Mike Huckabee, the US ambassador to Israel, is a Christian Zionist who believes that Israel is biblically entitled to all of the Holy Land. He’s pretty much the last person you’d expect to condemn Israeli conduct in the West Bank, where settlers have spent decades using a combination of construction, coercion, and outright violence to push Palestinians off their own land.

Yet earlier this month, Huckabee went out of his way to denounce the behavior of some settlers — describing them as “band of terrorists” who had committed “horrible activities of criminal nature.”

Huckabee’s surprising outrage stems, in part, from their recent choice of victims. Last month, settler extremists besieged three Palestinian homes in the village of Qusra, including one belonging to American citizen Lou Ridi. About two weeks later, masked settlers beat up a NBC News crew while they attempted to interview Aida Ahmed Abdullah, a Palestinian who had herself had been forced from her home by settler aggression.

But Huckabee’s outrage reflects something deeper. Settler terrorism, once relatively uncommon, has exploded in severity in recent years — with wink-nudge support from Prime Minister Benjamin Netanyahu’s government.

The violence is so egregious, and so indefensible, that retired Israeli generals have compared the settlers to Nazis and demanded action to stop them. In mid-September, the INSS — Israel’s top national security think tank — issued a strategic alert warning that “Jewish terrorism” had become a national crisis and even an existential threat to Israel’s future.

“As history teaches us, democracies that fail to restrain radical forces within them do not survive,” the alert argues.

In Washington, settler terrorism against Palestinians has flipped the Israel debate on its head. Congressional Democrats, who have long been divided over the Gaza war, have come together to support legislation that would impose sanctions on Israeli politicians and corporations implicated in the violence. The Trump administration, the most pro-settlement White House in American history, has very conspicuously stood aside as Canada and European nations implemented sanctions of their own.

For now, the settlers are mostly getting away with it — because the government wants them to.

For now, the settlers are mostly getting away with it — because the government wants them to. While basically all Israeli governments have allowed settlements to grow, the current Netanyahu government includes coalition partners unusually aligned with their most radical goals: the ethnic cleansing of the West Bank. So long as they see settler terrorism as a useful tactic toward that end, and have the ability to stymie preventive measures and block accountability, the attacks will continue.

But if Netanyahu loses Israel’s election in October, and Democrats retake the White House in 2028, things might change dramatically. The political stars could align for a serious effort to change what Israel is doing in the West Bank — not just attempting to merely slow settler violence, but also challenge the broader apparatus of occupation that makes it possible.

In “conversations that I’ve had with congressional Democrats and their staff, this [settler violence] is the No. 1 issue that comes up, the thing they’re angriest about,” said Michael Koplow, the chief policy officer at the center-left Israel Policy Forum. “If you have a Democrat in the White House, this is something the Israelis are going to have to deal with — whether they want to or not.”

The rise of settler terrorism

Under international law, Israeli settlement in the West Bank is illegal: Countries are not permitted to move their own civilians into territory they occupied after a war. However, under successive Israeli governments — including the more peace-minded ones — the settlements have continued to grow. Many of those closest to the border function as suburbs of major Israeli cities; some further east, like Ariel, look like small cities in their own right. During the era when a negotiated solution looked possible in the near term, their growth was often seen as part of a bid to dictate the eventual borders of a Palestinian state — or blow up negotiations entirely — with “facts on the ground” that would be hard to undo.

While individual settlers live there for all sorts of reasons — for many, the housing costs are cheaper — the political movement overall exists to seize land from Palestinians and slam the door on the possibility of a two-state solution to the conflict. 

On a macro level, the physical placement of the settlements cut Palestinian communities off from each other, making it hard — basically impossible — to construct a contiguous Palestinian state so long as they remain standing. On a micro level, settlements are often placed in ways designed to push Palestinians off their land — by, for example, putting Palestinian-owned land into no-go zones enforced by the Israeli military. And politically, the population growth in settlements creates a powerful constituency in Israeli politics whose entire way of life depends on preventing a peace agreement that would require settlement evacuation.

Settler violence is the literal bleeding edge of this overall strategy. Violent settlers live in ramshackle communities, tiny villages on hilltops or herding outposts encroaching on Palestinian farmland, that are often illegal even under domestic Israeli law. The people living there are the hardest of the hardcore settlers: fanatically devoted to the idea that the land is theirs by divine right, and that they have every right to use force to push their Palestinians neighbors out.

Their tactics include everything from killing Palestinian livestock to cutting off their water supply to burning down their homes to outright beating and killing them. The violence is autonomous, in that individual settlers decide on what to do, but enabled by the overall strategic plan of the settlement movement.

“There’s no hierarchy deciding that this [specific] house will be attacked. The decision is that this area is an area of all our interest, so we need to subsidize herding farms there. And those bring violence, which lead to displacement” of the local Palestinians, said Yehuda Shaul, co-director of the Israeli think tank Ofek and a leading observer of the settlement movement.

Settler terrorism is not new, but it used to be comparatively rare. In 2012, Natan Sachs — a leading expert on Israeli politics at the Middle East Institute think tank — wrote an essay warning that the growth of the settlements, and the radicalization of some settlers, were creating a dangerous new violent movement of settlers.  

“Back then, it was a fringe thing among settlers,” Sachs tells me. “It has become much more mainstream.”

Israel’s current government, which took power in late 2022 and is by far the most radical in Israeli history, bears enormous responsibility.

“This particular government is enabling settler violence beyond anything we’ve ever seen,” said Yousef Munayyer, the director of the Israel/Palestine program at the Arab Center think tank in DC.

Minister of Finance Bezalel Smotrich, a settler living in a reportedly illegal home and a longtime advocate of ethnically cleansing West Bank Palestinians, is currently in charge of civilian administration in the West Bank. In effect, this allows him to use state resources to orchestrate a historic expansion of settlements across the West Bank — including the illegal outposts that many violent settlers call home. 

“This is his life’s work,” said Mairav Zonszein, a senior analyst on Israel-Palestine at the International Crisis Group. “He’s completely dedicated to this and he knows exactly what he’s doing.”

Minister of National Security Itamar Ben Gvir, also a settler, is if anything more extreme: For years, he hung a portrait of Baruch Goldstein, a terrorist who massacred 29 Palestinians at a holy site in Hebron, in his living room. Ben Gvir has, among other things, instructed the police forces under his authority not to arrest violent settlers and given thousands of weapons to settlers themselves.

In theory, the Israeli military and intelligence establishment should be a check on the extremists. Settler violence is not only illegal, but also a national security threat. Settler violence prompts Palestinian retaliation and, at times, even targets Israeli soldiers and police themselves. It can lead to international incidents, like those seen recently, that undermine Israel’s support with key allies abroad. The Israeli military is the ultimate authority in the West Bank; it could act on these concerns if it so chose.

In practice, however, they’re of little help. Israeli government data shows that, between 2005 and 2025, 94 percent of all investigations into settler violence fail to yield an indictment. The military will facilitate illegal settlements’ connection to the electrical grid. And its ranks are increasingly made up of “national religious” Jewish Israelis, a demographic that’s theologically on board with the settlement enterprise, versus more secular Israelis who primarily see the conflict through a security lens.

And after October 7, the Army dealt with a manpower crisis by significantly increasing the number of “regional defense units” — essentially bands of armed settlers that can be tasked with local security in the West Bank in lieu of regular soldiers. It emboldens violence in exactly the way you’d think.

So while the recent spike in settler terrorism can fairly be blamed on the Netanyahu government, the phenomenon itself is an outgrowth of the structural settlement growth Israel has condoned or actively pursued for decades.

“It’s all one set of policies,” said Ilan Goldenberg, senior vice president and chief policy officer at J Street, an American lobby that favors a two-state solution to the conflict.

How the violence could lead to a deeper break between America and Israel

Other than Israel’s government itself, the most important player in all this is the American government. As Israel’s chief diplomatic ally and military supplier, it has immense leverage that could be used to affect the West Bank (or anywhere else). Thus, changing American politics on Israel could quite directly produce a transformation on the ground.

Since October 7, Gaza has dominated American discourse over Israel — and it is arguably the most divisive issue in both the Democratic and Republican parties. Many Democrats (and a majority of rank-and-file voters) call Israel’s actions in Gaza genocide, a label others in the party strongly reject. While the Trump administration and most elected Republicans have stood behind Netanyahu, a faction — including Vice President JD Vance, Tucker Carlson, and a significant chunk of younger GOP voters — have grown increasingly critical of American military support for Israel’s actions.

But settler violence, specifically, might as well be another political universe. 

On the Democratic side, there is basically unanimous condemnation of what’s going on in the West Bank. Even Democratic Majority for Israel (DMFI), a leading pro-Israel advocacy group, believes that Israel is erring here.

“DMFI unequivocally condemns attacks by violent Israeli settlers against Palestinians in the West Bank. Israel’s government must move beyond just words and take definitive action to protect civilians, and ensure that those responsible are held accountable,” Brian Romick, DMFI’s president, told me.

Last year, US Rep. Jerry Nadler (D-NY) — an influential progressive pro-Israel voice in Congress, where he’s long represented some of the nation’s largest Jewish communities — co-authored the West Bank Violence Protection Act, legislation that would sanction violent settlers and their enablers. The law would effectively codify an executive order issued by President Joe Biden in 2024, but scrapped by President Donald Trump upon taking office. 

The key question going forward is what this political dynamic means for policy.

More than 170 House Democrats and 45 senators have cosponsored it, the vast majority of Democrats in both chambers. Goldenberg, whose J Street outfit has been a leading voice supporting the law, says rallying support for it has been easy.

By contrast, no Republicans have cosponsored the bill. When you combine that with Trump reversing the Biden order, and his broader enabling of settlement expansion, you might think that the administration would be willing to take Israel’s side in the argument over settler violence.

Yet that’s not been the case — and it’s not just Huckabee freelancing. Earlier this month, when Canada, the UK, and France imposed significant sanctions targeting settlements, Secretary of State Marco Rubio pointedly refused to condemn these allied policies, saying that neither he nor Trump had any comment on their decisions.

“Obviously, we’re not going to do what the UK did. [But] we share the goal of stability: we don’t to see an uptick in violence or conflict or tensions in the West Bank,” he told reporters on September 8.

Settler terrorism, then, has a remarkable effect on both parties: Democrats in Congress go from fractious on Israel to united, and the Trump administration goes from Israel’s chief defender to a tacit enabler of allied pressure campaigns against it. Why?

I put this question to all the experts I spoke with, and everyone offered a basically similar explanation: that settler violence is morally and politically straightforward. Even the most hardline pro-Israel advocate, ones who rationalize mass civilian killing in Gaza as necessary to destroy Hamas and restore Israel’s security, blanch at videos of armed settlers beating up on defenseless Palestinians, which cannot be justified on the same grounds. Virtually nobody in American politics wants to be in a position of having to defend this kind of thing, and many of the most influential pro-Israel voices on the American side do not share the settlers’ extremist ideology.

“There aren’t two sides…it’s just one side terrorizing the other,” Israel Policy Forum’s Koplow said. “There are literally WhatsApp groups and Signal groups run by the Israelis perpetrating the violence where they themselves boast about it.”

On the White House side, there are also Trump priorities that the violence complicates. In his comments about the allied sanctions, Rubio said instability in the West Bank “has implications as well on our ability to make progress on Gaza, on the 20-point plan, and the Board of Peace that we’re very committed to.” However serious you think these initiatives are — there are very good reasons for skepticism — the White House seems to at least be publicly concerned about violence derailing it.

The key question going forward is what this political dynamic means for policy. While the Trump administration may not be willing to go out of their way to defend settler violence, they’re not exactly going out of their way to try and shut it down either. Huckabee’s comments about “terrorists” are symbolically significant, but the reversal of the Biden executive order speaks about the limits of this stance for actual policy. 

Democrats, by contrast, are clearly animated by the issue and willing to act on it. The question is what exactly those actions entail — especially if they retake Congress in 2026 and the White House in 2028.

Here, there’s real disagreement between the experts. 

Skeptics suggest that there may be less substance here than it appears. Targeted sanctions against some violent settlers might matter on the margins, but unless they go after the settlement enterprise and US-Israel relationship more broadly they’re leaving the root cause of the problem intact. In the worst case, a focus on settler violence specifically might even be counterproductive — functioning as a kind of pressure release valve that allows Democrats to satiate their increasingly Israel-critical base without actually doing much that matters.

Such a focus “creates, in a lot of ways, more problems than it solves,” the Arab Center’s Munayyer said. “It reinforces this idea politically that it’s too risky politically to hold accountable the actual decision-makers in the Israeli government, and the real processes at play here — which are driven by the state.”

Others see this as a misread of the political dynamics — one that Sachs of the Middle East Institute called “too cynical by half.” On this line of thinking, targeted action on settler violence is just morally necessary: the violence is really terrible, and if the United States can curtail it even on the margins it matters.

Moreover, they argue, something like sanctions on West Bank settlers opens the door to broader action: creating a real precedent for punishing bad actors in Israel that could create a kind of ratchet dynamic for future action taking on the deeper Israeli policies behind settler violence.

It’s hard to say in advance which of these views are right. Experts in both camps say there’s a lot of uncertainty here: we don’t know what will happen this November, let alone who the Democratic 2028 nominee will be or whether they’ll win. A Democratic trifecta with President Alexandria Ocasio-Cortez would likely be quite different than, say, a divided government with President Mark Kelly.

But either way, how Democrats handle the settler violence question could well be an indicator of where the party is going to go on the US-Israel relationship more broadly — and, by extension, the future for Israelis and Palestinians alike. 

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.

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.”

If you felt a gust of wind late on Friday, it came from hundreds of immigration lawyers who simultaneously exhaled after the Supreme Court announced it would not hear a case known as Genalo v. Black. That case asked whether certain immigrants could be held in immigration detention facilities indefinitely without ever receiving a bond hearing or other opportunity to seek temporary release. And if the Court had decided this case, its recent immigration decisions suggest that most of the justices may have blessed indefinite detention.

The Black case originally concerned two lawful permanent residents of the United States who were arrested during the first Trump administration because of crimes the two men committed years before, and that they had already served prison sentences for committing. 

These immigrants were arrested because of a federal law, which provides that the federal government “shall take into custody” noncitizens who committed certain crimes or who are accused of involvement with terrorism so that the government may begin deportation proceedings against these individuals. This law does not allow these noncitizens to challenge their detention while their deportation case is pending. (Notably, the relevant federal law sometimes allows an immigrant to be detained without hearing if they are merely suspected of terrorism, which means the person could be detained indefinitely based on false allegations.)

Both men sued, claiming that it is unconstitutional to hold them for too long without some kind of hearing to determine whether they should be released after paying a bond. And a federal appeals court agreed, holding that “due process bars the Executive from detaining such individuals for an unreasonably prolonged period…without a bond hearing.” 

Thus, Black was more than just another flash point in America’s debates over immigration. It was a test of one of the most fundamental protections that a liberal society provides to its residents — the right not to be locked up, forever, without any way to challenge the basis of that detention. 

Now that the Supreme Court has removed the Black case from its own docket, this appeals court decision will not be formally repudiated by the Supreme Court. So immigrants who are detained indefinitely may still ask courts to give them a bond hearing — at least for now.

Still, the Court’s nondecision in Black leaves a cloud of uncertainty hanging over similarly situated immigrants. The Trump administration will no doubt continue to detain people for prolonged periods of time (most of whom won’t be able to obtain a gubernatorial pardon, like one of the men was in this case). And the question of whether these immigrants can be detained forever will remain unresolved until the Supreme Court takes up another case involving a similarly situated immigrant.

Why the case was dismissed 

Both men at the heart of the Black case spent significant amounts of time in immigration detention facilities years after serving sentences for crimes. One, a Jamaican citizen named Carol Williams Black, spent seven months in an immigration detention facility. The other, Keisy Guerrero Mariano, spent 21 months in detention without a bond hearing or other procedure that could allow him to seek release while his case was pending. These 21 months in immigration detention more than doubled the time he spent in New York state prison for his actual crime — he pled guilty to second-degree assault after he got into a fight outside a New York City restaurant.

But there is no longer a legal dispute about what should happen to either man — in the words of the law, both cases are now moot. Black has since been released from detention and says that he “made the difficult decision to leave the United States” and has no intention to return. And the Trump administration’s case against Guerrero Mariano went up in smoke in late August, after New York Gov. Kathy Hochul gave him a pardon — thus wiping away the conviction that allowed the Trump administration to detain Guerrero Mariano in the first place.

Guerrero Mariano is one of six individuals that Hochul pardoned at the time. In her official announcement, she said that she did so because these six people “have demonstrated remorse, exemplified rehabilitation and displayed a commitment to improving themselves and their communities.”

There’s also a great deal of evidence indicating that Hochul pardoned Guerrero Mariano in order to resolve his immigration case — and potentially keep the Supreme Court from deciding Black. Among other things, the actual pardon document signed by Hochul specifically states that it will grant Guerrero Mariano “relief from removal.” Guerrero Mariano’s lawyers had sought this pardon, and Hochul granted it mere days before his brief was due in the Supreme Court. 

That brief’s very first sentence, moreover, states that Hochul “granted Respondent Keisy G.M. a full and unconditional pardon of the state criminal conviction that is the sole basis for his removal,” and it urges the justices to dismiss the case as moot.

Last Thursday, Trump’s Justice Department joined a stipulation calling for the justices to dismiss the case against Guerrero Mariano, most likely because even they recognized that a lawful permanent resident with no conviction may not be detained. The Court granted that request on Friday.

So that’s good news for Guerrero Mariano, who presumably will now be able to live freely in the United States. 

Guerrero Mariano’s lawyers were right to fear a trip to the Supreme Court

It’s possible that the Supreme Court might have agreed with the lower court’s holding that immigrants who are detained for an “unreasonably prolonged period” have a constitutional right to a bond hearing — this Court has, on rare occasions, broken with the Trump administration in immigration cases. But those decisions are few and far between.

Among other things, this Court has allowed President Donald Trump to deport immigrants back to war zones. The Court’s Republican majority effectively nullified the Convention Against Torture, a treaty that is supposed to protect immigrants from being deported to nations where they will be tortured. The Court also blessed so-called Kavanaugh stops, which permit suspected immigrants to be racially profiled so long as their race or ethnicity isn’t the sole reason why they are stopped by law enforcement.

Moreover, while the US Court of Appeals for the Second Circuit’s decision in Black — the one holding that immigrants like Guerrero Mariano may receive a bond hearing if their detention is “unreasonably prolonged” — reached a plausible legal conclusion, this conclusion was not a slam dunk under the Supreme Court’s previous precedents. And that means that the justices could have easily come up with a reason to reverse that decision if they wanted.

On the one hand, the Court said in Zadvydas v. Davis (2001) that “a statute permitting indefinite detention of an alien would raise a serious constitutional problem.” On the other hand, the Court held in Demore v. Kim (2003) that an immigrant similarly situated to Guerrero Mariano may “be detained for the brief period necessary for their removal proceedings.” 

Read together, these decisions suggest that the government does have some power to detain people while their immigration case is pending. While Zadvydas indicates that this detention can go on for too long, the Court has never established when an immigrant’s detention has stretched too long. So that means that the justices would have a fair amount of leeway to allow prolonged detentions without defying any of their previous precedents.

So it’s clear why everyone from Guerrero Mariano’s lawyers to Hochul seemed concerned about what would happen if the Court decided this case. In the worst-case scenario for immigrants, Trump could have gained the power to lock many people up for years without any meaningful way to challenge their detention. In the best case, the Supreme Court may have reached the same conclusion as the Second Circuit — but even that decision was vague about how long an immigrant must be detained before they must receive a bond hearing.

In any event, the bottom line is that the Court’s decision to dismiss the Black case is good news for Guerrero Mariano. But that dismissal merely delays a reckoning for other immigrants who face prolonged detention while their case is pending.