these restrictions during Obama’s final year in office. It reduced the number of physician visits required to obtain the drugs from three to one and increased to 10 the number of weeks into a pregnancy the drugs could be used. The revisions also permitted other medical professionals, such as nurses, to prescribe the drugs if they received certification, and eliminated a requirement for providers to report “adverse effects” other than death. Trump didn’t reverse any of the Obama decisions. He did side with conservatives by fighting a lawsuit from abortion-rights advocates to lift the requirement for an in-person doctor’s visit to obtain the drugs during the COVID pandemic. But by the time the Supreme Court ruled for the Trump administration in January 2021, Biden was days away from taking office. Within months, women seeking an abortion could consult with a doctor via telehealth and then receive the pills via mail.
The paradox is that the impact of these rules, for now, will be felt almost entirely in the states where abortion remains legal. Obtaining abortion pills there will be much more comparable to filling any other prescription. But 19 red states have passed laws that still require medical professionals to be present when the drugs are administered, which prevents pharmacies from offering them despite the FDA authorization. And although the FDA has approved use of mifepristone for the first 10 weeks of pregnancy, medical professionals cannot prescribe the drugs in violation of state time limits (or absolute bans) on abortion. In terms of anti-abortion states, the Biden administration’s actions have had “basically no impact,” Greer Donley, a University of Pittsburgh law professor who studies abortion law, told me in an email.
Although the red states have largely walled themselves off from Biden’s efforts on medication abortion, conservatives have launched a multifront attempt to roll back access to the pills nationwide. Students for Life has filed another citizen petition with the FDA, arguing that doctors who prescribe the drugs must dispose of any fetal remains as medical waste. In a joint letter released last week, 22 Republican attorneys general hinted that they may sue to overturn the new FDA rules permitting pharmacies to dispense the drugs. In November, another coalition of conservative groups filed a lawsuit before a Trump-appointed judge in Texas seeking to overturn the original certification and ban mifepristone. Jenny Ma, the senior counsel at the Center for Reproductive Rights, says that decision could ultimately have a broader effect than even the Supreme Court ruling overturning Roe: “This case,” she told me,“could effectively ban medication abortion nationwide. It means people in every state … may not be able to get abortion pills.”
Republicans will also ramp up legislative action against the pills, although their proposals have no chance of becoming law while Democrats control the Senate and Biden holds the veto pen. Republican Senator Cindy Hyde-Smith of Mississippi is planning to reintroduce her “SAVE Moms and Babies Act,” which would restore the prohibition against dispensing abortion drugs through the mail or at pharmacies.
However these legal and legislative challenges are resolved, it’s already apparent that the 2024 GOP presidential field will face more pressure than before to propose executive-branch actions against the drugs. “That’s going to be our clarion call in 2024,” says Kristi Hamrick, a long-term social-conservative activist, who now serves as the chief strategist for media and policy at Students for Life.
Katie Glenn, the state-policy director at Susan B. Anthony Pro-Life America, told me that, at the least, the group wants 2024 Republican presidential candidates to press for restoring the requirement to report adverse consequences from the drugs. Former Vice President Mike Pence, a likely candidate, has already suggested that he will support a ban on dispensing the pills through the mail. But the anti-abortion movement’s long-term goal remains the same: ban mifepristone altogether. Hawkins shows the growing fervor GOP candidates will face when she says, “This pill is a cancer that has now metastasized throughout our country.”
Simultaneously, abortion-rights advocates are pushing the Biden administration to loosen restrictions even further. “Medication abortion … has been overregulated for far too long,” Ma told me. Many advocates want the FDA to extend permitted use of mifepristone from 10 to 12 weeks, eliminate the requirement that the professionals prescribing the drugs receive a special certification, and begin the process toward eventually making the drug available over the counter.
The immediate question is whether the Biden administration will challenge the red-state laws that have stymied its efforts to expand access. Advocates have argued that a legal case can be made for national FDA regulations to trump state restrictions, such as the requirement for physicians to dispense the drugs. But Biden is likely to proceed cautiously.
“We don’t have a lot of answers … because, frankly, states have not tried to do this stuff in hundreds of years,” Ziegler, the author of the upcoming book Roe: The History of a National Obsession, told me. Even so, she added, it’s a reasonable assumption that this conservative-dominated Supreme Court would resist allowing the federal government to preempt state rules on how the drugs are dispensed.
These mirror-image pressures in each party increase the odds of a clear distinction between Biden (or another Democrat) and the 2024 GOP nominee over access to the drugs. Democrats are generally confident they will benefit from almost any contrast that keeps abortion prominent in the 2024 race. Some, like Lake, see access to the pills as a powerful lever to do that. The issue, she argues, is relevant to younger voters, who are much more familiar than older people with the growing use of medication abortion and are especially dubious that pharmacies can offer certain drugs in some states but not in others.
The impact of abortion on the 2022 election was more complex than is often discussed. As I’ve written, in the red states that have banned or restricted the practice, such as Florida, Ohio, and Texas, there was no discernible backlash against the Republican governors or state legislators who passed those laws. But the story was different in the blue and purple states where abortion remains legal. In pivotal states including Arizona, Michigan, Pennsylvania, and Wisconsin, a clear majority of voters said they supported abortion rights, and, according to media exit polls, crushing majorities of them voted against Republican gubernatorial candidates who pledged to restrict abortion. Those Democratic victories in the states likely to prove decisive again in 2024 have left many Republican strategists leery of pursuing any further constraints on abortion.
What’s clear now is that even as abortion opponents gather to celebrate their long-sought toppling of Roe, many of them won’t be satisfied until they have banned the procedure nationwide. “It is totally unacceptable for a presidential candidate to say, ‘It’s just up to the states’ now,” Marilyn Musgrave, the vice president for government affairs at the Susan B. Anthony group, told me. “We need a federal role clearly laid out by these presidential candidates.”Equally clear is that abortion opponents now view federal regulatory actions to restrict, and eventually ban, abortion drugs as a crucial interim step on that path. The U.S. may seem in some ways to be settling into an uneasy new equilibrium, with abortion banned in some states and permitted in others. But, as the escalating battle over abortion medication makes clear, access to abortion in every state will remain on the ballot in 2024.
Paxlovid is a paradoxlovid. The game-changing antiviral swooped in during the pandemic’s worst winter with the promise of slowing COVID deaths to a trickle. But since it became widely available this spring, death rates have hardly budged.
According to the White House, the problem is not the drug but the fact that too few people are taking it. A recent CDC report found that from April to July, less than one-third of America’s 80-plus-year-olds with COVID ended up taking Paxlovid, even though they had the most to gain from doing so. What gives? Some Americans may be having trouble accessing Paxlovid, but clearly, a significant proportion of patients and doctors are just saying no to antiviral drugs. There are no national statistics on Paxlovid refusal, so I talked with physicians around the country to learn more about their motivations. Who are the anti-Paxxers, and how dangerous is their dogma?
First things first: Paxlovid hesitancy does seem to be political, but that’s not the whole story. As a rule, fewer prescriptions of the drug are given out per capita in red states than in blue ones: Wyoming, for example, appears to be the nation’s leading anti-Paxxer state, with just one course of treatment given out for every 125 residents; in Rhode Island, the most Pax-enthusiastic state, it’s one in 28. (I’m using courses of treatment per capita rather than per COVID case because of the general unreliability of case data these days and differences in testing and reporting practices among states.)
Still, clinicians working in deep-red parts of the country told me that, on this matter at least, their patients are not significantly divided by politics. “Republicans and Democrats both love Paxlovid,” says Jason Bronner, the medical director of primary care at St. Luke’s Medical System, in Idaho. Some 20 to 30 percent of his COVID patients decline to take the drug, he told me, but they don’t appear to be driven by the same polarized attitudes he sees around vaccines. Jessica Kalender-Rich, a geriatrician at the University of Kansas Health System, told me that she still gets occasional requests for ivermectin, and that some of her patients insist that COVID is a hoax. But the ones who outright refuse Paxlovid are not obsessing over microchips or government overreach. Instead, they mostly tell her that they’re worried about treatment side effects and rebound infections of the virus.
Rebound COVID came up again and again when I asked doctors why their patients are hesitant to take Paxlovid. The link between the drug and a return of symptoms after an initial recovery has been the subject of much concern and debate since the spring; just last week, researchers reported in a study that has not yet been peer-reviewed that symptom rebound is more than twice as common among Paxlovid takers than among those who decline it. The fact that so many prominent figures in the federal government—including President Joe Biden, First Lady Jill Biden, CDC Director Rochelle Walensky, and White House Chief Medical Adviser Anthony Fauci—have now had rebound certainly doesn’t help inspire confidence. One of Kalender-Rich’s patients specifically cited Fauci’s experience when refusing the drug. (The next day, the patient felt worse and accepted a prescription.)
Rebound may not be dangerous, but you have to admit that it doesn’t sound like a good time. “People will say, ‘I’d rather be really sick for four or five days than just kind of sick for two weeks,’” says Adam Fiterstein, the chief of urgent care at the New York medical network ProHealth. The threat of rebound might be especially scary for geriatric patients and their family, because it means spending more time alone. “For some of these older adults, that isolation time is actually way worse than the virus at this point in the pandemic,” Kalender-Rich said. Paxlovid mouth—a bitter, metallic taste that can last throughout the course of treatment—can also be a concern for the elderly, who may already suffer from lack of appetite or other issues that restrict their eating.
Drug interactions are another source of worry for the anti-Paxxers. Official COVID-treatment guidelines warn that the antiviral may have ill effects when combined with any of more than 100 other medications. Geriatric patients in particular might need to tweak their daily regimens of pills while under treatment with Paxlovid, Kalender-Rich told me. That’s hardly ever a problem medically, she said, but some people are still reluctant to make the change, especially if a previous doctor told them to never, ever skip a dose.
These potential downsides are extra salient for people who don’t fear COVID like they used to. The patients who refuse Paxlovid are the ones who are doing well, Bronner said: “They don’t feel totally sick and are not scared like they were in previous waves.” Hundreds of Americans are still dying daily from COVID, but any given community might have seen only a handful of severe cases and deaths since the spring. Many patients “don’t feel like they need to take a medicine, because their neighbor was fine,” Kalender-Rich said.
Doctors too can be anti-Paxxers. Hans Duvefelt, a primary-care physician in rural Maine, won’t prescribe Paxlovid to his patients. He told me via email that he avoids it on account of rebound risk, side effects, kidney concerns, and drug interactions. “Paxlovid is an inferior choice,” he said, when compared with molnupiravir, another COVID antiviral. To be clear, the data hold that molnupiravir is less effective than Paxlovid at preventing hospitalization and death. Also, a June preprint found that patients treated with molnupiravir rebounded at least as often as those treated with Paxlovid. Duvefelt did not respond to follow-up questions, so I couldn’t ask him about these data.
Other doctors believe in the good Paxlovid can do but still struggle with the decision to prescribe. “This is a much more nuanced risk-benefit discussion than giving somebody amoxicillin for strep throat,” Jeremy Cauwels, the chief physician at Sanford Health in South Dakota, told me. “If you’re looking at that as an ER doctor, who by definition has no follow-up with the patient, it’s very hard to say, ‘I’m going to give you a drug that interacts with lots of medications.’” Persistent uncertainty about exactly how much Paxlovid helps people who are up to date on their COVID shots doesn’t help.
Regardless of what’s causing Paxlovid hesitancy, the exact stakes are difficult to define. Last month, Ashish Jha, the Biden administration’s COVID-19 response coordinator, told The New York Times that daily deaths from the pandemic could drop by almost 90 percent if every COVID patient over the age of 50 were treated with Paxlovid or monoclonal antibodies. The doctors I spoke with mostly didn’t dispute this; Kalender-Rich said she “would believe a number closer to 75 percent” but agreed with the general sentiment. That said, none of the doctors I spoke with could point me toward any specific cases where one of their patients refused Paxlovid only to end up severely ill or dead. And no one knows how many deaths could be reduced specifically by attacking anti-Paxxer beliefs as opposed to, say, removing barriers to access and encouraging more testing.
Because anti-Paxxerism appears to be less organized and ideological than anti-vaxxerism, some favored strategies to combat the latter—targeting influencers on social media, for example—might not work. The doctors I spoke with said that the best venue for changing minds is the exam room. “It really comes down to a face-to-face conversation” about the risks and benefits of the drug, Cauwels said: “Our patients still trust us enough to have that conversation.”
Pax-hesitant providers, on the other hand, may just need a bit more time to feel convinced that the drug is safe and effective when used correctly; some may be waiting on more data from large, randomized clinical trials. “Across different parts of the country, adoption of new things is always going to be slower,” Kalender-Rich said. That’s not exactly a comforting thought when hundreds of people are still dying every day, but it does suggest, at the very least, that we have something to look forward to.
Even before Donald Trump announced he was seeking the presidency again, last week’s election results showed Republicans how difficult it will be to escape the former president’s gravitational pull.
Widespread voter resistance to a Republican Party refashioned in Trump’s image offset disenchantment with the economy and President Joe Biden’s performance and allowed Democrats to post one of the best first-midterm showings for the sitting president’s party in more than a century. In almost all the key battleground states, the same powerful coalition of voters who opposed Trump in the 2018 and 2020 elections delivered stunning rebukes to GOP candidates running with the former president’s endorsement or in his polarizing style, or both.
The results were much better for Republicans running in red states and districts. But for party strategists operating anywhere outside the most reliably conservative terrain, the election’s message was unequivocal. In those contested areas, “there is no road back to relevance if Donald Trump continues to be the dominant figure in the Republican Party and especially if he is our nominee in 2024,” Dick Wadhams, the former GOP chair in Colorado, told me.
Trump’s unusually early presidential announcement, though, made clear that he will not surrender his grip on the GOP without a fight. Last night’s announcement speech itself was instantly forgettable, a rambling greatest-hits collection of familiar priorities (building a border wall), bombastic descriptions of American carnage (“the blood-soaked streets of our once-great cities”), and well-worn grievances (“I’m a victim”) delivered with surprisingly little emotion or energy. He pointedly denied responsibility for the GOP’s disappointing showing last week, instead blaming “the citizens of our country [who] have not yet realized the full extent and gravity of the pain our nation is going through.”
Yet Trump’s greatest obstacle to a comeback may be the widespread belief among party leaders, donors, and key figures within conservative media that continued hostility toward him is the principal reason Democrats last week succeeded at holding the Senate, adding control of more governorships and state legislatures and minimizing their losses in the House of Representatives, even though Republicans are poised to capture a slim majority in the chamber.
Such a strong performance is exceedingly rare for the party in the White House during the president’s first midterm. Over at least the past century, it is unprecedented for that party to do so well when the president faces as much discontent as Biden does now. Since 1900, the only other examples of the incumbent party running at least as well as Democrats did this year came for presidents who were soaring in popularity, such as Franklin D. Roosevelt in 1934 (during the early New Deal), John F. Kennedy in 1962 (after he defused the Cuban Missile crisis), Bill Clinton in 1998 (amid the backlash to the Republican Congress’s moves to impeach him), and George W. Bush in 2002 (after 9/11).
This year, though, just 44 percent of voters nationwide said they approved of Biden’s job performance, while a 55 percent majority disapproved, according to the exit polls conducted by Edison Research for a consortium of media organizations. Biden, the exit polls found, did not receive majority support in any of the states with the most closely watched gubernatorial and Senate races, and in some of those states (including Nevada, Georgia, and Arizona), his approval rating barely peaked above 40 percent.
In the 21st century, as I’ve written, there are very few examples of Senate (and even gubernatorial) candidates from the president’s party winning elections in states where his approval rating had fallen that low. Yet Democrats rolled to unexpected victories in many of the key swing-state races, including Senate contests in Arizona, New Hampshire, Nevada, and Pennsylvania, and governor’s races in Arizona, Michigan, Pennsylvania, and Wisconsin. (Democrats also led in the Georgia Senate race heading for a December runoff between Democratic Senator Raphael Warnock and the Republican challenger, Herschel Walker.) In more reliably blue states, such as Washington, Oregon, Colorado, Minnesota, and New York, Republicans were uniformly frustrated in their hopes for breakthroughs in Senate and governor’s races (though the GOP did flip several New York House districts).
GOP governors did score decisive reelection victories in Republican-leaning states such as Florida, Georgia, and Texas. GOP Senate candidates also won in states with large populations of non-college-educated white voters (particularly Wisconsin, Ohio, and North Carolina). Exit polls showed GOP candidates continuing to benefit from the electoral advantages Trump has bequeathed them: dominant majorities among white voters without a college education, nonurban, and white Evangelical voters, as well as a higher floor of support among Latino voters, particularly men.
But the overall ledger showed more bright spots for Democrats. And given Americans’ broadly negative views on Biden and the economy, the only plausible explanation for that success is many voters’ unwavering resistance to the Trump-era GOP. Democrats successfully painted many Republican nominees (including most of the high-profile contenders Trump endorsed) as extremists, citing their opposition to legal abortion and refusal to acknowledge the legitimacy of Biden’s 2020 victory. Outside the conservative heartland, Democrats in most key statewide races maintained a winning edge among the groups that most resisted Trump: younger voters, college-educated white voters, people of color, and secular adults, with women in each group tilting more toward them than men.
Most striking, the exit polls found that Democrats carried a plurality of independent voters nationally and won them by bigger margins in most of the marquee contests. “I think, at the end of the day, our crazy was more repelling than their crazy,” Jason Cabel Roe, a Michigan-based GOP consultant, told me.
Nationally, nearly six in 10 voters said they had an unfavorable opinion of Trump, and they voted almost four to one for Democrats. Among independent voters, Trump’s national unfavorable ratings rose to two-thirds overall, nearly three-fourths among women. Among women especially, that was a far more negative rating than independents gave to Biden.
Election results showed that the white-collar suburban areas across blue and swing states that rejected Trump remained locked down against GOP candidates this year, even amid the pervasive discontent over the economy. In Pennsylvania, the Democratic candidate John Fetterman matched Biden’s elevated advantage over Trump in the big four suburban counties outside Philadelphia; Warnock did the same in the populous Cobb and Gwinnett Counties, outside Atlanta. In 2020, Biden became the first Democratic candidate since Harry Truman in 1948 to carry Maricopa County (centered on Phoenix and its suburbs) when he won it by about 45,000 votes; as of this morning, Senator Mark Kelly led there by nearly 100,000 votes. In Colorado, Senator Michael Bennet almost exactly matched Biden’s massive 2020 margins in Denver and its big surrounding suburban counties.
Especially striking was that these suburban areas broke as badly against GOP candidates who tried to define themselves as centrists, including the Senate nominees in Colorado, Pennsylvania, and Washington State.
In Colorado, the GOP nominated Joe O’Dea, a moderate, energetic candidate who explicitly distanced himself from Trump. Yet he too was swamped. To Wadhams, that pattern is a clear signal that in Democratic-leaning and swing states, virtually no individual Republican can wash off Trump’s stain on the GOP image.
Heading into the election, Wadhams told me, the key uncertainty in Colorado was whether “those vast numbers of unaffiliated voters who had voted so strongly Democratic and anti-Trump in 2018 and 2020 would … give strong Republican candidates a serious look in 2022,” now that Trump is no longer in the White House. On Election Day, he added, “I got my answer, and the answer was no.” The lesson, he said, “is that even among the unaffiliated voters who I thought we had a shot at, they ultimately said, ‘Those Republicans are still crazy; they are still in the hip pocket of Donald Trump.’”
House elections produced the same pattern. Republican House gains were concentrated in the least urban districts, where Trump has always been strongest, including sparsely settled distant suburbs and pure rural areas, according to an analysis by The Washington Post’s Philip Bump. But the GOP’s overall House success was constrained because the party still faced a virtual brick wall of resistance in the central cities and inner suburbs of the large metro areas that repeatedly rejected Trump: With about 10 races still to be called, Democrats have won 129 of the 140 seats in the three most urban districts, according to figures Bump provided to me.
Such disappointing results have led more GOP leaders than at any point in Trump’s political career to publicly declare that the party must now move beyond him. Trump will likely also face much more serious resistance from party elites and leading conservative media outlets. His announcement speech had a musty feel, which may preview the difficulty he could face convincing GOP voters that his day has not passed. And in Florida’s Governor Ron DeSantis, Trump could face a challenger more formidable than any he swept aside in 2016.
But, still, displacing Trump may not be so easy. Compared with the Democrats, the GOP presidential primary rules favor winner-take-all systems that benefit the candidate with the largest block of support, even if that’s less than a majority, Benjamin Ginsberg, the former chief counsel for the Republican National Committee, told me. That could benefit Trump because even if the disappointment over last week’s results shrinks his potential ceiling of support, he retains a dedicated floor among non-college-educated, nonurban, and evangelical white Republicans. In 2016, as I wrote at the time, Trump pulled away from the field to become the presumptive nominee at a point where he had not won 50 percent of the vote in any state and had captured only about 40 percent of all ballots cast.
A second challenge is whether anyone, including DeSantis, can consolidate the college- educated Republican voters most resistant to the former president. Some early 2024 polls already show Trump attracting only about one-third of Republicans holding a four-year degree or more. But that’s about as much support from them as he captured during the competitive stage of the GOP race in 2016; he won because he amassed a dominant advantage among non-college Republicans (many of whom are also evangelical Christians), while those with degrees splintered among many alternatives, such as John Kasich, Marco Rubio, and Ted Cruz.
That could easily happen again, particularly if candidates who position themselves as more centrist on social issues, such as Virginia Governor Glenn Youngkin and former Maryland Governor Larry Hogan, run. Both men are probably too moderate (or at least perceived that way) to win a GOP presidential nomination, but they could siphon away too many of the voters that a more viable alternative like DeSantis would need to overtake Trump.
Then there is the grueling practical reality of running against Trump, who has shown himself willing to say and do almost anything. In 2016, he bludgeoned Cruz and Rubio so relentlessly that they still seem broken in a manner reminiscent of Game of Thrones. DeSantis might fare better, but until someone actually runs against Trump, it’s impossible to guarantee that they can handle the jackhammer pressure. Nor is it clear that the donors and strategists who now insist that the party must move on from Trump will remain steadfast if he threatens to trash the nominee or run as an independent should he lose.
Another wild card is a possible indictment of the former president, from investigations by either the Justice Department or the Fulton County District Attorney’s Office into his efforts to overturn the 2020 election results in Georgia. An indictment could cause more Republican voters to reflexively rally around him. But it could also make some back away, either because his behavior offends them, or more likely, because they conclude that his legal troubles would further degrade his capacity to win a general election.
Last week’s results signaled plenty of vulnerabilities also for Biden, including the national-exit-poll finding that two-thirds of voters do not want him to run again. But if the 2022 election demonstrated anything, it is that many Americans who are disappointed in Biden will stand with him and his party nonetheless if the alternative is to entrust power to a Trump-era GOP that they view as a threat to their rights, their values, and democracy itself. That’s the ominous prospect for GOP officials in swing states nervously watching Trump storm into the party’s next presidential nominating contest.
If Republicans win control of one or both congressional chambers this week, they will likely begin a project that could reshape the nation’s political and legal landscape: imposing on blue states the rollback of civil rights and liberties that has rapidly advanced through red states since 2021.
Over the past two years, the 23 states where Republicans hold unified control of the governorship and state legislature have approved the most aggressive wave of socially conservative legislation in modern times. In highly polarizing battles across the country, GOP-controlled states have passed laws imposing new restrictions on voting, banning or limiting access to abortion, retrenching LGBTQ rights, removing licensing and training requirements for concealed carry of firearms, and censoring how public-school teachers (and in some cases university professors and even private employers) can talk about race, gender, and sexual orientation.
With much less attention, Republicans in the U.S. House and Senate have introduced legislation to write each of these red-state initiatives into federal law. The practical effect of these proposals would be to require blue states to live under the restrictive social policies that have burned through red states since President Joe Biden’s victory in 2020.“I think the days of fealty [to states’ rights] are nearing an end, and we are going to see the national Republicans in Congress adopting maximalist policy approaches,” Peter Ambler, the executive director of Giffords, a group that advocates for stricter gun control, told me.
None of the proposals to nationalize the red-state social agenda could become law any time soon. Even if Republicans were to win both congressional chambers, they would not have the votes to overcome the inevitable Biden vetoes. Nor would Republicans, even if they controlled both chambers, have any incentive to consider repealing the Senate filibuster to pass this agenda until they know they have a president who would sign the resulting bills into law—something they can’t achieve before the 2024 election.
But if Republicans triumph this week, the next two years could nonetheless become a crucial period in formulating a strategy to nationalize the red-state social-policy revolution. Particularly if Republicans win the House, they seem certain to explore which of these ideas can attract enough support in their caucus to clear the chamber. And the 2024 Republican presidential candidates are also likely to test GOP primary voters’ appetite for writing conservative social priorities into national law. Embracing such initiatives “may prove irresistible for a lot of folks trying to capture” the party’s socially conservative wing, Patrick Brown, a fellow at the conservative Ethics and Public Policy Center, told me.
It starts with abortion. Senator Lindsey Graham of South Carolina in September introduced a bill that would ban the procedure nationwide after 15 weeks of pregnancy. In the House, 167 Republicans have co-sponsored the “Life Begins at Conception Act,” which many legal analysts say would effectively ban all abortions nationwide.
In elections, Senator Rick Scott of Florida has proposed legislation that would impose for federal elections nationwide many of the voting restrictions that have rapidly diffused across red states, including tougher voter-identification requirements, a ban on both unmonitored drop boxes and the counting of any mail ballots received after Election Day, and a prohibition on same-day and automatic voter registration.
In education, Senator Tom Cotton of Arkansas has proposed to federalize restrictions on how teachers can talk about race by barring any K–12 school that receives federal money from using “critical race theory” in instruction. Several Republicans (including Senator Josh Hawley of Missouri) have introduced a “Parents’ Bill of Rights,” which would mandate parental access to school curriculum and library materials nationwide—a step toward building pressure for the kind of book bans spreading through conservative states and school districts. Nadine Farid Johnson, the Washington director for PEN America, a free-speech advocacy group, predicts that these GOP proposals “chipping away” at free speech are likely to expand beyond school settings into other areas affecting the general population, such as public libraries or private companies’ training policies. “This is not something that is likely to stop at the current arena, but to go much more broadly,” she told me.
Representative Mike Johnson of Louisiana, along with several dozen co-sponsors, recently introduced a federal version of the “Don’t Say Gay” legislation that Governor Ron DeSantis of Florida pushed into law. Johnson’s bill is especially sweeping in its scope. It bars discussion of “sexually-oriented material,” including sexual orientation, with children 10 and younger, not only in educational settings, but in any program funded by the federal government, including through public libraries, hospitals, and national parks.The language is so comprehensive that it might even prevent “any federal law enforcement talking to a kid about a sexual assault or sexual abuse,” David Stacy, the government-affairs director at the Human Rights Campaign, an LGBTQ advocacy group, told me.
Johnson’s bill is only one of several Republican proposals to nationalize red-state actions on LGBTQ issues. During budget debates in both 2021 and 2022, Republican senators offered amendments to establish a nationwide ban on transgender girls participating in school sports. Representative Marjorie Taylor Greene of Georgia has introduced a bill (the “Protect Children’s Innocence Act”) that would set felony penalties for doctors who provide gender-affirming care to minors. Cotton, in a variation on the theme, has proposed to allow any minor who receives gender-affirming surgery to sue the doctor for physical or emotional damages for the next 30 years.
Meanwhile, Senator Steve Daines and Representative Richard Hudson of North Carolina have introduced legislation requiring every state to accept a concealed-carry gun permit issued in any state—a mechanism for overriding blue-state limits on these permits. When Republicans controlled the House, they passed such a bill in 2017, but the implications of this idea have grown even more stark since then because so many red states have passed laws allowing residents to obtain concealed-carry permits without any background checks or training requirements.
Ambler told me he expects that the NRA and congressional Republicans will eventually seek not only to preempt blue states and city limits on who can carry guns, but also to invalidate their restrictions on where they can do so, such as the New York State law, now facing legal challenge, barring guns from the subway.
Brown, of the conservative EPPC, said it’s difficult to predict which of these proposals will gather the most momentum if Republicans win back one or both chambers. Some congressional Republicans, he said, may still be constrained by traditional GOP arguments favoring federalism. The strongest case for contravening that principle, he said, is in those instances that involve protecting what he calls “fundamental rights.” Graham’s national 15-week abortion ban can be justified on those grounds because “we are talking about, from my perspective, the life of an unborn baby, so having a federal ceiling on when states can’t encroach on protecting that fetus in the womb in the later stage of pregnancy makes a lot of sense to me.”
In practice, though, Brown thinks that congressional Republicans may hesitate about passing a nationwide abortion ban, particularly with no hope of Biden signing it into law. He believes they are more likely to coalesce first around proposals to bar transgender girls from participating in sports and to prohibit gender-affirming surgery for minors, in part because those issues have proved “so galvanizing” for cultural conservatives in red states.
Stacy, from the Human Rights Campaign, said that although Senate Republicans may be less enthusiastic about pursuing legislation restricting transgender rights, he hasn’t ruled out the possibility of a GOP-controlled Congress advancing those ideas. “It’s hard to know how far a Republican majority in either chamber would go on these issues,” he told me. “But what we’ve seen again and again in the states is that when they can, they have moved in these directions. Even when you take a look at more moderate states, when they have the power to do these things, they move these things forward.” That precedent eventually may apply not just to LGBTQ issues, but to all the red-state initiatives some Republicans want to inscribe into national law.
These approaching federal debates reframe the battle raging across the red states during the past few years as just the first act of what’s likely to become an extended struggle.
This first act has played out largely within the framework of restoring states’ rights and local prerogatives. As I’ve written, the red-state moves on social issues amount to a systematic effort to reverse the “rights revolution” of the past six decades. Over that long period, the Supreme Court, Congress, and a succession of presidents nationalized more rights and reduced states’ leeway to abridge those rights, on issues including civil rights, contraception, abortion, and same-sex marriage.
Now the red states have moved to reverse that long trajectory toward a stronger national floor of rights by setting their own rules on abortion, voting, LGBTQ issues, classroom censorship, and book bans, among other issues. In that cause, they have been crucially abetted by the Republican-appointed Supreme Court majority, which has struck down or weakened previously nationally guaranteed rights (including abortion and voting access).
But the proliferation of these congressional-Republican proposals to write the red-state rules into federal law suggests that this reassertion of states’ rights was just a way station toward restoring common national standards of civil rights and liberties—only in a much more restrictive and conservative direction. “All of these things have been building for years,” Alvin Tillery, the director of the Center for the Study of Diversity and Democracy at Northwestern University, told me. “It’s just that Mr. Trump gave them the idea they can succeed being more [aggressive] in the advocacy of these policies.”
Like many students of the red-state social-policy eruption, Tillery believes that Republicans and social conservatives feel enormous urgency to write their cultural priorities into law before liberal-leaning Millennials and Generation Z become the electorate’s dominant force later this decade. “The future ain’t bright for them looking at young people, so they are acting in a much more muscular and authoritarian way now,” he said.
With Republicans likely to win control of the House, and possibly the Senate, the next two years may become the off-Broadway stage of testing different strategies for imposing the red-state social regime on blue America. The curtain on the main event will rise the next time Republicans hold unified control of the White House and Congress—a day that may seem less a distant possibility if the GOP makes gains as big as those that now seem possible this week.
