Last week, the Food and Drug Administration (FDA) approved a small pill called enlicitide. It is a tablet you swallow once a day on an empty stomach with a sip of black coffee, water, or tea. But it does something that until now took a needle and a specialist’s prescription: It lowers the most dangerous kind of cholesterol by nearly 60 percent, about as much as the strongest injectable drugs on the market.

If that sounds less innovative than some of the medical advances I sometimes cover here — there’s no AI or gene editing involved — you’re missing the story. Enlicitide is just the latest example of how medicine has been quietly making progress against the deadliest thing in the modern world.

That thing is heart disease. It has been the leading cause of death in the United States for essentially a century, and in 2025 it killed 694,708 Americans — about one in five deaths — more than every form of cancer combined. Around the world, cardiovascular disease kills roughly 20 million people a year, the biggest cause of death on the planet.

But today, our enemy is on the retreat. In the US, the age-adjusted death rate from cardiovascular disease has fallen about three-quarters since 1950. In plain terms: A 60-year-old today is roughly four times less likely to die of heart disease this year than a 60-year-old was when Harry Truman was president. As I wrote last year, deaths specifically from heart attacks are down 89 percent since 1970.

That progress comes down to a single number. Low-density lipoprotein, or LDL, aka the “bad” cholesterol your doctor always wants you to lower. Until recently, a high LDL score was all but inescapable, something you could nudge lower with a better diet and willpower but struggle to really fix. What has changed is that we can now lower LDL for nearly anyone who needs it — further, more easily, and earlier in life than before.

A lifesaving genetic mutation

It’s a story that goes back 20 years. In the early 2000s, two geneticists at University of Texas Southwestern, Helen Hobbs and Jonathan Cohen, wanted to solve a medical mystery: Why did some individuals have striking low cholesterol levels? They combed the Dallas Heart Study for an answer. They found a handful — many of them Black Americans — carrying a broken copy of a gene called PCSK9. Their bodies cleared LDL from the blood with unusual efficiency, and the payoff was staggering: carriers of the strongest variant had about 28 percent lower LDL and roughly 88 percent lower risk of heart disease than people who did not carry the mutation.

That finding proved lowering LDL prevents heart attacks, and it handed drugmakers a target: copy that gene. Every PCSK9 drug since — including the new enlicitide — imitates a mutation a few people in Dallas were simply born with.

Millions of Americans still take the old cholesterol-lowering workhorses, statins, and they’ve proven highly effective at reducing heart disease for most people. But not everyone: Some people can’t tolerate the muscle aches; others take them faithfully and still don’t get their LDL low enough. Enlicitide is built for exactly those people: a pill as cholesterol-lowering as an injection but without the needle, and a drug that spares them the statin muscle aches.

Closing the loop

If the pill is today, gene editing is tomorrow — and it may be the answer to a problem no pill can reliably solve: getting people to keep taking their medicine.

About half of patients on statins quit them within a year, and a daily pill, however potent, only helps the people who actually take it. So that demands a fix you can’t forget. A company called Verve Therapeutics, now owned by Eli Lilly, has been testing a treatment that makes a single-letter edit to the PCSK9 gene in the liver — one infusion, in theory for life. In its first human trial, published over the spring in the New England Journal of Medicine, a single dose cut LDL by as much as 62 percent, and held it there for more than a year. Instead of a pill mimicking the effects of the genetic mutation that protected those people in Dallas, gene editing just switches off the gene.

As important as it is, cholesterol isn’t the whole story when it comes to heart disease. There’s smoking, which declined from about 40 percent of US adults in the 1960s to under 15 percent today, sparing countless arteries. High blood pressure — the silent condition that killed President Franklin D. Roosevelt at 63 in 1945, when doctors had few effective ways to treat it — can now be caught early and treated with cheap generic pills.

And then there are the GLP-1s. More than one in 10 US adults say they are currently on an anti-obesity drug, and whatever else you may think of them, they’ll make a significant dent in heart disease. In one major trial semaglutide cut cardiovascular events by 20 percent.

The war continues

Still, the war on heart disease won’t be easy to win.

Just because a pill like enlicitide has been proven to lower a lab value does not mean it’s yet proven to lower deaths. They should — the injectable versions of these drugs cut heart attacks and strokes by about 20 percent in long trials. But enlicitide’s own outcomes study won’t conclude for years.

Precisely because the condition itself so widespread, treatments for heart disease will only be effective if they are equally widespread.

Heart disease is shifting, too. The same research showing heart-attack deaths down 89 percent found deaths from other heart conditions — heart failure, arrhythmias, hypertensive disease — up 81 percent since 1970, though because heart attacks were killing several times as many people, overall heart-disease deaths have still dropped by about two-thirds since 1970.  Some of that shift is perversely the result of success: people who might have died of an initial heart attack now live long enough for the heart to wear out in other ways. And some of this is the reverse of progress: As smoking and cholesterol fell, obesity climbed to about 40 percent of US adults, pulling diabetes and high blood pressure with it.

And then there’s perhaps the biggest problem in medicine: access. A 60 percent drop in cholesterol helps only the people who can actually get the drug. Half of patients abandon cheap statins within a year. Enlicitide arrives at about $300 a month with uncertain insurance coverage. The gene edit, whenever it becomes available, will certainly cost far more, and at first will reach only the sickest.

More than 60 percent of US adults are projected to have some form of heart disease over the course of their life. Precisely because the condition itself so widespread, treatments for heart disease will only be effective if they are equally widespread.

Which brings us back to that unassuming little pill. It’s just a tablet, doing what a generation of scientists spent their careers trying to do: turning one of the deadliest numbers in medicine into one you can change. It’s the kind of progress that’s too easy to miss — until it saves your life.

A version of this story originally appeared in the Good News newsletter. Sign up here!

The gerontocracy is real: The median senator is 64 years old, and 20 members of Congress are over 80. One legal scholar called it the “old-igarchy.” It seems the combination of President Donald Trump’s recent 80th birthday, the sudden death of Sen. Lindsey Graham, and the currently unknown health status of Sen. Mitch McConnell has called collective attention to the advanced age of our elected officials — and with good reason. 

So this week, I talked with Rep. Jim Clyburn of South Carolina on his 86th birthday. And I wanted to (delicately) ask a question that’s been brewing in my head since the whole fiasco with then-President Joe Biden: Why don’t the oldheads want to retire? 

Over a long interview, I asked the House Democratic leader about generational change, shifts in the electorate on corporate PAC money and artificial intelligence, and whether he thinks there are any lessons to learn from the 2024 election.

On the question of age, Clyburn told me, “I know people who are 66 years old with much less energy than I have, and none of the experience that I have.” Clyburn said he would also be open to a recently proposed law calling for members of Congress to take cognitive tests, though he dismissed the idea of term limits or an age cap. 

Here’s what else I learned: 

1. They aren’t giving up power because they don’t want to

That’s the whole thing. The reason the boomers (and Clyburn’s Silent Generation) won’t step aside isn’t that no one has asked. It’s that they don’t want to. And for Clyburn, I think the armor doubles as the blind spot. When I asked about younger generations being distrustful that older politicians can deliver, he invoked his grandparents, saying, “Don’t worry about what people call you. It’s what you answer to that’s the issue.”

And while that is wisdom, hardened over the decades, I don’t know if it works as well as a leadership philosophy. Stay the course and ignore the criticism can also be read as ignoring electoral feedback. “I don’t react to that stuff,” Clyburn said, when asked about calls for generational change.

2. Clyburn says what the establishment thinks: It’s the voters’ fault

Clyburn articulates the core view of establishment politics as cleanly as anyone: There is nothing much to change. He doesn’t believe the party made significant errors in 2024, and he doesn’t take the primary results in New York City, Colorado, and elsewhere to be anything other than a flash in the pan. Pushed on what political lesson he took from an administration built to stop Trump that ended with Trump back in office, he went to turnout: “When the white vote turned out 71 percent two years ago, and the Black vote turned out 59 percent, you tell me whose fault that is.” Asked directly whether the argument was that Black people let Kamala Harris down, he didn’t hesitate: “In many instances, absolutely.” 

At its heart, this is a philosophy that blames the voters and insulates the party establishment from reflection. 

But this is also why the next round of primaries is so important. It’s easy to file New York, Colorado, or Graham Platner’s rise in Maine as one-offs — local flukes, not an overwhelming trend. But the Michigan and Wisconsin primaries are coming, and those are the ones that decide whether this gets treated as a pattern. The temperature of the freakout is still yet to be set.

3. He defends the establishment’s alliance with the Congressional Black Caucus

The moderate wing of the Democratic Party is held up, at the grassroots, by Black voters — particularly in the South. Clyburn knows that, and he defended both the alliance and the corporate policies that tie them together. 

Clyburn holds that taking corporate dollars is necessary for minority candidates who don’t come from family wealth — “I would challenge you to find me one single vote I have ever cast that pharma supported and my constituents didn’t.” He deferred to a pro-Israel colleague, Rep. Gregory Meeks, on questions of Israel: “I’m guided by Gregory Meeks.” He made no apology for backing Andrew Cuomo over Zohran Mamdani in this year’s New York mayor’s race — the same Cuomo he’d said should resign in 2021.

I asked him what Black communities have gotten in exchange for that loyalty. His answer was an agenda: “What did we get out of our support for Obama? What did we get out of our support for Biden?” And that’s a real answer. But I think there’s also another one underneath it.

I see Clyburn’s actions through the context of changing power within the Democratic Party, just as much as what’s going on outside of it. The Black political class, specifically, is invested in holding its own position against the party’s rising coalitions, immigrant communities in particular. That’s part of what’s at the heart of Clyburn’s endorsements of Cuomo and Haley Stevens in Michigan, and even the recent fight over which states should vote first in the Democratic presidential primary. 

Find the full episode — including a bonus segment where Clyburn defends the party’s approach to Israel — wherever you get your podcasts.

Could you accidentally gamble away your right to vote?

If you live in Wisconsin, and you bought contracts on a prediction market like Kalshi about who would win elections there, you’ve done just that, according to state election officials. And they think that if you vote anyway, you could be prosecuted.

“We want voters to understand that they cannot legally make a bet on an election and cast a ballot in that same election,” Meagan Wolfe, administrator of the Wisconsin Elections Commission, said in a statement Tuesday, ahead of the state’s August 11 primaries.

The reason wasn’t a new law about online markets but a very old statute dating back to the year 1849 — just after Wisconsin became a state. 

“No person shall be allowed to vote in any election in which the person has made or become interested, directly or indirectly, in any bet or wager depending upon the result of the election,” the statute reads.

The bipartisan commission also said those voters could be on the hook for felony exposure, if they know about the prohibition and vote anyway. Intentionally voting while not being qualified to do so is a felony, per state law. “It’s important for voters to understand the consequences if they bet on an election outcome,” Wolfe said.

Many other states have laws on the books against gambling on elections. Wisconsin is the first where officials are saying people are banned from voting if they do it through prediction markets.

And it may not be the last, since New York has a very similar provision in both its constitution and state law. 

“In New York State, voting in an election in which an individual has placed any bet or wager on the result is prohibited,” Kathleen McGrath, director of public information for the New York State Board of Elections, told me. 

The New York attorney general’s office has not yet issued a formal opinion on whether Kalshi and Polymarket election bettors are barred from voting in elections they’ve wagered on. But they’re currently locked in a court battle to try and get Kalshi regulated under state gambling laws.

All this makes for a potentially explosive situation in the upcoming midterms, given the rapid growth of the industry, which has rolled out massive advertising campaigns and sponsorship deals to attract customers this election cycle. 

Prediction market companies have responded with fury. Benjamin Freeman of Kalshi posted on X that this was “insane,” blatantly unconstitutional,” “illegal,” “dishonest,” and “dystopian.” In an emailed statement, Kalshi said this was “incredibly dangerous to democracy.” 

Bettors may be less perturbed. “The reaction I am party to is almost amused by how idiotic it is — how unenforceable, and backwards, and emblematic of government regulators,” said Alex Keeney, who founded Eventual, a prediction market podcast he co-hosts with traders.

But Wisconsin Elections Commission member Ann Jacobs, who flagged the issue earlier this year and helped create the new guidance, told me in an interview that the decision was not taken lightly.

“This has been the law for a long time,” she said. “And if you don’t like the law, go talk to your legislator.”

So, where did this old law come from? Could it actually be enforced? And would it hold up against court challenges?

America’s hidden history of degenerate election gambling

It may seem surprising that a state would have such an old law of this nature on the books.

But, it turns out, many early 19th century Americans were degenerate election gamblers — so many that this became a topic of national conversation and condemnation.

In a 2012 paper, economic historian Paul Rhode and economist Koleman Strumpf wrote that betting on elections was “commonplace” since the US’s earliest years as a nation, but that it became “especially intense during the partisan conflicts of the Jacksonian era.” Newspapers, which in those days were mainly partisan, championed the practice.

Concerns eventually rose that election betting encouraged election rigging, just as people complain today that prop bets are corrupting sports. After the 1844 election, Rhode and Strumpf wrote, Whig Party members complained that “gamblers favoring Polk had committed voting fraud using the winnings from election bets to defray their expenses.” 

Then, in 1845, the governor of New York, Silas Wright, urged his state legislature to make “the extensive and rapidly increasing practice of betting on elections” illegal, due to the “corrupting tendencies which it exerts upon the election itself.” And, Rhode and Strumpf continue, evangelicals “preached long and hard against election betting” as part of the second Great Awakening movement.

The craze eventually faded, but it was peaking just around the time Wisconsin became a state in 1848. So its new state constitution specifically addressed the issue, saying “laws may be passed” excluding election bettors “from the right of suffrage.” Hence the 1849 law.

Why attention returned to this law in 2026

In recent years, in the rare occasions when the law has been noticed at all, it’s been treated as an amusing, antiquated curiosity. 

But the rise of prediction markets like Kalshi and Polymarket — and the corresponding surge in election betting — made it relevant again.

In March, after Jacobs of the Wisconsin Elections Commission heard a radio story about Polymarket, she posted on X: “WI friends – I know it’s all the rage to bet on everything, but you cannot bet on an election in Wisconsin!  If you do, your ballot can be challenged & thrown out.”

Kalshi has long taken the position that it doesn’t allow election “gambling,” but rather “financial products” called “event contracts.” But the commission’s legal staff studied the issue, and concluded earlier this month that it was “relatively clear” that a Wisconsinite “cannot, even indirectly” make a bet or wager on an election and then vote in that election. 

The press release warning voters — and the backlash from Kalshi and Polymarket — soon followed. 

How the law might (but probably wouldn’t) be enforced

So, what would happen, then, if an avid “event contract” trader decided to vote anyway?

Realistically, the answer is: probably nothing.

But if someone else had knowledge that this person was making election bets and voting, they could show up to try to get them disqualified.

“You would have to be there at the moment they showed up to vote — or when their absentee ballot is pulled out to be counted — and you’d say, ‘I’m challenging that voter,‘” Jeff Mandell, a Wisconsin election lawyer, told me. “But the chances that somebody is around with the right knowledge to block someone on one of these bases strikes me as pretty slender.”

The other theoretical risk is felony prosecution. Law enforcement officials could obtain information that people voted on elections they’d wagered on and, then, criminally charge them for  voting illegally. 

But Mandell pointed out that “that seems like a lot of work” for a prosecutor, adding, “I think that fears about enforcement, either civil or criminal, are probably overstated.”

Still, Jacobs argued, it’s possible. “This is the law,” Jacobs said. “It is a situation where, if people have placed a bet, they should consult with their own attorney and decide what to do.”

Would the law stand up to court challenge?

Since Wisconsin’s original state constitution specifically said the state could restrict election bettors from voting, the law would seem to be on firm ground.

There’s just one catch: That section of the constitution was repealed forty years ago. 

That repeal was made as part of a broader overhaul of the document and doesn’t appear to have been specifically targeted at the election betting issue. But it does mean that the statute doesn’t necessarily have the firm state constitutional footing it once did.

“The current constitutional language only authorizes the legislature to disenfranchise voters on two grounds — a felony conviction or incompetency — which does suggest that disenfranchisement on other grounds is impermissible,” Robert Yablon, a University of Wisconsin-Madison law professor, said in an email.

The law could also be challenged in federal court. As written, the law appears to prohibit even someone making a $1 bet with their friend on an election outcome from voting. Challengers could argue that law isn’t narrowly tailored enough to justify depriving qualified citizens of their voting rights.

For now, though, the law is on the books, and it says what it says. 

“As a policy, it makes sense,” Jacobs told Vox. “You want people to make their voting decisions based on who they think is best for the job — not who’s going to make them the most money.”

The New York question

Though the Wisconsin situation has made national headlines this week, it has largely escaped notice that New York has very similar provisions in both its constitution and in state law.

New York’s constitution says that no person who “shall make or become directly or indirectly interested in any bet or wager depending upon the result of any election, shall vote at such election.”

In fact, state law says that if a voter’s eligibility is challenged on these grounds, they must swear what is known as the “Bribery Oath,” swearing that they haven’t been paid to vote a certain way — and that they “have not made, or become directly or indirectly interested in any bet or wager depending upon the result of this election.”

When I inquired with New York state officials about whether these provisions about bets and wagers applied to Kalshi and Polymarket election event contracts, they declined to comment specifically on that.

But the New York attorney general’s office has repeatedly taken the position, both in their public rhetoric and in court, that prediction markets are “gambling platforms” that should be regulated by state gambling law. (Earlier this month, a judge gave the state a favorable ruling in a suit brought by Kalshi over this, though Kalshi is appealing.)

If New York reaches a similar interpretation as Wisconsin, Kalshi or Polymarket bettors on elections would not be legally permitted to vote in those elections. Of course, doing that comes with a risk of voter disenfranchisement, especially if this guidance isn’t well-publicized or is only belatedly clarified.

So, in both states, these very old laws have collided with a modern trend — and the result is a big mess. 

Ticks are taking over the United States. Due to climate change, changing land use, and an explosion in the deer population, ticks have been expanding their territory and infecting more people than ever. They carry pathogens that cause everything from Lyme disease to the red meat allergy-inducing Alpha gal syndrome. In some cases, tick bites can be fatal.

Ticks usually lurk in the tall grass in wooded areas. That means going on a hike or even just hanging out in your backyard or a park can expose you to a tick bite. In many parts, of the country fear of ticks is changing how people live their lives, including the way they dress, how they enjoy their hobbies, or even whether they spend much outdoors at all. 

The tick surge is catching public health officials off guard. Emergency room visits due to tick bites are the highest they’ve been since 2017. In spite of the uptick, most public health departments still focus on lowering the population of mosquitos in their areas over ticks. 

Climate reporter Jonthan Mingle says we can fix this problem. As Mingle explained in a recent New York Times op-ed, encouraging the public to do tick checks and use bug spray is a part of the solution, but we’re leaving a bunch of larger interventions on the table. Mingle joined Today, Explained co-host Sean Rameswaram to explain why ticks are expanding their range and what we can do about it. 

Below is an excerpt of their 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.

We covered Lyme disease and tick bites on this show back in 2018 because the tick situation was getting out of hand. How much more out of hand has it become since then?

You know some experts I talked to used the word exponential. So what’s happening is that some of these tick species are spreading into areas where people aren’t familiar with them, doctors aren’t familiar with them. Thanks to warmer winters, ticks are expanding their hunting season. You may have a day that’s like 40 degrees in January, ticks are out looking for you, waiting for you to walk by and grab on and grab a meal. 

In 2024, a pilot named Brian Weitzel, father of three in northern New Jersey, had a hamburger, at a barbecue, went home to mow his lawn, and a few hours later was unresponsive on the floor and he died that night. His family was left in shock, of course, trying to figure out why he had died. And it turned out that he had likely been bitten by the lone star tick and had developed an allergy to red meat. This is referred to as Alpha-gal syndrome, which is just the latest entrant into the files of all the many ways in which tick bites can make us sick. The most familiar one, of course, is Lyme disease. Each year, about half a million people are treated for Lyme disease. It’s the fastest growing vector-borne disease in the US. Cases have more than doubled over the past decade, and those cases are mostly as a result of getting bitten by the black-legged tick or the deer tick. The thing is both of these ticks — and many other ticks that are also marching northward and westward and expanding their empires rapidly across North America — they can deliver all kinds of pathogens.

They’re claiming more and more of the map, and they’re claiming more and more of our psychic map right? I tell people I’m not a tick expert, although I’ve talked to a bunch of them, but I’ve become a tick expert in the sense that I am very familiar with tick paranoia and how it can keep you from venturing out into the places you love: hiking paths or picnic grounds or parks. And so that was part of the story I wanted to write about, too — Why are we letting the ticks keep us, if not out of these places that we need and love, why aren’t we fighting back?

And why is it? Are we not fighting back against the ticks?

Not really. I mean, this is one of the surprising takeaways from my reporting is that we’re barely even trying. One way of understanding that is to think about two numbers. One number is 90 percent. 90 percent of vector-borne disease cases in the US are from ticks.

90 percent?

Yeah. And yet despite the fact that 90 percent of cases of vector-borne illness come from tick bites, if you look at what local city, county health agencies do in terms of vector control, 80 percent of what they do is mosquito control, and only about 10 or 11 percent of these local health agencies around the country do any kind of tick control. So why is that? It’s a familiar story in the public health world. It’s not enough funding or policy support for trying out, testing, deploying new approaches to controlling ticks.

Even though people are dying?

We’re just kind of taking for granted that, ‘Oh, well, what can you do? You just tuck your pants in and spray some insecticide on your boots and that’s all you can do.’ It’s like, well, actually we have a long history of going to war with mosquitoes. Before there was tick control, there was mosquito control. The CDC was founded with the sole mandate in 1946 of wiping out malaria and fighting mosquitoes. 

It feels like they lost that fight because in my neighborhood you can’t go out between the hours of seven and nine o’clock.

The mosquitoes haven’t gone away, but malaria did for the most part. You know, in talking to experts today, including folks at the CDC, they told me that there’s a suite of tools we could be using if we wanted to get serious about fighting ticks. As one veteran tick expert at the CDC told me, if you want to make a dent in this problem, you have to get to the deer. The deer are the engine driving a lot of these tick species spreading, and we just have way more deer than we did decades ago, especially in the eastern US and suburban parts of America. So how do you get to the deer? I had people in the comments section of my piece saying the clear answer is just we should all be hunting deer. But in talking to the experts, they’ll tell you it’s not really a feasible solution. You would have to knock deer populations way down to make a dent in the tick populations. 

What is more promising is a combined approach of stuff like vaccines. There are people developing vaccines that you could deliver to deer or to rodents, which are another important host for these ticks so that when the tick bites them, they’ll die. That, I learned from talking to folks who do this kind of research for a living, is a more promising avenue for controlling ticks than all of us picking up crossbows and becoming deer hunters.

So why is it that we’re not doing anything?

What I heard from experts is that we’re not even funding this research in a serious way. We do this stuff for mosquitoes. People don’t realize it, but your local county health agency, they go out and they find where the mosquito breeding grounds are and stagnant pools the water and they treat it. It takes this sustained quiet effort. 

We saw the consequences of not doing that recently. This is a bit tangential, but screwworm. Screwworm was this flesh eating larval pest that devastates cattle herds that it was eradicated in the US in 1966, and it was kept at bay by the vigilance of people at USDA and USAID who ran these programs to release millions of sterile screwworm males out of airplanes. It created this wall that kept the screwworm from coming into the southern US. And probably if we stopped doing the mosquito control at a local scale, we’d see more cases of dengue fever, West Nile virus, and all these other rare but serious illnesses that climate change is making more of a threat here in the US.

Could you just practically help people understand how they can protect themselves in the absence of, I don’t know, a functional government?

Doing tick checks. And we do it in my household pretty much daily when you come home, do a thorough tick check, throw your clothes in the dryer. Ticks hate heat. And some people like to use permethrin spray, which is this insecticide that’s designed to kill ticks on your boots or your pants when you go out for a hike. Researchers have known these things are really effective if you keep doing them, if you stay vigilant. And all it takes is that one time, that one time you go out for a hike and you come back and you forget to do the tick check. 

So we need those kinds of personal measures of vigilance and protection, but we still need to kind of push for a bigger public health response to this. The ticks are going to keep spreading into the calendar, too, in the sense that as winters get warmer, more and more days of the year when you’re outdoors, you’re going to encounter ticks who are hungry, and they’re looking for you.