Editor’s note, October 4, 8 am ET: We’re bringing you some of our best-loved Your Mileage May Vary columns while Sigal Samuel is on parental leave. The one below was originally published last year.

This unconventional advice column offers you a unique framework for thinking through moral dilemmas. It’s based on value pluralism: the idea that each of us has multiple values that are equally valid but that often conflict with each other. Submit your own question here.

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My partner and I did IVF recently and luckily we ended up with several embryos. One of those will be implanted in me so I hopefully get pregnant. But which one?

My fertility clinic is encouraging me to do PGT-A testing, which would screen for things like Down syndrome and would also let me see the sex of each embryo so I could potentially choose whichever I want. (And to be honest, I really want a girl!) I’m also hearing about these new companies that can test embryos for all kinds of things — like how smart the kid might be, how tall they’ll get, and whether they’ll have a lower chance of getting breast cancer, diabetes, mental illness, stuff like that.

I don’t know how to feel about any of this. On the one hand, it feels weirdly eugenics-y to do so much tinkering with embryos, and I can’t help feeling a little pressured into overmedicalizing everything with these expensive tests. But then again, if I could do something to make my baby healthier and happier, don’t I kind of have to do everything in my power? What does a parent owe their child?

Dear Expecting,

This is such an exciting — and also confusing — time. You’re about to have your first kid, and that comes with all sorts of fears and insecurities and hopes and dreams. You want to do the right thing — no, the best thing! — for your child. It’s a beautiful impulse. Unfortunately, it makes it easy for companies to prey on you.

So let me walk you through what these companies can and can’t really provide. After we talk about the science, we can talk about the ethics. 

The simpler test you mentioned, PGT-A, has been around since the 1990s. It can indeed screen for conditions like Down syndrome and let you see the sex of each embryo. Mind you, that doesn’t predict what gender your child will ultimately end up identifying with — more on that soon.

The newer testing you mentioned is called polygenic testing. The conditions it screens for are complex ones, influenced by thousands of genes. We’re talking about everything from breast cancer to depression. Some companies even offer screenings not for disease prevention, but for genetic enhancement — so you can select for a taller kid or a kid with higher IQ.

Polygenic testing companies claim to predict each embryo’s risk for each condition, and the potential reduction of risk you’ll get if you choose one embryo over another. As the statistical geneticist Sasha Gusev explains, it’s very, very easy to be misled by this claim. If the company claims to lower absolute risk of Type 2 diabetes by 12 percent, you might think this means, “The chance of my kid ever developing diabetes just went down by 12 percent — great!” But really what it means is that, all else equal, a kid who would’ve developed diabetes is likely now at the high end of pre-diabetes instead, or just develops diabetes a few years later. The same holds true for other conditions, like breast cancer. Sure, if your kid is going to develop diabetes or breast cancer, you’d rather they develop it later — but it’s not the bill of perfect health customers might imagine.  

“Typical risk reduction estimates tend to exploit statistical assumptions to overstate their benefits and lead to confusion,” Gusev writes.

It’s also important to note that there’s a difference between a physical disease like cancer, which is straightforwardly and universally negative, and a complex mental health condition like depression. For one thing, polygenic scores don’t perform as well in psychiatry, as the psychologist Eric Turkheimer notes. Plus, most mental health conditions come in mild to moderate to severe forms, and it’s not clear that we should want to get rid of mild or moderate manifestations. 

“Sure, it would be nice if no one ever got depressed, but what would that actually mean?” Turkheimer writes. “People are going to be sad, and the most modern models of psychiatric disorders view most of them as extremes on continuous dimensions of normal behavior. I don’t think we want some kind of genetic version of Soma.”

To give a personal example: I have generalized anxiety with some obsessive tendencies. Is that a major pain in the butt sometimes? You bet. But if I could wave a magic wand and get rid of it, would I? No. In my experience, this trait is linked to another trait I deeply value: my creativity. The same thing that propels me down rabbit holes of worry also propels me down rabbit holes of getting super curious about some topic, researching it into the wee hours of the morning, and then writing a novel or children’s book about it.

That brings me to one other scientific issue: pleiotropy. It’s a fancy term for a simple truth, which is that genes can have an effect on more than one trait. When it comes to behavioral polygenic testing, we actually know very little about which genes cause what — a gene that’s correlated with depression or anxiety may also be correlated with a bunch of other things. So, if everyone were to start selecting embryos to try to protect their kids from depression or anxiety, what would happen? We don’t know! 

Pleiotropy is a scientific issue, but it’s also a moral issue, because in trying to protect your kid from a negative outcome, you could also be accidentally barring them from a positive one.

And that’s just the tip of the moral iceberg.

Another issue is the potential psychological harm that can result from commodifying our kids — treating them like consumer objects with selectable parts. Let’s say you use polygenic testing to try to select for high IQ. Even if the company’s predictor is right 80 percent of the time, that means it’s wrong 20 percent of the time. What happens if it’s wrong about your kid, and they end up with a low IQ instead of a high one? How will your kid feel? Unless you hide the truth from them, they’ll know that they are not what you wanted, that they failed to live up to the vision you went out of your way to chase.

The same goes for sex selection via good old PGT-A. I know you really want a girl. But what would happen if you select for a girl, and then your child grows up and turns out to be trans? They may feel an extra sense that they’re letting you down by not conforming to the gender expectations you had for them.

Then there are the ethical questions around unequal access. Polygenic testing isn’t cheap. (One company, Orchid, charges $2,500 per screened embryo. Test 10 embryos and that’ll cost you $25,000.) So, at least in the short term, that raises the specter of entrenching a caste system, where the gap between rich and poor expands dramatically as the rich get smarter and stronger.

Technologies tend to get cheaper over time, so maybe everyone will ultimately be able to afford polygenic testing. But that raises another problem: implicit coercion. If more and more of us make ourselves smarter and stronger, we may create a society in which everyone feels pressure to alter their child’s biology — even if they don’t want to. To refuse embryo selection would mean to put a child at a huge professional disadvantage, or to face moral condemnation for making “suboptimal” kids when optimization is possible. Society may no longer offer health insurance benefits or accommodations for kids with disabilities (or even non-enhanced IQ), reasoning that “it was the parents’ choice.” 

Some philosophers, like Julian Savalescu, already argue that parents have a “moral obligation to create children with the best chance of the best life.” Polygenic testing companies love that argument; Orchid founder Noor Siddiqui tells parents that “the responsible decision” is to “protect their children” from disease, using language like, “What if you could have stopped it…but chose not to?” And we generally live in a culture that’s obsessed with optimization. 

So it’s no wonder that you find yourself asking, “If I could do something to make my baby healthier and happier, don’t I kind of have to do everything in my power?” 

It’s a view that will be very appealing to utilitarians, who believe the right action is the action that maximizes well-being or happiness. But maximizing principles can be dangerous. If we’re laser-focused on maximizing one value, however noble it may be, that can lead us to overlook a host of other important values. Think about diversity, for example; polygenic testing could lead to a less diverse world. 

And it’s not even clear how to maximize well-being given that each embryo will have some downsides: How would you choose between one embryo with a slightly elevated risk for schizophrenia, another with a moderately elevated risk for cancer, and a third with a high risk for Alzheimer’s? You’d have to decide how to rank the importance of each condition, which would require a dizzying bit of moral math: How much weight do you put on the longevity associated with each condition, how much on patient-reported quality of life for each condition, and how much on your own ability to cope with each — and society’s ability (which will change over the years)? Plus, even if the screening does end up optimizing life for your individual child, it could have negative effects on the population level, for the reasons we covered above.

As the Nobel laureate Herbert Simon pointed out, many problems contain way more variables and way too much uncertainty for maximizing along a single axis to be feasible or even desirable. So it often makes sense to just go with an option that’s “good enough.” He coined the term “satisficing” — a portmanteau of “satisfying” and “sufficing” — to describe opting for this good enough choice.

What would satisficing look like in the context of embryos? If there’s a very serious condition that runs in your family — like Tay-Sachs or the BRCA mutation that markedly increases cancer risk — then I do think there’s a strong case for screening for that. These conditions are debilitating and can lead to early death. Nobody wants them. Genetic testing that lets us prevent them is an awesome gift. 

Then there are conditions that can include suffering, like autism, but can also be very compatible with a happy life. Mental health conditions in particular are heavily socially constructed — a lot of the associated suffering comes about because society constructs a certain biological reality as a problem and doesn’t support the people who have it. In these cases, if you want to give your child a “good enough” or even “optimized” life, remember that you don’t have to achieve that by biological means; working to change the social environment can be just as important, and it doesn’t carry the societal risks associated with polygenic testing. 

Ultimately, when considering what counts as a “good enough” life, each parent will draw the line in a slightly different place. And there’s a part of that that can’t be boiled down to objective facts about disease, because this is also about how well-resourced the parent feels — emotionally, socially, and financially — to deal with a certain condition. What feels manageable to one parent may feel crushingly hard to another. 

So, I can’t tell you exactly which screenings to do and which to forgo. What I do want to tell you is to resist being bullied or shamed by others, especially those with a profit incentive to push you in a certain direction.

As the epidemiologist Abby Lippman has noted, genetic testing is supposed to offer parents more choice, but it too often has the opposite effect. When someone like Orchid’s Siddiqui says about a disease, “What if you could have stopped it…but chose not to?” — well, that language preys on parents’ worst fears and insecurities. It holds parents hostage while pretending to be giving them more autonomy. 

You are nobody’s hostage. You are a moral agent free to look at the many different relevant factors, weigh them all in the balance, and then make the choice that works well enough for your family.   

Bonus: What I’m reading

• Silicon Valley is obsessed with IQ, so it’s no surprise that tech execs there are using polygenic testing in hopes of creating supersmart babies. This article shows the kind of mental pretzels customers get into when trying to figure out whether to select the embryo with the highest predicted IQ or that with the lowest risk of disorders. One couple asks: “How much additional risk of ADHD cancels out against 10 extra IQ points?”

• Rereading “The Last Children of Down Syndrome,” Sarah Zhang’s 2020 Atlantic feature on prenatal testing, it struck me that when people think “prenatal testing,” Down syndrome is often the first condition that comes to mind, even though it’s not the most severe or straightforwardly negative (it’s compatible with a happy life). It’s just that Down syndrome was easy to test for, so we started testing for it early. I wonder if that built up the condition as a bogeyman in the expectant parent’s imagination — if the fact that we could screen for it shaped the public’s perception of Down syndrome as something that should be screened for and potentially screened out.

• One trait that many people assume we should select for is a great memory. But I highly recommend the short story “Funes the Memorious” by Jorge Luis Borges. It’s a reminder that having too good a memory is not always a benefit.  

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Think about what you’re wearing right now. Did you pick it out? Or was it chosen for you by an algorithm you haven’t even considered? 

You may think it’s the former, but with the state of the fashion industry, it’s likely the latter. There was a time when taste was decided by designers at luxury fashion houses, à la Karl Lagerfeld at Chanel, or Anna Wintour-type magazine editors (think of the famous cerulean sweater monologue from The Devil Wears Prada). Now, in the era of fast fashion, our clothing options are often dictated by computers. 

Amy Odell writes the Back Row newsletter and hosts a podcast with the same name. She told Vox that what’s known as fast fashion has been kicked into hyperdrive by companies like Shein. 

“I’ve also heard it called instant fashion,” she says. “The way it works is that they use algorithms to track trends and what people are interested in, and then they make a few hundred of a very large number of different items and they test demand.” She says this model has allowed companies like Shein to introduce around 4,700 new apparel styles per day. (For comparison, fast-fashion brand Zara produces around 20,000 a year.)

Some are trying to claw back their personal style by hitting the thrift store instead. Traditionally, it’s where people go to find less expensive clothes. But fashion journalist Hannah Marriott says it can be so much more than that. 

“For the last probably a hundred years, [the thrift store] has had lots of moments where it’s been cool within countercultures,” Marriott told Vox. “Whether it’s grunge, or the surrealists in the 1920s, or the Rolling Stones in the 1960s, secondhand clothing was cool because of the stigma.” 

So how did thrifting go from stigmatized to chic? And are thrift stores still thrifty now that they’re more mainstream, especially in an era of ultra-cheap Shein clothing? We find out that and more on the latest episode of Explain It to Me, Vox’s weekly call-in podcast. 

Below is an excerpt of my conversation with Marriott, edited for length and clarity. You can listen to the full episode on Apple Podcasts, Spotify, or wherever you get your podcasts. If you’d like to submit a question, send an email to askvox@vox.com or call 1-800-618-8545.

There’s sometimes this stigma that’s attached to buying secondhand clothes. How has its perception changed over time?

Secondhand clothing used to be something that there was a real sense that if you couldn’t buy new, you would buy secondhand. At the same time, it has had lots of moments where it’s been cool within countercultures. 

People within countercultures — whether it’s grunge, or the surrealists in the 1920s, or the Rolling Stones in the 1960s — secondhand clothing was cool because of the stigma. It’s also been a really important resource for people on lower incomes for a long time. 

I think it was a gradual shift by various things that happened in the pandemic, including this absolute influx of apps [like the RealReal and Depop] that got very, very popular during that time, particularly among younger Gen Z consumers. 

Thrifting became a social currency on social media platforms, especially on TikTok. It’s a vast ecosystem at the moment, and all of them have slightly different business models, slightly different fees that they charge, and slightly different audiences that they’re reaching. The stigma has really gone away, and it’s almost reversed.

What does that ecosystem look like?

There are different layers to it. There are consignment places like the RealReal where they take quite a big cut, but they will promote your items for you. I think those sites tend to work best if you’ve actually got designer clothes that have quite a big margin, particularly handbags. 

“I think maybe this is a reaction to 30 years of fast fashion just getting faster and faster and faster.”

Then there are other sites that are a bit more laid-back: eBay maybe skews a bit older, Depop skews a bit younger and trendier. There’s Vinted, which I know from the UK, but is making inroads into the US now. There’s ThreadUp as well. Poshmark. 

It’s an absolutely vast ecosystem at the moment, and all of them have slightly different business models, slightly different fees that they charge, and slightly different audiences that they’re reaching.

One of the biggest secondhand shops here in the US is still Goodwill. Can you walk me through how Goodwill has adapted and changed to the secondhand boom?

Neighborhood thrift stores of that kind are the sort of stores that people on lower incomes do rely on more. It’s less trend-led than something like Depop. And it is somewhere that people have often been going for decades to get clothes that they can afford. 

Goodwill undeniably has put its prices up. Inflation is such an issue for everyone, so I’m sure that there would be an element of prices going up anyway, but a lot of shoppers feel strongly that they’ve gone up a lot — that you can’t find bargains anymore, that the bargains get sent online to either their website or are bought by resellers who sell them for an inflated price online. 

It’s hard to get to the bottom of exactly how true all of that is, especially because Goodwill is run as 150 autonomous [nonprofits], and each of them set their own prices. But what I would say is you are seeing things like the Goodwill branch in Connecticut charging $75 bucks to go on a thrift tour coach to get early access to a Goodwill store, and then you get to go to another store. You used to be able to buy 10 things in Goodwill for $75.

It’s so interesting that thrifting used to be this edgy original thing, but it’s really gone mainstream. Has it sold out? 

I remember when I was much younger, people would say, “Ooh, you got that secondhand.” I just don’t think anyone would ever say that now because that’s kind of how we shop. 

But I still think it is great if you find something original that you love that no one else has, and I still think you’re more likely to find it secondhand or in certain other under-the-radar brands that aren’t fast fashion. 

I think maybe this is a reaction to 30 years of fast fashion just getting faster and faster and faster. I think we’re all feeling a bit tired of that business model, so we’re trying to find other ways to shop and express ourselves.

For many people, using AI chatbots is incredible at first. It makes them feel productive, confident, maybe even smarter. But later, there’s a hangover. Perhaps there are problems with their memory, or certain skills, like writing or coding, don’t seem to be as sharp as they once were. Maybe they feel like they can’t solve problems or make decisions or remember facts as well as they could before they had the help of AI. 

Susette Brooks, a marketing director living in Philadelphia, said she started using AI tools reluctantly but ultimately relented. She let AI write some of her emails, which lightened her workload, but then the dulling effects sank in. “I felt my writing and thinking decline as it was happening,” said Brooks, who has an MFA in nonfiction writing. “I had a harder time recalling information and synthesizing ideas.”

When you use external tools to reduce the cognitive effort required to do a task, you’re doing something called cognitive offloading. If you’ve ever used a calculator to do a math problem or used a calendar to remember an appointment, you’ve engaged in cognitive offloading. Tools like Claude and ChatGPT can do math problems and remember your appointments, but they can also write your term papers or create your work presentations. This is cognitive offloading at a scale we’ve never seen before.

Cognitive offloading isn’t necessarily bad. It’s actually what makes it possible for humans to be so productive. But as you outsource more and more cognitive tasks, you can start to become forgetful or see certain skills, like writing, start to decline. 

There’s a term for this: de-skilling. This is an old economics term that has emerged as a bit of a buzzword used to describe the perceived downward spiral of competency that’s accompanied the proliferation of AI tools. And it certainly sounds bad, especially if you’re a novice who needs to build skills. De-skilling can affect your critical thinking, your writing abilities, and your creative process. It can also affect your recall, as relying too heavily on AI tools can make it harder to remember things. 

Young people, at least, are worried about the long-term consequences of frictionless thinking. A recent survey by Gallup and researchers from the University of Pennsylvania found that 68 percent of Gen Z adults in the United States are concerned that offloading too many cognitive tasks is robbing them of important skill-building. About the same percentage of those surveyed worry that AI discourages them from critical thinking and social learning. Some 37 percent of US adults under 30 say that AI will have a negative effect on them personally, according to a Pew Research Center study published in June. And yet, more than half of Gen Z Americans use AI on a weekly basis. 

The paradox of AI is that, even if we feel like using these tools is bad for us, saving time and avoiding the friction of thinking is too tempting. We’re hardwired to seek out the path of least resistance, according to Daniel Willingham, a psychology professor at the University of Virginia, because cognitive activity is so taxing, and may or may not get you to the right solution. Memory, on the other hand, is efficient and effective — you know that something worked in the past, and it will work again.

“Our mind is really set up to save you from having to think,” Willingham told me. “Thinking is what you do when you’re in trouble.”

The good news is that experts say it’s possible to use AI in a way that helps you save time and protects your cognitive abilities instead of diminishing them. Here’s their advice.

It’s not your imagination — too much AI use can erode your skills over time

Derek Salyers, a content creator in Ohio, started using AI to get more done, faster. But over time, two things happened. First, the work got worse. “A lot of what I was putting out became AI slop, for lack of a better term,” Salyers told me. And then, his brain got worse, too. 

“When you get used to the AI making the decision, you stop pausing to actually think about things,” Salyers said. “And if you were never really present with it, you don’t remember it later. I wasn’t forgetting things because my memory got worse; I was forgetting because I was never really thinking in the first place.”

This effect is showing up in classrooms, too. One study of nearly 1,000 high school students found that those using ChatGPT scored 48 percent higher on a math test than their peers who didn’t have access to the AI tool. But when they were tested again without the chatbot, their scores were 17 percent lower than the students in the control group who had never had ChatGPT access. Similarly, researchers at the University of California Irvine looked at longitudinal data from online tests starting in 2015, and found that students spent less time and performed better on the text-based questions after the introduction of ChatGPT. (ChatGPT is very good at helping with text-based questions.) But when those students were later given offline tests, without the ability to use AI help, they performed worse. 

All of these students, it appears, were offloading the cognitive work to AI, which provided short-term gains. But in the long term, their thinking skills suffered.

Your basic cognitive abilities, like your working memory and selective attention, are quite resilient.

Evan Risko is a psychology professor at the University of Waterloo in Canada who co-authored the foundational paper on cognitive offloading a decade ago. He recently told me there’s not a lot of research into what’s going on in our brains when we’re cognitive offloading, but scientists are gaining a pretty clear picture of the pros and cons of doing it. The advantages vary depending on the task, but in general, cognitive offloading allows us to extend our imperfect memory systems, which you’ve probably done if you’ve ever set a reminder for yourself. The downside, Risko said, comes in offloading mental processes that are important. “Then we risk compromising our cognitive performance,” he said.

Your basic cognitive abilities, like your working memory and selective attention, are quite resilient. But as Risko and his colleagues explained in a paper this year — bluntly titled “Is AI making us stupid?” — other skills, like doing arithmetic and flying planes, are learned behaviors. You first have to acquire them and then, in order to retain them, you have to practice. AI use can compromise both the acquisition and retention of these skills — and people might not even realize this is happening to them, because AI makes them believe they’re more capable than they really are.

“People may have difficulty realizing that their skills are decaying or that they are failing to learn when using AI tools because the output and their performance with AI is at a high level,” said Brooke Macnamara, a psychology professor at Purdue University who co-authored the “Is AI making us stupid?” paper. “They may not realize that if the AI tool were unavailable how low their independent performance might be.”

Be intentional about the tasks you use AI for

The most important step to preserving your cognitive performance is to ask yourself if you should be using AI for a given task at all.

“Just because AI is a tool that’s available to us and it can accomplish a lot of tasks for us, it doesn’t mean that we should always use it,” Anjali Singh, a human-AI interaction researcher at the University of Texas at Austin, told me. Writing, for example, is something that a lot of people are now using AI for. But offloading that work means that you lose out on the independent thinking and reasoning that goes into expressing your thoughts. You also miss the chance to improve your writing skills if you don’t actually write. 

“We keep outsourcing these kinds of skills to AI over time and do not engage in those activities ourselves, then the de-skilling occurs,” Singh told me. “And that is I think probably one of the main reasons people could be feeling that they’re getting dumber as they’re using AI over time.”

“We are not getting these moments to reflect.”

Anjali Singh, Univeristy of Texas

It might seem counterintuitive, but it’s actually best to use AI for things you’re already pretty good at, the tasks you’re fully capable of performing yourself. A recent working paper by MIT economist David Autor and his colleagues (note: Several of them work for Google, who funded the study) describes how giving AI tools to 133 patent lawyers and then taking away those tools led to different outcomes, depending on the lawyers’ level of experience. All lawyers saw performance gains while using the AI tools, but those gains disappeared for the younger lawyers when the tools went away. Experienced lawyers, however, performed better afterward than their counterparts who never had access to AI tools. 

A similar effect showed up in a recent experiment by Middlebury College researchers. In the first session, more than 200 undergraduates learned about an unfamiliar topic and then wrote an analytical essay, some with the help of an off-the-shelf AI tool. They performed a similar test a week later, except this time none of the students had access to AI. The students who had AI access improved across the board, but what’s telling is that there appeared to be two types of AI users: augmentation users, who used AI to improve their work, and automation users, who just had AI do the work for them. The augmentation group performed better than everyone.

“Using AI to deepen or develop one’s own thinking on or understanding of a topic, rather than letting AI do all of the thinking, seems like the best way to use these tools,” Lauren Richmond, a cognitive science professor at Stony Brook University in New York, told me.

Tell your chatbot to treat you like a student

If you, like me, have ever fallen down a rabbit hole while trying to understand the geopolitical nuances that led to the outbreak of World War I and ended up staring blankly at a mountain of text feeling more confused than when you started, you know that using AI to learn doesn’t always go as planned. You may have also had the experience of writing prompts or asking questions and then receiving a long, overly detailed response. That can initially seem satisfying, but it’s often too much text to digest at once, so maybe you ask another question — and get back another wall of text. 

Older ways of accessing information, like reading books or even using Google to do research, happened more slowly, and that gave us time to process the information, Singh from UT Austin said. But that’s gone now. “We are not getting these moments to reflect,” she said.

If you find yourself drowning in content, that’s also a sign that you’re probably not expert enough in the material, or you’re not being intentional enough about your approach. 

It starts in the settings. Here, you should explain that you’re trying to build skills, not offload them, and instruct the AI to challenge you and engage with you. If you’re using ChatGPT, you can plug in custom instructions by going into the personalization tools. Claude has similar options called Instructions for Claude. 

If you’re explicitly trying to learn something new, you might also try some of the tools these companies have designed for this. OpenAI has study mode in ChatGPT. Anthropic offers Claude for Education. Google has Gemini for Students. Instead of simply providing answers, these tools act more like tutors, by asking questions, working through problems, and encouraging you to come up with solutions on your own.

Slow down and embrace friction

Something that’s both tempting and dangerous about AI is how fast it can do work. Vibe coding an app can take minutes, rather than days of manual coding. That’s very appealing if you have too much on your plate and want to get through it all quickly.

“The workload was so heavy and crazy, you have no time to think,” Joei Chen, a former brand director at a tech company, told me. “So you just throw stuff into AI and say, ‘What do you think?’”

At the same time, creating more code does not necessarily lead to more finished software, according to a recent Wharton School study. That increased productivity also doesn’t necessarily lead to happier workers. And the faster you move, the more critical thinking you’re going to offload. “Your boss asks you, ‘What does Claude think of this?’” Chen said, so AI “inadvertently becomes the final boss.”

Slowing down and forcing yourself to do more critical thinking is an easy way to hold onto some agency — not to mention some brain power. One easy way to do this is to make your interactions with AI more collaborative than transactional. For example, if you are going to use AI to help you write something, ask for five options of a draft instead of one, and then read each of them yourself and decide which is the best.

“Ask for feedback, hints, examples, explanations, advice, practice questions.”

Evan Risko, University of Waterloo

“Just the simple act of comparing things stimulates a great deal of the critical thinking processes that we kind of care about,” said Advait Sarkar, an AI researcher at the University of Cambridge, “and has beneficial effects for things like developing your judgment, your own awareness of what you don’t already know, and stimulating your recall.”

The word that came up again and again as I talked to experts about how to use AI without getting dumber was metacognition, or thinking about thinking. A lot of AI users let metacognition take a back seat to whatever content is flowing freely from a chatbot. And it can happen fast. 

While letting AI do all of the thinking for you is tempting, Matt Beane, an associate professor at the University of California Santa Barbara and author of The Skill Code: How to Save Human Ability in an Age of Intelligent Machines, told me that approaching AI this way “is your worst enemy.” To counteract this, you have to introduce more friction.

“You must be very aggressive about how you experiment with it,” Beane said. Risko, the cognitive offloading expert, echoed this advice. “Ask for feedback, hints, examples, explanations, advice, practice questions,” he said.

The best test for judging whether you’re offloading too much thinking to AI and the technology is chipping away at your skillset: Stop using AI and use your brain, and see what happens. You don’t have to stop forever, but you should, for example, spend a day writing emails without AI’s help to see if you’re as fluent as you used to be. Or revert to using Google for research and confirm that you can still find facts without a chatbot finding them for you. Build an app with your own code and see if it flows naturally. 

You might be troubled to find that AI made you worse at something. But you’re not actually dumber than you were before, and you can rebuild your lost skills the old-fashioned way: read, write, do arithmetic. If something requires thinking, go ahead and think.

In October 2024, students at Cornell University received a campus crime alert about a reported sexual assault. At the time, it was just a campus story. Nearly two years later, on September 16, the victim, known only as “Jane Doe,” filed a civil lawsuit that brought national attention to her story. People across the country are asking what happened and why criminal charges never followed. 

Doe alleges that seven men drugged and sexually assaulted her at the Chi Phi fraternity house two years ago. Her lawsuit also accuses the university, fraternity and sorority organizations, and a local bar of failing to protect her. 

The lawyers for several of the men have denied the allegations and any wrongdoing. Cornell says its disciplinary actions led to suspensions and expulsions for some of the young men, and that the Chi Phi fraternity remains barred from campus. 

Doe went to campus police in November 2024, and the district attorney’s office reviewed her account and declined to bring charges. Tompkins County District Attorney Matthew Van Houten has said that what she described to Cornell police didn’t meet the state’s requirements for criminal charges. 

Van Houten reopened the investigation late last month while continuing to defend his original decision to not pursue charges, but it’s now out of his hands: On Thursday, New York Gov. Kathy Hochul named the state attorney general, Letitia James, as special prosecutor to investigate the allegations, saying she had “lost faith” in Van Houten. 

To break down why Van Houten didn’t pursue the case at the time and what should have happened instead, Today, Explained co-host Noel King spoke with Lauren Hersh, a former Brooklyn prosecutor who led the office’s sex trafficking unit and CEO of World Without Exploitation, about how authorities handled Jane Doe’s allegations, the limits of New York’s consent laws, and what needs to change. 

Hersh also explains where she believes the case should go next and what a special prosecutor can do to investigate (the interview took place prior to James’s appointment). 

Below is an excerpt of Hersh’s conversation with Noel edited for length and clarity. There’s much more in the full podcast, so listen to Today, Explained wherever you get podcasts, including Apple Podcasts, Pandora, and Spotify.

I want to start with what we know in 2024. A young woman who we know as “Jane Doe” goes to the Cornell campus police and says she had gone to a frat house while under the influence of alcohol. 

At the frat house, she was given more alcohol and ketamine. Several men had sex with her while she was intoxicated. This is what she tells Cornell campus police. What, in your view, is supposed to happen next? 

There are a number of things that could happen. What I would say about these cases is there is no perfect scenario of what is supposed to happen, because what is critically important is we listen to the desire of the survivor. 

We want to take this at her pace. We want to be guided by her wishes. We want her to decide if she is ready to go forward, if she wants to speak to campus police, the Title IX office, if she wants to speak to the local law enforcement. There are a lot of variables here, but for me, what is critically important is that we’re listening to the survivor and what she ultimately wants to happen. 

In the present day, the district attorney who was involved has said that his office reviewed Jane Doe’s statement at the time and found at the time that what she described didn’t meet the legal definition of a crime. 

I think people want to understand, Lauren, how is that possible? 

To be really candid with you, Noel, this is an area that seems super unclear to me because the role of the district attorney in that moment is to investigate. 

When you first get a case file, you first get a victim statement, and especially with facts as horrific as these facts are, or our understanding of this six-page document that the DA read — I would never say that this is a clear-cut case where there’ll be a conviction at the end. We never know that. 

What I can say with 100 percent certainty is if you get a document like that, as a prosecutor, that is a significant investigative lead. And so, as a prosecutor, what I believe to be good practice is starting to pull the layers back, trying to understand what transpired here. Interviewing the victim. That feels critical. That never happened. We now know that there are all these text messages that were shared between these boys, and the prosecutor’s now saying, “I didn’t know about the text messages.” 

It’s my understanding that there were a lot of boys on that particular text thread. And so a good investigator would have gone to that fraternity house and tried to interview some of those boys, tried to understand what were the contemporaneous statements made at that time. Were there any text messages? Was there any social media activity? And I believe that had they done that in a timely fashion, they likely would have come up with these text messages at that time and not two years later.

What you’re saying is interesting because the DA has come out publicly and defended himself by saying, essentially, the details of this lawsuit, which was filed in September of this year, are different from the details in the young woman’s 2024 statement to the police. 

He has used that in his defense, right? “Here’s what I knew at the time versus what this young woman is saying today.” I think I hear you saying that maybe that’s not an excuse?

You’re asking about the inconsistent statements, and I find it troubling that the DA is leading with this notion that the victim has inconsistent statements because that feels to me like here we are making excuses and blaming the victim. 

To my knowledge, the DA has not yet interviewed this victim. Perhaps he’s talking about the civil complaint, which I would think is written in a way where she has worked with her lawyer to put this together. And the initial statement, the initial six-page document that the DA read, my understanding is that it is basically a summary of a conversation. 

Inconsistencies come in all shapes and sizes, so it’s hard to know exactly what we’re talking about here, but it is very common for there to be some inconsistencies. That is not a dealbreaker, despite the fact that this prosecutor wants the public to believe that it is. 

What do you make of the prosecutor speaking publicly in the way that he is at this moment?

I find it rather confusing. I’m not really understanding why he is doing a media tour rather than sitting in his office doing the work, interviewing this particular victim, interviewing witnesses, seeing what evidence actually exists.

It seems to me that the DA has gotten to a conclusion before he’s done the work in actually investigating the case, and it is deeply troubling. And I think the governor should consider appointing a special prosecutor because I am not certain, based on this media tour, that this DA is able to give this particular survivor a full and fair investigation of the facts. 

Drugs and alcohol are central to this case, right? The young woman admits she had been drinking and she was using ketamine. Under New York law, how does that affect whether or not someone is believed to be capable of consenting to sex? 

New York law is actually really problematic here. It’s a place where I believe we are desperate for a legislative fix. I think that there have been a lot of advocates who’ve been championing a correction to this voluntary intoxication loophole for a lot of years, and we’ve not been able to get it. 

New York law makes it very, very hard to prosecute a person when the victim is voluntarily intoxicated, but not unconscious, and this new law would allow the prosecutors the ability to bring cases when the victim is so severely intoxicated but not physically helpless and where a reasonable person should have known the victim’s condition. 

In this particular case, based on what we’re hearing, she was in a condition where a reasonable person should have known her condition. And so in this particular instance, the DA is right. This is a very, very hard case to prove in this moment, but I’m a big believer. We don’t not prosecute cases because they’re hard cases. But at the same time, we know that a change to the law is critically important. 

You clearly want more investigation here. What questions do you want asked? Who do you want to be [interviewed]? 

Before I say who and how and what that investigation looks like, I think it’s really important to say that when two years have passed and the DA did not investigate these cases immediately, we have a big problem on our hands.

The fact that the DA did not investigate this from the moment he found out about this, it’s really problematic because as we know, evidence disappears, memories fade. When you’re dealing on a college campus with a specific culture, there may be a narrative that takes hold. And so it’s important to talk about the time lapse and how that harms the case. 

That said, I still believe that the investigation is critically important. I don’t believe that this DA is the right person to do the investigation. I think a special prosecutor should be appointed. And then I think that the prosecutor and law enforcement should be interviewing everybody who was in that fraternity on that night. Anybody who saw this victim before, saw this victim after. Were there any statements in the immediate aftermath of her leaving that fraternity? Was there an outcry witness? We know that some text messages have come to light. Are there other text messages? I suspect that there are. 

I’d want to interview as many of those boys as possible to understand what was going on because some of those text messages that have come to light — one says, “Free pussy” — don’t sound like a mindset that is engaging in consensual sex. 

I think it is critically important that we understand all of the correspondence of that night. I think we want to see what is out there that helps us get closer to understanding what transpired that night. 

I’ve seen two lines of thinking about this. One is that this is a horrific incident that never should have happened, but it is in some ways singular. But I’ve seen another line of thinking that says, “No, this is a systemic failure. This kind of thing goes on on college campuses, and the steps that follow the outcomes are often the same.”

I wonder if you think this is a systemic failure, and if you think it is, what would need to be done to fix this problem? 

That’s a big question. I do think it’s a systemic failure. I also think it’s a cultural failure. And the reason that I would say this is because I don’t think this is isolated to this specific college campus. I think that sexual assault is happening across the country on college campuses everywhere.

In terms of additional systemic failures, I’ve been working with the Epstein survivors for the last year and a half, so I’ve seen so many systemic failures, so many prosecutorial failures, so much failure with law enforcement. I think that this is yet another example of prosecutorial failure. 

I think the law enforcement failed this young person — the fact that there’s no investigation that happened immediately in the aftermath of this incident, no investigation. We just continue to fail survivors all over the place, and we have to start doing better.

This story appeared in Today, Explained, a daily newsletter that helps you understand the most compelling news and stories of the day. Subscribe here.

Hi readers, happy Friday! It’s been a big week for the AI debate — not the one about whether it will cause the robot apocalypse, though there’s still plenty to worry about there, but instead about whether the technology is conscious. 

The folks at Anthropic, the AI company behind the large language model Claude, certainly seem to think it is — or at least, they’re extremely open to the possibility. 

As the New York Times reported earlier in the week, the company has spent the last year grappling with the question by speaking with religious thinkers from many faith traditions in an effort to chart a moral course for the LLM (that is, to keep it from killing us all, so maybe it is all one big debate). 

In the process, the Times reports, some of those thinkers observed that members of the Anthropic team were “relating to [Claude] like a conscious being” and even, according to it, a degree of “moral status.” 

On the flip side of this debate is Pope Leo XIV, who decidedly does not seem to buy into AI consciousness arguments. His “Magnifica Humanitas” encyclical earlier this year argued that AI will never be able to replace humanity — and reportedly “alarmed” Anthropic’s co-founder, Christopher Olah.

Since then, Pope Leo has continued to emphasize the differences between humans and machines this week. “There is an ontological difference, even before an aesthetic one, between art and what a machine can generate through statistical calculation based on millions of images created by others,” he posted on Friday. “Algorithms lack the spark of humanity.”

Loneliness machines

Conscious or no (and that’s a no from me), it’s hard to argue that tech companies don’t want you to interact with their models like people. That includes OpenAI and Meta, both of whom introduced “cute” new AI agents — called Dots and Muse, respectively — last month. 

As my colleague Adam Clark Estes reported this week, though, the promise of a companionable, always-there AI might not be the best idea in the world — especially for children. A new study, still under review, suggests that AI use may be causing loneliness in middle schoolers. 

Adam spoke with the lead researcher on the study, UNC Chapel Hill professor Anne Maheux, who explained that “middle school students using AI for emotional intimacy and companionship developed greater loneliness over time.” 

According to Maheux, one big point where AI chatbots fail compared to human beings is “friction,” or the complicated push-and-pull dynamic of any connection with a real human being. By contrast, chatbots are “sycophantic, highly agreeable, anthropomorphized,” she says, which can lead to kids “developing expectations or understandings of interactive relationships that are actually fundamentally at odds with a normal human relationship.”

People, in other words, still matter, no matter how much the AI companies want us to build our lives around machines instead.

One link for later

➨ Why is horror so fun? It’s October, which means you might be planning a horror movie marathon or a trip to a haunted house/forest/corn maze/what have you in the near future. It’ll probably be a great time — but why? Terrifying yourself doesn’t intuitively sound like fun, but humans love to seek out frights, whether that means ghost stories or a rollercoaster. In 2024, Vox’s Unexplainable podcast spoke with some researchers trying to figure it out.

Before you go…

• Did you know…that Disney’s “Magic Kingdom” in Florida is way, way better than most of the US at managing a complex network of underground cables and pipes? My colleague Sara Herschander dug into why, and whether other American cities can catch up.
• Today’s trivia: What musical note is equivalent to a G sharp? (You can find this and other brain puzzles in Vox’s daily crossword. Look for the answer in Monday’s edition.)
• Yesterday’s trivia: Yesterday, we asked you which constellation contains the North Star and the Little Dipper. That would be Ursa Minor, the Little Bear. 

“In what world,” New York Gov. Kathy Hochul asked on Friday, “would the police learn from a victim that she’d been literally gang raped while she was intoxicated by five men in a fraternity house and not elevate those allegations to the district attorney?” 

Hochul was speaking about the case of a former Cornell student who said she was raped by several members of the university’s Chi Phi fraternity in 2024. At the time, the district attorney filed no criminal charges.

The case has rocked the nation and forced a renewed reckoning over how sexual assault is dealt with in higher education. While the district attorney has defended his handling of the case, many politicians and legal experts are now examining whether certain details of the alleged victim’s account were neglected, and prosecutors have reopened the case.

Amy Wang is a staff reporter at the Washington Post who’s been covering the story over the past week. She spoke with Today, Explained co-host Noel King about what allegedly happened on the night in question, what happened afterward, and what we still don’t know. 

Since the two spoke, New York state Attorney General Letitia James has also been assigned to oversee the case and said it is now “an active criminal investigation.” As new information comes to light, further legal action could be taken. 

Below is an excerpt of the conversation between King and Wang, edited for length and clarity. There’s much more in the full podcast, so listen to Today, Explained wherever you get podcasts, including Apple Podcasts, Pandora, and Spotify.

In October of 2024, a young woman went to a fraternity house near Cornell University’s campus. Who is this young woman, and why did she go to the frat house that night?

The young woman is only identified in documents as Jane Doe, so we don’t know her name. She was, at the time, 20 years old. She was a sophomore at Cornell. And around 11 pm on the night of October 19, 2024, this Jane Doe goes to a bar on campus, and then, after that, goes to the Chi Phi fraternity house to hang out with a friend. 

She said that she was already pretty intoxicated at that point, and she’d had maybe 10 drinks in about three hours. Her friend at the fraternity house hands her a beer. After that is where she alleges that another member of the fraternity pressured her into taking drugs, specifically ketamine and marijuana, and drinking more alcohol. She alleges that two members of the fraternity assaulted her, and that one of them later sent a Snapchat message out to active Chi Phi members. The message is pretty graphic, but essentially invites them to join in, and several did.

In about three weeks, this young woman was going to go to the Cornell campus police and report what happened that night. But in the interim, what was going on? What was happening?

We now know, based on reporting by the New York Times and CBS News, this young woman was a member of a campus sorority, so she went to a member of her sorority and was trying to make sense of what happened. She was still processing it in real time. She wasn’t using, according to their reporting, the word “rape” or “assault.” And she was also seeing rumors circulating around campus about what had taken place at the fraternity house and was growing concerned about how they portrayed her. 

She, in the interim, also received a text message from one of the seven men at the fraternity essentially apologizing for how things went down the other night. She is not yet accusing them of assault, but is chatting, even seeks to reassure him in that first message. 

On October 22, she then makes an appointment at the campus health clinic because she had what she thought was a UTI and wanted to be tested because she told the doctor that she had gone through a traumatic experience. 

According to the New York Times reporting, you could see her thinking about what happened kind of evolve over those few weeks. She at some point says that this is starting to ruin her life, and she’s sleeping and crying and she’s feeling ashamed. She’s just really grappling with what had taken place, trying to make sense of it. By November 3 is when, according to these investigative documents that were obtained by the Times, she kind of comes to this conclusion that what happened at the party at Chi Phi was assault. 

She texts one of the seven fraternity members and says, “This was not consensual. I was given more ketamine than I can remember,” and that she was uncomfortable. A few days later, November 7th, 2024, according to these documents, she goes to the ER and asks for a rape kit. And the following day is when she goes to Cornell University Police.

When she goes to the police, how does she characterize what happened to the police? What does she tell them?

What she tells the police is that she believes she was assaulted, and she tells the police that it had started out as something that was consensual. And then at the end she says, “I can say with 100 percent confidence I was raped.” She tells police she was extremely uncomfortable and that she kept taking ketamine in part because she thought she might black out and pass out. She had thought of at least two of the men as her friends. After the events of that night, she is then confronted with rumors that were spreading across campus, sort of depicting her as loose and blaming her essentially.

What happens after Jane Doe talks to the police? What do they do?

When she talks to Cornell University Police, they summarize what she said in a six-page statement that she then signs. And that is the statement that is submitted to the Tompkins County district attorney. 

And the district attorney would be the person who would bring charges or decide not to bring charges. What does he decide? 

Yes, so the district attorney decides not to bring charges in 2024 based on, he has said, the sworn statement that she signs to police. 

The DA says no charges for the seven men. Were they disciplined in any way?

We don’t know exactly how each of the men were disciplined. Cornell has said that they faced a range of disciplinary measures, including expulsions and suspensions. One of the details that had gone particularly viral about this is that the disciplinary measures included for some of the students to write essays. Cornell has not denied that, but it has specifically denied that the students only had to write essays as a disciplinary measure. The university has cited privacy laws and said it really can’t release any more specifics about how individual students were punished or not punished. 

What did Jane Doe do after first talking to the police and then learning the DA wasn’t going to press charges?

After she goes to police, we know she remains on campus and she has to continue seeing some of these men. And she also participates in the school’s Title IX investigation, which takes place over several months and concludes at some point in 2025.

I want to ask you about the DA. He is out in public defending his decision to not press charges in 2024. How is he defending himself?

The DA is a big part of the story. This is the Tompkins County District Attorney. His name is Matthew Van Houten. And he has said that in 2024, based on the written statement from Jane Doe, they did not have what they needed to press criminal charges. 

It’s important to note that we, as in the public, we’ve not actually seen a copy of Jane Doe’s sworn statement. The DA issued a press release in which he summarizes that statement. And in that summary, he describes her characterization of this as voluntary and conscious and consensual. That is at odds with some of the investigative documents that we’ve seen reported since then, including that transcript of Jane Doe’s interview with Cornell Police in which she very confidently says that she believes she was raped and even says that she was physically hit during that night.

The DA said that he did not see, before the lawsuit, the screenshot of the Snapchat message where the frat members are talking pretty crudely about the situation, and he also says he didn’t see the transcript of the interview between Jane Doe and police.

We now know the names of the seven men who were there that night. Have they said anything?

The seven men themselves have not publicly said anything, and the lawyers for three of those seven men have publicly denied the allegations. One of them says that his client went into the room, but immediately left and didn’t participate in the assault.

This is a story that is developing very quickly, and it seems like new information is coming out just about every day. What do we know about what happens next?

So there’s at least two things going on here. There is the reopened criminal investigation. 

Separately, there’s the civil lawsuit that Jane Doe filed last month, and that is not dependent in any way on how the criminal investigation goes, but that will also proceed against the university, the seven fraternity members, and the fraternity itself.

There’s a lot to be anxious about as AI agents and bots get more integrated into every aspect of our lives. Meta, which recently agreed to pay over $17 billion to settle a lawsuit related to harming kids, now wants you to hand over all your online accounts to an inexplicably cute “agent” named Muse that might give a stranger your home address. OpenAI just introduced little blobs called Dots that can supposedly automate routine tasks, like planning dinner and ordering it from your favorite neighborhood spot. AI companies don’t just want you to talk to their chatbots; they want their agents to be an indispensable part of your daily routine.

As a parent, however, I think that perhaps the worst thing AI could do is be my kid’s friend. 

AI companions have been around longer than ChatGPT, and they’re growing in popularity with young users. More than half of teens have interacted with AI companions at least a few times a month, and one in three decided to talk about a serious issue with AI companions instead of real people, according to a Common Sense Media survey conducted last year. In certain groups and situations, a chatbot could offer some benefit — a lifeline for, say, LGBTQ youth who don’t have any in-person support networks, one study found. But even so, there are important caveats and risks.

Meanwhile, other experts are telling parents never to let their kids access AI companions, warning them that these chatbots have a history of offering dangerous advice and engaging in sexualized conversations. Sixteen-year-old Adam Raine died by suicide last April after developing a relationship and discussing his plans with ChatGPT.

If you have kids, these are horrifying stories to hear. It’s reasonable to wonder how widespread the issues are, and who they are affecting most. As of right now, the majority of younger kids aren’t using AI for companionship (phew!). But for those who are, where do the issues arise? And how do they go from using ChatGPT for help with their homework to opening up to it about their problems to preferring it to their human friends? 

Some answers are starting to emerge from research. 

For even young adolescents, there’s a direct link between AI companion use and mental health issues, according to a new study by researchers at the University of North Carolina at Chapel Hill. Their paper, which is still under review, is the first longitudinal study in the US that has looked at the bidirectional association between AI companionship in adolescents and mental health issues, according to one of the researchers. It charted AI use among 2,300 middle schoolers and found that about one in five used AI for emotional companionship. Those who used AI more reported higher levels of loneliness.

“It’s not just that the lonely kids are using AI, and they’re otherwise unharmed,” said Anne Maheux, an assistant professor of psychology and neuroscience at UNC Chapel Hill and the lead author on the study. “It is that using AI comes first, and middle school students are increasing their sense of loneliness following the use of AI.”

I recently spoke to Maheux about her research and the role of technology in young people’s lives. We discussed how much parents and teachers know about what is going on, what kids get out of human relationships that AI can’t provide, and whether she’d let a child under her care use an AI chatbot. While she said there is a lot to be scared of right now, there is some evidence that, when designed with the intention of promoting child learning and development and under the supervision of a caring adult, AI can offer some benefits, and, ultimately, she’s optimistic that we can design a better future for kids. 

The conversation below has been lightly edited for length and clarity.

How do so many kids end up with an AI companion? Do kids start using AI for homework help and end up in an emotional relationship with the technology? 

At a high level, AI companions — in our darkest vision of what that might look like — would be a kid calling an AI chatbot their best friend. That phenomenon is still quite rare. There are certainly plenty of kids who are experiencing that, but it’s not to say that it’s all kids or even most kids. I think that’s good news. 

But it’s also true that the line between opening up AI to ask a question about your homework and a full-blown AI companionship relationship involves a lot of gray areas. There’s evidence, mostly preliminary and anecdotal evidence, to suggest that very few people open up to AI with the primary initial goal of developing an intimate friendship or relationship. 

Most people open it out of a curiosity, sense of novelty, or seeking an answer to a question that’s very pragmatic. Then that can potentially evolve into something more akin to seeking personal advice or help making a decision or help making sense of one’s recent experiences with other humans. And that can potentially evolve to something that’s a bit more emotional.

What did your latest study on adolescents, AI companions, and mental health reveal?

Some kids seek out AI for certain purposes in different ways than other kids. For some kids, AI companionship is particularly attractive, especially the kids who maybe don’t have close friends or social networks in their offline life and who are already lonely. 

It’s a chicken-and-egg problem. Is it that these kids are seeking out AI companions or is it that having an AI companion is exacerbating those potential vulnerabilities or exacerbating risk for mental health problems? What we found is that interacting with an AI companion in a way that’s akin to emotional intimacy among middle school students is longitudinally associated with increases over time in loneliness. So the kids who are seeking out these companions, who are presumably already lonely, are also experiencing an increase in loneliness over time. 

There is this potential directionality question that we’re starting to answer here: It’s not just that the lonely kids are using AI, and they’re otherwise unharmed. It is that using AI comes first, and middle school students are increasing their sense of loneliness following the use of AI. In other words, middle school students using AI for emotional intimacy and companionship developed greater loneliness over time.

Do you have a sense of how often these kids are using the chatbots? 

In our sample — so again, these are US middle school kids — about 15 to 20 percent say that they’re using it at least a few times a week for any purpose. We don’t have specific rates of use for companionship because the questions that we asked were just not framed in a frequency measure, but more in how emotionally intimate they felt with the chatbot.

What else could have been causing that loneliness?

There are almost definitely many causes, and I think that our data suggests that AI companionship may be one cause. It certainly isn’t definitive. Obviously, I have to say that. I’m a scientist and trying to be hesitant about these things, but the reality is that whether or not AI use causes loneliness in this particular case, there are definitely other things that are also causing loneliness. 

That could be a myriad of things about the kid, maybe they have a lot of social anxiety, maybe they struggle with social skills, maybe the kid has had struggles in their family life and doesn’t have a strong sense of connection and belonging at home. It could be structural things. The kid just doesn’t have enough access to appropriate resources. So certainly there’s other things that are at play here, and typically technology use is one of many factors that can influence a kid’s mental health. 

And how much do you think that parents and teachers know about what’s going on, and how well-equipped do you think they are to intervene or to just be more involved in how these kids are using this technology? 

It’s a very slippery technology. The way kids are using it has changed rapidly in just the last year or two years. I would expect that parents, teachers, people who care about kids are probably struggling with the rapidity of change. But it’s also true that all the things that we have known for a long time about supporting kids and helping them thrive, those things are still true and they’ll be true with whatever technology comes after AI that kids are exploring. 

Those things include being curious, asking kids questions about their lived experiences online and offline, having conversations with kids so that they can understand the implications of different technology use. They can understand how, for example, AI is embedded within a broader system of social and political and economic factors, including the fact that many companies are trying to exploit kids’ attention in order to make money, which many kids are quite interested to hear about. 

Supporting kids also means providing a warm and supportive space for them to learn, to make mistakes, to be kids in the offline world, to have the frictionful, challenging, awkward conversations and first dates and all of the things that parents are sometimes trying to protect kids from by providing a safe container for them to explore those things. All of that can also provide avenues for kids to learn what they need to learn and develop — all the resources for a long life of thriving, even in the context of AI or other new technologies. 

What do kids learn from having these kinds of conversations with other humans that they can’t get from AI? 

Kids need to engage with other people, period. That’s true for all of us. We’re an incredibly social species. Simply being around other people and talking to strangers, let alone having strong social bonds, is really good for us. And all those things are uniquely important during adolescence, when kids have this neurobiological sensitivity to social information and reward. That’s when kids learn how to engage in conversation, they learn how to maintain eye contact, how to read body language, how to read emotions and perceive the world from the lens of someone else, to take their perspective. That’s not to mention other things, like being a member of one’s culture, what is valued, and what is expected. All of that is learned in the context of other human social relationships or relationships with broader social groups that a kid might be a member of. 

AI obviously can’t and never will be able to offer some of those things. It can’t actually experience empathy or care. It can’t engage in a true mutual human relationship. It may be able to simulate some of those things, and there’s some evidence that it can serve as a source of social practice. It can help kids work through the potential for difficult conversations and then serve as a bridge to engaging with other people. But there are aspects of AI that just simply can never replace the core sacred aspects of humans. 

Can you be more specific? What is it about human relationships that can’t AI simulate?

The way that AI systems are currently designed, which is not an inherent feature, but is a design choice, is to be sycophantic, highly agreeable, anthropomorphized, and all of those things can lead to kids developing expectations or understandings of interactive relationships that are actually fundamentally at odds with a normal human relationship. Some of the most consistent things that I’ve seen in the educated hypotheses on this topic and also in the emerging empirical research is that people need the friction that comes with human relationships. 

Human relationships are just hard and messy, and they’re also really beautiful. They’re what make so much of human life valuable and worth living. And with AI that’s always agreeable, that’s always available, that has no needs of its own, that can’t care or be cared for, it just doesn’t serve the same context to help kids learn things like conflict resolution or negotiation, being pro-social or caring for someone else who has needs. So many of those aspects that can feel uncomfortable in the moment, dealing with another person or a person who’s not responding right away, those things are actually important in the building blocks of developing the skills and capacities to be a functioning and thriving person in the social adult world. 

This is a problem with AI in general, isn’t it? It makes things effortless, but if you choose this path of least resistance, you’ll avoid the friction that causes you to learn and develop and build skills you need to exist in the world. 

Absolutely. And I think that all these things are connected too. AI offers this effortless, frictionless solution to our day-to-day problems, whether they’re social problems, whether they’re problems doing our homework, and those immediate solutions feel really good in the moment, so they’re quite tempting to keep coming back to. But there’s this real possibility that in the long term, that erodes our capacity for not only social relationships or cognitive skills, but just a general ability to withstand the momentary day-to-day distress of being a person living a normal life. And so I think every domain of human psychology comes together at that point, whether it’s social, emotional, mental health, or cognitive. 

Do you think that there are interventions that legislators could make or even that tech companies could make that would improve outcomes for kids, maybe make them a little less lonely? 

There are a million specific design changes that I would recommend. I think at a very minimum, AI systems can afford a pretty phenomenal amount of access to information, but there’s been no benefits that I’ve seen of them acting as friends. Kids need other human friends, full stop. Designing systems that are intended to exploit kids’ vulnerability or sensitivity to human social information and relationships, I think, is bad for kids. 

At the federal level, it seems that regulation is not coming, but at the state level, there have been many state regulations intended to protect kids, intended to create safer systems, to put in guardrails, to modulate different aspects of the models, the design, the user interface. These things could potentially make a real difference, I think.

What do you recommend parents do with regard to AI and their kids? Should they let them use chatbots? 

In short, no. But I am not a parent, and it’s much easier to dole out advice than it is to enact it. Parenting decisions about technology are not one-size-fits-all. Kids, parents, family dynamics, technology, and the context in which it is used differ, and in so many cases are personal choices (parents must weigh various potential opportunities and risks). Decades of research indicate what conditions a child needs to thrive. Extremely minimal research addresses the effects of AI on youth, and what we have so far suggests that the risks outweigh the benefits. 

I would not give a child under my care AI chatbots of any kind to use without me or another trusted adult present. I would talk to them openly about AI and its risks and benefits, but to me AI, like all technology, should be a tool used to promote human thriving, and when the evidence is unclear or suggestive of harms, I think it’s best not to experiment on kids. Currently, the off-the-shelf AI chatbots most kids are using appears more likely to undermine well-being for vulnerable users, especially children. 

Well, as a father of two daughters, I’m definitely terrified of what’s to come in the next few years. 

There’s a lot to be scared of, but there’s a lot to be hopeful of too. I think that everyone wants kids to thrive. Some of us are under different incentives, and some of those incentives might be perverse. But most of us are working really hard to design a better world for kids. 

In 1995, gender studies researcher Judy Chu found herself chauffeuring around her 13-year-old brother and his friend. The boys’ curiosity got the better of them, and they asked what she was learning: adolescent girls’ development, she told them. 

One of the boys looked at her and said, “‘You should study boys. You can start with me,’” Chu recalled. So she did. That fall, she spoke to 13-year-old boys from home for her clinical interviewing class.

In the years since, Chu has researched boys between the ages 12 and 18 — their wishes, their desires, what they wanted from their friendships and romantic relationships — and discovered some felt largely unknown. There was a gap between what the world expected of them — the stoic, strong, independent stereotypes that have persisted for centuries — and how they saw themselves, but had internalized so many messages for so long that they felt like they had no choice but to accept this version of masculinity. Chu theorized that these beliefs must have taken root during their childhood, and she later published a book on the subject.

When toddlers enter school, she discovered, they begin learning the rules of boyhood. “Regardless of what their parents had encouraged or enabled at home, they were learning that at school, if you wanted to be seen as and treated as one of the boys and you wanted to be with the boys, you wanted to play with the boys, be friends with the boys, there were rules you had to follow,” Chu said. “It was kind of like a microcosm of our society, which is if you want people to see you as and treat you as a quote unquote real boy or real man, you need to prove yourself.”

Since Chu’s work on the subject, American culture has changed to address gender inequities — the ones that negatively affect girls. As a part of this movement, girls were empowered to be more autonomous and pursue careers and financial independence to build a life beyond marriage and childrearing. (Though it should be said, women still trail men in earnings, outpace them in household responsibilities, and have higher rates of anxiety, depression, and PTSD.) 

But boys are still stuck in place. 

Across the country, lawmakers have promoted policies and legislation aimed at helping men reach their potential. In California, Gov. Gavin Newsom signed a 2025 executive order outlining education, career, and mental health initiatives targeting men. Maryland Gov. Wes Moore created the state’s Young Men and Boys Initiative, focusing on men’s health, employment, and community connections. But these programs are reactive, attempting to disrupt decades of socialization. At the same time, the rise of the manosphere and misogynist online spaces and increasingly right-leaning voting trends among men signal a cohort of young men at a turning point.

Recent studies have found that boys are less likely to graduate high school on time compared to girls — that gap is even bigger for Black and Hispanic boys — and fewer young men obtain bachelor’s degrees compared to their female peers. And as fewer men graduate from college, fewer participate in the labor force, too. The suicide rate among men is nearly four times higher than that of women. While men and women report similar rates of loneliness and number of friends, men are less likely to turn to their social networks for support. Out of the over 750,000 jobs created since Donald Trump took office in 2025, men have gained none of them. 

So what will it take to help men get unstuck? If we are truly committed to ending the male loneliness crisis, to tackling suicide and gun violence — society has the power to change things for the next generation, experts said. Rather than aiming to reach men after the constraining masculine worldviews have already taken root, we can prevent them from warping boys’ sense of self in the first place: To help men, we must change how boys are raised. 

Reject the myth of the “real boy” 

In 2023, psychologist Michael Reichert conducted a nationally representative survey of more than 2,000 American men, asking them questions about their lives, relationships, internet habits, and sources of social support. One finding was particularly staggering: two-thirds of young men between the ages of 18 and 23 felt like no one really knew them well. (In a follow-up report two years later, in which women were also surveyed, equal percentages of men and women — about 50 percent — said they were not truly known.)

The conclusion Reichert came to, he told Vox, was “boyhood is failing at the most important task.” American society is producing young adults who feel like they’re on their own, “a tragic outcome of a boyhood that’s not preparing our males for a resilient life in a world where things are harder, more complicated,” said Reichert, the executive director of the Center for the Study of Boys’ and Girls’ Lives at the University of Pennsylvania.

Because the idea of what a man looks like and how a man behaves is so ingrained, boys are taught to conform from an early age, experts said. From their earliest years, as evidenced in Chu’s work, boys are taught to adhere to stereotypical gender norms reinforced through comments like “boys don’t cry,” “toughen up,” and “don’t be a girl.” 

“It starts with mothers having a fear of turning their son into a mama’s boy, so they push them away at young ages — 3 and 4 years old. Go play with your dad, go play with your older male siblings,” Joseph Derrick Nelson, an associate professor in the department of educational studies at Swarthmore College, told Vox. Fathers, for their part, tend to emphasize self-defense, goal pursuit, and overcoming adversity with their sons, Reichert said. Black boys in particular are perceived as older and less innocent than their white counterparts, only pushing them further toward rigid gender roles, Nelson said. If they don’t conform, they may be teased by other boys.

A large part of proving yourself as a “real boy” means rejecting anything deemed feminine, including emotional vulnerability and relationships. As babies and young children, boys and girls are equally emotionally expressive, but by the time they start school, boys show fewer emotions and use less emotional language. When boys are taught that showing their feelings or forging deep friendships is girly, they stop prioritizing those relationships. That shift happens during the teen years, when boys go from reporting having best friends with whom they can share their deepest secrets, to feeling like they’ve drifted apart from these very connections by the end of high school. And it’s not for lack of desire, Chu said, or some inherent biological difference: Boys have simply learned not to show their need for affection, to hide their sadness, to not be tender. 

A new paradigm for raising boys, experts said, begins with how masculinity is first presented at home and in school. 

To encourage boys to be better in touch with their emotions means adults should not pit masculinity against femininity, Christopher Reigeluth, an associate professor at Oregon Health and Science University, told Vox. This goes beyond simply telling boys not to conceal their feelings, but making clear that confiding these feelings in a friend and fostering platonic connections isn’t girly: it’s a universal human need. 

In schools, specialized emotional education in curricula can help boys express their emotions and embrace vulnerability. 

Simply talk to them 

One of the easiest ways to do this is to allow and encourage boys to engage in an activity traditionally seen as more feminine: talking.

Reichert, the psychologist, has led an emotional literacy program in a boys’ school for over 30 years. In that time, he’s seen the sentiment among students shift from skepticism to genuine interest. “It has become, by 2026, the most popular program in the school,” Reichert said, due to an increased cultural awareness of emotional health. In the group, students discuss their daily stressors and hardships, and they learn that letting their peers see them for who they are — connecting with them — benefits their well-being. 

Before joining Reichert’s peer counseling group, high school senior Chris Burnetta expressed his emotions on the field. “You’re almost allowed to be emotional when you’re playing sports, and you’re not allowed to be emotional when you’re not,” Burnetta, 18, told Vox. In middle school, he attended a co-ed school and found himself performing aspects of masculinity to impress his female classmates. But once he met older classmates who he respected and wanted to emulate, he discovered many of them attended the counseling group and encouraged him to go, too. “I don’t want to speak for everyone, but I think for guys in general, looking up at people above you gives you a big impression and a big influence on how you want to live your life and what you want to be like,” he said. 

Seeing his peers so enthusiastically discuss their struggles and triumphs helps foster maturity and gives him permission to show his emotions, Burnetta said, an outlet he never had before.

Adolescence, a time when many behavioral health patterns are forged or discarded, is the time to engrain healthy social habits in boys — and for parents to be explicit, Matt Englar-Carlson, a professor of counseling and the director of the Center for Boys and Men at California State University Fullerton, told Vox. Now is the time to have dedicated phone-free time as a family, to give them opportunities to share how they’re feeling without fixing their problems, to listen to them even when they’re frustrating you. When his own son was younger, Englar-Carlson thought he knew all the tricks: showing empathy, trying to help. “Me doing that with him actually was making him feel worse, I think,” he said. Instead, Englar-Carlson took a lighter touch. He would acknowledge when his son was upset, but wouldn’t press a conversation. Whenever his son was ready to talk, he was available.

One easy way to do this? Talk to them when you’re driving. As my colleague Rachel Miller previously reported, not having to make direct eye contact can make it a little easier for kids to be vulnerable. 

And if you’re a man, make sure you’re leading by example: Be willing to share your own moments of embarrassment, disappointment, and sadness, so they know it’s okay for them to do the same.  

Help them foster non-romantic intimacy 

While in school, boys have ample avenues for connection through classes and sports, even if they aren’t interacting with others on a deeper level. It’s when they lose access to these organized outlets for socialization in adulthood that they slide into isolation or start looking to their romantic partners to fulfill all of their social needs. 

The idea that emotional intimacy is reserved for your significant other is how society gets to a point where 15 percent of men say they don’t have any close friends. Those without a partner are even more adrift: Men are less satisfied being single than their female counterparts. “We teach boys to not ask for help…figure it out on their own,” Nelson said. “I don’t know why we’re surprised when they become adult men and struggle with building relationships and close and connected communities, because all they’ve been taught, even since they were young children, was about figuring it out on their own and denying emotions, suppressing emotions, that then leaves you not in relationship and quite lonely.”

In the absence of in-person friendships, digital spaces provide an attractive alternative. While not altogether negative, some online forums — interactive video games, sports gambling, the manosphere — enable young men to further retreat from society. While pursuing community, boys may find their way to adult-centric spaces, which can be rife with misogynistic and patriarchal messages, feeding the belief that the only way to advance is through hyperconsumption, materialism, looksmaxxing, and dominating women, Nelson said. “They’re quarantining themselves to their rooms and their tech devices and these online communities where they play video games, they gamble on sports, and they have conversations with other boys and young men online about somehow feeling disadvantaged as men in our society,” he said.

Burnetta, the high school senior, said he and many of his classmates’ feeds are populated with “super masculine” content that sometimes pokes fun at men who open up about their feelings, which can further add to the stereotype that men should not be emotional. 

Even if boys don’t necessarily agree with these sentiments, they often don’t have other alternatives online. “I don’t think a lot of boys go on to YouTube…and say, ‘I really want to find the most misogynistic content I can find. That’s what I’m looking for,’” said Englar-Carlson, the director of the Center for Boys and Men. They may have simply wanted to watch a video about sports but were fed an ad for betting and then fell down the rabbit hole. Because traditional masculinity content is often fed to boys via their social media feeds, a brief introduction to these themes only leads to more. 

By young adulthood, they will have a fairly concrete idea of what’s expected of them as a man. In a 2017 study, young men largely agreed that the cornerstones of masculinity are self-sufficiency, toughness, physical attractiveness, being a financial provider, heterosexuality, hypersexuality, aggression, and control. Notably, they said they feel external pressure from family, friends, and society to meet these ideals.

If adults start with the understanding that boys are emotional and they have the same social needs as girls, they can encourage them to make friends before they learn otherwise. 

Teachers can recognize the signs of loneliness in young boys (resisting authority, talking back, and challenging boundaries) and use it as an opportunity to connect with their students instead of reprimanding them — because when they feel heard, their behavior softens. “What are these behaviors communicating to me from this boy about a met or unmet need, and how can I be responsive to it in my classroom? How can I help them facilitate close and connected friendships with not only their peers, but also with me as their teacher, like a primary adult in their lives?” Nelson said. When young boys simply get kicked out of class, they might fall behind and internalize a “bad boy” persona, he said, a cycle that enforces stereotypes and comes at the cost of their education. 

The story of masculinity online and from political leaders is that men must be protectors, high earners, and muscular and strong, and when boys fail to meet that standard (which they inevitably do because they are children), they are made to feel inadequate. “They’re struggling in school, they’re having a difficult time finding work, but everything about what they’re learning about to live in America is about the dream, the aspirations, acquiring, hitting these life milestones,” Nelson said.

Demonstrate an alternative masculinity

But for some young men, the most impactful interventions take place while they’re young. Growing up, Michael Dean looked to his father and his friends’ fathers for how to be a man. These men often spoke of the importance of providing for a family, being decisive, and being a stable force. Dean thought everyone was raised with these values and had similar upbringings until he reached high school and joined Reichert’s peer counseling program.

His junior year, one of Dean’s teammates on the football team suggested that some of the young men check out the group to discuss any problems at school, issues with parents, friends, or partners. Dean was frustrated with his performance on the field and decided to attend. Hearing from his classmates — their grief, their struggles — helped give him perspective. He also learned how to be an emotional outlet for the people he loves, including his younger brother. 

“I never felt that I had to be some kind of way or be some kind of man based on traditional values of being that strong, tough guy and to keep persevering through. I could definitely see that through my dad, and I did have that belief for a little while as I was in middle school and in the beginning of high school,” Dean, now 21, told Vox. “I learned that that’s not necessarily what it means to be a man, and I can make my own judgment through my own experiences and listening to other people to help me figure out what it means in my own belief to be a man.”

For Dean, learning how to be a man began when he was a child, but his path to adulthood was punctuated by formative adults — his mother, Reichert, and yes, even his dad — who fostered a safe environment to be vulnerable and emotional. Now, when he’s lonely, he knows he can call his family, friends, or his girlfriend for support. These are the outlets experts hope men feel empowered to call upon.

“If we’re really going to make a bigger difference with having healthier men who have connected friendships, who are emotionally expressive and connected in their friendships,” Reigeluth said, “it’s got to start with boys.”

In the moody alcoves of a lobby bar in Chicago in 2021 over French 75s, Dr. Louise King, a gynecologic surgeon, and Katie L. Watson, a bioethics professor, found themselves in conversation about a topic that had long frustrated them both: Female surgeons are consistently underpaid compared to male surgeons, even after accounting for specialty, rank, age, and other factors. 

What troubled them even more was how the pay gap compounded in King’s own field. Surgeons who perform procedures that are specifically for women, like gynecological surgeries, are paid less for their services than surgeons who perform comparable surgeries for the male anatomy. Gynecologic surgeons are also predominantly women. Over the course of the conversation, Watson termed this situation “double discrimination,” a phrase that captures the overlapping dilemma of lower pay for surgeries in a specialty that is overwhelmingly female and also serves a primarily female patient population.

That term, which has since entered the medical literature, stuck because the problem it describes has been well documented for decades. In 1997, a group of gynecologic surgeons published a paper in the journal Gynecologic Oncology with a title that gets straight to it — “Is Adam worth more than Eve?” Dr. Barbara A. Goff, now chair of Obstetrics and Gynecology at University of Washington Medicine, and colleagues found that doctors are paid around 44 percent more for performing male-specific procedures than analogous female-specific ones. 

In the three decades since, the problem hasn’t been fixed. To the contrary, it has been effectively institutionalized, built into the systems and codes that determine how surgeons bill for procedures of all kinds. Today, gynecologic or female-specific procedures are in large parts still reimbursed at lower rates than male-specific procedures even when they take similar time and skill.

Those disparities have consequences that extend beyond the compensation of individual doctors. When gynecological procedures don’t bring in as much money to hospitals, those same hospitals are disincentivised to offer women’s health services. That can lead to worse care for women and, crucially, fewer training opportunities for the surgeons who do that work. 

But this historically persistent inequality is not a foregone conclusion.

How healthcare services are billed changes all the time as procedures get reevaluated, new ones get added, and medical societies and experts push for revisions. In fact, one of the biggest changes in how maternity care is billed and reimbursed is set to take effect early next year, splitting up services for prenatal care, delivery, postpartum care, and more. While this is a long-overdue fix for obstetrics, gynecologic surgery — which covers most of a woman’s life outside of childbearing years — continues to be left out of the conversation. 

And although real change will require concerted efforts, King and Watson — and other advocates who have spent years documenting this disparity — have a fairly clear sense of how to start fixing it.  

How surgical procedures are valued

The work of deciding how much a medical procedure is worth starts well above the head of any given doctor, medical practice, or hospital. In the United States, the Centers for Medicare and Medicaid Services, a federal agency that administers healthcare and health insurance policies, sets rates for different procedures based on a metric called relative value units (RVUs). An RVU is supposed to take into account how long a procedure takes, the skill it requires, and the intensity of work it demands. Both Medicare and private insurers consider these figures when they’re settling on reimbursement levels. If a procedure has a higher RVU, it is valued more highly, and makes more money.

In a recent study, cheekily titled “Price and Prejudice,” researchers from the Mount Sinai Health System found that out of 55 pairs of sex-specific procedures that they evaluated in 2023, 75 percent had lower RVUs for procedures on female patients. On average, RVUs for male-specific procedures were 30 percent higher, and when those procedures were performed in a hospital or surgical center, surgeons were paid around 26 percent more.

For example, doctors will often perform biopsies — taking a small sample of tissues, cells, or fluids — on both male and female genitalia to diagnose problems. In 2023, researchers found that Medicare’s standard national rate for reimbursing surgeons was $121.32 for a penile biopsy but only $65.74 for a vaginal biopsy. 

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King, the director of reproductive bioethics at Harvard Medical School Center for Bioethics and a contributor on the study, believes that when the RVU system was created back in the 1990s, gynecological services were largely ignored, leaving the specialty undervalued from the start. While Medicare and Medicaid Services has undertaken some efforts to make RVUs more equitable across specialties over the years, that undervaluation has persisted. 

That problem may come down to how those values are determined in the first place — and who determines them. RVUs are set by a committee of doctors convened by the American Medical Association (AMA), with most of the seats allocated to members of major medical societies. The committee surveys different doctors on the time and skill required for procedures in their specialties. Based on these responses, the committee recommends values for each service to the federal government, which has historically accepted nearly 90 percent of them.

While the data quality of the underlying surveys has improved over the years, it is still not very high, said Dr. Miriam Laugesen, a tenured associate professor of health policy and management at Columbia University Mailman School of Public Health. Because the committee’s process isn’t transparent, it is often unclear what evidence its valuations rest on. This leads to distortions of all kinds, she said.

“It’s not a government process; It’s not a federal advisory committee,” Laugesen said. “It’s just a committee that was put together by the [AMA]. It’s pretty unusual in terms of how policy is made.”

In particular, King said that the surveys have a very low response rate from some specialties and are only sent to a small subset of doctors. She has never received a committee survey in the 17 years that she has practiced. 

The American College of Obstetricians and Gynecologists (ACOG) has a core seat on the committee that determines RVUs. But most ACOG members are general OB-GYNs, who split their time between obstetrics and gynecology and typically operate relatively rarely. The surgeons who perform the bulk of gynecologic operations are subspecialists – gynecologic oncologists, urogynecologists, and minimally invasive gynecologic surgeons — who complete an additional fellowship after residency. They mainly belong to their own societies and don’t have a seat at the table when RVUs are being determined. 

“From a purely cynical or economic standpoint, [ACOG] has no reason to advance billing for gynecology. It doesn’t represent a large portion of the practices of their members,” said King, adding that ACOG has been heroic in its efforts to obtain reimbursement equity for its own members. (One unintended possible result of that advocacy is that pushing for a smaller pay gap for services related to pregnancy, has in turn sent the message that women’s bodies are literally worth less, and are less deserving of care when they’re not engaged in the god-given duty of reproduction.)

The result is that doctors in specialties like OB-GYN who operate infrequently are answering the surveys about complicated surgical procedures that gynecologic surgeons perform more frequently. King said that her surgical schedule aligned more closely with those of general surgeons. For example, she operates two to three times a week whereas, according to her, an average OB-GYN will likely operate once a month. 

“So they’re not the right people to be answering these surveys. They [the survey committee and ACOG] don’t target the surveys to people who operate a lot,” she said. 

Part of the problem with using surveys to determine a key foundation of medical reimbursements is that the data is self-reported by doctors. This is especially relevant when more objective avenues may be available. One of those avenues is the American College of Surgeons’ National Surgical Quality Improvement Program, which is an initiative that collects and manages key surgical data to track quality and improvement in surgical fields, including the actual time spent performing surgical procedures, making it a more definitive measure than self-reported surveys.

Dr. Shitanshu Uppal, a gynecologic oncologist and division chief for gynecology oncology service at the University of Michigan, and his colleagues analyzed 901,917 surgeries using both the National Surgical Quality Improvement Program as well as the self-reported surveys used to determine RVUs. They found that median RVUs per hour vary widely between specialties. Gynecology had the third-lowest median RVUs per hour of all the specialties studied. In effect, that means that gynecological surgeons are paid less for every hour that they work. 

The researchers also found that compared to the operating times logged for real surgeries in the Surgical Quality Improvement Program, surgeons in certain specialties tended to report longer procedure times in the self-reported surveys sent out by the RVUs committee. Specialties that reported longer operating times were more likely to be awarded higher RVUs, leading to greater hourly rates of reimbursement.

According to Uppal’s analysis, urologists — a profession most often associated with procedures on men because their work routinely concerns the prostate and the testicles — reported times that exceeded the baseline data by a median of 20 minutes. By contrast, estimates from gynecologists only exceeded the actual time by a median of five minutes, meaning that urologists tended to overestimate their time spent in surgery by four times as many minutes. Generally, urologists earn much more than general OB-GYNs, who in turn earn more than other subspecialties like gynecologic surgery. Despite having access to reliable electronic records of operating time, Uppal and his colleagues note, the AMA committee still continues to use self-reported operating times, which influences their RVU recommendations, ultimately cementing disparities in female-specific procedures. 

“The system that they have now developed over time,” King said, “now creates discrimination because of its complexity.” She added that this is how systemic discrimination is perpetuated, even if systems or rules appear seemingly neutral.

How low reimbursement rates make women’s lives worse

The US healthcare system has never been especially good at putting its money where its mouth is when it comes to women’s health. Experts have been sounding the alarm on sex-based disparities in medical billing for a long time — long enough that governing authorities like the committee responsible for RVUs and ACOG have had time to respond to the concerns. 

Over the years, the gap between male-specific procedure reimbursements and female-specific reimbursements has decreased slightly. But researchers of the Price and Prejudice study showed that between 2003 and 2023, there were no statistically significant improvements to the pay disparities. Comparing a smaller set of procedures across 1997, 2015 and 2023, they found that the gap had narrowed only minimally.

One common justification that ACOG provides for the pay gap is that obstetrics and gynecologic services see a higher-than-average share of patients on Medicaid, which pays doctors less than other insurers. King agreed this is a real factor, but it doesn’t explain why Medicare itself values procedures on women lower in the first place. And as her account of double discrimination makes clear, undervaluing gynecology ultimately affects women everywhere for the worse.

“I have patients who are waiting for surgery with me for a year at a time. I mean, that’s crazy.”

Dr. Louise King

Lower reimbursements in gynecologic surgery disproportionately affect female surgeons because they represent a majority of this specialty. It’s not just the surgeons’ salaries that are affected. Hospitals and facilities work on a revenue-based model — if gynecologic surgeries are not bringing in enough money, institutions tend to allocate fewer resources to those procedures. That, in turn, can limit access to operating rooms, surgical staff, and operating times. 

“I have patients who are waiting for surgery with me for a year at a time. I mean, that’s crazy,” King said. As a minimally invasive gynecologic surgeon, she surgically treats women with endometriosis, fibroids, cysts or other such conditions.

It also affects the training that gynecologic surgeons receive. When there aren’t enough resources to operate regularly, opportunities to train residents are rarer than they should be. The result is that low reimbursement rates have contributed to a workforce of low-volume gynecologic surgeons who are sometimes not as well-trained as other surgeons who operate frequently.

The relationship between volume of surgeries performed and patient outcomes is well-documented in other fields. Research shows that surgeons who operate infrequently have worse outcomes, including more complications before, after, and during surgeries, compared to surgeons who operate regularly. 

Low volume gynecologic surgeons — who perform a particular procedure less than 12 times a year — have significantly higher rates of causing bowel and urinary tract injuries in their patients. Especially in benign gynecological surgery (procedures not related to cancer), having surgeons who operate frequently also increases the amount of minimally invasive procedures performed, which is related to better patient outcomes. 

Payment reform is an uphill battle, but not a lost cause

It takes multiple years and pressure from different entities to update or add new RVUs for procedures — but crucially, it is not impossible. The first few steps to creating a sustainable system might look like submitting gynecology-related procedure codes for reevaluation to the AMA committee or prompting a congressional report on the matter. 

For example, for years there has only been one billing code for endometriosis, regardless of the complexity of surgery or technique used. This disincentivizes surgeons from taking on complicated surgical cases of endometriosis because of the low reimbursement rate. Reevaluating that rate or diversifying the various surgical approaches that different cases require would help affected women get the care they deserve.

Medicare’s payment system also has what’s called a budget neutrality rule, which dictates that significantly increased payments for any given procedure must be offset by cuts elsewhere. The AMA itself believes that reforming this rule would make it easier to work toward reimbursement equity for female-specific procedures.  

Experts have suggested creating gynecology-specific conversion factors to bring parity to a system that naturally undervalues these procedures, while others think that eliminating sex-specific billing codes whenever possible is the right move. For example, the code for genitalia biopsies is different for men and women. This means that those procedures can be reimbursed differently even though they are essentially similar. Adopting one sex-neutral code for any genitalia biopsies would avoid this. While the reform required for this would be substantial, researchers believe that it would narrow the billing gap significantly.     

Authorities often justify lower RVUs for female-specific procedures by pointing to training: Gynecologists spend fewer years learning to operate than urologists and other higher-paid surgical specialists, according to King.

Historically, surgeons who operated on the female pelvis trained in ways that were more closely aligned with general surgeons than OB-GYNs. When obstetrics and gynecology merged into one specialty in the 1900s, the training for gynecologic surgery was truncated. 

“General OB-GYNs will train for four years and of that four years about 18 months is devoted to surgical training in gynecology,” said King, contrasting the new training period to those of general surgeons which is in years. 

She believes that training periods should be increased for gynecologic surgeons. That change would secure better reimbursement for the speciality, while also producing better trained surgeons who would be more attuned to advances in minimally invasive surgery that will ultimately improve the outcomes for their female patients. In some cases, the experience gained during a two-year fellowship in gynecologic surgery was equivalent to 19 years in practice.  

In their initial work on double discrimination, Watson and King argued that failing to implement solutions for parity is tantamount to saying that female patients deserve less well-trained surgeons than male patients.  

As with most women’s health issues, it is unclear if this systemic disparity in medical reimbursement is the result of conscious misogyny or a by-product of ignorance. But that question of origins matters little when its consequences have been enshrined in medical policy, with lasting consequences for the practice of medicine more generally. We have allowed this wage gap to persist, even as many have sounded the alarm for decades. It is long past time to heed their warnings.

This story appeared in The Logoff, a daily newsletter that helps you stay informed about the Trump administration without letting political news take over your life. Subscribe here.

Welcome to The Logoff: Donald Trump is once again selling access to the highest bidder(s). 

What’s happening? On Thursday, the Washington Sun’s Jeff Stein reported that Trump will reprise his 2025 “crypto dinner” later this year, hosting some of the top investors in the $TRUMP memecoin at his Virginia golf club. 

The top 185 holders of $TRUMP will receive an invite to the event, which the website describes as the “Most EXCLUSIVE DINNER IN THE WORLD.” The top 29 $TRUMP holders will also be eligible for a “special VIP reception.” 

What is $TRUMP? As my colleague Adam Clark Estes explained last year, memecoins like $TRUMP are “all but make-believe.” The coin is a crypto token, or “a type of digital asset that’s built on a cryptocurrency’s blockchain, but it is not a full featured cryptocurrency, like bitcoin.” 

In other words, buying it doesn’t get you very much — the value of the coin has collapsed since early last year when Trump took office — but it will get you a chance to have dinner with the president. 

What’s the context? This will be the third major event Trump has hosted for buyers of $TRUMP, following a May 2025 dinner at his Virginia club and a “crypto and business conference” earlier this year at Mar-a-Lago, where Trump gave a keynote speech. 

But it’s just one of the many, many ways that Trump and his family have found to enrich themselves through crypto: There’s also another memecoin, $MELANIA, and his lucrative crypto firm, World Liberty Financial, which received a $500 million investment from a member of the United Arab Emirates royal family last year.

Strictly speaking, as Stein points out, Trump himself does not own the company minting $TRUMP, though he still profits handsomely, to the tune of $636 million last year, from transaction fees and other revenue. And he’s made even more off World Liberty Financial, which he and his sons do own, along with others: $799 million in 2025 alone, according to financial disclosure forms filed earlier this year.

And with that, it’s time to log off…

Don’t miss this story about “junk journaling” from my colleague Rachel Miller, a hobby that she describes as “a great way to cope with digital malaise and existential dread.” (Needed!) You can read it with a gift link here.

Plus: It’s a big day for Denali National Park’s sled dog puppies, of whom I’m a big fan.

This story appeared in Today, Explained, a daily newsletter that helps you understand the most compelling news and stories of the day. Subscribe here.

Depending on your political appetite and your geographic location, you absolutely do not need me to remind you of the upcoming midterm elections. But for those of you unencumbered by an unhealthy attachment to political news, and unassaulted by the onslaught of ever-more-brazen political ads, consider this your official notice that the midterms are approaching. Fast.

In less than six weeks, Americans will head to the polls to decide which party controls Congress, along with a slew of state and local offices. The stakes are arguably unusually high: Voters will choose whether to check the power of a president who has bulldozed over historical norms and limits. 

So starting this evening, I’m partnering with my colleague Astead Herndon and Vox’s Midterms, Actually team for five weekly editions on the biggest issues shaping the 2026 midterms. Together with outside experts, we’ll break down one issue each week and suggest further reading and races to watch in November.

Up first, and without further ado: the profound shift that both parties have experienced since the 2024 election. These are not your mother’s Democrats. Or Republicans.

Go a little deeper

To kick this series off, I asked Astead to imagine a hypothetical world in which he hadn’t followed politics since 2024. (An outlandish counterfactual: Astead is acutely plugged into politics.) But in this alternate universe, I asked, what would surprise him most about 2026?

Easy, he said. The GOP’s disillusionment with President Donald Trump, who remade the party in his image. 

Let’s put some numbers on that phenomenon, to start. Trump’s approval rating has dipped to record lows, even among Republicans. According to an NBC poll conducted in mid-September, just four in 10 Republicans strongly approve of Trump’s performance, down 11 percentage points from the spring.

Republicans have soured on Trump over his handling of the economy and attacks on Iran, which violated his promise to keep America out of foreign wars. Trump’s delayed release of the Epstein files also fueled distrust in his base by exposing his own ties to the dreaded “elite insiders.”

In response, some Republican candidates have worked to distance themselves from Trump, even defying him in campaign ads. But it’s unclear whether that tactic will win over disillusioned or disengaged Republicans. If enough stay home, Astead said — especially with Democrats eager to vote — Democrats could flip the House and/or Senate and make Trump’s last years in office far more difficult.

And speaking of Democrats…they’re also undergoing a major transformation after their 2024 presidential defeat. That loss disproved their previous theory of Trump-era politics: namely, that Trump’s rise was an aberration that competence, decency, and normalcy would eventually overcome.

By contrast, today’s Democrats want a party that “fights,” Astead told me. “The open question is who they’re fighting: The oligarchy? Big Tech? The Billionaire/Epstein class? Trump’s Republican Party?” 

Democrats face ideological questions, too. Since 2024, voters have lost trust in the establishment and in party leaders’ ability to pick the best candidates; left-wing candidates have thrived in that vacuum. It’s pretty wild, when you think about it, that a Muslim democratic socialist in New York ranks among America’s most popular Democrats.

For both parties, then, November 3 is a test of their respective visions for America. Not just between the parties — as in, Republicans vs. Democrats — but within them, as well. That, in turn, will help determine the rest of Trump’s presidency…and the 2028 presidential election. 

But it’s only October 1. Let’s not get ahead of ourselves. 

➨  Races to watch: Michigan’s Senate race, where progressive Democrat Abdul El-Sayed faces Republican Mike Rogers; Florida’s 27th District, where Republican María Elvira Salazar publicly broke with Trump; and the Nebraska, Idaho, and South Dakota’s Senate races, where independent candidates will test both sides’ exhaustion with the two-party system. 

➨  More from Vox: 

• It’s not the left rising. It’s the center falling.
• More Republicans are breaking from Trump. Is it too little, too late?
• What Democrats are still getting wrong about voters

One link for later

➨ “Decant” your berries and asparagus. They’ll last longer with more space and air. It’s one of several gloriously simple ways you can reduce food waste without resorting to complex cooking projects or pricey “storage systems.” 

Before you go…

• Did you know…that octopuses’ arms are individually intelligent? When cut off, they can crawl away, grab food, and lift it to where an octopus’s mouth would be if it were still connected.
• Today’s trivia: What constellation contains the North Star and Little Dipper? (You can find this and other brain puzzles in Vox’s daily crossword. Look for the answer in tomorrow’s edition.)
• Yesterday’s trivia: Yesterday we asked you where Napoleon was exiled after his forced abdication. That was a bit of a trick question, since he was exiled twice: first to Elba, in the Mediterranean Sea, and then to Saint Helena, in the South Atlantic.

Horse racing can be an unusually dangerous profession for both the jockey and the horse: Riding a half-ton animal at nearly 40 miles per hour means your fate depends on the health and performance of both athletes. And the horse can be at risk of catastrophic injury if the jockey doesn’t have the required physical fitness to maintain proper technique and lightning-quick reflexes. 

But new wearable technology and advances in sports medicine are enabling everyone involved in the sport of horse racing to identify risks earlier and prevent injuries to horses and jockeys alike.

In order to find out more about both of these athletes, I took a trip to Belmont Park, to watch competitive horses train and to speak with Dr. Sara Langsam, an equine veterinarian and chair of the American Association of Equine Practitioners Racing Committee. And to learn about the jockey side of the equation, I talked to Michaela Keener, a jockey health researcher at University of Kentucky, and ReyLu Gutiérrez, a jockey who has started in over 6,000 races.

Read more about horse racing safety and health:

• Article about wearable biometric sensors as a horse injury detection system
• “Physiological Demands and Muscle Activity of Jockeys in Trial and Race Riding”
• New York Racing Authority’s page on equine safety
• Horseracing Wrongs, a nonprofit committed to ending the horse-racing industry for reasons of animal welfare
• Information about the new Belmont Park racetrack, including details on its new, technologically advanced surfaces

This video is presented by Colgate. Colgate doesn’t have a say in our editorial decisions, but they make videos like this one possible.

Buried beneath every American city is a mysterious jumble of cables, pipes, and gas lines, entangled like a pair of wired headphones the moment you pull them out of your pocket. Every time a contractor sticks a shovel in the asphalt, they embark on a high-risk excavate-by-dots obstacle course, dodging color-coded clusters of spaghetti-like power lines, gas mains, sewers, and fiber-optic cables. A line of blue spray paint means water. Red means power. Yellow is gas. Orange is telecom. 

About 700,000 times a year — that’s once every 47 seconds — something goes wrong. 

A backhoe slices into a cable and cuts off a 911 call center, or a woman comes home to find her dryer and hot water heater on fire after a contractor pierced her electrical line. Just last week, a contractor accidentally severed a single telecommunication cable that proved critical enough to ground flights at some of the nation’s largest airports on the eve of the UN General Assembly, ensnaring even world leaders like Canadian Prime Minister Mark Carney in delays. 

The ground beneath our city streets has never been so crowded, driven by a furious race to lay fiber optic cables carrying the data that fills your social media feeds and transmits your ChatGPT queries. Nor have the systems we use to find out where it’s safe to dig — namely, a hotline and all that colorful spray paint — ever felt so catastrophically insufficient. 

“If the locator mismarked the line, if the line wasn’t marked, if there was no map that even said the line was there,” said Sarah Magruder Lyle, president of the Common Ground Alliance, a trade association focused on underground damage prevention, “there are a variety of issues that could happen before the excavator even puts a shovel or a backhoe in the ground.”

According to Common Ground, such incidents cost the US about $83.2 billion per year, roughly as much as we invest in public transit annually nationwide. But the actual financial toll may be even higher, because every time a crew stumbles across a mislabeled power line or a gas pipe everyone else forgot about, it can delay construction for months on end. As Magruder Lyle put it, “if they get out there and they find something that they’re not supposed to, you have to go back and reengineer the whole project.” 

Such surprises can also lead to tragedy. A 5-year-old named Alistair Lamb was killed in Missouri last spring after a contractor drilled into a gas line near his home, spewing fumes that leveled his house when his unsuspecting father flipped a light switch. And just this May, another unmarked gas line killed three people when contractors struck it, leading an apartment complex in Dallas to explode.

Yet the messy underbelly of our cities remains largely invisible, with accountability for issues foisted upon and at times evaded by a hodgepodge of finger-pointing private utility companies, agencies, and contractors. And that’s a shame because there is, in fact, a better way to bury the cables and pipelines that our modern lives depend on, and a multitude of better ways that we can find the ones we’ve already buried. 

What Disney World gets right about the stuff we bury

To understand one utopian vision for how all this could work, look no further than the happiest place on Earth. That’s a moniker Disney World has earned, in my mind, not for its Mickey Mouse waffles (though my niece may disagree), but for its world-class utility corridors, also known as utilidors.

Directly beneath the Magic Kingdom is a sprawling network of tunnels. Initially designed to shepherd around Mickey and his friends, the system now also serves as one of the largest utility corridors ever created. Unlike the rest of America, where cables are typically dumped in ditches before being covered with dirt, the electrical lines that power Cinderella’s castle quite literally get the princess treatment. 

Alongside water pipes, sewers, and animatronic control systems, these power lines lace the walls and ceilings of the utilidors, meaning they’re protected from weather and changes in the soil. They are also easy to monitor, catalog, and access if something needs fixing. While the cost of building a controlled system like this is much higher upfront than burying directly in the ground, the practice virtually eliminates the risk of accidentally rupturing a gas main or slicing a fiber optic cable during routine maintenance. Once they’re built, they can also drastically reduce costs in the long run because you no longer need to tear up a street every time a utility needs fixing. 

“Obviously, it’s expensive,” said Debra Laefer, a professor of civil and urban engineering at New York University, “but in the long term, it would be hugely cheaper,” especially “in areas where we are digging all the time, there’s a direct business case for moving towards these utilidors.”

As fantastical as Disney World’s imagineered system may seem — and it was, to be clear, predicated on a not-easily-reproducible master plan — the idea of storing utility lines in easy-to-access tunnels is not just for amusement parks. It is possible even in places where most of those lines are currently lying in the dirt, as Prague proved back in the 1970s, when the city decided it was fed up with destroying its precious cobblestone streets every time a buried pipe or cable needed fixing. The city now boasts a sprawling utility tunnel network, occasionally patrolled, evidently, by a couple of robot dogs tasked with mapping out every cable. 

Singapore has also spent years building out walkable utility corridors that operate much like the Magic Kingdom’s, transmitting water, data, and energy from the safety of well-organized underground tunnels. Some of Tokyo’s largest districts store their cables and gas lines in huge concrete utility ducts, and many Parisian water lines and fiber optics are kept across the city’s centuries-old sewer system, a catacombs of waste made easily navigable by blue-and-white street signs that correspond to the avenues above. Many university campuses across the US also boast their own sprawling utilidors.

In most cases, cities chose not to relocate utilities all at once, a feat that would probably be financially prohibitive and deeply disruptive. Rather, they took advantage of all the times they’ve needed to relocate utility lines anyway, a standard (and expensive) practice for big building projects like the Wallis Annenberg Wildlife Crossing or the Second Avenue Subway, a major transportation project in New York City that’s been consistently delayed by unmapped utility lines. A group of graduate students found that building such a tunnel in parts of NYC would likely cost at least twice as much as dropping a utility line in the ground, but could recoup the costs within 47 years. 

“There are streets in New York City that have been excavated at least once a year, every year for the past 30 years,” Laefer said. If you just prioritize those streets, gathering the piping in a “big concrete box” underground, you could allow workers to complete most repairs without needing to disturb the streets or sidewalks above at all.

But building new utility tunnels would require that we first come to better understand the wires and piping already entangled under our cities, which if you recall, we have only a surprisingly flimsy picture of in most cities today. But if every surprise utility line is an opportunity to move it somewhere better, it is also an opportunity, at the very least, to map out where it is.

To that end, a few years ago, Laefer led a $1.2 million pilot funded by the National Science Foundation to create a test case for 3D-mapping New York City’s underground utilities, a project that’s since been adopted into a citywide initiative. The city says it plans to roll out the spruced up utilities locating system in 2028. The UK debuted a similar digital map of over 3 million kilometers of underground pipes and power, owned by hundreds of utilities and agencies a few years ago. The nation projects that it could help save over $500 million per year by minimizing delays and accidental damage. In places where Singapore has not yet stuffed its utilities into walkable tunnels, the city’s own mapping and utilities coordination has already saved it an estimated $230 million in avoided clashes since 2024. Not bad for an intervention that doesn’t even require any physical rebuilding.

So why hasn’t every American city copied London or Singapore?

Well, US cities tend to be plagued by even more private utilities and patchwork local and state norms and regulations than a nation like the United Kingdom. Getting them to pool together what they often consider proprietary underground data is challenging, and few local officials have opted to prioritize such efforts. But this may well change as more and more fiber optics go into the ground, more flights get canceled, more apartment complexes explode, more power lines flicker off, more sinkholes form, and more Americans come to be all too acquainted with the perils lurking just beneath our feet. 

“I think at this point, it’s more about political will and money than any technical obstacle,” Laefer said. “Technically, we’re there. It’s just a matter of doing it.”

Welcome to The Midterms, Actually. Every week I’ll be writing about two things: one big idea or trend I see forming across the 2026 primaries, and one thing I’m hearing from a voice on the ground. You can sign up here to get it in your inbox every week. Let’s get into it.

One big idea: Democrats’ Laken Riley vote is aging badly

Two things happened this week that reveal how quickly the politics of immigration enforcement are shifting.

First, Republican Sen. Jim Justice of West Virginia, a staunch ally of President Donald Trump, urged the administration to dial back its enforcement push. “Before you know it, you get people that get carried away in their job and whatever it may be, and all of a sudden, then you’re dragging people away that have lived on your street corner for 15 years,” Justice told Politico this week. “I don’t know that we need to be doing that stuff.” And he’s not the only red-state Republican who’s been pushing back on ICE lately, including some facing voters in tough races next month.

The second thing flew under the radar: Sen. Jon Ossoff, the Georgia Democrat running for reelection who has also been floated as a 2028 presidential candidate, struggled to explain himself when a reporter confronted him on camera about his vote for the Laken Riley Act in January 2025. Passed within days of Trump’s inauguration and signed nine days into his second term, the law requires ICE to detain undocumented immigrants who are merely arrested for or charged with theft-related crimes, before any conviction.

In the exchange with a reporter from Drop Site News, Ossoff talked about his Senate work investigating alleged ICE abuses, but didn’t directly address his vote after being asked if he regretted it. “Laken Riley was my constituent and what happened to her should happen to no American, to no person in this world,” Ossoff said. “I think that immigration enforcement should be focused on those who are convicted or charged with serious crimes.” He excused himself to walk into a meeting as the reporter pressed him on whether the law undermined due process. 

In both cases, you see changing winds of electoral politics. Back in 2025, when Ossoff and 11 other Senate Democrats joined Republicans in supporting Trump’s immigration bill, they implicitly validated Trump’s premise on immigration enforcement: that not only was the border out of control, but that there also needed to be new efforts to step up interior enforcement through expanding agencies like ICE. In the year-plus since that vote, Trump has hired more ICE officers, launched sweeping raids in cities like Minneapolis, Chicago, and Los Angeles, and fueled a cauldron of chaos that’s led to shootings across the country. Politically, it has now put Democrats like Ossoff in a pickle, one that will matter more the closer we get to 2028.

How do you explain giving more immigration powers to a Stephen Miller-led White House? How can one argue you couldn’t have seen this coming?

In some ways, you can understand the political logic of the time. Ossoff, who is running in a state Trump carried, and many of the congressional Democrats who supported the Laken Riley law were in competitive races, and Democrats left the 2024 election thinking they had misread the electorate on the issue, particularly after Latino voters swung hard toward the right. But given what’s happened since, it’s clear many congressional Democrats made a familiar mistake: prioritizing political triangulation over standing on their values of protecting marginalized communities.

Take a look at some of the Democrats who have already had to walk back their votes. In the Democratic primary for Minnesota’s open Senate seat, Lt. Gov. Peggy Flanagan made US Rep. Angie Craig’s vote for the law a key focus of her campaign, calling it “disqualifying.” The attacks were so effective that Craig eventually expressed remorse, saying, “I wanted to be honest with the people of Minnesota. I will tell you when I get it wrong, and I got that one wrong.” Craig lost the August 11 primary to Flanagan.

Maryland’s April McClain Delaney, another congressional Democrat, also said she regretted her vote: “I will say that this was in the beginning of my term. And I never thought that ICE immigration and the horror of what has happened would happen.” (She survived her primary, defeating David Trone by 6 points.)

It’s easy to see where the buyer’s remorse is emanating from. Trump’s ICE is broadly unpopular. And as we’ve talked about on this Substack and in our reporting on America, Actually, Trump is doing worse and worse with Latino voters, with both prices and immigration enforcement driving the slide. A Hart Research poll for TelevisaUnivision of 1,500 Latino registered voters in battleground House districts (August 6–17) found 63 percent disapprove of Trump’s job performance and 62 percent disapprove of his handling of immigration enforcement and deportations. Sixty-four percent view ICE unfavorably. 

When I recently talked to Stephanie Valencia of Equis Research, she said this: 

The people who feel most regretful who voted for Trump in 2024 are most regretful because of immigration. They feel like there was a broken promise there. Like, they were told he was gonna focus on the border, which everybody agreed was chaos, and he was gonna focus on violent criminals and serious threats, and at the end of the day, he has not complied with that.

But while the shift in public opinion helps explain the elected officials’ political logic, it doesn’t change the material harm of their votes. Just this week, ICE announced plans to hire 5,000 more employees, most of them deportation officers, by the end of the year as enforcement continues to ramp up.

And these raids have a lasting effect on targeted communities, like in Maine, the Chicago area, and Texas. It’s the No. 1 issue that has come up in my conversations with local reporters. The chief architect of this chaos is the president, but make no mistake: Trump had help from shortsighted Democrats.

One thing I’m hearing 

Maya Miller is a Report for America corps member covering democracy and government for the Gulf States Newsroom, a public radio collaboration that includes Louisiana’s WWNO and WRKF. She’s been reporting on Mississippi’s redistricting fight and what residents are saying about their representation and the upcoming midterms.

You’ve been reporting from redistricting hearings in Mississippi. What are residents most concerned about, and is there a conversation or moment that captures the mood?

Residents are most concerned about their representation. In Mississippi in particular, race and party are strongly intertwined, and Black residents worry that by being drawn into new districts, voters may elect a Republican candidate. There was a bit of secrecy around redistricting earlier this summer, with Gov. Tate Reeves, a Republican, canceling a special session to redraw judicial lines. So advocates created the People’s Hearings, a series of meetings held across the state to voice concerns and create a public record of testimonies from Mississippians. Quickly after, lawmakers decided to host their own public hearings, and at these hearings, hundreds of residents showed up, mostly to urge them not to redistrict.

“It seems to me that the threat of losing representation has made people more aware of the moving parts.”

At one hearing, I spoke to Joyce Arceneaux-Mathis, president of the Natchez NAACP. She’s frustrated that the state is going to spend millions on new maps when people are struggling with day to day expenses. And Ramona Sanders of Meridian, Mississippi, has a lot of concerns on whether mid-decade redistricting is illegal. While it’s not, she says that lawmakers are opening themselves up to legal action. I haven’t heard anything from voter advocacy groups that points to future lawsuits, but only time will tell, if and when lawmakers redraw the maps, if these maps are constitutional or not.

Redistricting is often covered as a fight over which party wins more seats. What would these changes mean for the communities you cover and their ability to have a voice in Congress?

One change that could happen is that residents who are Democrats might lose the state’s only Democrat leader. Out of four congressmen, there’s only one Democrat, Bennie Thompson, who represents District 2. His district spans much of the west, from the capital city of Jackson to most of the Mississippi Delta and southwest Mississippi. It’s a heavily Black district, somewhere around 63 percent Black. He’s held this seat for 33 years and has brought millions to the district for health care, infrastructure, and agriculture. 

So residents are worried that Republicans are trying to edge him out and replace him with a more conservative leader who may not have the same concerns as the community. 

How are these fights affecting people’s interest in the midterms? Are you hearing more determination to vote, more doubt that voting matters, or something else?

People are fired up. They’re incredibly engaged. I’m hearing from a lot of people who are more determined to vote in November than when I covered redistricting in Alabama in 2024. It seems to me that the threat of losing representation has made people more aware of the moving parts. So they’re attending hearings, participating in rallies, registering to vote and checking their registration, phoning a friend and making plans to be at the polls on November 3.

What is the national conversation about redistricting missing that becomes clear when you spend time in these communities?

I think the national conversation is missing the voice of the community. It’s one thing to report on the politics of redistricting, but there’s a layer of real concern from residents that shouldn’t be ignored. They’re worried about hospitals closing. They’re worried about public schools losing funding. They’re worried about the rising cost of groceries and gas. I find that talking to and listening to residents helps me understand a community more than calling up a lawmaker and asking them their thoughts. There’s a place for that side of the conversation, of course, but I’ve always tried to center people who will be most impacted in my reporting, and I feel that leads to a better story for our listeners.

Is the best shot Democrats have at defeating safe-seat Republican senators…not running candidates at all?

That’s the theory behind the party’s approach to several Senate races in deep red territory this year — races in which they hope independent candidates might manage to take down Republican incumbents, if only the Democratic Party would get out of the way.

In Nebraska, South Dakota, and Idaho, the candidate who won the Democratic primary has since quit the race — often with some “urging” from the party establishment — to pave the way for a two-way matchup between a Republican incumbent and an independent. (Democrats tried to similarly clear the way for an independent in Montana, but the party’s nominee refused to quit the race.)

The theory is that the Democratic brand is so toxic to so many voters in these states that it’s impossible for a Democrat to win there nowadays — but that there’s no great love for the Republican establishment either, and dissatisfaction with the political status quo more generally. So perhaps a fresh-faced independent could capture essentially all of a red state’s Democratic voters and peel away enough Republicans and independents to win.

It’s a bold bet and, most believe, unlikely to succeed — but polls do show surprisingly close races in some of these contests. And it’s not an entirely new strategy. In several red-state Senate contests dating back to 2014, Democrats concluded that the only way to win is not to play, even as all the independents they cleared the way for have lost.

But this year’s crop of independents stands out. For one, they’re running in a national environment that seems much more hostile to the GOP, making it more plausible that one or more makes it to Washington. For another, they’ve formed a loose alliance over group text, and they have something of a shared platform — a focus on economic populism and taking on corporate power, while downplaying cultural issues. 

Brian Bengs, the independent running in South Dakota, told me: “I think I can speak for the others when I say our collective efforts are based on the idea that the left-right social issues are what is being used to keep us at each other’s throats. The real fight that we need to have is big money versus little folks — the regular folks.”

They also have some specific plans for how, if elected, they’d get together to shake up how the Senate works.

“If a couple of us, maybe just as few as two independents, get across the line, we can deny a majority to either party. We can create a Fulcrum Caucus,” Todd Achilles, the independent in Idaho, told me. “Both parties would have to negotiate with us to get stuff done.”

Whether these candidates win or lose, their stronger-than-expected candidacies have made Republican incumbents take notice, and are an intriguing model of how to bring at least some competition to states that seem very solidly red — or even, potentially, very solidly blue. Should they perform well in November, their shared message could end up influencing candidates across the partisan spectrum. 

Furthermore, if they do reach critical mass in the Senate, it could mean the rise of an informal third party, one that can advance its own agenda in Washington. Yet it should also be noted that the more of them win, the harder the math for a Republican majority specifically gets, since they’d be knocking Republican incumbents — and only Republican incumbents — out of power.

Amidst rising dissatisfaction with both parties, there would seem to be an opening for a different approach. But busting up the two-party system is easier said than done — particularly when all these candidates have past ties or present coziness with Democrats that, their opponents argue, call their supposed independence into question.

The Dan Osborn model

Democrats have tried this strategy of clearing the field for independents in red-state Senate races before — in 2014, when entrepreneur Greg Orman (I) challenged Sen. Pat Roberts (R-KS); in 2020, when orthopedic surgeon and commercial fisher Al Gross (I) challenged Sen. Dan Sullivan (R-AK); and in 2022, when former CIA officer Evan McMullin (I) challenged Sen. Mike Lee (R-UT). Yet all those independents lost by double digits.

But the current model of an independent challenger was inspired by a different candidate — Nebraska’s Dan Osborn, who came surprisingly close to unseating Sen. Deb Fischer (R) in 2024, and is now challenging the state’s other GOP senator, Pete Ricketts, this cycle.

Osborn has a background as an industrial mechanic, labor leader, and Navy veteran with a plain-spoken affect. He did not graduate from college, he’s said he didn’t own a suit, and he has forearm tattoos. He had led a strike at a Kellogg’s plant in 2021 that won concessions in the company, but he was later fired. 

Union figures helped recruit him to challenge Fischer; the consultant Daniel Moraff (who later coaxed Graham Platner to run for office in Maine) also became involved in Osborn’s campaign. Osborn’s admaker Tommy McDonald later co-founded the consulting firm Fight Agency, which is now semi-famous for challenging the Democratic Party establishment by backing Zohran Mamdani and Platner’s campaigns.

Dating back to his initial campaign launch, Osborn’s messaging focused heavily on criticizing “monopolistic corporations,” aligning him with a faction on the left that believes the Democratic Party doesn’t do enough to challenge big money and concentrated corporate power. Osborn also took moderate or conservative stances on some cultural issues, supporting gun rights and President Donald Trump’s border wall. (“If Trump needs help building a wall, well, I’m pretty handy,” he said in one ad.) The Democratic Party stood aside; no Democrats filed to run in the primary.

The result was that in 2024, when Trump won Nebraska by 20 points, Osborn lost his race by just 6.7 percentage points. That closer-than-expected outcome in a disappointing cycle for Democrats made many in the political world take notice, spurring polls and research projects about whether it could be replicated elsewhere — and whether, amidst more favorable national conditions, it could actually succeed.

A squad of independents?

So this cycle, in addition to Osborn himself running again, there are several other candidates trying their luck as independents with similar platforms. 

In South Dakota, Brian Bengs, a Navy and Air Force veteran, had previously run for Senate as a Democrat in 2022 and lost in a landslide. Working as a park ranger in 2025, Bengs told me that he became dispirited by DOGE cuts to the National Park Service, and got in touch with Osborn to discuss whether he should run again — this time as an independent against South Dakota’s other GOP senator, Mike Rounds. 

“Our economic system and our political system have the same problem, which is too much concentration of money and not enough competition,” Bengs told me. “And it is producing poor results for regular folks in both systems for the same reason.” 

The winner of South Dakota’s Democratic primary, Julian Beaudion, quit the race in August, saying he’d faced “intimidating threats to drop out,” setting up a two-way face-off between Bengs and Rounds.

In Idaho, meanwhile, Army veteran, former corporate executive, and former Democratic state legislator Todd Achilles is running as an independent against 83-year-old Sen. Jim Risch.

Before running for office, Achilles had written for the American Economic Liberties Project, the left’s leading anti-monopoly think tank. He told me that “toxic concentrated corporate power,” brought on by “wave after wave of mergers and consolidation,” was destroying free markets in the US, as well as corrupting the political system. 

“You can’t tell the difference between a corporatist Republican and a corporatist Democrat anymore,” Achilles said. “They’re both checks from the same organizations, the same special interests.” 

In the Idaho race, too, the winner of the Democratic primary dropped out after state party leaders withheld their support.

Finally, in Montana, Seth Bodnar, an army veteran and former president of the University of Montana, is running as an independent for an open seat contest against Republican Kurt Alme. But Democrats’ high hopes that Bodnar could take on Alme untrammeled went awry when the winner of the Democratic primary, Alani Bankhead, refused the entreaties of practically the entire state party establishment to drop out. As a result, polls suggest, Bodnar and Bankhead will split the anti-Republican vote and likely let Alme cruise to victory.

The independents’ big plans for exercising leverage in the Senate

These various independents running have a lot in common — they all have military backgrounds and roughly similar platforms. They’re also all on a group text, per the New York Times — and they’ve started to think about how they could shake up the Senate if they win.

The few independents elected to the Senate in recent decades — centrist Joe Lieberman in Connecticut (after he lost the 2006 Democratic primary), socialist Bernie Sanders in Vermont, and center-left Angus King in Maine — had little in common with each other, but all ended up deciding to caucus with the Democratic Party after they won, believing that’s the best way to score their preferred committee assignments and help advance their priorities.

But Bengs, Achilles, and Bodnar have vowed that they would not do this. They’ve all said they wouldn’t caucus with either party if they win, and that they’d instead caucus with any other independents, making what Achilles calls the “Fulcrum Caucus.”

Achilles told me that, if these independents stick together, they could demand major reforms to the political system such as term limits and age limits for members of Congress and Supreme Court justices, restrictions on dark money spending on elections, and bans on gerrymandering. “I think we’re all aligned on this,” he said. (Several of these ideas would likely be shot down by the current Supreme Court as unconstitutional.)

“The goal is to deny the majority,” Bengs told me. “So neither Team Red or Team Blue gets to impose their will on the other side, without either going through us or working together — which would be a win unto itself, if they would work together.”

With the Senate growing more fiercely partisan in recent years, many have wondered why centrists on both sides don’t get together and try to seize control of the agenda. 

Yet the unity of this hypothetical new independent bloc already seems a bit shaky — in part because Osborn hasn’t committed to this strategy. In fact, Osborn has recently begun offering a new answer to the “caucus question” that has dogged him throughout two campaign cycles.

“I’ve given that a lot of thought and completely done a 180 on that,” Osborn told me. “Caucusing with nobody, you wouldn’t get anything done. I’m gonna caucus with everybody.” 

That meant, he said, he’d try to caucus with both parties at once. When I asked him whether that was possible and how it would work in practice, he told me, “Nobody really knows, and nobody’s been able to tell me that I can or can’t.”

While Osborn is an underdog, he is generally believed to be the independent candidate with the best shot at winning — several recent polls have shown his race to be tight. Since he has a shot of actually being in the Senate and having to follow through on his promises, he may feel less eager to box himself in.

But are they actually just Democrats?

When I asked the independents why they weren’t Democrats, they offered varying answers. Osborn said that “Biden and Harris failed on our border,” and that “if we don’t have a border, we don’t have a country.” He also said Democrats weren’t fighting hard enough for guardrails on the artificial intelligence industry, and complained that “Chuck Schumer’s daughter just got a job at OpenAI.”

Bengs said “the open borders of Biden” were disastrous, called defunding the police and abolishing the police “stupid ideas,” and said he condemned socialism. Achilles criticized “the dangerous decision to put President Biden forward for a second term” and the “corporatist” lean of the party generally.

But the reality is that prominent Democrats have implicitly or explicitly backed all their candidacies — and some of the candidates themselves were registered Democrats very recently.

Bengs told me he was a registered independent for his entire life, until he wanted to run for Senate in the 2022 cycle, to prevent Sen. John Thune from winning reelection unopposed. When it was too difficult for him to get on the ballot as an independent, he sought the Democratic nomination instead. And when he learned that state law required a party nominee to be a member of that party, he registered as a Democrat. When he lost, he swiftly became an independent again.

“My biggest weakness in this race is the fact that I ran as a Democrat in 2022, and that I was a registered Democrat for 13 months,” Bengs said.

Achilles, for his part, said he was a registered Republican for most of his life — but that, in 2024, state Democrats wanted to appoint him to an open state legislature seat, so he joined the party.

Then, in June 2025, he resigned from the legislature, announced he had switched his party registration to unaffiliated, and launched his Senate campaign against Risch, saying “the two-party system is just fundamentally broken right now.”

“It makes it a lot easier to tag you as a secret Democrat if you’re a former Democratic officeholder or a former Democratic Senate candidate,” Jacob Rubashkin, the deputy editor of Inside Elections, told me.

Osborn’s version of the problem is a series of leaks that have come out in recent weeks, in which he addressed Democrats privately and struck a very different tone than he typically does in public.

The Trump border wall he’d publicly backed was “a symbol of racism,” Osborn privately told a group of Latino and Black Democrats last year. “It’s a joke,” he added. “It does nothing, you know.”

Another recording, from a private campaign-related event, featured Osborn discussing how “Billy Bob in fucking Red Cloud, Nebraska” waves the Trump flag because he wants to be “on the winning team.” He added: “That’s all they care about because their lives probably suck.” (Osborn apologized for those comments after they were leaked, and said: “My life sucks too.”)

“When you’re funded by Democrats, hold the same policies as Democrats, and let your campaigns be run by Democrat consultants with ties to Chuck Schumer and Zohran Mamdani, you’re a Democrat,” Bernadette Breslin, press secretary for the National Republican Senatorial Committee, told me in a statement.

That’s the message that Republicans will be broadcasting to voters in these red states. Whether it will work will depend on each particular state and matchup. In Montana, Bodnar has the additional problem of the Democratic candidate staying in the race to split the vote.

But Rubashkin, the deputy editor of Inside Elections, argued to me that Bengs and Achilles have the toughest road — in 2024 Trump won their states, South Dakota and Idaho, by the overwhelming margins of 30 and 36 points, respectively. “It is just hard to find the votes in those states,” he said. But he pointed out that Rounds is up on the airwaves in South Dakota, and said Risch appears to be “taking the race seriously” and “running a real campaign” — so, at the very least, these runs mean the incumbents won’t take another term totally for granted.

Osborn, in contrast, has “the proof point” of coming within 7 points of winning in 2024, Rubashkin said, and this is now a more unfavorable national environment for the GOP. The question is whether his own behavior and comments will have damaged his prior reputation for independence, particularly once they’re amplified by millions in spending from his opponent Pete Ricketts, the self-funding scion of a billionaire family, and the super PAC backing Ricketts.

Still, if Osborn pulls it off, it will be seismic — as the candidate himself mused on one leaked recording. 

“If I beat Pete Ricketts, if a shop floor mechanic — independent mechanic — beats an entrenched Republican billionaire in a state like Nebraska, I will be one of the most popular politicians overnight, right?” he said. “And people are going to want to listen to what I have to say.”

After moving to West Virginia last year, Steve Kuo signed up for a new insurance plan that would cost him $500 a month. But there was one upside: He knew he was entitled to a free preventive visit. He wanted to take advantage of it, so he made an appointment at a clinic near his new home.

But then when he got there, they asked about his medical history and he mentioned prior kidney problems. When he received a bill a few weeks later, he had been charged twice for the same appointment: Once as that free preventive visit, once as an “office sick visit” because of the kidney conversation. He was flummoxed — and very annoyed, as he shared on social media. “No copayment means no copayment, exactly as stated in the insurance guidelines,” Kuo told me over email. “What is written and agreed upon should be honored.”

He is far from alone. On Reddit, I easily found more than a dozen examples in just the past year of people getting a surprise bill for what they thought was going to be a free visit. 

One woman posted a nearly $1,000 bill she’d received for what she thought was going to be a preventive gynecology visit. Another woman said that she ended up facing roughly $3,000 bills because she was given an ultrasound (which she said she didn’t request) at a preventive visit, and then her blood draw was sent to an out-of-network lab. Another person lamented that they had been billed $170 for an office visit because they had briefly mentioned back stiffness.

It’s not supposed to be like this. Americans don’t get much when it comes to our healthcare, but most of us are supposed to be entitled to at least one thing: Once every year, no matter your health insurance, you can go to the doctor with the goal of preventing future health problems by discussing important vaccinations, cancer screenings, and cardiovascular health screenings. The Affordable Care Act made that the law in 2010.

But more than 15 years later, people all over the country are walking into their doctor’s office, thinking they’re entitled to that one free visit every year, and walking out being billed for a sick visit, blood labs, and more. Researchers estimate that Americans spend tens of millions, maybe hundreds of millions of dollars every year on services that are supposed to be free under the ACA.

Dr. Yalda Jabbarpour, a family physician in the Washington, DC, area and medical director of the Robert Graham Center for Policy Studies, told me she still deals all the time with people’s confusion about what a preventive visit really means.

“Every single time I’m in the clinic, this issue comes up with a patient. And it’s sad that it comes up,” Jabbarpour told me. “In my mind, the blame is not to be put on the patient. The blame is not to be put on the physician. Really, this points to a bigger system issue that we need to solve.”

How could a seemingly simple promise of one free annual doctor’s visit result in a situation so convoluted that patients and doctors are still struggling with it nearly two decades later? And how might we fix it?

Patients are getting surprise bills from their doctors — and they’re pissed off

The goal of the ACA was to expand coverage and make sure health insurance would be comprehensive to actually help people stay healthy. As part of that project, the authors of the law added a mandate for insurers to cover those services, including an annual wellness exam. The problem is, they did not define what the parameters of that preventive visit actually were, said Alex Hoagland, a healthcare economist at the University of Toronto. 

“It didn’t establish a clear definition of…all the diagnosis codes and procedure codes and how frequently you get that combination within a year,” he said. “They don’t define what actually is preventive care and what’s not.”

That has left each insurer to define a preventive visit on their own — and that’s where the perverse incentives that leave patients in a lurch begin. Preventive visits are supposed to be reserved strictly for screenings and talking about other preventive measures you can take to protect your long-term health, but you may get billed for an “office visit” or a “sick visit” if you talk about any specific symptom you’re experiencing, the same as if you had come in because you had the flu. 

Health insurers have an incentive to keep the definition of preventive care as narrow as possible, so they have to pay fewer claims without any contribution from the patient. At the same time, doctors want to be paid for the actual services that they are providing. If somebody does bring up a bigger health problem during a preventive visit, then the doctor reasonably wants to be paid accordingly. 

“I know, particularly in the healthcare space, it’s really popular to blame one party or another, and here I don’t think it’s a matter of corporate greed or physician incompetence or whatever,” Hoagland said. “It’s just a natural mismatch of incentives.”

So the reality is that “one free doctor’s visit” sounds straightforward, but, in practice, it’s much more complicated. You as the patient might think of it as one visit, but in our fee-for-service healthcare system, where providers bill based on each specific thing they do, it’s not. The conversation about your vaccination may be free — but asking about your back pain is not. If you get blood tests ordered, that’s another line item. The list goes on. “It’s not like you walk into a doctor’s office and it’s just one thing that happens, right?” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University. “It’s multiple different things that are happening when you go into a doctor’s office.”

Part of the problem may be that it’s one free visit. We Americans are consumers at heart: Tell us we’re going to get something for free and we want to take advantage of it. But having just one free visit may also lead to people bringing a laundry list of questions to that preventive visit, because they think of it as their only chance to ask everything of their doctor. 

That makes it easy for the discussion to tip over into a sick visit — and not only does that lead to a surprise bill, it can also crowd out the conversation about prevention that the visit is supposed to be focused on.

“What ends up happening a lot…is that a patient comes in for their annual visit, and in their mind, that is their time to bring up every single thing that’s been happening during the year, because they see it as the free visit to bring up everything that’s happened during the year. For some patients, that takes up the entire visit,” Jabbarpour told me. “They leave, and it’s like, ‘Oh my god, we forgot to do all the screening things: the vaccinations, the cancer screenings, and the cardiovascular risk screening.’ And then something happens down the line because you never address those screenings.”

A 2021 study by Hoagland and Paul Shafer, both of Boston University at the time, estimated that Americans with employer-sponsored insurance had in 2018 alone paid between $75 million and $219 million in medical bills that should have been free. They were more likely to be charged for things like contraception or cholesterol and diabetes screenings, with individuals sometimes paying hundreds of dollars for those services.

Hoagland told me he had been billed for preventive visits because he has type 1 diabetes and the system automatically categorized his appointment as a diabetic visit. Earlier this year, he co-authored a study that found people with chronic conditions were more likely to be charged for preventive care. Corlette said that she too had recently been charged for what was supposed to be a preventive visit after she mentioned an issue as an aside. And these are folks who study health care for a living.

“It was literally maybe a 10-second conversation where I would ask the doctor a question about something,” she said. “And that triggered it.”

Colonoscopies are another dramatic example of how this issue plays out in real life; Corlette told me the procedure was one of the first services where this fuzzy line between prevention and treatment under the ACA became obvious. People go under for what is supposed to be a preventive colonoscopy. But then their doctor finds a polyp and decides to remove it — good clinical practice, but as a result, their patient could end up being charged thousands of dollars because the colonoscopy was no longer preventive once that polyp was snipped.

“All of a sudden, that would trigger what the patient thought was a preventive service into a cost-sharing obligation,” Corlette said. “Colonoscopies can be thousands of dollars. That was when we were first like, ‘Oh, yeah, this is a more complicated area than I think the lawmakers that drafted this provision originally envisioned.’”

How the US could fix our preventive visit headaches

The ACA’s preventive visit promise was clearly well-intentioned and it’s worth remembering that, if you look in the aggregate, more Americans are getting more free preventive care than they did before the law was passed. The problem, as much as anything, is expectations: People think they’re entitled to a free visit and are understandably frustrated when they get billed for it.

“The difference is before the Affordable Care Act, maybe they anticipated some kind of cost-sharing,” Hoagland said. “But after, they expect it to be free.”

It doesn’t have to be this way. Corlette’s team at Georgetown University recently released a proposal that Americans be entitled to three primary care and two urgent care visits every year with no cost-sharing. This approach has two virtues, she told me: It will help people feel like they are actually getting value from their insurance — the very complaint that Steve Kuo raised — and, because we know primary care helps prevent problems down the road, it should also improve people’s health in the long term. Take the pressure off that one free visit and let people see the doctor a few times a year without worrying about being charged.

“In employer-based insurance, a lot of people feel like, ‘What the hell am I getting for my premium each month?’” Corlette said. “We wanted people to feel like they’re getting good value, and we wanted to get to better population health.”

Hoagland also endorsed the idea of at least one free physician’s visit every year, no matter what’s discussed. In the long term, Jabbarpour said she’d like to see copays eliminated entirely for primary care. 

But any payment reforms are not going to happen immediately. What can we do right now?

For one, doctor offices could make an effort to be as transparent as possible. Jabbarpour’s MedStar system has started calling people a couple of days before their appointment with a brief script that tells the patient that they could be charged if the conversation with their doctor touches on additional medical problems. If your doctor’s office doesn’t proactively bring it up, ask when you schedule your appointment or when they call you to confirm it. Worst-case scenario, ask your provider what they consider preventive care when your visit begins. You might also want to educate yourself on what services are generally considered preventive and should be available for free: Your insurer may make that information available on their website, or KFF has a database you can peruse.

It’s not a perfect solution. “What ends up happening is patients come in, and they say, ‘I know I’m not supposed to talk to you about anything else, so I’m not going to tell you about anything else.’ And you don’t want that to happen,” Jabbarpour said. You should ask your doctor directly: What do you consider to be preventive care? Establish boundaries at the start. That way, you can at least be aware if you are going to get charged because the conversation crossed the line to discussing an active health problem.

And if you want to see the underlying laws change, start organizing. Contact your state and federal reps and ask them what they are doing to ensure this stops happening. Things could be different: Jabbarpour said she hopes to one day work in a health system where the cost of a single primary care visit isn’t so high-stakes, where doctors and their patients can manage their health according to their particular needs, rather than worry about how to bill for one specific conversation that covers the whole range of somebody’s health — like primary care is supposed to do.

“I think some patients can be managed by seeing us once every year, once every two years, and some patients need to see us monthly,” Jabbarpour told me. “To put all patients in the same box and say you can only see your primary care physician once a year if you want it paid for, it makes zero sense.”

With the 2026 midterm elections fast approaching, polling increasingly suggests that the GOP is in for a bad time. As the Iran war drives up inflation and fuel prices, Republicans are on the back foot not just in swing states like Michigan, but in redder parts of the map: Iowa, Texas, and maybe even Kansas, among others. (Not to mention Georgia and North Carolina.) 

It’s shaping up to be a Democratic wave, in other words, and a major repudiation of President Donald Trump. According to Sarah Longwell, the publisher of political news site the Bulwark, there’s a clear reason why this is the cycle that things seem to be falling apart for Trump, who has dodged scandals and bad poll numbers before. “The average person is often voting on instinctual things,” she explains, “and those instincts are a lot of your animalistic desires for things to be okay materially.” And for many voters right now, things are not okay materially.

Longwell would know: She regularly speaks with voters for her podcast, The Focus Group, and she’s the author of the new book How to Eat an Elephant: One Voter at a Time. 

Longwell talked with Vox’s Astead Herndon for a special live recording of the America, Actually podcast at the Texas Tribune Festival earlier this month about why voters are both more and less complicated than punditry sometimes suggests, what the future holds for the Republican Party post-Trump, and the lesson Democrats need to learn to capitalize on their wins.

Below is an excerpt of Astead’s conversation with Longwell, edited for length and clarity. There’s much more in the full show, so listen to America, Actually wherever you get your podcasts or watch it on Vox’s YouTube channel.

One of the themes in the book is to talk to voters like real adults. What does that mean? 

There was a long period of time in our history where the artifice of politics was part of the performance of politics.

You could give a good speech. You’d do a debate. Those are not the rules of politics in this communications environment anymore. Every single one of you, if you’re a Bulwark person, you interact with me. I am in your ear, and we’re having a conversation.

We have a parasocial relationship. I walked in here and met a bunch of people, and they were like, “I feel like I know you.” And people want to feel like that about their political leaders now. And so they want to know what makes you tick. Are you a real person? And so the artifice of a debate on CNN is starting to feel really stupid, no offense to CNN.

People demand more now. And a lot of it is just that artifice is falling away for voters. Donald Trump understood that as a person who had been in people’s living rooms as a performer. Democratic politicians still have not figured it out. 

One of the things that comes through in both the book and I think the work that we both do is how voters don’t always fit into those neat ideological boxes.

I always tell the story about when I was at the Iowa caucuses, and I remember in 2019 in the Democratic primary, someone telling me they were stuck between Bernie [Sanders] and [former New York City Mayor Michael] Bloomberg, and asking, “How did you get there?”

And what was the answer? 

I think the short answer was they liked a strong guy where they knew what he believed in. And they did not care which side of that coin that was, as long as it felt consistent and something they could put their hands around.

If ideology is not the controlling paradigm for voters, how should we think about the different ways people are sorting themselves right now? 

My answer is genuinely not to sort them as much. This is the reason people say things like, “It’s the economy, stupid,” and then everybody gets bored with that answer, and they want to talk about 10 other things because they’re like, “Well, that’s so straightforward.”

But I try in the book to say it really is about improving people’s material well-being and ensuring their safety. So you go back to: What are the most human things that people want? They want to be able to afford gas. They want a job. They want a job [where] they think that they can go up the ladder. 

They want their kids to get a good education. Then they want to be safe. They want to know that they’re safe in their community. They want to know they’re safe in the places that they go. And Donald Trump and Republicans really do understand: People vote with weird animal instincts. 

Now, I bet a lot of the people in this room are college-educated suburban voters, but the average voter in a general election is a 55-year-old white guy without a college degree.

The average person is often voting on instinctual things, and those instincts are a lot of your animalistic desires for things to be okay materially — your cost of health care, and then for you to be safe. And so if you think about those base-level desires and then think about what Democrats spend most of their time talking about, you’re like, “Is that the thing that captures all these people?”

When I watch Democrats as somebody who’s an immigrant into the Democratic ecosystem, there’s a lot of, like, “And you get a policy, and you get a policy, and you get a policy.” And I don’t really understand that because everybody needs cheaper gas.

Everybody needs groceries that they can afford. And so talking about the things that unite us or that everybody needs, to me, is the secret sauce for how Democrats should think about policy. 

Three years ago, Democrats thought that being against January 6th was a thing that united everybody. There was a belief that pro-democracy arguments were going to unite people across ideology. Why did that fail in 2024? 

I’ve been thinking about this a lot as Trump gets terrible poll after terrible poll, and this is my point.

The coup, all of the horrible things he said about women, all of the lawsuits — I mean, he told everybody an election was stolen. Why is he underwater right now? Because of gas prices, because of a war in Iran, because the negative personal consequences of his policies are hitting people.

I know that it frustrates people. I’m so aware of the frustration where people are like, “Why are people so selfish? Why don’t they think about the bigger picture of democracy?” And one of the things I try not to do is magic words — consultant stuff, because a lot of consultants do that. They’re like, “Say freedom,” and “Say affordability.”

There’s nothing to back it up. But the one magic word I do think that Democrats should start using is “America,” and swap it in for “democracy.” And the reason is, voters practice democracy in America by its individual things.

They practice free speech. They like rule of law. They like checks and balances. So they like the elements of democracy, but they don’t think about them up here as democracy. And also the word democracy now is very polarized, right? Republicans think that Democrats are a threat to democracy because they stole the 2020 election. And Democrats think Republicans are a threat to democracy because they lied about the election being stolen and then tried to overturn the entire government.

I think one side of that equation is more right than the other. But I think that’s why it didn’t work. 

I want to look ahead. Our show focuses on building a roadmap for American politics without Trump, and part of that question has been about Republicans.

They have made themselves into a new kind of America First-esque party. But what does that mean without Trump at the center of it? When you’re in your focus groups, is it clear what values or principles Republicans believe in besides what Donald Trump says to them?

Absolutely not. They don’t have anything. This is why I wrote the book. I wrote the book because we have 2026, we have 2028, and we have 2032. 

By 2032, there’s going to be a new census, and things are going to get worse for Democrats. Hear me on this. People are not grokking this yet. The map — people are leaving California for Texas, people are leaving New York for Florida, and it’s just going to get harder for Democrats to win if this same trajectory that we’re currently on holds.

But there is a generational opportunity right now, and it’s why I desperately wanted to bring this book and get it out there. The Republican Party at this moment is as hollowed out as … Donald Trump is going to leave it in shambles. There is no Trump heir who can do what Trump does, who has the longstanding parasocial relationship with voters where they give him this blank check that other people don’t get.

But my concern is that 2026 will go really well and that Democrats will say, “See? It’s fine. Everybody likes us.” They don’t.

This was the big mistake in 2022. The midterms were extrapolated [to signal] Biden’s re-election, and those were not the same thing.

They are not the same thing. And again, the average voter is a 55-year-old white man without a college degree. And you can just hold that in your head and picture that guy and say, “Do we have candidates who can appeal to that guy?” 

I was being annoying when I was flying here, tweeting things, and there’s a new poll out for [Pennsylvania Gov.] Josh Shapiro. He is beating his Republican opponent by 21 points in the poll right now. This is the largest swing state in the country, and Democrats hate Josh Shapiro.

Hate feels a little strong. I think the left doesn’t like Josh Shapiro. I don’t think that’s the whole party.

That’s a good point.

I’ll just say, as a slight Josh Shapiro stan, perhaps I feel more than most people’s antipathy to the idea of Josh Shapiro running. I get a lot of people just being like, “Absolutely not. He’s a corporate centrist. We would never consider him. And also he’s Jewish slash Zionist.”

And a lot of this is Twitter discourse, but it feels like he doesn’t get the same buzz or interest, which seems insane to me when you’ve got somebody that popular in such a big, important state that Trump was able to win twice. 

The electoral argument for the Josh Shapiros of the world is clear.

Twenty-one points in Pennsylvania at any rate is impressive, but let’s use him as an example, because I do think it speaks to where some Democrats have gone in the last couple years. The polling will tell you that the majority of Democrats want to see their party reshift its relationship with Israel and want to see things like an arms embargo.

Polling would tell you that the majority of Democrats believe that they shouldn’t be taking corporate money, or that things like AIPAC money are bad. How does a Josh Shapiro — let’s use him as an avatar. … Is that compatible with where the Democratic base is right now, even if it’s clearly compatible with Pennsylvania?

The way that you just said it doesn’t sound compatible. But I don’t think that it’s incompatible. 

This is a book about what the voters think, and the voters want a new relationship with Israel, hands down. Without question. They want America to reevaluate our relationship with Israel. And the next Democratic presidential candidate is going to have to do that.

And I have a theory about this. I do think that the 2028 nominee is very likely to be a Jewish person who is highly critical of Israel, because I think that it helps to heal the deep divide right now on this issue within the Democratic Party.

Now, do I think it’s more likely that that is the very handsome Jon Ossoff? I kind of do. But I just … a big part of this book is, “Don’t you want to win? Don’t you guys want to win?” Like, do you want to win more than you want to be right about everything?

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The last US troops in Iraq formally withdrew today, 23 years after the United States first invaded Iraq and 12 years after it returned to take on the Islamic State. It’s a historic occasion, by many accounts — but also a pretty low-key one: The US has steadily scaled back its presence in Iraq for years as part of a phased drawdown inked by the Biden administration. 

That drawdown represents the end of a long (and often, ugly) chapter in US military history. The US and its allies deployed tens of thousands of troops to Iraq as part of the larger war on terror that started in 2003. 

Those troops left Iraq in 2011. But a smaller contingent returned three years later to stamp out the Islamic State, a violent jihadist group that had gained a major foothold after Western forces left the country. 

Neither campaign was particularly popular with the American public in the end, and more than 4,500 Americans have died in Iraq in the past 20 years. Large numbers of civilian casualties, as well as drone strikes that were seen as violations of Iraq’s sovereignty, have also fueled periodic Iraqi protests against American intervention. 

As the US withdraws, however, it’s leaving behind some very loose ends. Loose ends that, as we’ll see in a minute, ultimately benefit…Iran.

Go a little deeper

Don’t quite believe me? Just look at how Iran’s allies are celebrating today’s news. The commander of one Iranian-backed militia in Iraq called the withdrawal “a crushing defeat for the American project.”

Both Iran and the United States have spent the past 23 years attempting to shape the new Iraq. Historically, Iran and Iraq were bitter rivals — an enmity probably best demonstrated by Saddam Hussein’s 1980 invasion of Iran. 

After the US toppled Hussein in 2003, however, Tehran redoubled its efforts to build political and military clout in the new Iraqi state. It strengthened ties with figures like Hadi al-Amiri, whose Iran-backed Badr Organization has become a major force in Iraqi politics. It poured hundreds of millions of dollars into soft-power projects, like expanding Shiite pilgrimage sites in Iraq. And it funded, equipped, and trained a number of powerful paramilitary groups.

Some analysts have warned that the final withdrawal of US troops could embolden Iranian-linked groups in Iraq. That also seems to be a concern on the ground, where ordinary Iraqis have told reporters they fear their country “could be swallowed up” by groups linked to Iran.  

Already, the Iraqi government has pushed back the deadline for Iranian-backed militia groups to disarm. It was originally supposed to happen on the official date of the US withdrawal — today.

It’s an inglorious ending, all told — and a sobering lesson on the limits of American power. The US may have the resources to handily win any military spat it gets itself into. But securing a desired political outcome is a different and more time-consuming project altogether.

It doesn’t help that US rivals like Iran seem very willing to play the long game. By dipping in and out of places like Iraq, the US may risk giving Tehran more openings. 

One link for later

➨ Don’t throw out that old receipt! It — along with the political mailers, ticket stubs, business cards, product packaging, and other printed ephemera you encounter in your day — is perfectly suited to the newly viral hobby of junk journaling. It can be a powerful creative practice and the ideal antidote to doomscrolling.

Before you go…

• Did you know…that your sense of touch peaks in your late teenage years, and declines gradually from there? It might be one of the reasons that elderly people are prone to falls.
• Today’s trivia: Where was Napoleon exiled to after his forced abdication? (You can find this and other brain puzzles in Vox’s daily crossword. Look for the answer in tomorrow’s edition.)
• Yesterday’s trivia: We asked you for the origin story of civil rights icon Ruby Bridges. She was the first Black child in the American South to attend an all-white elementary school, and she went on to start a foundation devoted to tolerance. 

Everyone knows how much gasoline prices matter. The recent spike in gas prices triggered by the war with Iran has fueled deep pessimism about the economy and weighed heavily on President Donald Trump’s approval ratings.

But diesel fuel — the lifeblood of shipping, agriculture, and heavy industry — usually flies under the radar. Its price has surged too, and while truckers and farmers are feeling the initial blow, the rest of the country won’t be far behind.

“Most products in America are shipped along the road via trucks,” Nathan Bomey, a business reporter at Axios, told Today, Explained co-host Noel King. Diesel prices “directly affect their cost of doing business, which then eventually trickles down and affects the consumer.”

On the podcast, Bomey discusses what’s driving the price spike, how quickly it’s going to become a problem for everyday consumers, and whether electric semi trucks could offer a way out.

Below is an excerpt of the conversation, edited for length and clarity. There’s much more in the full podcast, so listen to Today, Explained wherever you get your podcasts, including Apple Podcasts, Pandora, and Spotify.

What is happening with diesel?

There was one major geopolitical event this year that disrupted the entire energy economy, which is the US and Israel attacking Iran. Iran is at the center of the oil economy in some ways, but primarily you have to look at the closure of the Strait of Hormuz and the jockeying over it that has happened in the months since.

Once they closed the strait, it disrupted the entire global energy economy because it handles a substantial portion of the shipping bringing supplies out of the Middle East. That affected diesel prices, gasoline prices, jet fuel prices, and effectively everything based on crude oil.

Who are the people right now that are profoundly freaked out about the cost of diesel?

First off, truckers are freaked out because their cost of doing business is going much higher. Farmers are also freaked out because they’re already facing real pressures from trade wars and things that are out of control, like climate issues, that have caused their costs to go higher. 

The price of diesel affecting farmers eventually affects the price they charge, which ultimately gets to the consumer because it ends up costing more to pay for things like an ear of corn.

How stark do you think this might be? In a month or two, do you think I could go down to Walmart and see that something I buy all the time is now a dollar more expensive? 

I think the impact is imminent. This flows through very quickly. We’re not talking about months; we’re talking about weeks, if not days, before people will start to notice increases, especially in the grocery aisle. That’s the first place people will notice it because fresh food has to be shipped on a weekly basis. Diesel prices are going to have a big effect on food inflation. This is coming off of several years of food price increases that we experienced in the wake of the pandemic.

We’re also barreling toward the holiday shopping season, which is going to be affected by this as well. If a toy, for example, is made with a resin affected by the cost of crude oil, which also affects the cost of diesel, and then it’s shipped over the road to Walmart in a truck that uses diesel, all of these things add up and will probably lead to higher prices.

We’ve also got an issue with heating oil, which is a fuel used primarily by households in the Northeast to heat their homes. Heating oil, diesel, and all of these oil-based products are caught up in this vortex right now. Ultimately, it is not something the ordinary person can do much about.

Do the industries that rely on diesel have any other options?

There are definitely alternatives to diesel, but in many cases, they cannot be switched to quickly. If you think about the trucking industry, they are invested heavily in big rigs that take products from place A to place B. If you are invested in a truck, yes, you could theoretically switch, but you would be scrapping this huge investment you’ve made. Diesel trucks are not really going anywhere immediately. A lot of times, they’re simply still the best way to get somewhere.

You can switch to rail; railroads are definitely a competitor to trucking, but really only best for certain types of products. There are other types of trucks you can buy. Compressed natural gas or liquid natural gas is an alternative fuel for some trucks, and biodiesel can actually be good. Hydrogen is more of a futuristic thing down the road.

In the short term, there is the possibility of using electric trucks. That is starting to become more realistic. In fact, in recent days, Tesla began major production of the Tesla Semi, an electric semitruck we’ve been waiting for for years. I remember covering this in 2018 when Tesla debuted the semi, and we all thought it was going to be coming out soon.

It has taken nearly a decade for this to finally become a reality in large proportions, but the Tesla Semi is an electric truck that could be an alternative for some. There are other companies making electric trucks too, so that could be viable. But the problem with electric trucks is that the battery is so heavy, making it tough to compete with diesel on shipping heavy items.

It was often joked that when the Tesla Semi first debuted, the very first thing it shipped was a bunch of bags of Cheetos because they were so light and the truck couldn’t handle extra weight. They had a deal with PepsiCo, and it wasn’t ready at the time to ship anything heavy. 

It’s a lot better now, but the issue is still how heavy electric truck batteries are, which will make them somewhat limited in capacity. However, we are seeing some demand for the Tesla Semi that indicates it might become more competitive because of the price of diesel.

So when prices are high, generally somebody somewhere is benefiting. Who is it, in this case?

The people benefiting from diesel prices being so high are the refineries, which a lot of people don’t think about much because they’re the middle person in this entire process. They take the crude oil and turn it into usable diesel for a pickup truck, a semi truck, or farming equipment. 

The refinery business is experiencing high demand right now, and there’s limited capacity to do this because of issues in Russia, Iran, and other places throughout the world. There’s really nowhere else to do this, and therefore they can charge higher prices. That means higher profits for the refineries.

All of this is shaping up to potentially mean a really ugly winter. One thing I think about a lot is that American consumers will accept a lot of pain. We had Covid — the inflation, and shortages of literally everything. Then we had the war in Ukraine, and prices went up again. 

People still keep spending money, even as we predict this one’s going to get bad. People go to the store and spend money, and maybe they gripe, but it’s not like we’re out in the streets. Do you think this coming diesel shock — imminent, in your words — is going to be different?

I’m not an economist, but there is an interesting phenomenon emerging in the economy where consumer sentiment is at rock bottom, but consumer spending is actually really strong. There’s a gap emerging between what people say they feel and what they’re actually doing — in this case, they’re still spending. 

Maybe it’s YOLO spending. They’re thinking they don’t have much going for them, so they’re just going to keep spending. I’ve experienced that a little bit, so I don’t blame anybody.

At the end of the day, the numbers matter a little bit more than what people say they feel. But I do think people are going to hit a breaking point because they simply cannot continue this level of spending if the underlying fundamentals of the economy start to collapse.

The Soviet Union famously churned out tens of thousands of new apartment buildings in the 1960s, ’70s, and ’80s — some assembled in as little as 12 days — together comprising tens of millions of individual apartments. Such speed is not unique to communist command economies, or even to grim concrete mega-blocks. In Sweden and Japan today, modern, high-quality new homes can be factory-built and assembled in a matter of weeks using the same basic method — prefabrication — as the Soviets.

The US, alas, evinces no such urgency to build housing. 

In some of our highest-cost cities — San Francisco, New York, Miami — it takes, somewhat astonishingly, nearly five years to erect a modestly sized apartment building, from the time an application is first submitted to building completion. That was one of the top-line findings of a remarkable new economics working paper on housing construction timelines across 60 US cities. The gaps between the fastest and slowest cities were just as striking: In Raleigh, North Carolina, a builder can complete a 20-unit apartment building in about as much time as it takes just to approve the permit for one in San Francisco, where applications languish for more than a year. In Indianapolis, a single-family home can be built in six months from proposal to completion, less than one-eighth the time it takes in San Francisco.

Such delays have costs — in delayed housing supply at a time when America is millions of homes in the hole, in lost staff time that developers ultimately bake into the cost of the new homes, and in homes that simply never get built because the process is discouraging to anyone but the best-resourced developers. The authors, Leonardo D’Amico, Evan Soltas, and Audrey Wang, found that longer permitting lengths are correlated with higher housing prices and lower rates of housing production, though they don’t claim to have shown that these are causal relationships. The research (which has not yet been through peer review and, like any working paper, may be revised before final publication) represents the first such comprehensive dataset comparing homebuilding timelines across the US. To build it, the researchers assembled 1.1 million permits covering 2.7 million housing units between 2000 and 2025 — about one in 13 new homes permitted nationally over that period, they write. 

It probably won’t come as a shock to you that housing can be built faster in Sioux Falls, South Dakota, than in Los Angeles or pretty much anywhere in California. But perhaps the most notable takeaway (to me, anyway) from the paper was how massively home permitting times have lengthened across the board over the past 25 years. Across the cities in their sample, the researchers estimate that permitting time for a standardized multifamily building rose from 0.6 years in 2000 to 1.5 years in 2023, and, for a single-family home, from 1.6 months in 2000 to 4.9 months in 2023. 

Is there really any good reason why we should take nearly a year longer to approve an apartment building than, Soltas joked in a recent interview, “the barbarians of 2006”? Shouldn’t we be getting faster and more efficient at building housing over time, not slower — especially at a time of acute housing scarcity? 

You would think. So what is going on here?

One building, very different wait times

Permitting refers to everything that happens after a developer submits an application to build a house or multifamily building, before they’re allowed to break ground. The proposal is then reviewed for compliance with a range of different sets of rules, from building safety and energy codes to plumbing to zoning and, in some places, aesthetic design. Initial applications will often be found noncompliant and then sent back to the builder for revisions, Soltas, an assistant professor of economics at Princeton, told me.  

The gulf between housing starts in California and Texas has become something of a meme in housing abundance circles. But, for all that, we have until now lacked rigorous apples-to-apples comparisons of permitting and building times in different metro areas, Soltas said. That gap in seemingly basic knowledge, what should be “step zero” facts for the national housing reform debate, became apparent to him when he was teaching an urban economics class, which became one of the impetuses for the new paper. “I realized if I needed that information to teach my students, that it might be useful for other people,” he said. 

Rather than merely pulling permits from different cities and comparing how long whatever happened to be built in each city took to approve, the researchers used the data to estimate how long an identical, standardized project would take in each place between 2015 and 2019, keeping constant its size and the density of the surrounding neighborhood. Their uniform archetypes were a 2,800-square-foot detached single-family home on a 0.15-acre lot and a 20-unit multifamily building with 1,200 square feet per apartment.

Cities with longer permitting times also tended to have longer construction periods — the longer it takes to get an application approved, the longer it then takes to do the building itself, which compounds the gap between the fastest- and slowest-building cities (it’s possible that “cities that make the permitting process difficult also put in lots of burdens that slow the construction process,” Soltas said). One advantage of the researchers’ method is that the differences across cities can’t merely be chalked up to something like the complexity of building within already-dense environments like Manhattan — the analysis already controls for that. So the enormous gaps between different places become harder to dismiss as inevitable features of development in big cities.

The study wasn’t designed to answer the “why” of it all — those will be questions for future research. “Our paper doesn’t directly identify any smoking guns,” Soltas said. Still, some of the culprits are likely obvious — California, for example, has long subjected some housing projects to extensive environmental review requirements under the California Environmental Quality Act (CEQA). Apartment buildings, especially larger ones, are more likely to have to go through CEQA review, though they’re more environmentally friendly than single-family homes (recognizing this as an obstacle to housing affordability, California has been moving to exempt many housing projects from such reviews). 

Why are we taking so much longer to permit housing?

But why, as the study finds, is permitting becoming slower across the country, not just in the most regulated cities? “We estimate that, in 2000, our standardized multi-family project had a 71-percent probability of approval within six months of applying for a permit,” the researchers write. “In 2025, that project had a 44-percent approval probability within six months.” Permitting times have come down a bit since 2023, but it’s unclear whether that just represents the reversal of pandemic-era highs, or if it reflects real progress from the pro-housing policies that have been passed in many cities and states in recent years. 

That discovery dovetails with other economics research finding that zoning codes, which were first widely adopted in the US in the early-to-mid 20th century, have continued to become more restrictive even in recent years, making it harder to build housing. 

Without knowing why exactly permitting lengths have ballooned, it’s hard to say whether those increases have occurred for good reasons. At least some of it may have to do with the aforementioned intensification of zoning and other land-use restrictions, which, I can say from having written a lot about zoning, tend to be pretty ill-conceived and hard to justify. 

The slowdown may also be connected to expanding building code requirements. I’ve written at length about that issue, too; although ever-more stringent rules might seem like a great idea — who could be opposed to more safety? — they tend to be biased against multi-family housing and likely inflate the cost of building, all without having to show that the benefits are worth the costs. Particularly the cost in housing supply that never gets built, which has the effect of keeping more Americans living in older housing stock. And do we really think a home built to 2005 standards is dangerously subpar today?  

We might ultimately decide that many of today’s building requirements — particularly ones like stronger energy efficiency standards — are worth it, but first we’d need to determine what their full costs are, which we remain far from doing. 

At a minimum, it seems unlikely that an apartment building that’s okay to build in Grand Rapids today would be unsafe for New York. So what, exactly, is all that extra permitting time buying the city? Now, at least, Mayor Zohran Mamdani can put an exact number on the delay.