As rents and homelessness climbed in San Diego over the last decade, leaders watched in frustration as affordable housing projects took months to get approved. The longer a project dragged on, the more expensive it became.  

Housing in America is notoriously slow and complicated to build, so San Diego Mayor Todd Gloria decided to use one lever he had available. In January 2023, he signed an executive order to speed up project approvals, so every fully affordable project now had to be reviewed in 30 business days or less.

To meet this new goal, San Diego had to overhaul how it had been handling permitting. The city streamlined work that had been spread across multiple departments and filled positions it had budgeted for but left vacant. Within a year, fully affordable projects were clearing review in nine days on average. Citywide, 2023 marked San Diego’s biggest year for housing permits since at least 2005, with 9,691 homes approved, or an 82 percent jump from the year before.

Austin, Texas embraced a different approach to tackling its housing shortage. After years of local zoning reform, the city legalized up to three homes on most single-family lots in late 2023, then cut the minimum lot size from 5,750 square feet to 1,800 in 2024. Those changes made it easier to add homes, including backyard accessory dwelling units (ADUs), and followed a broader construction boom that has helped bring rents down. Austin, which was becoming increasingly unaffordable, is now one of the few major American cities where asking rents have fallen since the pandemic.

Atlanta adopted a third housing strategy that didn’t require changing any laws at all. Mayor Andre Dickens rallied the heads of every public agency that affects housing, from the city’s housing authority and school system to the transit agency and land bank, and convened them in one room on a regular basis. He called it a “housing strike force” and it has helped advance the city’s broader effort to build or preserve 20,000 affordable homes by 2030. Every housing deal now comes to the mayor’s office, Dickens told me, and “I just start pushing buttons to push them out the door.” 

Seen as a nationwide issue, the housing shortage is an enormously difficult problem, sitting at the nexus of the economy, the financial system, and decades of local zoning decisions. But the fixes don’t all have to be complex. A mayor can do all three of these — faster permitting, ADUs, a housing strike team — without waiting on Congress or their state legislature to act. And now one major nonprofit is betting that other cities could adopt them too.

On Tuesday, Bloomberg Philanthropies is announcing that it will fund up to 30 cities to adopt one of those three housing ideas. Each will get between $450,000 and $750,000 directly and two years of help from Accelerator for America and the digital consultancy Public Digital, also funded by Bloomberg. The philanthropy has already selected the first 15 cities, including Albuquerque, Chattanooga, Cleveland, Durham, Louisville, Miami, Nashville, Pittsburgh, and San Jose.

By housing construction standards, the money doesn’t go very far. The grants are geared toward hiring city staff, buying new software, and helping cities quickly develop the expertise that let San Diego, Austin, and Atlanta do what they did.

“You don’t need everyone to be innovating everything all the time when there are good ideas in the world that are working,” said James Anderson, who leads Bloomberg Philanthropies’ government innovation program. “They need help adapting those ideas to local contexts.”

According to Anderson, the cities were chosen because their mayors had already taken hard political votes on zoning, and wanted help now to do more. Their timing is also intentional. On the federal level, the 21st Century ROAD to Housing Act became law in July, and it creates competitive grants for cities that modernize their permitting, for preapproved housing plans, and that open up their public land. These are the same reforms Bloomberg is now funding, and cities that can show they’ve already done work around it will be better positioned to tap into new federal dollars.

Mayors say they’ve seen big federal programs pass before and then found that actually leveraging those new funding streams in practice can be quite difficult. “We saw that with the Inflation Reduction Act,” Cleveland Mayor Justin Bibb told me. “Even some of the aspects of the bipartisan infrastructure bill, there was a lot of red tape to get some of that stuff across the finish line.”

The Bloomberg bet is that figuring out what to do isn’t as hard as organizing the knowledge of how to do it. The philanthropy thinks that with enough money and hand-holding, good ideas can spread.

It’s an experiment worth testing, but even at the outset there are real limits to what kind of help a short-term infusion of cash can do in practice. San Diego, Austin, and Atlanta all had substantial housing staff in place before they started, and many cities don’t have the same depth to draw on. A two-year grant covers a few staff roles, but doesn’t guarantee they’ll stay long-term in a city where most of the local budget is already committed.

What a “housing strike force” actually is

Dickens had campaigned for office in Atlanta on building 20,000 affordable units in eight years. When he became mayor in 2022, his staff told him the city was on pace to fall 4,000 to 5,000 units short of this goal, and that the main federal subsidy for affordable housing, which gets rationed out by the state in fixed amounts each year, wasn’t going to make up the difference.

What Atlanta did have was land, spread across more than a dozen public entities, each with its own board and its own ideas about what the land was for. One 10-acre city site just northwest of downtown was being used to store trash cans before delivery to residents. “It’s not the highest and best use of the land, but we’ve been doing it for decades,” Josh Humphries, then Dickens’ senior housing adviser, told The Guardian.

So Dickens pulled the heads of those agencies into one body reporting through his chief housing officer. The transit system and school district both answer to their own boards, so his pitch was that they weren’t giving anything up by getting involved. “You are still in charge of your organization, these are your deals, but we are an accelerator,” Dickens told me.

They spent nothing setting it up and hired no new staff for the strike force itself — though when Dickens advises other mayors, he’s blunter about the pressure a mayor would need to exert in convening such a team. An agency that opts out of participating, he said, is “outside of the scope of the mayor’s vision” and “that’s not a safe place to be.”

“I didn’t need another task force,” Dickens added. “Task forces are good, but we know what we’re doing. We don’t have to describe the task. No, this is a strike force. We know the deals, we have the land, we know where the money is for most of these deals, and we have the political will.”

What Dickens did was create “a horizontal way of organizing otherwise vertical players,” as Anderson of Bloomberg Philanthropies put it.

As part of the strike force, agency leaders meet monthly, and quarterly with the mayor. Each one reports what they will produce in the next 30 days, whether that’s a signed agreement, bank financing, or a permit, in front of everyone else. The goal is to move everything as fast as possible to keep down costs.

“You’re in a meeting with 20 colleagues talking about your four or five projects, and everybody is aware of everybody’s projects,” Dickens said. “You don’t want to come back to that meeting saying nothing happened over the last 30 days.”

The limits of the model

Dickens was fairly blunt about where the model stops working. “It works best in cities that have a sizable amount of competent housing development people,” he told me. “A strike force is Army, Navy, Air Force, Marines. You all are capable.” A city still standing up its housing program, he added, should just focus on collaboration, because it would be hard for a small city without “the knowledgeable skills, the capacity” to operate like this.

Most cities can’t easily build that internal bench. Local governments pay less than state or federal employers for the same specialized work, and between half and three-quarters of a typical city’s operating budget is already locked up in salaries, pensions, debt payments, and basic services before the mayor makes a single discretionary call.

In Cleveland, they’re hoping to use the Bloomberg funding to bring in some new support. “Right now it’s a capacity game for us,” Bibb told me. “IT staff, planning staff, development staff, the list goes on. Policy staff as well.”

Cleveland also faces different challenges than Atlanta, which built its strike force for a growth market that already had projects lined up. Cleveland is an older, industrial city with an aging housing stock and a population that has only recently stopped shrinking, so Bibb needs code enforcement and rehab as well as new units. He plans to point the strike force first at a housing innovation district he launched earlier this year, an area spanning parts of three East Side neighborhoods where the city has concentrated its financing and permitting reforms.

Two-year grants can generally be a challenge for cities. Philanthropy often pays for staff long enough to prove a policy works, but when the foundation money goes away, cities can struggle to find the dollars to keep the positions going. While Atlanta’s strike force was organizing around people the city already employed, Cleveland’s will require new ongoing resources for a growing payroll.

Asked what happens when the money runs out, Bibb maintained he’s concentrating on the near term. “Right now we’re just focused on securing the grant, getting the team in place, and really seeing some positive results with the strike force team in our housing innovation district,” he said.

Can a good idea be scaled?

The 30 cities won’t be working alone. Bloomberg is running them as a cohort, meaning each city will pair with the city that pioneered the idea. The goal is to trade advice, mentorship, and opportunities for city leaders to visit and tour. Cleveland is one of roughly 10 cities that will take up the strike force model, meaning Bibb’s team will work with Dickens and his staff.

“One of the major reasons that good ideas do not spread is a lack of clarity around what it took in the original city to get the hard work done,” Anderson said. Adopting cities need to hear from the originals on both a political and a technical level, he told me, to understand “the trade-offs, the costs, the errors, and lessons learned” before they start.

Bloomberg has been testing a version of this model since 2024 through its Idea Exchange, which now includes more than 1,000 cities across 95 countries and has nearly 200 policy replications completed or underway.

Within two years, cities pursuing permitting reform are expected to cut their housing approval timelines in half, those pursuing ADUs to double their pipelines, and participants ultimately to post gains in citywide housing supply.

The housing shortage runs into millions of homes, and these proposed strategies don’t touch challenges like interest rates or the price of lumber. But across the country, they could show how quickly a good idea can spread.

In theory, getting a donor liver in the United States when you need one should be an extremely equitable process: The sickest patients with the greatest chance to benefit from a donated organ should jump to the front of the line regardless of their gender, race, or other factors. 

But in practice, things look quite different. 

One study from 2020 showed that women were 8.6 percent more likely than men to die waiting for a liver transplant and 14.4 percent less likely to receive a deceased donor liver transplant compared to men. That gap may not seem enormous, but it still represents a significant disparity. As it turns out, it’s rooted in the very system that’s supposed to make the process fairer, a process that unintentionally ranks women lower on the waitlist for livers.

The system in question is known as the Model for End-Stage Liver Disease (MELD). The scoring model has been used since 2002 to rank candidates on the waiting list based on how likely they are to survive without a liver transplant in the short term. The higher your score, the reasoning goes, the sicker you are and the more urgently you need a liver transplant.

One of the values used to calculate the score is creatinine — a waste product made by muscles as they break down proteins or other compounds to release energy. In medicine, the creatinine levels in your blood are used to determine how well your kidneys are functioning because they process and remove creatinine. 

And this is where the system designed for equity gets a little less than equitable for some patients. 

Creatinine levels are affected by muscle mass, and women typically have lower muscle mass than men. A man and woman experiencing the same level of kidney dysfunction will therefore have different levels of creatinine in the body. The MELD model doesn’t take this difference into account — and so lower levels of creatinine in a woman’s blood can make her seem healthier than she is, bumping her farther down the liver waiting list. 

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In 2023, Dr. Ray Kim, a transplant hepatologist at Mayo Clinic in Arizona who developed the original system, debuted a new model called MELD 3.0. The model not only seeks to address the sex disparity in liver access but also improve the accuracy of scores for all patients. Among other changes, it takes into account the sex of the transplant candidate and uses it to adjust the MELD score by 1.33 points for women. This is meant to address the difference in creatinine levels between men and women and provide a more accurate understanding of how sick a female patient really is.

Simple fix, right? Even though MELD 3.0 took the sex disparity in liver access seriously and developed changes to combat it, early research on its efficacy found that even this new and improved system hasn’t yet brought men and women to parity on the liver waitlist. 

And the problem may lie less with what MELD 3.0 did than with what it did not do, prompting the question: Are we focusing on the wrong problem? 

Sex matters…but so does size

Before the MELD score, liver transplants were largely conducted on a first-come, first-served basis. Those who were added to the waiting list first, received livers first. If a really sick candidate was added to the waiting list late, say because of delayed diagnosis, they would almost certainly die while waiting for a liver to become available.

The original MELD fixed that problem by creating a measure of urgency that was easy to calculate. The initial model used three main blood test values — bilirubin, creatinine, and a measure of blood clotting time — and later improvements also took into account the sodium level. 

Traditionally, the MELD model assigns a score between 6 and 40 to liver transplant candidates. MELD 3.0 adds 1.33 points to women’s scores to account for the differences in creatinine levels between the sexes. The new model also measures albumin, an additional biomarker, and adjusts for interactions between the different variables.

Sommer Gentry, a professor at NYU Grossman School of Medicine and contributor to the paper on MELD 3.0, said that using sophisticated algorithms with more biomarkers not only helps to better predict risk for women, but using a more accurate model also benefits the whole population. The researchers estimate that this fine-tuned MELD 3.0 model will reduce at least 20 waiting list deaths per year. Last year, around 800 liver transplant candidates died while waiting for a liver. 

But creatinine is only one of the two main problems that create a disparity in liver access for women. The second, Gentry says, is body size, an issue that’s not addressed by MELD 3.0. A transplanted liver has to physically fit inside the body of a recipient, and women are typically smaller than men, so a very large liver cannot be offered to a small woman. But the reverse is not necessarily true because receiving a liver that is small for the potential recipient doesn’t typically harm the candidate.    

“The smaller you are, the less likely you are to be offered something that’s actually going to work for you,” Gentry said, adding that women end up waiting longer to receive a liver that will actually fit their body. 

Part of the conversation on sex disparity in liver access is based around which of the two problems — creatinine or body-size interventions — to fix first, and whether it is possible to create equity by addressing just one of the two, Gentry said. MELD 3.0 was an attempt to remove the former barrier. 

“I think that some other papers are coming out that suggest that perhaps the other aspect of size matching is still a concern and still possibly not addressed by the resulting liver transplant system,” Gentry said. 

Why is the new model still falling short?

Gentry believes that MELD 3.0 has increased liver transplant rates for female candidates since its adoption in 2023. But early research, however, suggests that the new model falls short of fixing the problem. 

Studies done on MELD 3.0’s impact on liver transplant rates for women indicate that the model increased the number of liver transplants for female candidates — but the gains were short-lived. 

An analysis published in July of nearly 10 million daily records from over 60,000 candidates on the US liver transplant registry found that rates of completed liver transplants for women increased in the period immediately after MELD 3.0 was implemented, but the increase was temporary. Women’s estimated odds of receiving a transplant drifted back to pre-MELD 3.0 levels by the end of the study period, 15 months after the new model was implemented. Women on the waiting list and women who had received a transplant also had higher scores in the three months right after MELD 3.0 took effect, but their scores later fell back to levels comparable to those of men.

Both the successes and shortfalls of MELD 3.0 demonstrate how rethinking existing policies and standards can help reduce inequities in organ access and healthcare.

The authors think that the early surge in liver transplant rates for women was a onetime catchup. MELD 3.0 pushed a group of women who had been stuck on the list — sicker than their old scores suggested — over the priority threshold all at once, leading them to receive liver transplants. 

Notably, the one effect that did persist was that under MELD 3.0, women received more “organ offers” than before. Every time a deceased donor liver becomes available, the system generates a ranked list of the patients suitable to receive that organ. Under MELD 3.0, the number of times an available liver was offered to a female candidate increased, probably because their (more accurate) MELD 3.0 scores better reflected how sick they were. But they’re not necessarily receiving those livers, presumably because of organ size issues. 

These findings suggest that revising the MELD criteria alone may not be enough to eliminate the sex disparity, especially if the body-size disadvantage is part of the problem. 

The authors say that a patient’s sex is merely a poor proxy for the real issue — we don’t have allocation systems in place to ensure that candidates with smaller body sizes also have the same robust access to livers.

Toward liver donation equity for all

If we could figure out how to better address questions of body size in organ donation, the benefits could be enormous. According to Gentry, body-size disparity affects the organ allocation system in general. Similar issues arise with heart and lung transplants too, where the size of the organ relative to body size has to be taken into consideration during organ allocation.

She says that a size-aware organ allocation system would therefore benefit patients on the waiting list across the board. Whether an available organ is the right fit for the potential recipient should be weighed heavily in allocation algorithms, rather than just a list of ranked waitlisted candidates. 

“That should be a larger consideration in sorting the patients who will be offered a certain organ — to ask if this organ is especially suited to one kind of patient over another,” Gentry said.

Under such a system, she said, smaller livers could be offered first to the smallest candidates on a ranked list of those who are also sickest. The assumption is that a smaller candidate will have to wait longer for a viable liver that fits them, even if they have a very high MELD score. 

For such a policy to be instituted, the Organ Procurement and Transplantation Network – a nonprofit that oversees the distribution of donor organs — would have to approve it. And before such a system could be presented to the regulatory organization, more research is required.  

It is often the case in medicine that our definition of what counts as a healthy body is measured against the average white male. This too often lowers access and quality of care for both women and people of other races. For example, the standards for creatinine levels in blood reduced access to kidney transplants for Black transplant candidates for years until recent efforts were made to start correcting it. 

In that sense, both the successes and shortfalls of MELD 3.0 demonstrate how rethinking existing policies and standards can help reduce inequities in organ access and healthcare. The conversations and critiques that followed its rollout have exposed a clear gap in organ allocation strategies, one that disadvantages a large group of patients. Closing that gap, not just in liver transplantation but across the board, could bring us a step closer to equity while also making more efficient use of the organs available to save lives.

“There’s no mechanism right now, if a small liver is available, for offering it preferentially to the small women who might not be able to accept lots of other organs that are becoming available,” Gentry said. While fixing the model to rank women more accurately on the liver waiting list is a start, including body-size considerations in the organ allocation system might be the real bottleneck to address.

Most of America’s major cities have made little to no progress reducing racial segregation in their public schools over recent decades. Many have slid backward, and are more polarized today than they were at the turn of the century.

These challenges were highlighted in Nikole Hannah-Jones’s wrenching New York Times Magazine piece in September about her experience sending her daughter to poor, intensely segregated public schools in New York City as part of a campaign to fix them — only for her child to fall behind in her education and demand a change to a more selective school with few Black and Hispanic students. The essay ends with both the writer and subject frustrated: Hannah-Jones with the seemingly insurmountable barriers to improving and integrating schools, and her daughter, with the burden of confronting these structural barriers on her own. 

But Washington, DC, the city I’ve called home on and off for most of my adult life, is one of the few standout exceptions to these trends. 

During the 2000s and 2010s, its public schools underwent a dramatic set of reforms that helped improve teaching and student achievement. At the same time, the number of white students leapt up, and the share of schools that had been almost uniformly Black or Hispanic plummeted by about 20 percentage points, the largest drop among the country’s 50 biggest cities.

Recently, I called Kaya Henderson, DC’s former top schools official, to ask about that era of progress, and whether she thought the policies she implemented had helped encourage integration. If not, what had? Her answer surprised me a bit: It simply wasn’t a question she had ever really pondered. 

“For me, integration was never the point,” Henderson said. “Giving our citizens of the district, no matter where they come from or what they look like, a high-quality school system, that was the point.” 

It’s always perilous to read too much into a single example of success in education. Each state and school district is different, and seemingly small differences in how reforms are implemented can make or break them. 

Each state and school district is different, and seemingly small differences in how reforms are implemented can make or break them.

But I think DC’s story is an instructive and hopeful counterpoint to the pessimism that seemed to pervade Hannah-Jones’s discourse-devouring essay. Having witnessed the dysfunction of these schools firsthand and concluding she was wrong to sacrifice her daughter’s education in a noble attempt to address it, Hannah-Jones doesn’t offer any explicit solutions. But she does seem to suggest that we won’t be able to fix the deep-seated problems in our education system unless we find a way to end de facto segregation, which she has long argued is a critical prerequisite to improving school quality for historically disadvantaged minority students. In her media tour, she has been more explicit, calling for New York City Mayor Zohran Mamdani to produce “a plan to address and dismantle school segregation in the city.” 

“Nothing can help the working class change its material condition more than actually having access to an equal and quality education,” she told radio host Brian Lehrer.

I agree with much of that sentiment. But I can’t help but feel like Hannah-Jones is reversing the order of operations. As DC’s example suggests, the most realistic way to desegregate our schools today might actually be to focus on improving their results first. We don’t need to wait. And while Hannah-Jones famously sought to do that by rallying better-off parents to enroll and advocate for their children on a school-by-school basis, DC shows that, with the right plan, school administrators and teachers can deliver gains as well. 

Integrating schools is hard

One of the many reasons integrating public schools has proven so historically difficult is that most modern-day segregation is driven by differences between districts, rather than within them. Well-to-do and white families decamp to wealthy suburbs when it’s time for kindergarten or middle school, while Black and Hispanic families remain within city limits, or in working-class suburbs.  

Overcoming municipal boundaries tends to be an insurmountable challenge, both politically and legally. Forced bussing was never popular, and in 1974, the Supreme Court ruled that court-issued integration orders that required swapping students between districts were effectively unconstitutional, taking away one of the few tools activists thought they had to break through borders. 

Today, ideas like redrawing school boundaries to make them more diverse poll well when Americans are asked about them in the abstract, but it’s at best unclear how many suburbanites would tolerate such a thing if it was proposed in their town. 

Those sorts of options were never available to DC, anyway. It’s a politically isolated city bordered by neighbor-state suburbs like Arlington, Virginia, and Montgomery County, Maryland, where the region’s well-off professionals have long moved for the school systems. The only way to meaningfully integrate its own schools racially and economically was to lure more white or high-earning families into the district and keep them there. 

How DC saw a major drop in segregated schools

And that is in fact what happened. 

Starting in the early 2000s, DC’s population started to balloon with Gen X and millennial professionals of all races, which had the net effect of raising the overall share of white residents. Many flocked to the city after the financial crisis and Great Recession, since Washington was one of the few places where jobs remained plentiful. And they eventually set down roots. Public school enrollment — including both charters and traditional schools — grew alongside the city’s population, and the share of those students who were white jumped from 3.9 percent in 2000 to 13.7 percent in 2023. 

The influx led to a large drop in the number of what the Civil Rights Project at UCLA has defined as “intensely segregated” schools — where fewer than one in 10 students are white. In 2000, 90 percent of DC’s traditional public and charter schools fell into that category, the most of any district covering the country’s 50 largest cities, according to data from the Segregation Tracking Project at Stanford’s Educational Opportunity Project. By 2023, it had fallen to 69 percent, leaving it in the middle of the pack. 

Over that same period, only five of the 50 largest saw any decline at all. 

I don’t want to oversell DC’s progress. It went from among the worst in the country on this measure to looking more like a typical urban school district — similar to New York City today, where 71 percent of schools remain “intensely segregated.” I doubt many are satisfied with that status quo. There are also obvious downsides to the kind of gentrification that made these gains possible — the city lost thousands of Black families during the 21st century to rising housing prices (though the decline was even larger in the ’80s and ’90s, as its economy was in collapse). 

DC’s white students still tend to cluster in public schools serving affluent neighborhoods, such as Capitol Hill or the famously leafy areas west of Rock Creek Park, and there are vanishingly few white families in the city’s poorest wards, east of the Anacostia River. Using the Segregation Tracking Project’s “normalized exposure” index, I found that there were only three other large cities where white students were spread less evenly across their school district. But because white enrollment grew so much, it still spilled out of those enclaves, and helped diversify schools that had previously been overwhelmingly low-income, Black, and Hispanic. As a result, the city became a rare example of progress on one of America’s most stubborn social ills. 

The city’s school performance improved

During the same period in which its schools became less segregated, DC was also embarking on a high-profile education reform effort.

That drive began with the arrival of charter schools in the late 1990s, which put new competitive pressure on the district’s traditional public schools; today the charter sector teaches almost half of the city’s students. But the pace of reforms hastened after 2007 when then-Mayor Adrian Fenty took control of the city’s schools. His major changes included a controversial pay-for-performance system for teachers known as IMPACT, as well as stronger curriculum standards tied to the Common Core. Later leaders adopted more rigorous standardized tests that allowed parents to easily compare results between schools, a single citywide school lottery, and the city’s much celebrated universal pre-K program.

These changes did not work miracles — but they did lead to a major rise in students’ reading and math scores. DC became the fastest-improving large urban school district in the country on the National Assessment of Educational Progress (NAEP), considered the gold standard for measuring learning gains, with both Black and white students seeing significant progress. Again, this was largely a game of catchup: Washington went from among the very worst performing urban school districts on the NAEP to matching the large city average. But it led to a broad sense that schools were on the upswing. 

It’s difficult, and maybe impossible, to say how much any one of the reform policies actually affected parents’ decisions to stay in the city, or helped reduce segregation in schools. Some have had an obvious impact: DC’s universal pre-K program, which began in 2008, anchors professional families here when their children are young, then acts as a funnel into the public school system. Others are probably less consequential on their own: Studies have found that centralized lotteries like the one DC adopted have only small impacts on integration. 

Regardless, the total package seems to have worked. It’s theoretically possible that the army of Sweetgreen-chomping, DC-Brau-chugging millennials who showed up to DC in the Obama era would have decided to raise their kids here no matter what the state of the city’s schools had been. The more reasonable reading, however, is that DC created a virtuous cycle, by taking steps to improve its K-12 system just as its economy was attracting a new influx of relatively well-off transplants. One telling fact: While the number of white children in DC roughly doubled in this time, the number in public and charter schools more than quadrupled, meaning parents were choosing to send them at higher rates. 

Still, it’s a model, one that shows how a city can change the makeup of its school system when it realistically can’t just make kids commute in from the suburbs. 

It seems telling that one of the only other cities to see similar declines in segregation, Atlanta, put a similar emphasis on education reform early in the century. Although those efforts were eventually sidetracked by a cheating scandal in which schools and teachers were caught faking standardized test scores, it did notch real improvements, as shown on the NAEP. 

Some will ask how much of a model DC can really be, given the uniqueness of its circumstances — not every city will have a chance to capitalize on a boom in young professionals. Still, it’s a model, one that shows how a city can change the makeup of its school system when it realistically can’t just make kids commute in from the suburbs. 

What Henderson, who served as DC schools chancellor between 2010 and 2016, emphasized to me was that insofar as DC has succeeded more than other cities at integrating in its schools, it was at best a side effect of education reform policies, rather than an explicit goal. At one point in our chat, I started reading a few of the stats I had dug up about the decline in “intense” segregation before she stopped me.

“I don’t even know if people collected that kind of data,” she said. “We prided ourselves on ‘what gets measured, gets done.’ If integration was a goal, that would have showed up on some of my [performance indicators]. And we just literally never had that conversation.” I suspect she was exaggerating slightly — Henderson and her deputy celebrated DC’s increase in white enrollment back in 2011. But it’s hard to think of a deeper contrast with Hannah-Jones’s view — where unless cities take politically implausible steps to desegregate, we’re doomed to failing children.

A grove of coast redwood trees is a forest of forests. Individual trees can live for thousands of years, and as they grow, their canopies develop mats of soils and ferns, creating something like a second forest floor hundreds of feet above the ground.

These elevated ecosystems are home to creatures like the wandering salamander, which can spend its entire life cycle on top of a single tree, and the marbled murrelet, a seabird whose nesting habits were a mystery until one day in 1974, when a tree-trimmer stumbled upon a nest 150 feet above the ground. Sometimes a stray seed — a sitka spruce or oak or even another redwood — finds its way up a massive redwood and grows into another tree entirely, nestled among the branches of a giant. 

For millennia, redwoods have been the anchors of this incredibly stable ecosystem; they can even survive wildfires that devastate other tree species. They’ve also been the source of plenty of human inspiration and drive millions of dollars to California’s tourist economy. But like other living things, they aren’t immune to warming temperatures, and it turns out these trees have a particular weak spot. 

A new study from researchers at University of California Davis, using measurements taken twice a month for two years, found that coast redwood leaves essentially dial down their photosynthesis during periods of extreme heat. This means trees are slowing their “breathing” and “eating” because they can’t cool down fast enough when temperatures rise. It’s a problem that’s only going to get worse as climate change continues to drive global temperatures up, and it raises urgent questions about the future of these iconic trees and the layers of life that live on and around their shadow-dappled lengths. 

How a redwood fasts

To understand what’s happening to the redwoods — and what that may mean for the species that rely on them — first we need to take a quick foray into tree anatomy. Trees use the pores in their leaves, stomata, to do two things: take carbon dioxide in, and let water out. Open stomata mean the tree is “breathing” in carbon dioxide and photosynthesizing, but probably also letting water out. Closed stomata mean the tree is conserving water but also slowing down its photosynthesis, since it isn’t taking in any carbon dioxide. 

“Because leaves are a physical, light-absorbing object, they heat up just like asphalt would in the sun,” said Lily Klinek, a PhD student at UC Davis who was the lead author on the study. 

“They’re heating up faster than the air around them,” she said. “And one way that they can cope with this is by opening their stomata and allowing water to transpire out of the leaf, which is kind of like the way that humans sweat. When water evaporates off our skin, it cools us down, and it’s the same for leaves. But they can only really do that if they have enough water to lose.”

Klinek and her colleagues studied coast redwoods in Mendocino County, near the southern part of their range, where the researchers used specialized instruments to measure whether or not individual leaves were photosynthesizing. During heat waves, they found, coast redwoods hit a point where they can’t cool down fast enough, and they just keep their stomata closed. While that saves water, it also means the tree isn’t taking in more carbon — which means it’s not “eating” or building up energy stores it can use to keep growing. 

This may sound like a technicality of tree physiology. But it could have a big impact on these forests, creating a vicious cycle where trees don’t have enough carbon stored to replenish their leaves in the future, which means they won’t be able to photosynthesize as efficiently, which will starve them even further, repeating until trees eventually die. And while this sort of behavior has been observed in tropical trees, it’s the first time anyone has studied how coast redwoods respond to the same heat stress. 

“The term people use is carbon starvation,” said Chris Still, a forest ecologist at Oregon State University who didn’t participate in the study. “Leaves can be expensive to build for a plant.” 

Most of the redwoods in California and the Pacific Northwest nowadays are new-growth forests planted in the last couple of centuries. That means the trees are relatively hungry, like growing adolescents, compared to their old-growth cousins, so they need to suck in lots of carbon dioxide to grow taller. 

Redwoods are also incredibly good at storing carbon. Thanks to their bulk and long lives, they store more carbon dioxide per acre than any other forest in the world. “Not only is it negative feedback on the climate system itself, with less carbon sequestration from these trees and forests, but the trees themselves are going to obviously not grow as big,” said Anthony Ambrose, a plant physiological ecologist and co-founder of the Ancient Forest Society. So even if the trees survive, they might not have as much space for fern and soil mats, which means less habitat for the creatures that live in them, and they may not grow as tall as they once used to, which could hurt them in another way. 

The fog of old forests

A central threat to these trees, Klinek explained, is that in addition to the heat stress, they may also lose a crucial source of hydration and protection: Coast redwoods have an intricate relationship with the fogs of their native Northern California and the Pacific Northwest. The trees are so tall that their canopies reach high into fog layers, where they can sip water directly from the sky. The fog also shades the trees from the sun and helps coast redwoods create their own microclimate, which is why these forests are noticeably cooler than the areas adjacent to them. But warmer oceans and drier air are making fog more sporadic, which means the trees are missing a crucial source of relief from heat that is only getting more intense. 

“It’s kind of a double whammy,” said Todd Dawson, a plant ecophysiologist at the University of California Berkeley, who also didn’t participate in the study. “They’re running out of water and also getting this heat stress,” he said. “They’re used to living in a very narrow temperature range of 8 to 27 degrees Celsius (about 46 to 80 degrees Fahrenheit). California, like everywhere, has been getting long periods of much warmer days than we’ve ever experienced, and now the fog, which is normally kind of like an air conditioner, has also declined between 30 and 40 percent.” 

These temperature swings also impact the organisms living high up in the trees. “If they experience really excessive heat throughout the summer,” Ambrose said, “then the soil mats and ferns will probably dry out much faster. And then those salamanders and birds might not be able to live there. So we’ll see cascading effects through the whole ecosystem at that point.”

Klinek said, the trees seem to be doing okay after the heat passes; while the leaves she and her team looked at over their two-year study didn’t acclimate to the heat, they also didn’t lose their capacity to photosynthesize after the heat passed. While that’s a bit of hopeful news, it doesn’t reduce the urgency of the need to better understand the impact of climate change on these trees, and to reduce the warming itself. 

“Right now the temperatures are coming back to normal in the fall and winter and letting the trees recover,” Klinek said. “But in five or 10 years, if temperatures are even hotter and heat waves are even more frequent, we don’t really know if there would be a recovery.”

For now, the salamanders and seabirds still have their homes high atop the coast redwoods. But we’re a part of the redwoods’ larger ecosystem too, even if we don’t live near them — they, like all trees, are key to keeping our planet hospitable. The trees Klinek studied have the potential to live for more than a thousand years. The question is if we’ll let them. 

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.

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.”

The Supreme Court ruled on Friday that Missouri may not use a newly drawn Republican gerrymander during the 2026 congressional election. This decision should surprise no one because, about two weeks ago, the Supreme Court ruled that Missouri may not use a newly drawn Republican gerrymander during the 2026 congressional election.

That second decision, moreover, followed an even earlier one by Justice Brett Kavanaugh, which ruled that Missouri may not use a newly drawn Republican gerrymander during the 2026 congressional election. In that matter, Kavanaugh acted alone under a process that allows a single justice to dispose of a case — a process that the justices rarely invoke unless they view a case as so one-sided that there’s no need to formally refer it to their colleagues.

So, for those keeping track at home, that’s three times that the Supreme Court needed to decide the same exact question in less than three weeks. 

This happened because of an extraordinary round of defiance by Republican judges in the lower courts. Just minutes after Kavanaugh determined (for the first time) that Missouri cannot use the Republican gerrymander, a Trump-appointed judge in Missouri tried to countermand Kavanaugh’s decision. Then, after the full Court reaffirmed Kavanaugh’s decision, a panel of three Republican appellate judges again tried to reinstate the new maps that the Supreme Court had already twice rejected.

These judges’ behavior is disturbing. But it is also potentially a window into the future of the Supreme Court — at least if Republicans keep winning elections that allow them to fill seats on the federal judiciary.

The lower federal courts are gravid with ambitious Republican judges who reach conclusions that are either too extreme or too partisan for the current Supreme Court — such as the ones they reached in this case. These courts are also full of plausible candidates for a Supreme Court nomination who have shown unwavering loyalty to Trump, the MAGA movement, or the Republican Party — regardless of whether there are legal arguments supporting the GOP’s preferred outcomes.

Indeed, one lower court, the US Court of Appeals for the Fifth Circuit, now functions as a kind of think tank for MAGA legal theories that less partisan judges would scoff at in disgust. This is the same court, for example, that attempted to pull the abortion medication mifepristone from the market. It’s a court that declares entire federal agencies unconstitutional. Or that orders thousands of lawfully cast ballots thrown in the trash after the Republican Party asks them to do so. The Fifth Circuit is also frequently reversed from the left by the Supreme Court.

That means that, if Republicans hold onto the Senate after the upcoming 2026 midterm elections, Trump will be able to easily identify and confirm Supreme Court nominees who make Justice Samuel Alito, the most partisan member of the current Court, look like an icon of disinterested fairness. And many of these ultra-partisan judges are young enough that they will remain viable Supreme Court candidates in future Republican administrations.

Eliminating judicial filibusters transformed who gets nominated to federal judgeships

About 13 years ago, the Senate fundamentally changed how federal judges are confirmed. Prior to late 2013, senators in the minority party could use the filibuster to block any judicial nominee who couldn’t find 60 senators who would support their confirmation. But the Senate voted in November of 2013 to allow judges to be confirmed by a simple majority vote.

Both parties have their own narratives blaming the other for this development. Republicans often claim that Democrats’ decision to filibuster a handful of President George W. Bush’s lower court nominees — before the second Bush administration, judicial filibusters were rare — was a major escalation in the partisan war over judicial confirmations. Democrats, meanwhile, blame Republicans for a significant uptick in judicial filibusters under President Barack Obama.

In any event, Senate Democrats eventually decided to allow judges to be confirmed by a majority vote after Republicans filibustered all of Obama’s nominees to three vacant seats on the powerful US Court of Appeals for the DC Circuit. That broke a logjam that otherwise would have prevented Obama from filling any of these seats, but it also created a new world where lawyers who wished to become federal judges or justices no longer needed to worry about winning votes from senators in the other party.

This new world was apparent immediately after Trump took office the first time in 2017. There was a vacant seat on the Supreme Court, largely because Senate Republicans had held it open for a year until Trump could fill it. 

During his first term, Trump largely delegated the task of picking judges to the Federalist Society, a kind of bar association for right-wing lawyers. And the Federalist Society was obsessively focused on weakening the power of federal agencies to regulate private business. 

Trump’s eventual nominee for the open seat, now-Justice Neil Gorsuch, secured his new job by advertising his eagerness to advance the conservative legal movement’s top priority. Shortly before his nomination, Gorsuch wrote a pair of opinions laying out his plan to make federal agencies subservient to the judges. And one of these opinions, according to the journalist David Kaplan, “proved decisive in clinching” the nomination for Gorsuch.

In the pre-2013 world, judges with Supreme Court ambitions often avoided making their most controversial views public out of fear that doing so would antagonize other-party senators who they might need to support their confirmation to a higher court. In 2011, for example, Kavanaugh, then a judge, was assigned to a panel considering the constitutionality of Obamacare. But he dodged the key issue in the case, instead claiming that he lacked jurisdiction to rule on whether Obamacare is lawful.

After Gorsuch’s anti-regulatory opinions scored him a Supreme Court seat, however, lower court judges took notice. And the most ambitious Republican judges started looking for opportunities to prove their conservative bona fides to the Trump White House. Before 2017, for example, Kavanaugh had avoided taking a public position on abortion. Months after Gorsuch’s confirmation, however, Kavanaugh gave a speech to a conservative think tank signaling that he would be a vote to overrule Roe v. Wade if he were given a promotion.

The confirmation process, in other words, now favors candidates who audition for judicial jobs by demonstrating that they are dependable votes on issues that drive their political party. This is especially true for Republican judicial candidates, because the Trump White House has shown such favor toward candidates who are personally loyal to Trump. But Democrats who want a judicial appointment also have similar incentives. 

Gorsuch got his seat because Republicans, who controlled the Senate in 2016 when Justice Antonin Scalia’s death opened a vacancy on the Supreme Court, refused to confirm anyone that Obama nominated to fill this seat. It now appears, in other words, that no Democrat can get confirmed to the Supreme Court unless their party controls the Senate. So Democrats with Supreme Court ambitions also have no incentive to make nice with Republicans.

The way to get a high-powered judgeship is to convince your own political party that you will use that judgeship to advance its goals.

Republican judges are openly auditioning for the Supreme Court

Gorsuch and Kavanaugh are hardly the only judges who started advertising their ideological and partisan loyalty in an apparent effort to get ahead. The lower courts are now full of judges who write extreme and often needlessly provocative opinions that seem designed to catch the eye of someone in the White House.

The Ninth Circuit’s Lawrence VanDyke, for example, is a particularly vulgar judge who was reportedly on Trump’s short list for the Supreme Court during his first term. He’s best known for opinions mocking his colleagues and left-leaning litigants in a tone more often found on MAGA podcasts than in judicial opinions. VanDyke began an opinion about transgender women last March, for example, with the line “this is a case about swinging dicks.”

Or consider Andrew Oldham, a Fifth Circuit judge known for his opinions undercutting the First Amendment, attacking voting by mail, and standing up for vaping companies’ ability to sell bubblegum-flavored nicotine products — among other things. Oldham’s chambers is a factory pumping out decisions that even cause many of the Supreme Court’s Republicans to cringe — his vaping opinion was tossed out in a unanimous decision by Alito — but that also align perfectly with the Trump administration’s preferred policy outcomes.

The federal judiciary has become a partisan institution. And that means that the future of the courts is on the ballot every two years.

Or take Judge James Ho, Oldham’s colleague on the Fifth Circuit, who is also known for his trolly opinions attacking liberal shibboleths. Rather than attempt to summarize Ho’s jurisprudence, I will simply refer readers to my 2023 profile of him: “The edgelord of the federal judiciary.”

I could name more judges who behave similarly — I bring up these three largely because they’ve been discussed in the national media as potential Supreme Court candidates if Trump gets to appoint another justice. But there’s no need to belabor the point. The bottom line is that, if a vacancy does open up on the Supreme Court, Trump will have no shortage of judges who appear to have spent their judicial careers looking for opportunities to demonstrate just how eager they are to advance a MAGA agenda, even when that means moving several steps to the right of a Supreme Court dominated by conservative Republicans.

Indeed, the Missouri incident reveals just how widespread these sorts of judicial partisans are within the lower courts. None of the Republican judges who tried to reinstate the Missouri gerrymander after it was rejected by the Supreme Court, for example, have received the same attention that VanDyke, Oldham, and Ho have received as possible Supreme Court candidates. One of them, Judge James Loken, is an 86-year-old George H.W. Bush nominee with no prospects whatsoever of getting promoted.

But the culture in the lower courts has grown so open to partisan decisionmaking that he, along with two younger colleagues, literally tried to give the Republican Party an extra US House seat after the Supreme Court had told them not to do it twice.

Which isn’t to say that every Republican federal judge, or even every Trump appointee, is a partisan hack. One of the most pointed opinions rejecting Trump’s attempt to overthrow former President Joe Biden’s victory in the 2020 election, for example, was authored by Judge Stephanos Bibas, a Trump appointee. But, while Bibas’s opinion in Donald J. Trump for President v. Secretary (2020) was excellent, it also almost certainly guaranteed that he will never become a justice. And it absolutely guaranteed that he will never be nominated by Trump.

There’s no good solution to this problem

The biggest reason why America is stuck in this mess is that its two major parties have polarized on the proper role of judges. Even setting aside the youngest generation of hyperpartisan judges, it’s long been the case that any Republican nominated to the Supreme Court will be a reliable vote against causes like abortion rights, affirmative action, and the Voting Rights Act, and an equally reliable vote in favor of the “unitary executive” and for religious conservatives who seek exemptions from state and federal laws. Any Democrat, meanwhile, will take the opposite position on these, and a whole array of other issues where the two parties have consistent positions.

This is why restoring the old filibuster rules that existed prior to 2013 will not succeed in moderating the judiciary. If anything, allowing the minority party to filibuster judges again would mean that no one would ever be confirmed to the Supreme Court, because any nominee who is acceptable to one party would be radioactive in the other party.

Ultimately, the only effective way to keep people like Oldham, Ho, or VanDyke off the Supreme Court is to elect senators and presidents who do not want them on the Supreme Court. The federal judiciary has become a partisan institution. And that means that the future of the courts is on the ballot every two years.

Lisa Marie Wilson matched with a man on a dating app who claimed to be 5-foot-10 and to live on the beach. Only one of those facts turned out to be true. When she showed up to the date, Wilson observed that she and her date were the same height — and she isn’t 5-foot-10. She wasn’t planning to mention it, but her date did: “He told me I wasn’t really 5-foot-9,” Wilson, a 51-year-old author, told Vox.

Even though he accused her of lying about her height before he even said hello, Wilson told Vox she still gave the man the benefit of the doubt. But as they continued on with their planned walk along the beach, Wilson sensed her date was suspicious of her. “The whole time it was like he was an investigative reporter asking me questions, but kind of like if you were interviewing someone you didn’t like,” she said. 

By the end of the date, Wilson was sure she didn’t want to see this guy again, so she turned down his offer to give her a massage and left. She couldn’t get past his accusatory comment about her height. “I was like, ‘I’m not a liar,’” Wilson said. “But I think he was — because he obviously wasn’t as tall as he was saying he was.” (To add insult to injury, Wilson’s date emailed her the next day breaking things off with her.)

If you’ve been on a date recently, the phrase “love is a battlefield” might seem a fitting descriptor for the sordid state of romantic affairs. 

According to this year’s Kinsey Institute Singles in America Survey, the percentage of singles with a “checklist” of what they’re looking for in a partner rose from 25 percent in 2021 to 34 percent in 2026. Dating has also become even more partisan this year, another survey found: A date’s political affiliation, especially if it conflicts with their own, is a major dealbreaker. This year, traditional gender roles and values have made a return, hardening some people’s idea of what romance looks like — a dynamic where a woman is pursued by a man with an absurdly strong jaw — and warping the expectations that women have of men and vice versa. Daters are also increasingly using AI to chat with matches on apps and bots’ infiltration of dating apps might have you questioning who you’re even chatting with in the first place. 

It stands to reason that we’ve forgotten how to be human — and some of the basic rules of human decency — in our love lives. Relationship experts, historians, and critics agreed: Dating feels different now.

TikTok has only added fuel to the fire. A popular outlet for singles to share their gripes, the platform has given rise to new dating vernacular — rosters, breadcrumbing, goblintimacy. These new dynamics seeped into the dates themselves, with people openly antagonistic and confrontational from the jump. 

Experts say that if your goal is to find love, or even just have a night of fun, assuming the worst of others — as so many seem to do right now — isn’t an effective strategy. “If you’re eternally suspicious, that tends to be a boundary to attraction,” Paul Eastwick, a psychology professor at the University of California Davis and author of Bonded by Evolution: The New Science of Love and Connection, told Vox. 

The consequence of such hostility in dating is less tolerance — for ordinary friction, for learning lessons, for romance itself. So, what’s a single in 2026 to do?

The problem with dating right now

Most of modern dating followed a predictable pattern: Two singles met at church or at school or at work or at a party hosted by a mutual friend or through family. They might continue to see each other in social settings, gradually growing accustomed to one another’s personality, quirks, interests, until one person (usually the man, if they were straight) asked out the other on a date. Because they had mutual friends or coworkers in common, there was someone to vouch for them, to give some context to their life. 

Since the early 2010s, the most popular way to meet a potential romantic partner has been through online dating. App users are exposed to swaths of people they might not have ordinarily met without having to leave the comfort of their homes, meaning they are going on dates with virtual strangers. The sussing-out phase — where your perception of a person grows from simply “hot woman” to “Amy, the funny blonde from my dodgeball team” — has been condensed or eliminated altogether. “It’s not like, I got to know this person naturally,” Eastwick, also the co-host of the podcast Love Factually, said. “When somebody is a stranger, it’s maybe a little easier to come in with whatever negative assumptions you’ve gleaned from these online spaces.”

Life as a whole in the US has become more combative and tense in the past decade, from political polarization to increasingly rude behavior. At work, our labor and time is extracted until we’re laid off; at home, we’re suspicious of our neighbors. And dating is inherently vulnerable, rife with rejection and negative consequences. 

Dating apps have played a huge role in this dramatic shift in tenor. While effective at connecting users with multiple eligible singles, apps don’t encourage slow-burn connections, which is how humans have historically grown attracted to one another. And when a date goes awry, terrible tales can be mined for engagement online, where commenters are quick to validate a unique experience as universal, often reinforcing gendered stereotypes, like “all men are toxic” and “all women are shallow.”  

People have historically commiserated over their romantic lives as a way of bonding: Think of men in bars with their buddies bemoaning the old ball and chain, women lamenting their husbands not shouldering their share of household labor. During the feminist movement of the 1970s, women gathered to validate each other’s experiences and consider political responses to sexist issues, according to Rebecca Davis, a professor of history and women and gender studies at the University of Delaware. Social media now fulfills many of the same functions as these in-person conversations, Davis told Vox; people can take to TikTok or Reddit to share their frustrating or traumatic experiences, and comment sections are populated with others sharing their own similar stories. But unlike in the relatively private spaces of the past, these gripes now spread from individual to individual with little context, follow-up questions, or nuance.

Instead, posts beget more posts. Algorithms reward extreme content and creators may embellish details to encourage engagement. Whether intentionally or not, TikToks about how coffee dates signify low effort and Reddit threads parroting misogynist language perpetuate harmful stereotypes. “People are good at finding a reason to externalize the difficulty of dating,” the writer Asa Seresin told Vox. It’s much easier to assume the people you date are altogether bad than it is to assess your own actions.

In a viral essay published in 2019, Seresin gave the outward disdain with heterosexuality a name: heteropessimism. Since then, dating culture has only gotten more dismal, he said, in large part due to a national regression toward conservative views of gender and sexuality. The overturning of Roe v. Wade, contentious debates over transgender rights, and a generation of young men who believe a woman should obey her husband have become a dark cloud over the world of romance.

Some of these more traditional beliefs have filtered into 33-year-old Brittni Kristine’s dating life. After only a few weeks of dating, a man Kristine had met on an app asked her to be exclusive, but his actions suggested he wasn’t fully invested. Whenever Kristine inquired about their plans for the week, the guy would get irritated. “His defense mechanism was essentially like, ‘Well, I didn’t tell you I wasn’t seeing you next week, so why would you assume?’” Kristine told Vox.

Over the course of the month they dated, Kristine and the man got into multiple arguments of this nature until she’d grown exasperated with his stonewalling. His antagonism, Kristine suspected, stemmed from a puritanical view of sex and romance, where casually dating is seen as a moral failure. “I’ve had so many people tell me, ‘If I go on a first date with you and I find out that you have gone on another date in the past two weeks, basically I would never talk to you again because you’re promiscuous,’” she said.

These off-putting experiences fuel heteropessimism. A key aspect of heteropessimism, the pervasive embarrassment with which some young women express being attracted to men, only adds to a cycle of shame that makes people feel guilty for who they’re attracted to, Davis said. This has led some to internalize the idea that queer relationships are easier or more ideal. “When women talk about division of labor…it makes sense that there’s a longing for a relationship where the gender division of labor isn’t at play,” Seresin said. “I actually do think that is one way in which queer relationships are a lot easier, but I wouldn’t say that overall queer relationships are easier.”

Negative stereotypes and preemptive defensiveness plague queer relationships, too, Seresin said. “A lot of gay men also say, ‘I wish I wasn’t into men,’ and will blame a culture of very casual intimacy on being unable to find a boyfriend,” Seresin said. “A lot of lesbians will blame there not being enough queer women out there or enough of their type.”

The result is a population of singles, regardless of who they’re attracted to, walking into dating scenarios with strangers who they might already be suspicious of.  

Dating with walls up

As soon as his date walked through the coffee shop doors recently, Alex Alberti told Vox he sensed an air of negativity. “Literally from the jump, he kind of felt on the defensive and a little bit guarded from just buying coffee,” the 35-year-old education researcher said. Even a change of scenery on their walk around a nearby lake did not help matters. Alberti remembered his date venting about his dating troubles: how shallow and rude and awful the men were. About halfway through the get-together, Alberti decided there would not be another.

It was clear to Alberti that his date was letting past negative experiences color his current one. But instead of protecting him, drawing attention to bad behavior only pushed Alberti away. “I think people believe that if they can just beat the bad thing to the punch by calling it out, they’re going to make themselves safer,” he said. “When someone approaches a first date being highly skeptical and highly guarded and even a little bit combative, they think that it’s going to serve as a helpful filter.”

When you approach other people with distrust and ire instead of openness and curiosity, forging genuine connections turns into a monumental undertaking. People tend to like folks they feel comfortable opening up to, and the gradual revelations and bits of your interior life you show each other are what foster attraction. Fearing someone will weaponize your vulnerability against you turns dating into a surface-level endeavor at best, or, at worst, a contentious battle no one can possibly win.

The walls people put up are meant to be protective: You can’t hurt me if I never let you in to begin with. And the youngest prospective daters are dating even less in 2026: One recent study found that more than half of single young adults, ages 22 to 35, said past breakups made them more reluctant to pursue new relationships. Those are just the ones who’ve had previous romantic experiences. A Pew Research Center survey found that about a third of singles who have never married have never been in a committed romantic relationship to begin with.

When daters lack experience and are primed to see the worst in each other, the very normal aspects of courtship — negotiating boundaries, establishing trust, navigating conflict — are seen as dealbreakers. “There’s a growing discomfort with the normal friction, that if you say or do the wrong thing, it’s cringe, it’s disqualifiable; there’s no appetite for any kind of misstep,” Daniel Cox, the director of the Survey Center on American Life and author of Generation Uncoupled: America’s New Gender Divide and the Crisis of Human Connection, told Vox.

This is an impossibly high bar to clear and runs contrary to how many relationships form, Eastwick, the psychology professor, said. Most people’s affection for another person grows the more they get to know them. But if you’re meeting a stranger from an app who you assume has nefarious intentions, that first date isn’t likely to turn into a second.

Letting your guard down

Trauma and past negative experiences, both your own and others, can be a helpful teacher, a useful framework for what to avoid, and what lessons could be gleaned from pain. But it can also be distorting, Seresin, the writer, said. One bad relationship or date doesn’t mean all future relationships and dates with a similar type of person will be doomed. “It’s almost like if you’ve had a bad experience and you want to protect yourself, that’s almost morally good,” Seresin said.

Instead of focusing on avoiding any bad feelings (an impossible task), singles should question their own assumptions and operate from a place of curiosity. Resist the urge to cast judgment based on what little you know of someone. Even couples who have been married for decades can still discover new things about their partner. “It’s very easy to think, ‘I know exactly how this person thinks. I know what they want. I know how they’re trying to manipulate me,’” Seresin said.

The process of getting to know someone is a risk. All relationships come with potential disappointment; there will always be a person who ghosts or makes a bad joke or minimizes your accomplishments. But it doesn’t mean that person represents all men or all women, that they’re the enemy, that these connections are inherently toxic or not worth pursuing in the first place. 

To find love, we have to turn down the instinct to protect ourselves and open ourselves to the possibility that the person across the table might also be a flawed human who’s been hurt before. And they might want the same thing, too.

Nationally, abortion has faded as a campaign issue. Four years after it helped Democrats stave off a red wave, candidates in battleground races are focusing their attention on cost-of-living issues, immigration, and policing. As of mid-August, abortion was mentioned in less than 5 percent of Democratic Senate ads, a key difference from the past two cycles, according to the Wesleyan Media Project.

Maine is different. As of September 16, Democratic advertisers had spent roughly 15 percent of their $40.8 million broadcast TV and streaming dollars on ads focused on abortion rights, according to Nate Schwartz from AdImpact. It’s one of the biggest topics there, he told me, after ads about President Donald Trump and healthcare. Planned Parenthood’s political arm is also making its biggest ad buy of 2026 against Susan Collins, at $600,000, and WinSenate, a super PAC aligned with Senate Democratic leadership, has spent 70 percent of its TV, streaming, and digital money in Maine on abortion-focused ads.

The target is Collins, the only Republican senator up for reelection in a state Trump lost in 2024, and one of Democrats’ best chances to flip a seat. Seeking her sixth term, Collins is running in a year when Democrats lead the generic congressional ballot by about 9 points. It’s also the first time she will face voters since Roe v. Wade was overturned — a decision Justice Brett Kavanaugh helped deliver after Collins, who has long described herself as “pro-choice,” cast the pivotal vote to confirm him in 2018. 

For the abortion rights movement, this is the race that has to work. Groups are pouring their biggest investments of the cycle into a state where fewer than half a percent of voters call abortion their top issue, in a year when Democrats have opportunities to win nearly everywhere. If a blue wave arrives and lifts every Democrat except the one running to avenge Roe v. Wade and remove the senator who famously sealed its fate, the organizations will have a harder time telling donors the issue still moves voters, and a harder time arguing that Republicans will pay a political price — even in blue states — for votes that restrict access to abortion.

“We know that abortion is the number one negative in Maine voters’ mind,” Lisa Margulies, a Maine spokesperson for Planned Parenthood Votes, told me. “It’s really the No. 1 dealbreaker.”

The first job for Democrats and abortion rights advocates is convincing Mainers the issue is still a pressing one. Seventy-two percent of Maine adults say abortion should be legal “in all or most” circumstances, and since Democrats took control of Maine’s government in 2018, the state has expanded who can provide abortions, required and subsidized insurance coverage for the procedure, eliminated most patient cost-sharing, loosened restrictions on care after viability, and shielded patients and providers from prosecution and lawsuits.

Collins has made that her defense. The Dobbs v. Jackson decision, she said in June, “has not had an impact on the state of Maine in that Maine actually expanded its law.” Advocates call that the central misunderstanding. 

“There’s this perception — and Sen. Collins herself has said it — that somehow Maine is immune, and that’s just not true,” Margulies said, pointing to their state-level efforts to keep access intact and to federal Medicaid cuts that have already hit Maine providers.

Also muddying the waters is the senator’s Democratic opponent. Collins is facing off against Troy Jackson, a longtime fixture in Maine politics who rose from the state House to the Senate presidency but fell short in bids for Congress in 2014 and governor this year. Early in his career, Jackson said that abortion “should never be legal” and that women should be required to view an ultrasound if they want to end a pregnancy. He has since renounced those positions and has earned 100 percent ratings from Planned Parenthood since 2017. (Jackson replaced Graham Platner, the original Democratic Party nominee, who quit the race after being accused of rape, an allegation he denies.)

While Collins prevailed for reelection in 2020 despite voting to confirm Kavanaugh, Democrats say her decision is much more salient for voters now that Americans live in a post-Roe world, one where more than 15 states have near-total abortion bans. 

If Collins loses, Democrats and abortion rights groups will say her Kavanaugh vote is no doubt partly why. A win for Collins would be harder to read, though the explanations that leave out abortion are already being prepared, including a messy nomination process that produced a candidate fewer voters were excited about, and a “unicorn” incumbent with decades of personal relationships across a small state and a long record of bringing federal money back home.

The abortion rights bet hinges on two things: that the Kavanaugh vote cost Collins something on top of what an unpopular president and rising gas prices already have, and that voters will judge Jackson by the positions he’s renounced rather than the ones he once held. 

The vote Collins won’t apologize for

When Collins voted to confirm Kavanaugh, she said she believed his assurances that he considered Roe v. Wade settled precedent. She had previously said that she would not vote for any nominee who expressed “hostility” toward the 1973 decision that established the constitutional right to an abortion.

As many observed at the time, Kavanaugh’s record gave strong signals that he would in fact vote to overturn Roe v. Wade. In her floor speech announcing her vote, Collins dismissed those warnings, suggesting opponents had been whipped into a “frenzy” by advocacy groups. When he ultimately did side with the conservative majority in Dobbs, Collins issued a statement calling the ruling “ill-considered.”

Four years later, though, Collins is doubling down on her vote for Kavanaugh, telling local media this summer that she does “not regret” it. “Given what subsequently happened to Roe, I don’t think that simply fades into the background,” Robert Glover, a political scientist at the University of Maine, told me.

Democrats are zeroing in on the fact that Collins has continued to confirm anti-abortion federal judges, even as recently as this month. Last fall she voted to confirm Joshua Dunlap, a Maine attorney, to the US Court of Appeals for the First Circuit over objections from 20 Maine organizations citing his record on abortion and marriage equality. 

“Susan Collins says she has no regrets about confirming the judges who overturned Roe v. Wade, and has proved it by continuing to vote for Trump’s right-wing judges,” Maine Democratic Party spokesperson Misha Linnehan told me in an emailed statement. “Now, her approvals are underwater, and she’s trailing with women voters because Maine women have had enough of being betrayed.” 

George Hill, the president and CEO of Maine Family Planning, told me Collins “defied” them with her vote for Kavanaugh, causing “irreparable harm” across the country. He emphasized how vulnerable Mainers are if Republicans retake control of state government.

Blake Kernen, a spokesperson for Collins’s campaign, dismissed the criticism about anti-abortion judges, emphasizing that her pro-choice boss also voted for 188 judges nominated by President Joe Biden, including Julie Rikelman, who served as litigation director of the Center for Reproductive Rights. Collins, she noted, is the only Republican who voted to confirm all three of the court’s liberal justices, and she voted against Amy Coney Barrett.

Margulies rejects this accounting. “We deserve better than, ‘Well, she’s not as bad,’” she said. “When it comes to reproductive rights, she’s not a moderate anymore.”

While her judicial votes are facing scrutiny, Collins has also spent decades building up a brand as a Republican willing to buck her party on abortion when the issue comes up in the Senate. 

In May 2025, Planned Parenthood Maine Action Fund published a memo online titled, “Senator Susan Collins’ long history of supporting Planned Parenthood and access to essential health care.” Among other things, the memo highlighted Collins for speaking out against proposed Medicaid cuts, for co-sponsoring a bill in 2022 to codify Roe v. Wade, and for opposing a 20-week abortion ban bill in the Senate. This past summer, the memo was quietly taken down from their website.

Asked about the removed page, Margulies didn’t say when or why it was taken down, but pointed to what she described as a sharp shift in Collins’s record over the past year, particularly on judicial confirmations. “There are times when she’s been true to her word and put Mainers ahead of politics, but she closed that chapter this year,” she told me.

“Because she is a Republican, the national groups continue to twist themselves into a pretzel to support these male candidates with terrible records,” Kernen said, referring to Platner and Jackson. 

So far, Mainers appear to have split Collins in two in their minds: There’s the dedicated public servant who puts her state first on one side, and the partisan Republican who sometimes disappoints them on the other. A University of New Hampshire poll over the summer found Collins rated far better on bringing federal dollars home to Maine than on her Supreme Court confirmation votes. Maine voters, Glover said, “have historically been willing to separate Collins from the national Republican Party and evaluate her through a broader lens of incumbency, independence, and constituent service.” 

The turnout math

Even if Democrats can win the argument on abortion around Collins, it’s an open question how much it will move votes. “Right now, I feel quite confident that affordability, healthcare, and good jobs trump abortion access by a long shot,” Dan Shea, a political scientist at Colby College, told me.

But abortion rights advocates believe the ranking obscures how the issue actually works. Mini Timmaraju, president of Reproductive Freedom for All, said her group has spent years testing how to talk to voters about abortion, consistently finding that it overperforms as an attack. “If you go to a voter in Maine and you say, what are your top three or five issues, they may not name abortion,” she told me. “But if you say to them, Susan Collins took the following vote — and one of them is Brett Kavanaugh, which led to overturning Roe — it is extremely salient, and it moves that voter.”

The Kavanaugh vote works, she argued, as a character verdict — “an indicator that you’re willing to side with extremism over your own constituents.” That, she said, is the piece that’s missing in the analysis of what voters say they care about. “It is one of the most salient attacks in Maine and in a lot of other parts of the country.”

Ashley Kirzinger, a pollster at KFF based in Maine, said priority rankings are a weak guide anyway, noting “the economy” means different things to different voters, and issues compete with candidate dynamics and party loyalty. What has changed since Roe’s overturn, she told me, is who the single-issue abortion voter is.

“Before the Dobbs decision, abortion was a motivating issue for Republican conservative voters,” Kirzinger said. “Now what we’ve seen is a complete shift.” Those voters are more likely to be Democrats, younger women and women of color, and include more people who don’t reliably show up in midterms.

Abortion messaging, therefore, is doing two jobs. The first is turnout. Kirzinger said the Kavanaugh vote is aimed at Democratic women “who are not as enthusiastic about Jackson as a candidate” and who “may be more motivated to turn out as a vote against Collins’ record on abortion rather than for Jackson.” In a tight race inside the margin of error, a couple of points of turnout could make the difference.

The second job is persuasion, and the target is older women, who reliably vote. Women made up nearly 60 percent of Maine’s turnout in 2020, and Collins won them by 3 points. What Democrats need from them is a switch, which is why many of the abortion ads are built around regret. One Planned Parenthood ad features a woman who voted for Collins and “will not make the same mistake twice”; WinSenate’s features a voter who “felt [Collins] was the better choice” and doesn’t anymore. 

Jackson’s change of heart

Complicating the race is Collins’ opponent, Troy Jackson, who is in some ways a mirror image of her own political persona: a Democrat with a history of culturally right-leaning positions to appeal to voters in the other party.

Jackson, who started his political career in the rural and fairly conservative county of Aroostook, used to earn 100 percent ratings from Maine Right to Life. In 2010, as CNN’s KFILE reported, when he filled out the group’s candidate questionnaire saying he thought abortion should never be legal, he declined to say whether there should be exceptions even to protect the life of the mother, for rape or incest, or because of fetal disability. Maine Right to Life, which has not issued an endorsement in the Senate race, did not return requests for comment.

Jackson told MS NOW he evolved on the issue thanks to “a lot of conversations over time” with women, doctors, and community members. “It became more and more clear to me that abortion access was healthcare,” he said.

In 2023, while serving as Senate president, he co-sponsored a bill allowing abortions after fetal viability when a physician deems them necessary, one of the most expansive such laws in the country. In 2024, he shepherded through the Senate a shield law protecting Maine providers and patients of reproductive and gender-affirming care from other states’ bans, despite bomb threats that emptied the statehouse and a letter from 16 Republican attorneys general threatening to sue. “Troy stood up for and never wavered in his commitment to reproductive rights during some really harrowing moments,” Margulies said, “when it would have been a lot easier to step down.”

“I’m rock solid on this now, and Susan has been the opposite,” Jackson said in an interview with Maine Public Radio this summer. Kernan, Collins’s spokesperson, has charged Jackson with flip-flopping for “political convenience.”

The national environment is looking strong for Democrats, and Jackson has been narrowly ahead in recent polls, though all have been within the margin of error. A CNN poll released this month found nearly two-thirds of Mainers feel negatively about the Dobbs decision, including about half saying it makes them angry. A Fox News poll in August found 55 percent worried Collins votes with Trump too often. 

Whatever happens, the explanations are ready. If Collins loses, abortion rights groups will cast it as proof that the issue still moves voters even where it doesn’t top their lists, and as a warning to all Republicans running in 2028. Timmaraju previewed the argument in our conversation: A loss would signal “a crack in the armor” of so-called moderates, and show that voters “are not going to tolerate” incumbents complicit with an extremist administration. 

If Collins wins, the groups that spent millions on abortion ads are unlikely to conclude that doing so was a mistake. Kirzinger pointed to the turmoil that followed the Democratic primary and the late swap of Platner for Jackson, which she said benefited Collins “in a way that is hard to capture in polls.” Glover, the political scientist, noted the things Mainers have always weighed alongside her votes, including decades of relationships, the Senate Appropriations gavel, and federal money. Even Timmaraju, the abortion rights leader, offered the same hedge in advance: A Collins win, she told me, “says more about Susan Collins and Maine than it does about 2028.”

A win wouldn’t show that judicial votes carry no consequences, Glover added. But if Collins holds substantial support among voters who support abortion rights despite the Kavanaugh vote and the fall of Roe, “that would certainly suggest limits” for retrospective accountability for downstream consequences of Supreme Court confirmations.

Though the race is supposed to clarify whether voters will punish elected officials for taking actions that restrict abortion access, it probably can’t — at least not definitively. It will decide, though, who holds the seat, and reproductive rights leaders have been clear that without a Democratic Senate, nothing they want gets a vote.

When we think about the stakes in healthcare, we tend to think of them in terms of life and death, being sick or being healthy. The conversation is about your physical well-being and maybe your mental health — and it pretty much stops there.

But health affects so much more than your body’s biology or even just you personally, as a new survey from Gallup and Pivotal, a philanthropic group founded by Melinda French Gates, shows. That’s especially true for women, who frequently report negative experiences with the health system and ongoing struggles to get their concerns taken seriously; poor health affects the trajectory of their careers and their ability to be engaged with their families, friends, and wider community.

It starts at the doctor’s office or hospital: 51 percent of women say they have had a negative healthcare experience in the past five years, versus 39 percent of men. About one in three said that a doctor did not take them seriously when they said they were feeling pain or other symptoms, versus 21 percent of men, and 33 percent said that they either were misdiagnosed or did not receive a diagnosis. The cost of paying for care is another deterrent: 32 percent of women said they have skipped or delayed care in the past year because of the cost, compared to 25 percent of men.

“To see that half of women in the United States who sought care in the last five years came out feeling like they hadn’t gotten the help or care they needed, that’s frankly staggering,” French Gates told me in an email. “It says a lot about how little we’ve invested in women’s health and how much we expect them to just push through pain or accept uncertainty.”

And the effects of those experiences, the failure to receive proper treatment, ripples out into the rest of the women’s lives. More than half of US women, 54 percent, said they had experienced at least one health-related impact on their family life or relationships; 42 percent said their health had led to a negative effect on their career or work. It also affects their community: 32 percent said their health had affected their ability to participate in civic life.

The toll is not only physical but mental: 48 percent of women said they’d dealt with a mental health condition like depression or anxiety. And socioeconomic disparities abound. Black and Hispanic women are more likely to report being in poor or fair health. Women who have lower incomes are more likely to face career struggles because of their health than those who make more.

I had the opportunity to interview French Gates, who has made women’s health a priority in her work, over email about the survey; its findings on community engagement, menopause, caregiving, and more; and what could be done to address the problems that it reveals. Our exchange is below, lightly edited for clarity and length.

Which of these survey findings surprised you most and why?

The number of women [54 percent] who said they experienced a mental health challenge during or after pregnancy should stop us all in our tracks. And the fact that less than one in three women who sought care found it helpful is really concerning. It’s why I feel so strongly about integrating women’s mental and physical healthcare, especially during pregnancy and postpartum. Mental and physical health are so linked together.

Too much of the burden is placed on women to get answers. All of us deserve so much better.

Nearly one-third of women said in the survey that health problems limited their ability to be involved in their community. What does that look like in practice, and what do communities lose when women can’t fully participate?

Women are so often the backbones of their communities, whether they’re rallying their neighbors around a cause, leading the PTA, or serving in elected office. Without having women — and their ideas and voices — in those roles, we’re missing half of the conversation. Issues that affect women and families are less likely to get on the agenda. They’re less likely to be solved.

When a woman has a health challenge, and she has to spend so much of her time and resources chasing down answers, that makes it harder for her to show up in those spaces. We saw that in the survey: 30 percent of women said their health limited their ability to be involved in their communities. And when women couldn’t get the care they needed, that percentage doubled.

Women’s health is often talked about as a personal issue, but this data is helping us prove that it’s also an economic issue, a family issue, a community issue — it affects all of society.

Caregiving and family responsibilities prevent many women from getting medical care, in particular Hispanic and Black women. That seems to create a vicious cycle: Women are often so busy being the caregivers in their families that they neglect their own health. Eventually, they are the ones who will need care.

What do you think can be done to break that pattern? Is there a philanthropic solution? What public policy changes could be made?

Women are often taught to put themselves last and minimize their own needs. They don’t always have time to care for themselves because they’re so busy caring for others. And they might not be able to afford childcare or home health support for their aging parents. Our survey showed one in six women delayed healthcare because of their responsibilities caring for their family members. For Black women it’s one in five, and Hispanic women one in four. Too many women are facing an uphill road to even just get to a doctor’s office.

It’s possible to make it easier for people to balance healthcare and family responsibilities — but it’s going to take action from many angles. That’s exactly why I invest in both women’s health and in caregiving, and I’d encourage more philanthropists to do the same. Businesses can also support employees with good paid leave policies and reliable but flexible schedules.

But for women everywhere to benefit, we need government leaders to prioritize increasing access to affordable childcare, home health supports, and paid family medical leave. These are policies that have the support of large majorities of Americans because these are issues that affect everyone. So there’s a real opportunity here to offer meaningful help to families.

I am struck by our collective failure on menopause: Women report that they aren’t aware of menopause symptoms until they experience them on their own, that they struggle to get their doctor to take menopause symptoms seriously, and that their menopause experience has held them back in their career. What are some short-term and long-term steps we can take to address those problems?

“Right now, women need better care at critical moments in their lives.”

If more than a third of women only learn about menopause symptoms when they go through them, the system is clearly not working. Women need to learn about menopause from their doctors before they experience it. But doctors aren’t getting the education and training they need on menopause while they are in school. One doctor told me she got just one lecture on menopause across all her years in medical school. One said it was mentioned one time. They are seeking out better training but it can be hard to find. That’s why Pivotal is partnering with the Menopause Society to expand physician training on menopause so doctors, nurses, and other healthcare providers can access the information they’re looking for to better help their patients.

Because menopause isn’t just about being uncomfortable; it can also bring anxiety, heart palpitations, insomnia — significant symptoms that can really hold women back. More than a quarter of women who’ve experienced menopause or perimenopause said it made it harder to live up to their full potential at work. One in 10 had to take leave or leave their jobs entirely. That just shouldn’t be. Women shouldn’t have to step back right at the moment when they could be stepping into leadership roles.

The most immediate steps can come from policymakers, especially at the state level. They can include menopause care in insurance and Medicaid coverage and offer workplace protections to women in menopause the way they do for pregnancy, so women can get the care they need without losing their jobs. I’m also focused on longer-term solutions, like expanding training for healthcare providers and investing in research to accelerate treatment options.  

Women are at the forefront of a lot of wellness trends these days and yet, as the survey reveals, women also report encountering a ton of health misinformation on social media. Why do you think women are so often the targets of this kind of content? What can be done to point women toward and build their trust in sound medical information?

One in three women said she left an appointment without a diagnosis, with her pain being dismissed, or with no answers or next steps. You can understand why those women would start looking for information online. And because women’s health has been underfunded and under-researched, there just isn’t as much reliable information out there as there should be, which leaves a lot of room for people to come in with misinformation. Investing in credible scientific research to fill that vacuum will give both women and their doctors more information going into their appointments.

In terms of your own organization’s work, which investments are you making that you think can make progress on the underlying problems revealed in this survey?

We need to address the right now and we need to address the longer term. Right now, women need better care at critical moments in their lives.

One way we’re investing in that at Pivotal is by making it easier for women to get the mental healthcare they need during and after pregnancy. So we are investing in integrated models that put mental and physical healthcare under one roof. I visited a health clinic in Alabama earlier this year where they identify issues like depression and anxiety right at the outset and then help the mom all the way through her pregnancy care, all in the same place. That model is something we strongly believe in.

Better care for menopause will require better training, which we are thinking about in both the immediate and long term. I mentioned that we’re making more menopause training available to doctors who are currently practicing. That is something I’m really excited about because I’ve heard from physicians who really want to better support their patients and are looking for better information so they can do that. And longer-term, menopause needs to be a much bigger part of the curriculum at medical schools moving forward.

Another longer-term focus of ours is trying to make up for decades of lost time in research. We are funding medical research focused on how diseases specifically impact women, in partnership with an innovative organization called Wellcome Leap. They are working to accelerate progress in women’s health on everything from autoimmune diseases to cardiovascular disease in years, not decades, which is how long health breakthroughs usually take. That’s the kind of urgency women need and deserve.

Even before the latest batch of alarming AI news, a lot of Americans were souring on AI. That may be for big, existential reasons — concerns about widening inequality, mass job loss, and the still-unclear environmental impact of data centers — or for very specific, personal, everyday ones, like being forced to use a worse version of Google search. 

None of this is to say that AI cannot be a useful tool for some people some of the time. It’s just that the untested technology was thrust upon millions of people who didn’t necessarily ask for it and really seem to not like it. More than twice as many Americans distrust AI as trust it, and a growing number of people think it will have a negative impact on productivity and economic growth, according to a recent survey by Gallup and the Special Competitive Studies Project. While about half of Americans now report using chatbots, a majority also think that AI will put their personal information at risk and nearly half think it will have a negative impact on society, according to a 2026 Pew study.

“It’s being forced on users, there’s no clear way to turn it off, and it feels like this unwelcome addition to their lives,” Rory Mir of the Electronic Frontier Foundation (EFF), a nonprofit that defends digital privacy and free speech, told me. “It’s this kind of continued pattern of disrespect to users that I think is part of the pushback.”

If you want less AI in your life, opting out is not always easy. But there are things you can do to minimize your exposure. 

There are ways to turn off AI features, although the process can be tedious. There are also steps you can take to prevent your data from being used to train AI models, though it’s difficult to keep all of your online data away from web scrapers. 

I talked to five experts — including a computer scientist and a researcher studying AI resistance — who offered distinctive perspectives on what AI is doing to us, and who shared some simple and concrete steps you can take to push back against AI’s creep into our daily lives.

The AI that’s suddenly everywhere

In the early days, which were just a few years ago, you really had to know what you were doing if you wanted to test out AI. Now, it’s impossible to avoid. 

“More and more AI use is through its integration into digital products like search, email, camera apps, and social media,” Arvind Narayanan, a computer science professor at Princeton University, told me. “It will become increasingly hard to strip these out unless one is willing to forgo digital products altogether.”

What you’re specifically encountering is generative AI, and one of the most common types is a subset called large language models (LLMs), which ingest huge amounts of data and learn statistical patterns to predict and generate text. ChatGPT is powered by an LLM. The AI Overviews that sit on top of your Google search results come from an LLM. The grammar checker in your email app is likely powered by an LLM. Other subsets of generative AI include models that can produce images, video, audio, and software code. 

The data that makes many of these tools work has been scraped from the open web, pirated books, and rare print books that are subsequently being destroyed. Everything from Wikipedia articles to YouTube videos has become training data for LLMs, and in order for the models themselves to get better, AI companies need more fresh data, which is in increasingly short supply. (Disclosure: Vox Media is one of several publishers that have signed partnership agreements with OpenAI. Our reporting remains editorially independent. Future Perfect is also funded in part by the BEMC Foundation, whose major funder was also an early investor in Anthropic; they don’t have any editorial input into our content.)

As a result, some of these companies are venturing into their users’ profiles to find more data. Meta, for example, sparked global outrage in 2024 when it informed some Facebook and Instagram users that it was using their public photos and text to train its AI models. Meta still does this. That your family photos or social media updates are being used to train AI to look and sound more human is, at the very least, very dehumanizing.

Generative AI, of course, is not the only type of AI that’s invisibly moving levers in your digital life. Recommendation algorithms are arguably even more inescapable. They power everything from Amazon to Netflix to Spotify and dictate what we buy, what we watch, and what we listen to. If you have trouble picking out an outfit in the morning, it might be because your brain is used to having algorithms around to help make decisions. This is also dehumanizing. 

All of this — the societal harm, climate impact, the cognitive surrender — should be on your mind as you consider whether it’s worth enlisting these tools to write emails for you or to generate memes, according to Tania Duarte, founder of We and AI, a nonprofit focused on critical AI literacy. 

“People are becoming increasingly aware of not just the impact on themselves but on the impact on the society they want to live in and the future that they want to have,” Duarte told me. “Is it worth all of that?”

How to minimize your AI exposure

If you’re reading this, you’re probably doing so on a smartphone or a computer. So let’s start with the assumption that you’d like to continue using devices like these. 

If you’d like to minimize your exposure to AI, that presents a bit of a paradox. It’s seemingly impossible to use mainstream tech products without engaging with AI. But you can take steps to remove as much of it from your life as possible without going completely off the grid.

“You look for the spaces of agency rather than lamenting the fact that you can’t escape everything,” Dylan Orchard, a researcher at King’s College London who studies everyday resistances to AI, told me. “You can’t expect a perfect escape.”

Let’s start with the easiest options: You don’t have to use ChatGPT or Claude or Copilot. The same goes for Google Gemini and Apple Intelligence. If you’re happy with the way you access information online, save yourself the time. (Note: This will be much harder to do if you’re being required to use these tools at work or at school, so for the sake of this article, we’ll focus on the things you can control.) 

Things get more complicated when you consider how your existing devices or software have recently been AI-ified. If you’re using an iPhone, for instance, you might be aware that the latest operating system comes with an updated version of Apple Intelligence, a layer of AI that does everything from summarize your notifications to power a new Siri. Earlier this year, Google launched its own version of this layer called Google Intelligence, which it says will make Android transition “from an operating system into an intelligence system.” The same push toward cramming AI into every corner is also happening on Windows 11, where Microsoft Copilot promises to be helpful.

If you were happy with your phone or laptop when it was slightly dumber, however, you can turn these features off. You can also opt out of other AI features built into your device’s operating system. Here’s a helpful guide that gets into the weeds of how to do it; it covers Apple Intelligence; Google Gemini, including AI Overviews and AI writing help in Gmail; Microsoft Copilot; Meta AI; and Samsung Galaxy AI. Turning off the AI features on Android devices is more complicated than flipping a single switch, but it can be done.

A lot of your AI exposure will happen in your web browser, though, so you should consider ways to bypass those features or switch browsers. Here’s another helpful guide that explains how to remove AI content from search results as well as AI features built into Chrome and other browsers, along with Microsoft Office. If you want a quick fix, adding “-ai” to a Google search should get rid of AI Overviews and some AI content in the search results, but none of these hacks will guarantee that you avoid AI slop altogether. Using a privacy-focused browser, like DuckDuckGo, might do a better job at it than Google, though.

When it comes to other online activities, like shopping or scrolling on social media, avoiding AI gets even harder. TikTok, Instagram, Facebook, and YouTube lack a master switch that lets you opt out of all the many AI features on offer. Still, you can try to tone down the algorithmic sorting that all the apps use to serve you content by switching to a chronological feed or removing suggested content from your feed. (Try tapping the Instagram logo in the app and then hit “Following” to see just the accounts you follow.)

Unfortunately, once you dig into the various user agreements and privacy policies, you’ll find that it’s very difficult to avoid AI exposure on social media platforms. If you’re posting publicly, you should assume your content is being used to train that company’s AI models. (You can keep some of your data away from Meta’s crawlers by setting your Facebook or Instagram account to private. X also allows you to opt out of having your data used for training its AI.) If you want to turn off video summaries on Instagram Reels, too bad. You can’t. If you want to turn off comment summaries on Facebook, you’ll have to go four menus deep in your settings to find the right switch. The most straightforward way to avoid being used as training data is to stop using these apps entirely. Or at least stop posting your own content, which is easier said than done, but worth considering if you really want to resist the AI takeover.

There’s a programming term that describes the inundation of AI features and slog of opting out: “user-hostile.” It’s a play on the term “user-friendly,” and it describes software that values the company’s priorities over the end users. You may love AI, although that’s doubtful if you’ve read this far. If it drives you crazy, though, you should feel at least a little bit empowered to know that there’s a way to reclaim the experience you had and loved without AI — or to use AI on your own terms. 

“Ultimately, I think the important thing for folks to keep in mind is that AI is just a tool,” said Mir from EFF, “and it makes sense to want control over your own tools, including the option to not use a tool if it’s not right for you.”

It’s frustrating that we have to deal with this at all, if only because most of us did not ask for our cyber existences to be sullied by untested tech. But it’s actually refreshing to consider that, because of a never-ending onslaught of annoying features, AI might actually discourage us from using social media so much.

If anything, the extent to which we feel the need to flee from AI also reflects our craving for something real, that makes us feel more connected and more human. So when AI summaries interrupt your time on Instagram, consider texting your friends a handful of photos from your week or calling them on the phone. If you’ve finally seen one too many AI slop videos on TikTok, put on a classic movie or TV show. 

At the very least, put down your phone and take a walk outside; your attention span will thank you for it. Yes, your individual rejection of AI might be a drop in the bucket for these huge tech companies, but that doesn’t mean it’s not worth doing anyway.

Correction, September 21, 2:10 pm: The way this story originally represented Tania Duarte’s comments has been revised to clarify her concerns with AI.

Wildfires are popularly considered wild — restricted to the remote wilderness or the edge of forests, and to most, a problem for the dry and hot states of the Western US. But over the past few years, and now across the country, these fires are getting less wild and far more urban. 

This summer, fires in Spokane, Washington, demolished over 800 homes in a suburban neighborhood, and earlier in the season, the northeast coast was engulfed in smog from fires in Ontario. The Hawk Fire in Nevada razed more than 15,000 acres near Reno, destroying 47 homes before it was extinguished. The Los Angeles fires of last year remain some of the most devastating in recent memory, with over 37,000 acres burned — much of it densely built residential neighborhoods — and displacing 205,000 people from their homes. In Boulder, Colorado, the 2021 Marshall Fire destroyed nearly 1,000 homes. 

This changing geography of fires is affecting the health risks they present, too. 

When vegetation burns, it releases particulate matter, or PM 2.5, and with over 46 million homes in the continental US — this is approximately one-third of all homes — on the edge of fire-prone wildland, many more of us are being exposed to air filled with that soot. This alone is a major health risk. According to the World Health Organization, PM 2.5, is associated with premature death, severe damage to respiratory health, and cognitive impairment. It is especially dangerous for aging populations: a study published in February found that accumulated exposure to wildland smoke was associated with greater hospitalization risk for various cardiovascular diseases in older Americans, including irregular heart rhythms and heart failure, even when they are only exposed to moderate levels of PM 2.5.   

But the urban landscape has also changed the very composition of the smoke that increasingly hangs over all of us. As human structures and vehicles burn, the fires expose us not just to particulate matter but also to the chemical toxins of urbanization itself, from plastic to metal oxides and vehicle fuel. The changing nature of this smoke, in fire zones but also in surrounding regions as it drifts outward, exposes us to a new class of health risks. 

While researchers are still learning what exactly those risks might entail, early research suggests long-term dangers that are deeply troubling, especially as exposed populations age.   

The changing fire frontier 

In 2020, the worst California fire year on record, ate up 4.2 million acres of land, most of it wild, spewing huge amounts of PM 2.5 into the air as the blazes raged. Emergency rooms, already short-staffed by the ongoing pandemic, buckled under the burden immediately. Northern California’s Stanford Health Care system saw a 12 percent jump in hospital admissions over the weeks following the fires, and a 43 percent increase in cardiovascular conditions. In Oregon that same year, 10 percent of emergency room visits were due to asthma-like conditions induced by smoke as fires migrated north.  

Unfortunately, in a world of warming temperatures and drying conditions, that story is becoming all too common. In 2025, a total of 5.2 million acres of land burned across the US, and this year that number has already climbed to 8.5 million, before we’ve even hit the winter dry seasons that plague parts of the Southwest. 

Despite this, the global footprint of human housing continues to expand, and with it the danger.  

For centuries, human development has breached wildfire territory. However, over the last three decades, the zone that links the wild to cities and towns, called the wildland-urban interface (WUI), has grown substantially due to suburban construction. The US Forest Service found a 46 percent increase in the number of houses in the risky WUI zone between 1990 and 2020. By 2020, a third of US homes had been built in this highly vulnerable landscape. The math is simple: As suburbia expands into wilder regions, the more houses are exposed to wildland, and the fire risk grows greater. And when houses and other human-made goods burn, different and potentially more toxic forms of smoke can be produced. 

The Los Angeles County fires in January 2025, which saw large urban regions devastated by flames, were an unfortunate case study for these risks. The Palisades and Eaton fires began on the northern edge of the LA foothills, where dense housing meets more wild, and more fire-prone, terrain. In a retrospective analysis, Underwriters Laboratories’ Fire Safety Research Institute detailed how the urban-wildland makeup of Los Angeles County has not only put more communities physically in fire-prone zones, but also has historically made the geographic region itself more vulnerable to fires. 

As those fires spread into LA’s more urban areas in 2025, the smoke they produced became more dangerous, largely because of what was burning: more than 16,000 buildings, household items, and electric vehicles. The resulting emissions were thus far more complex than typical vegetation-only fires. 

“What’s burning is now very different,” said Jackie Goodrich, an epidemiology professor at the University of Michigan. “So now modern homes have tons of plastic, metals, and all of our electronic appliances, and electric vehicles have these batteries that have a lot of rare metals and other toxic materials we don’t even know about.” 

As a result, these emissions contain higher concentrations of volatile organic compounds (VOCs), metals, and carbon monoxide. PFAS, commonly dubbed “forever chemicals,” are also released through fire extinguishing foam and damaged firefighting gear, which traditionally contains PFAS to protect the skin from fuel that may soak through. These chemicals are associated with adverse health effects, including higher risk of certain cancers and weakening of the immune system. Many of these compounds are dangerous carcinogens. 

These urban fires have a dangerous impact on indoor air quality, too, as chemicals and metals are absorbed into soft surfaces like pillows or textiles. Studies conducted in the aftermath of the LA fires found that post-wildfire VOC levels were elevated inside evacuated homes during the months following the fires. All of this goes to show that Americans can face the health risks of WUI smoke exposure, even when their homes emerge from the blaze relatively undamaged.

These dangers mount over time and across populations

Studies examining hospital admission rates or emergency room visits offer some perspective on the short-term health effects of wildfires. But work by Goodrich and University of Arizona public health professor Jeff Burgess is providing new insight into long-term harm by using a subset of the population repeatedly exposed to and vulnerable to fires: the people who fight them. 

In a study published last year, Goodrich and her fellow researchers examined blood samples from fire responders working in mixed urban and wild areas. They found that exposure to smoke limited the genetic expression of a tumor suppressor known to inhibit gastric cancer cell growth. It also affected regulatory expression similarly associated with tumor proliferation across cancer types, as well as neurodegenerative diseases. 

Burgess has run similar studies across 33 states with 9,000 participating firefighters, allowing the researchers to examine changes in microRNA levels, blood proteins, and DNA methylation (which controls whether genes are on or off). His research on a small cohort of new fire recruits found altered DNA methylation at various sites in the genome, many of which are similarly linked to cancers, neurological disease, and cardiovascular disease. 

It is still unclear whether these biological warning signs lead directly to cancer, Burgess said, largely due to the natural latency period between exposure to toxic substances and actual onset of disease. But as participants age, he expects to see a higher incidence of cancer, especially as exposure to big fires accumulates. 

Firefighters have more prolonged exposure to these toxins than most, of course. But the health effects of wildland-urban fires can extend beyond self-selecting groups, especially as more people move into regions exposed to fire. Residents in the WUI are exposed to the same particulate matter and chemical slurry as firefighters. Goodrich suggests that this could lead to a higher risk of asthma and respiratory problems for children, as well as cardiovascular health incidents in adults.  

Examining longer-term gene expression effects, however, is still more difficult in the general population than it is in the firefighters that her lab studies. While firefighters are often exposed to the same chemicals over and over again, it can be harder to get a clear sense of how toxins affect the average civilian who encounters them more sporadically. 

That said, researchers at UCLA have been keeping a close eye on background toxic chemicals in the aftermath of the LA fires. In a paper published in June, they identified high levels of chromium 6, a carcinogenic metal nanoparticle that can cross cell membranes easily, in wildfire cleanup zones for up to two months following the actual fire. Abnormal concentrations of these heavy metals were also found up to six to nine miles downwind from the zones themselves.

Even following the disaster and immediate recovery periods of urban destruction, the public health dangers can persist: Toxic compounds like VOCs can contaminate waterways, and damaged air filtration systems can make it harder to protect surviving homes against future incidents.

As wildfires become less confined to the chaparral and forests and more likely to rage through suburban streets, we’ll all have to prepare to face the orange haze of fire season. And as we do, we’ll have to confront new dangers that may persist long after the blaze dies down.

A decade ago, insulin became the poster child for America’s out-of-control drug prices. The 2017 death of Alec Smith, who was rationing his insulin before he died, and repeated price hikes for a 100-year-old medication (the patent for which was originally sold for $1 to a university to prevent it from being exploited commercially) sparked widespread outrage that a lifesaving medication could be unaffordable to the people who depend on it to survive.

And then politicians actually acted. Starting with a Colorado law passed in 2019, states began passing laws capping the out-of-pocket costs for many people who take insulin; 27 states (plus Washington, DC) now have such a policy. Then in 2022, Congress included a provision in the Inflation Reduction Act that established a $35 per month cap on insulin prescriptions for people on Medicare. Given the national response — drugmakers also made splashy public announcements about reducing the cash price that uninsured people pay — you would be forgiven if you thought this was the one health care cost crisis that the US had genuinely managed to solve.

But the diabetes community has a dire warning: It’s not over. Millions of people continue to struggle to pay for their insulin and having their long-term health put at risk because of, in the words of one advocate who put it bluntly, pharmaceutical greed.

“There has been so much attention and promise to action around the insulin price crisis. … There has been so much action,” said Shaina Kasper, executive director of T1 International, a global nonprofit that advocates for people with diabetes. “And shockingly, frustratingly, critically, the data from our 2024 survey showed that the rationing rates were worse than ever. Ultimately we’re facing such immense and monstrous corporate greed. … When we put a Band-Aid on one hole, another one’s going to find a way to pop out and keep profits high.”

Fixing the insulin crisis will require a multifaceted approach: drug pricing reform, insurance mandates, and possibly even public manufacturing. Out-of-pocket caps, Kasper said, were always a temporary fix for a very broken system. There is still a lot more work to do.

Why so many Americans still struggle to afford insulin

Both national and local surveys indicate that the policy changes of the past decade have not had the desired effect.

A study published last year from researchers at the Yale Diabetes Center found that people treated there were rationing insulin at the same rate in 2024 as they were in 2017; about one in four people reported some rationing due to the cost of the drug in both years. When you added in the people who rationed because of insurance delays or supply limits, more than one in three people — 38 percent — were still having trouble keeping this lifesaving medication on hand in 2024. A 2024 T1 International survey likewise found that nationwide, 34 percent of the Americans who use insulin reported rationing the medicine. (About 8.4 million people in the US rely on insulin to survive.)

Dr. Kasia Lipska, an endocrinologist and researcher who treats patients at the Yale Diabetes Center and who co-authored that study, was surprised by their findings.

“I was surprised because I’ve been looking at the policy and advocating for policy change; you think things are moving, they should be really improving,” Lipska said. “But if I talked to the nurses and our staff at the Yale Diabetes Center, they told me, ‘Of course they haven’t changed. We’re still hearing these stories.’”

How could this be? The explanation is multifaceted, according to Lipska and Kasper. 

“There’s just still a lot of holes in one who is covered by various protections and then how they’re covered and how they access this,” Lipska said. “It’s not as simple as just showing up at the pharmacy and asking for your insulin, and the sticker price is there, and that’s what you pay. It’s extremely complicated.”

For starters, millions of Americans remain uninsured and have to pay the cash price for drugs. While drugmakers make flashy announcements about helping those people, the process of enrolling for savings cards to get those lower prices can be a nightmare; one congressional investigation found in 2023 that uninsured patients were still paying an average of nearly $100 for insulin despite Eli Lilly’s pledge that its generic product would be available for $25 per vial. Even if you manage to get your discount card, the same investigation found that Lilly introduced several restrictions based on geography and needs, and that the specific insulins that are subject to these voluntary price caps are often out of stock at the pharmacy when people go to fill a prescription (while the more expensive brand name version is consistently available).

And then there are the loopholes in those existing federal and state laws. The federal $35 cap applies only to Medicare; the private insurance that covers half the country is excluded. (There have been bills proposed to extend the cap to private coverage, but they have not gone very far in Congress.) The state laws that do exist typically apply only to small-group and individual plans that are subject to state regulations; larger self-funded plans are exempt from state mandates and currently have no enforced limit on out-of-pocket insulin costs. One national estimate found that around 775,000 people who use insulin and had private insurance were protected in 2025 by the caps in states where they’d become law. But more than 1 million people in those states were not, nor were the 2.1 million commercially insured insulin users in states without a cap.

Even for people who benefit from the mandatory out-of-pocket caps instituted by Medicare and state laws, some of them still struggle to come up with $35 a month, given all of the other price hikes Americans have faced since the pandemic. They may have to navigate a complex process in order to actually receive the promised discount. And while a $35-per-month cap sounds straightforward, in practice, people can still face higher costs. Each individual person requires a unique amount of insulin and, for some of them, they might need two different kinds; the pharmacy may not have the right version and will make substitutions that lead to higher costs. That’s how one of Lipska’s patients ended up paying $140 per month for his insulin — despite being on Medicare.

“These things really add up…and frustrate people,” she said, “because what seems like a great idea is not actually how things work on the ground.”

The consequence is that, despite all the legislative activity and self-congratulations, millions of Americans are still at risk of serious health problems because they can’t get insulin.

The worst-case scenario is what happened to Alec Smith: Somebody is forced to spread their insulin so thin that they put their life is in danger. When diabetics have their blood sugar spike without insulin on hand, they can go into diabetic ketoacidosis, “which literally means your blood is turning into acid,” Kasper said. “I can speak from experience: it feels like you’re dying.”

To recover from an episode, they may have to go to the emergency room and end up taking even more insulin while eating in order to get their body back to equilibrium. But even short of an emergency, Kasper said, people who resort to rationing insulin can experience significant side effects. Prolonged high blood sugar due to rationing could lead to serious vision and nerve problems that were supposed to be a thing of the past once insulin became available.

Those were the scenarios that lawmakers wanted to prevent as they tried to make insulin more affordable. But they remain a very real threat for too many people.

The big idea that could make insulin truly affordable

If there’s good news to be found, it’s that the advocacy community is not giving up. They are sounding the alarm about the ongoing affordability crisis and urging Congress to act. But they do worry that the issue has become less urgent: The truly comprehensive mandate for insulin out-of-pocket caps, which is typically introduced every Congress, was delayed this time. “This year, neither bill was introduced for over a year, and it was very concerning,” Kasper said.

But they are also placing bets on something much more profound than a price cap: the government itself procuring or even producing insulin and making it available to people at the lowest possible cost. 

“This idea that medicines should be for people and not for profit I feel like is really catching,” Kasper said. 

Some states are taking baby steps in that direction: Oklahoma passed a bill this year that would offer government funding for private companies that pledge to produce insulin and sell it at a low price. 

Others are going bigger. As I reported in 2023, California has launched a program that is eventually intended to lead to government-owned facilities producing insulin to be sold on the cheap, though it will take years until publicly owned production begins. The New York state Senate approved a similar plan this year, although funding for it didn’t make it into the state’s budget. Kasper said that she is optimistic the project will make it into next year’s spending plan, and says a lot of work is currently being done to ensure it happens.

In the future, public manufacturing could also help to address the supply problems that continue to pop up. There are only three insulin manufacturers in the US right now. As those for-profit pharmaceutical companies place more emphasis on GLP-1 production — which often takes place in the same facilities as insulin production — nonprofit initiatives could fill in the gaps.

“In this time of tariffs even, with these concerns around shortages and rising prices and the corporations having this monopoly and price gouging ordinary Americans for decades now, as we’ve seen on insulin, let’s just make it ourselves,” Kasper said.

This is a long-term vision; if you need help right now, T1 International has resources to help people get health insurance, access discount programs, and even find emergency insulin. But a more affordable future for insulin will only be possible if lawmakers feel compelled to act. Public outrage created one round of reform, but the risk of political complacency is real. So if you care about this issue and want to get involved, T1 International also has a tool kit for people who want to advocate for policy changes, including around public pharma.

“The general communication that we’ve been hearing is that the insulin price crisis is over,” Kasper said. “Everyone should have access to a $35 copay for insurance. As the data shows, as we’ve been talking about, that is just not true.”

On stage at Davos in the Swiss Alps earlier this year, Bill Gates, before an audience of the global do-gooding elite, announced a $50 million partnership between his foundation and an unlikely new ally, OpenAI, aimed at improving healthcare in Rwanda.

Just a month earlier, the Gates Foundation had released a harrowing report about widespread global health cuts and collapsing foreign aid infrastructure, documenting a rise in child deaths for the first time this century. But at Davos, even as the US hemorrhaged funding for vaccines, maternal healthcare, and HIV treatment, the Microsoft co-founder struck an optimistic tone. 

“Using innovation, using AI,” Gates told Reuters, “I think we can get back on track.”

As it turns out, the partnership was just an opening salvo for what’s become a wholesale embrace of AI by the world’s largest global health philanthropy. A $200 million partnership with Anthropic came just a few months later. And then, on Tuesday, the Gates Foundation announced a plan to dole out a jaw-dropping $1 billion over the next two years for scaling up AI interventions across healthcare, education, and agriculture around the world. 

The sense that AI will soon change everything, and mostly for the worse, has perhaps never felt so pressing and alarming as it does right now. But this hefty new commitment is premised on the idea that AI could eventually make our lives much better too. In a country like America, AI requires massive investments and buildout — in the grid, in power, in technology, in water. In many parts of Africa, already infrastructure-poor, the foundation is effectively betting that AI can compensate for some of the infrastructure that isn’t in place or that has been lost — and offer a new layer that can help in education, in delivering healthcare, and more. 

The Gates Foundation’s new commitments include projects to improve how farmers analyze their crops, how doctors diagnose patients, and how students learn. Some have already proven to be quite effective, according to the foundation, with one tool improving the accuracy of medical diagnoses by 16 percent across several Kenyan clinics. “In poorer countries with enormous health worker shortages and lack of health systems infrastructure,” Gates wrote on his blog earlier this year, “AI can be a game-changer in expanding access to quality care.” 

Last year’s foreign aid cuts were unfathomably destructive for some of the world’s poorest countries, shuttering thousands of clinics and perhaps hundreds of thousands of classrooms in places where critical workers and supplies were already stretched thin. No, AI cannot deliver a baby, administer a vaccine, or manage a classroom — not yet, at least — but it can, the Gates Foundation hopes, help ease the burden and augment the quality of care for nurses and teachers now tasked with serving far more people than any one person should. 

“This is the most transformative technology of our lifetime,” Mark Suzman, CEO of the Gates Foundation, told me, and while there are “very real risks and challenges” surrounding AI, it also presents genuine opportunities to tangibly improve many people’s lives.  

It is a tantalizing premise: We can’t afford to build clinics, hire teachers, or lay new power lines, but perhaps AI could create the digital infrastructure needed to help billions of people do more with what they have — or rather, with what’s left. The question is, can the right layer of innovation help bolster a buckling system, even as the physical and logistical infrastructure surrounding it crumbles?

Is AI really what global health needs right now? 

Most Americans have yet to see AI improve their lives in meaningful ways, much less those living in poverty or in countries where only a sliver of the population has ever used ChatGPT. 

But those numbers in the developing world are slowly changing, a shift enabled in part by other global health funders convinced that as foreign aid dries up, AI could soon help the world do more with less. The Trump administration itself is on board with this thinking, so long as it benefits American tech companies. Last year, the State Department announced a $150 million partnership with the drone company Zipline to transport medical supplies in several countries.

To Zipline’s credit, an NPR reporter in Rwanda last month found that the company’s drones were already saving lives in places with poor road infrastructure, where driving to the nearest hospital can take hours on winding hills, but where drones can deliver crucial blood transfusions within minutes. 

And yet, for Rwandans to benefit fully from these high-tech deliveries, they need staffed clinics to visit. As a result of foreign aid cuts, some of those literal landing spots are now on the verge of closing in some of the nation’s most vulnerable rural corridors. “Without the underlying infrastructure, like roads, energy and power and unless there is accessibility, rural and otherwise,” Enoh Ebong, president of the global development department at the Center for Strategic and International Studies, told NPR, “then all of these solutions will stop short.”

But just as medical delivery drones still need a clinic to fly to, most of these interventions require some layer of physical infrastructure — roads, schools, power, and quite obviously, broadband  — to function. Satellite imagery shows that some rural communities in sub-Saharan Africa quite literally went dark in the aftermath of USAID cuts. It will be much harder for their kids to prompt an AI math tutor, or for a local farmer to download a weather app. 

“We’re seeing this very much as a both/and,” Suzman told me, calling more traditional funding for education and healthcare “the bedrock for long-term economic growth,” which AI is meant to supplement, not replace. But, in practice, foreign aid cuts have left serious cracks across much of that bedrock, which could make it harder for state-of-the-art solutions to function as intended.  

It is obviously not incumbent on the Gates Foundation to pay for all of this alone – nor would it even be feasible for them to do so. And for the record, plenty of the foundation’s other grant programs are not AI-related at all. But this tension does speak to a broader question that may be felt most acutely in a context like global health, but ultimately one that touches us all: Do we spend our scarce resources on the digital infrastructure of the future at the peril of our needs right now? Could you justify buying the new $1,999 folding iPhone if you can barely afford to buy groceries? 

The answer is not actually always an easy one. It is not for us to say, for example, that just because a community lacks reliable running water, its people should be excluded from the benefits (and encumbrances) of the smartphone, especially if that smartphone can connect them to health advice they could never access otherwise, or guidance that could help them survive a drought. 

In some parts of the world, digital forms of banking arrived long before local brick-and-mortar branches did, instantaneously connecting countless people to a cheap and secure way to save and send their cash to family and friends in need. It is certainly possible that AI, or at least the kind of applications the Gates Foundation funds, could one day have a similarly transformative effect on how people access personalized levels of care, education, and other services in places without the resources to do so otherwise. 

That is the hope, but it is also hard right now to believe uncritically in a technology that, as Gates himself blogged just last month, “will either be the greatest equalizer ever invented, or the worst source of injustice,” ushering in “one of the most turbulent times in human history.” 

In an interview with the New York Times soon after, he seemed convinced that AI will likely do more harm than good. “I don’t like bringing bad news to people, and I don’t like saying that innovation may be a net negative,” he said. “But that’s where we are.”

Now he wants billions of people around the world to use it? Yes, Suzman said, because if not, then inevitably the best parts of AI — the potential for exponentially better cancer treatments, for example — will go only “to those who can pay for it,” while the worst parts of it will fall, as they so often do, on those who benefit the least. “These decisions are being made now,” he said, “and the decisions being made now will then probably shape the following two decades.” Here’s hoping they’re good ones.

Russ Kremer is a longtime hog farmer in the Missouri Ozarks, where his 2,000 pigs have plenty of space to roam on his 150 acres. He doesn’t feed them antibiotics, and you won’t find a single animal in a cage. Kremer is decidedly anti-industrial hog farming.

Whenever he sends his pigs to slaughter, like every hog farmer in the US, he’s legally required to give over a small share of his sales — 35 cents for every $100 — to the National Pork Board.

If you’re not a hog farmer, you might not have heard of the National Pork Board. But you’ve probably seen its ads. Its job is to promote pork to consumers, and it’s the group behind the once ubiquitous slogan “Pork. The Other White Meat.”

The idea behind the National Pork Board — financed with mandatory contributions from Kremer and virtually every other American hog farmer — is that all pork producers should benefit from this kind of prominent marketing to buoy their product. So a dollar or so from each pig should be worth it. 

The group’s funds, by law, are limited to advertising and research. They specifically can’t be used for political lobbying to influence legislation. There’s a good reason for that: While boosting pork consumption should help any pig farmer, when it comes to laws and policies, some benefit certain types of producers over others, such as more industrial producers. And because virtually all farmers have to pay into the fund, it seems only fair to keep it policy-neutral. 

It’s essentially a tax, one that consumers indirectly pay each time they buy any kind of pork, too. “I’m not opposed to paying a tax if the tax does us some good,” Kremer told me. But Kremer and many of his fellow anti-industrial hog farmers believe it is not doing good. That’s because the National Pork Board has moved millions of their dollars to the largest industrial pork lobby in America. 

It’s called the National Pork Producers Council, and over the last 70 years, it has emerged as the loudest advocate for factory-farm style hog production. 

Since 1999, NPPC has spent nearly $45 million on federal lobbying on a variety of issues — including many of the kinds of policies that more humane and sustainable hog farmers like Kremer tend to benefit from, like antibiotic restrictions, pollution regulations, and protections for independent farmers who sometimes get screwed over by big meatpackers. In recent years, the group has also thrown millions of dollars into lobbying for the very unpopular practice of keeping pregnant pigs in tiny crates — a method that big, industrial operations are much more likely to use than smaller farms. 

Kremer, for his part, is the former president of the Missouri Farmers Union — the state chapter of the National Farmers Union, which is a small but mighty counterweight to the Big Ag lobby groups like NPPC.

The two organizations — which are legally required to operate as separate — have a very close relationship that has allowed the National Pork Producers Council to capture tens of millions of dollars from the Pork Board over the past two decades. According to a new, exclusive analysis of public financial transactions gathered by the Accountability Board — a nonprofit that advocates for higher-welfare animal farming — the National Pork Board has paid the National Pork Producers Council $66 million with its farmer contributions since 2004. Of the $66 million, nearly half of these financial transactions have not been previously reported in the news media. 

Critics say the financial transactions between the two organizations have effectively created something of a reverse Robin Hood effect in the pork business, in which an industrial farming lobby group has taken millions of dollars from smaller farmers only to use it against them and their typically more responsible ways of raising animals. 

Or, as Kremer calls it, a “kick in the groin.”

And it amounts to a meaningful chunk of the pork lobby’s overall budget: According to Vox’s review of the financial documents, some 18.5 percent of NPPC’s revenue has come from farmer checkoff dollars since the early 2000s.

The money stems from two sources: highly profitable trademark deals and a sizable real estate arrangement. Over the past 22 years, the pork promotion board has paid a remarkable $59.5 million to own and license a trademark package and another $6.5 million in rent to its landlord, the National Pork Producers Council. Although one of these cash transfers has been the subject of a lawsuit — and the organizations’ intertwined relationship has been repeatedly criticized by opponents of industrial agriculture, lawmakers, federal agencies, and farmers forced to pay the money — the groups’ close relationship has persisted.

The National Pork Producers Council didn’t respond to several detailed questions about the relationship and financial arrangements over email; in a statement, a spokesperson said that the deals between the organizations had been approved by the USDA and a legal challenge to one of the deals had been dismissed in court.

The National Pork Board also didn’t respond to an interview request for this story, or to detailed questions over email. And the US Department of Agriculture, which oversees the National Pork Board and has approved these deals, declined an interview request for this story, and did not respond to detailed questions over email.

The long saga of redirected pork-industry dollars shows how the interests of industrialized farming can find ways to overwhelm the interests and values of smaller-scale producers — and operate with relatively little government scrutiny. It also raises meaningful questions about whether the USDA is protecting the interests of American food consumers and farmers across the country, or just guarding the specific agenda of the largest players in the ag industry.

How Big Pork set up its federal piggy bank

The idea of a marketing fund that farmers pay into wasn’t new in 1985, when Congress created the National Pork Board. The egg industry had one, which had made the famous “Incredible Edible Egg” slogan, while a state-level dairy program later created the “Got Milk?” slogan.

They’re called “checkoff” programs, and with those funds, there were fears from the start that the pot of money that every farmer was required to pay into might be used improperly: “We should protect against making these producers de facto members of any association that they may not wish to be involved with,” Sen. Chuck Grassley (R-IA) warned at the time.

Grassley’s concern was prescient. The National Pork Producers Council had its own voluntary checkoff program, which it set up in the 1960s and aimed to raise a modest $40,000 in its first year. It then successfully lobbied to create a mandatory checkoff program in 1985, and even drafted the regulations for it — which became the National Pork Board, the fund that farmers have to pay into. Turning it from voluntary to mandatory brought in way more money — from $40,000 in 1966 to an estimated $25 million in 1987.

And even though this new pork promotion entity was supposed to be independent, the NPPC essentially ran it. The National Pork Board had eight program areas and $500 million from farmer checkoff funds to use over its first 15 years — but only two employees. So it contracted the NPPC to execute on those programs, along with handling its accounting and operations. The two groups even shared office space in Iowa for their respective headquarters. 

They were, in effect, separate groups in name only.

“It’s very difficult to tell where NPPC ends and the Pork Board begins,” Matt Penzer, chief legal officer of the Accountability Board, who analyzed the pork groups’ financial records, said about the early years of the pork checkoff program. Which was a problem, because farmer checkoff dollars weren’t supposed to be used for political lobbying — yet here was a lobbying group making money by being the Pork Board’s primary contractor.

In the late 1990s, the arrangement drew sharp scrutiny from the Clinton administration’s USDA inspector general — an internal government watchdog — which wrote in a report that the groups “should maintain an arms-length business relationship.” 

And by 2000, hog farmers voted to end the National Pork Board altogether because, according to an organizer at the time, it had “been used to promote the interests of factory farms and corporate meatpackers and hasn’t helped independent producers increase their bottom line.” (According to reporting by the Associated Press, the NPPC had paid a PR firm $48,000 in checkoff dollars in the late 1990s to “monitor” the activities of sustainable agriculture groups that had criticized it.)

The farmers won the vote, but their celebration didn’t last long. The National Pork Producers Council sued the USDA over a procedural technicality, eventually settled the lawsuit, and the Pork Board survived. The settlement, reached in 2001, preserved the farmer checkoff fund but ordered NPPC to, basically, stop running it. It also required that any deals between the two groups be conducted at “fair market value.” 

It seemed that the flow of money from the farmer fund to the pro-industrial National Pork Producers Council might grind to a halt, but instead it just took new forms. Internal emails, obtained by Penzer through separate litigation, reveal how.

The $59.5 million question

After the USDA told the two groups they needed to cut more of their day-to-day ties, they got creative and began moving money through big, expensive trademark deals and a lucrative real estate arrangement.

In 2003, the CEO of the National Pork Board had said in an email that the National Pork Producers Council needed an extra $881,000 per year. The next year, the National Pork Board began paying it more than $800,000 per year to license the “Pork. The Other White Meat” slogan for its advertising (it had previously been licensed for $1 per year). 

Then in 2006, with farmer checkoff dollars, the National Pork Board outright bought the “Pork. The Other White Meat” trademark from the National Pork Producers Council in a $60 million deal, to be paid out at $3 million annually in farmer checkoff funds for 20 years. This $3 million made up around 20 to 25 percent of the NPPC’s annual revenue at the time. 

The deal was questionable on multiple fronts. For one, the council — the lobbying group — should never have owned the trademark in the first place. By law, it was the federal government’s. Second, according to Parke Wilde, a nutrition and food policy professor at Tufts University and former USDA agricultural economist, the value of the slogan had been built with advertising funded by farmer checkoff dollars, so “they’re double paying and they’re not protecting the interests of the farmers who paid in.”

A National Pork Producers Council spokesperson defended the sale, stating it was “fully vetted and approved by USDA.” (The USDA did not respond to Vox’s questions for this story.)

Finally, when the National Pork Board stopped using the slogan in 2011, it continued to pay the annual $3 million to the Pork Producers Council, even though it could have ended the contract with a year’s notice. 

In 2018, a judge ordered an end to the payments, calling them “arbitrary and capricious.” (Penzer worked on the lawsuit against the USDA while working at Humane World for Animals, where I have also worked, but I was not involved with the effort.) A year later, the National Pork Board paid the council $3 million for the termination of the $60 million deal, which hasn’t been reported elsewhere.

But here’s where things get even more unusual. After the annual payments stopped — some 12 years and $36 million into the 20-year, $60 million deal — ownership of the “Pork. The Other White Meat” trademark package, which also included a simple “Pork” logo (that had more value at the time), reverted fully back to the National Pork Producers Council. The group then sold it all back to the National Pork Board in 2020, with the NPPC this time making $17.2 million in additional checkoff dollars from the transaction. 

Penzer said the deal “couldn’t pass a basic intellectual property course.” This deal, surfaced by Penzer after he submitted a public records request and a subsequent lawsuit against the USDA, has not previously been reported.

If, by this point, you’re lost in the minutiae of dealmaking, I don’t blame you. The long and short of it is that, despite the legal requirement that farmers’ checkoff dollars can’t be used for lobbying, the NPPC lobbying group has received over $59 million of checkoff dollars for repeated deals involving the same trademark package. 

Wilde said that many of the guardrails designed to protect the integrity of the checkoff program are simply not being followed. “And that leaves us with little assurance that the programs serve either the farmers’ interests or the public interest,” he told me.

“The money for advertising is just being used as a cover to transfer wealth to the lobbying entity,” David Muraskin, who’s long tracked checkoff programs and sued the USDA over Montana’s beef checkoff program, told Vox. Muraskin is an agricultural law professor at George Washington University Law School and a lawyer at FarmSTAND, a nonprofit that advocates against industrial agriculture. 

The National Pork Board maintains that it represents all hog farmers. But both the National Pork Board and the National Pork Producers Council work to protect and expand a hyper-industrial vision of American hog farming. The board and staff of both groups, for example, are largely composed of leaders and executives from industrial pig farms, companies, and trade groups. There is also something of a revolving door between the two groups. NPPC’s current CEO, for instance, is a former Pork Board executive, while a past NPPC president held a leadership role at the National Pork Board.

The National Pork Board’s lobbying landlord

The two groups didn’t limit themselves to tossing the “Pork. The Other White Meat” trademark back and forth to each other. They have also maintained a long-term real estate arrangement, the details of which have also not been previously reported. 

Remember that Iowa office they shared? The National Pork Producers Council, the lobbying group, owns it. The property was valued at $2.9 million in 2007 and the Pork Board agreed to a 30-year rental lease, for which it’s now likely to pay more than $13 million (with farmer checkoff funds) by the lease’s end. The NPPC has increased the rent several times. Most of those hikes were modest — though in 2022, it raised the rent by 74 percent, the same year it sharply increased spending and was engaged in two lawsuits to dismantle state animal welfare laws.

Over the course of its lease, the National Pork Board had also spent $6.58 million to improve the NPPC’s building, a detail also not previously covered by the news media.

To understand whether this real estate arrangement is unusual or not, I reached out to nearly 20 real estate brokers, appraisers, and experts, including many in Iowa. No one in Iowa agreed to speak with me at all, let alone comment on the record. One expert told me that, on its face, the lease deal itself didn’t raise any major flags. “It is possible that the initial lease rent was set at a low rate, with a large future increase, which would create a ‘fair market value,’” said Brent Ambrose, a real estate professor at Penn State. “It may be a terrible deal, but…it is possible that the terms reflect current market conditions.”

The National Pork Board didn’t respond to detailed questions about its lease.

“The office rent agreement between NPB and NPPC is reviewed and adjusted on a periodic schedule and is also approved by USDA, along with all other checkoff expenditures and contracts,” a National Pork Producers Council spokesperson told Vox over email. 

In the 2001 settlement in which the two groups agreed to operate independently, a provision specifically allowed the lease to continue.

All of this money ends up going into the budget of the NPPC. And although it’s unknown exactly which dollar goes where, the proceedings of a lawsuit several years ago appeared to confirm exactly what small farmers are worried about: that there’s no clear line preventing their contributions from going to lobbying efforts.

In a 2018 opinion in the Humane World for Animals lawsuit against the USDA for wrongly approving the 2006 trademark deal, a district court judge said that “at least some portion of the money that the Board pays NPPC… ultimately goes to influencing legislation.” But just because money from the trademark deal wound up being used to influence legislation, the judge said, doesn’t mean the deal was made for that purpose. And so, according to the judge, the groups hadn’t technically violated the law.

But Muraskin argues these deals have all added up to a convenient facade to fund a pro-industrial farming lobby group with required dollars from every pig farmer. 

“It seems like they’re paying for a logo that has limited value, if [any] at all, and an office space that they’re paying well in excess of what they should be,” to move money from the National Pork Board to NPPC, which in his view, “is plainly against the statute.”

It’s not a good look for a group that represents Big Pork to be perceived as taking money from small and mid-sized farmers and using it to lobby against those farmers’ interests, and it’s been a source of controversy for decades. So how and why have they managed to continue this arrangement? 

They’re “exploiting a loophole” that the USDA has failed to address, Muraskin said. “I think the entity to blame there is USDA.”

Since 2017, Sens. Mike Lee (R-UT) and Cory Booker (D-NJ) have introduced legislation to reform the checkoff programs by prohibiting them from entering into new contracts with lobbying groups (like the NPPC), among other changes. If it were to pass, the two groups would not be able to, say, engage in a new trademark deal or renew the rental lease when it expires. 

“America’s farmers are being ripped off by federal checkoff programs that take farmers’ money and play favorites with who they serve,” said Lee in a press release last year. The bill lost a floor vote during 2018 Farm Bill negotiations; it’s been reintroduced several times since but hasn’t been taken up for a vote.

The pork lobby is using farmers’ money to try to keep pregnant pigs in tiny cages

If you want a clear idea of why Kremer and other producers are upset about helping subsidize the NPPC, look no further than the biggest, most expensive battle the lobby is currently waging: A fight centered around the publicly unpopular practice of keeping pregnant sows confined to tiny crates for nearly their entire lives. 

Called “gestation crates,” which are so small the pigs can’t even turn around, these enclosures have been widely condemned by animal welfare groups and veterinarians as inhumane, and voters tend to agree. California and Massachusetts have banned — via ballot measures — any pork sold in their states coming from farms that use these crates. (Disclosure: I worked on the Massachusetts initiative.) 

But many industrial-style pork producers are heavily invested in continuing to use the crates because it’s how they’ve bred pigs for decades, and there’s a large upfront cost to switching to a crate-free system. So the National Pork Producers Council has sued both states to overturn the anti-crate laws. One case even went to the US Supreme Court — an extremely costly endeavor — where the industry group lost.

The pork producers group has also intensively lobbied for legislation called the Save Our Bacon Act, which would overturn the state laws. This spring, the act was included in the House’s version of the Farm Bill, the legislative package that covers much of US agricultural policy. But the chance of the act making it into the Senate’s Farm Bill, and thus the finalized bill, appear slim. Senate negotiations are expected to resume this month though, so the pricey fight isn’t over yet for the NPPC. 

Smithfield Foods, the largest US pork producer — which has two seats on the National Pork Producers Council board — has supported this sort of legislation. 

Gestation crate bans help more welfare-minded farmers like Kremer compete against big industrial producers. Crate-free producers have been able to continue to sell their pork into California and Massachusetts, while farms that did use the crates had to spend money to retrofit their barns or lose out on participating in those markets. Some big producers have been going in that direction, too: One of the nation’s largest pork companies, Clemens Foods, strongly opposes the Save Our Bacon Act because the company has already moved away from gestation crates.

Talking to Kremer and other pork producers who long ago abandoned keeping pigs in small cages, I’ve gotten the sense that these dollars moving from their hog sales to the sorts of lobbying efforts behind the Save Our Bacon Act and other pro-industrial policies mean more to them than the actual monetary amount. “They’re going after producers like myself,” Kremer told me of the fight over gestation crates. “And so yes, I feel more betrayed by them than ever.”

Without reforms within USDA or forced by Congress, it’s hard to see a way out for farmers like Kremer who have no option but to continue to give up a small share of their profits to organizations that sometimes actively fight against their interests. 

But that goes for consumers, too: Each piece of bacon, rib, or pork chop purchased indirectly funds an advertising pot encouraging people to buy more pork. 

And as the latest findings on the pork checkoff program reveal, some funds also go into fighting to uphold farming approaches that put profits over animal welfare and continue practices most Americans oppose, and that many have already voted to abolish.