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Online hate is spilling into the real world, AFP warns

AFP Commissioner Krissy Barrett began her late-night appearance at the Senate estimates hearing noting “a heaviness that hangs across Australia” after the alleged attack on independent MP Helen Haines.

Lone actors are being motivated by a convergence of personal grievances, mental health vulnerabilities and ideological concerns …

What helped keep us safe in recent times, such as our geography, analogue systems and far away criminals, has been impacted by fully integrated technology, social media and artificial intelligence.

We hear about the devastating impacts of racism from communities every day. But many experiences go unreported or uncounted, and our systems often do not capture the full picture.

This is not about collecting more data to prove racism exists. We already know it does. It is about making inequality visible, holding institutions to account and giving communities greater agency over their data to drive real change.

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© Photograph: Mick Tsikas/AAP

© Photograph: Mick Tsikas/AAP

A government watchdog is considering a probe into the Home Office’s use of ChatGPT technology to process asylum claims amid concerns over the tools’ accuracy and secrecy surrounding their use.

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© Photograph: Andrew Caballero-Reynolds/AFP/Getty Images

© Photograph: Andrew Caballero-Reynolds/AFP/Getty Images

© Photograph: Andrew Caballero-Reynolds/AFP/Getty Images

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Calculations from the Center for Global Development (CGD) found the UK was on course for a large shortfall in promised official development assistance at the end of 2027.

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© Photograph: Patrick Ngugi/AP

© Photograph: Patrick Ngugi/AP

© Photograph: Patrick Ngugi/AP

"That's a 12-year-old view of the world."

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When millions of voters fill out their ballots in November, they won’t just be choosing elected representatives. Many states are offering the chance to impact conservation and wildlife as well, through ballot measures focused on things like dedicating more money to habitat protection or mitigating the impacts of climate change. One could even reshape wildlife management in one of the country’s most picturesque mountain states — and also lead to the indiscriminate deaths of all kinds of wild animals. 

And while ballot measures might seem like small potatoes in the grand scheme of electoral politics, they could have an outsized impact this year. The Trump administration has been systematically rolling back protections for endangered species, taking a hammer to longstanding pillars of climate regulation, and cutting funding to agencies like the National Park Service and National Forest Service, both of which oversee vast stretches of wildlife habitats. In many cases, states have had to step up, putting more resources into conserving the habitats and species within their borders, and ballot measures can help shape those decisions. 

Here are the seven ballot measures that could transform ecosystems across the country this election: 

California — Proposition 45: Cutting pesky environmental reviews, also maybe cutting habitats  

This ballot measure would shorten environmental review periods for “essential projects” like housing, water systems, clean energy, and medical facilities, among others. In a state that’s been struggling to build what it needs fast enough, this could help speed essential clean energy projects that could help slow climate change. On the other hand, reducing California Environmental Quality Act review time, as this proposition would do, could also lead to increased habitat destruction, leading advocacy organizations like the Sierra Club to oppose it. 

Georgia — Amendment 1: Tax breaks for conservation land (maybe)

This amendment might seem a little in the weeds — and mostly in the interest of farmers and ranchers looking for tax breaks. But it would double (from 2,000 acres to 4,000 acres) the amount of land an owner can get tax breaks from if they protect it under the state’s Conservation Use Valuation Assessment program. As Yanshu Li, an Associate Professor of Forest Economics at the University of Georgia, told me, the amendment could incentivize landowners to set aside larger tracts of their property for wildlife habitat conservation, which would benefit species like the nine-banded armadillo and the northern bobwhite quail that call these habitats home. 

Massachusetts — Question 6: A fund for nature

Question 6 would create a “Nature for All Fund,” routing existing taxes on sporting goods, recreational vehicles, and money spent at golf courses to conservation. That fund could then be used on natural resource conservation, making it the first time the state has a dedicated funding source for conservation projects.

Colorado — Proposition 137: More money for restoration and wildfire prevention

This proposition, similar to Massachusetts’, would direct existing sales taxes on sporting goods to a state fund dedicated to conservation and wildfire prevention. In a state where wildfires have torn through more than 2 million acres in the past decade, dozens of conservation groups are supporting this measure to protect habitats and species.

Arkansas — Issue 4: Waterworks and waterways 

Here, voters are being asked to approve up to $500 million in bonds that can be used to fund water-related infrastructure projects like water treatment, waste disposal, and wetlands infrastructure. A boost to wetlands under the Arkansas proposal could help animals that live in those habitats, which are often overlooked in this region. 

Rhode Island — Question 5: New money for climate resilience and habitat protection

This measure would allow for $55 million in bonds to fund environmental and recreational projects. The largest chunk of this change — $25 million — would go to helping to protect the state from the impacts of climate change. Another $7 would be devoted to protecting Narragansett Bay and its watersheds, which would include funding to “restore natural habitats and control invasive aquatic plants,” according to the Rhode Island Current. 

These ballot measures are all relatively straightforward so far, but there’s one question up to voters this fall that puts wild animals front-and-center — and is splitting hunters and anglers down an ethical centerline. Which takes us back to Colorado: 

Colorado — Amendment 83: A constitutional right to hunt…traditionally

On its surface, this amendment seems fairly innocuous. It asks voters to enshrine “the right to hunt, fish, and harvest fish and wildlife by traditional methods” in the state’s constitution. Hunting and fishing are already big in Colorado, and they’re protected by statute, so this may not seem like a major change. But, as Rebecca Niemiec, co-director of Colorado State University’s Animal-Human Policy Center and a Colorado Parks and Wildlife commissioner, speaking for herself, told me, neither the text of the bill nor its proponents define what “traditional methods” of hunting and fishing would be allowed under this amendment.

“Read plainly, traditional methods could be interpreted to include practices like poisoning, leg hold traps, gill nets, or baiting and hounding,” Niemiec said. Many of these practices injure or maim animals, including ones that aren’t targeted: Steel-jawed traps and poisons don’t discriminate between, say, a deer, a wolf, and a lynx. All of these practices have been outlawed in Colorado over the years, either through other ballot measures or regulatory changes; in 1992, for example, Coloradans voted to ban hunting bears using bait and hounds, and four years later they banned leg-hold traps and snares. 

The new amendment also continues on to propose: “establishing hunting and fishing as the preferred means of managing fish and wildlife populations.” This would leave far less room for wildlife agencies like CPW to make nuanced decisions or roll out alternative programs, like birth control or animal relocation. It also reduces their ability to take into account the preferences of people who value wildlife for reasons other than hunting. 

“Biological science can inform decisions about how many animals can be killed without threatening a population,” Niemiec said. “But it can’t tell us what hunting practices are ethical, or how to balance hunting opportunities with the public’s desire to see wildlife alive — and protected from unnecessary suffering.” 

The push for these constitutional protections, Niemiec told me, is part of a larger backlash against conservation groups. But in this case, it’s not as simple as hunter vs. non-hunter: Plenty of hunters and anglers support taking ethical considerations into account when making decisions about how to manage wildlife, and some hunting groups in Colorado have publicly spoken out against the amendment. 

“If we’re going to enshrine anything in the Constitution, it should say we should be balancing the diversity of public interest in wildlife in all of our management decisions,” Niemiec said. “We need innovative methods, not traditional methods, if we’re going to deal with the complex challenges that our wildlife is facing moving forward in the state and throughout the country.”

A newly launched stock class being offered was partially engineered to help Meta founder and CEO Mark Zuckerberg pay the "billionaire's tax," should the measure be voted into law.

President Donald Trump has been attacking Rep. Ilhan Omar (D-MN) since she first entered Congress in 2019. At various points, he’s called for Omar — a progressive lawmaker who came to the United States as a child refugee from Somalia and who is one of Trump’s most vociferous critics — to be investigated, arrested, and deported. 

Now, Trump’s Justice Department is seemingly trying to make good on his threats. Last week, Omar’s Washington, DC, home was raided by federal agents from Homeland Security Investigations, an arm of the US Immigration and Customs Enforcement. According to the Wall Street Journal, the raid was part of an investigation into her immigration paperwork with the explicit goal of denaturalizing and deporting her.

The timing alone would make the raid unusual — it’s rare for the Justice Department to take action in political cases so close to an election — and as Washington Post immigration reporter Ted Hesson explains, it also feels uncomfortably pretextual. “It’s almost as if the outcome of the investigation has been stated before anything has taken off,” he told Today, Explained co-host Sean Rameswaram. 

Hesson joined Sean to talk about the long history of Trump’s attacks on Omar, what the agents might have been looking for, and whether the administration could actually undermine Omar’s citizenship or even deport her. 

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

What do we know about what federal agents were looking for in Rep. Ilhan Omar’s Washington, DC, residence?

What we’ve learned through our reporting is that the investigation has looked at both her birth date and whether [Omar or her father] may have lied about it on the naturalization application. 

A second piece is whether, looking at her father’s military service, she was born in Somalia and was there during the civil war and fled with her family as a young child to a refugee camp in Kenya and was there for years before they eventually came to the US as refugees.

This is the president of the United States and his administration entering a sitting representative’s home to figure out what her original birthday is. What is the motivation here, to the best of our knowledge?

For years, President Trump has criticized Rep. Omar and made unsubstantiated accusations related to immigration fraud. 

There have been theories circulating on the far right — again, unsubstantiated — that she had married her brother as part of an immigration fraud scheme. President Trump himself has repeated that. And several top Trump administration officials in the last few months have said that they believe that there is fraud in her background. They’re making these statements prior to there being an investigation, prior to there being evidence put forward. And it’s almost as if the outcome of the investigation has been stated before anything has taken off. 

One thing I should say is that while it does appear that they’re looking at her birthdate, when refugees come into the US, it’s extremely common that their birth records are unreliable because people are fleeing countries that are often in disarray, whether it’s due to civil war or other reasons. 

Often, nations like Somalia don’t maintain accurate birth records. So it’s common that refugees who’ve left their country as children, spent time in refugee camps, and then come to the US don’t have a solid understanding of when exactly they were born. I don’t know for sure that that’s the case here, but I know that generally when you’re dealing with refugees, that is true.

I know there’s a lot we don’t know here, but investigators enter Rep. Omar’s home. Potentially they’re looking for some documents that may list her birthday. If they find some information that’s maybe contrary to official government records, what could that mean, in theory?

It’s unclear what sort of charges could be brought from this. And part of the question is, was she 17 and a child at the time of that application or was she 18? 

Even if it was determined that she was not a child, I don’t believe they would be able to, say, launch a denaturalization process based on that fact alone. And even if they did attempt to do something like that, these things are not taken lightly and it’s a long involved legal process and very uncommon to pursue something like this over something as simple as this sort of paperwork discrepancy.

The president has a long history of hating on Somalia and Somali immigrants to this country. 

How does this investigation into Rep. Ilhan Omar fit into the president and his administration’s broader efforts to take away American citizenship?

In the past year especially, we’ve seen President Trump use really inflammatory and derogatory language to refer to Somali Americans and Somali immigrants in the US. Even for someone who frequently employs anti-immigrant rhetoric, and the president has in his past, some of the things he said went beyond even that. He does seem to have particularly targeted Somalis in the US and Somali Americans, and Rep. Omar has been part of that. 

I think what’s interesting here or what could be interesting is that this case wades into different territory of taking somebody who’s a naturalized citizen, who’s been in the US for decades as a citizen, and saying, “We’re potentially going to reopen that and go back and look at your file and see, do we find anything that might be out of line?”

The idea that you could do that with someone who’s a sitting lawmaker could mean that you could potentially do that to any other person who may have applied.

Now, one thing we’ve learned is that in the case of Rep. Omar, the administration has looked at the idea, in the event that criminal charges can’t be brought, of potentially canceling her citizenship certificate. It’s almost like a fast-track way to disrupt someone’s citizenship. 

It doesn’t remove it. You remain a citizen, but you lose the document that is the underlying proof of that, which could then cause problems with federal government documents, and it could even lead to immigration proceedings where the government tries to make the case that you should be deported.

How has Rep. Omar responded?

Her camp has vociferously pushed back against the allegations. 

In regard to the search, they’ve actually said that there was a court-ordered guideline that should have been followed, and that involved consulting the counsel for the House of Representatives before the search happened. They said that never happened, and if it had, it would’ve given Rep. Omar perhaps time to prepare for this or some sort of legal recourse. 

They’re saying that not only is this continuation of President Trump’s attack on her politically motivated, but also that the actual legal guidelines that were outlined in that search warrant were not followed.

Are other Democrats speaking up on her behalf?

Former President Barack Obama in particular is one extremely prominent person who came out and made a social media post elevating her case. 

The interesting part is that President Obama does not often weigh in on public debates like this or is at least measured in the opportunities when he does. So it comes with more gravity to hear him stepping in and raising concerns about this. 

I think it speaks to the fact that he thought this was very significant. And if you remember, President Trump’s political career was built on the narrative that Barack Obama was not born in the US.

I do remember, Ted.

And the hunt for his birth certificate. You can imagine that former President Obama saw a parallel here and realizes that this mirrors the sort of attacks that were made on him when he was in office.

We’ve talked about President Trump a bunch in this conversation, and he’s made no secret of his disdain for Rep. Omar and the country from which she comes. What has he explicitly said about this investigation?

He’s saying that the Justice Department is acting independently. That said, he has been extremely critical of Rep. Omar in his public statements and continues to be. And the president himself and other top officials have said that it should be investigated. 

We’ve had, for months now, a sort of public encouragement of top officials and saying that they should be looking into this. So whether he’s directly liaising with them or whether they’re just reading his social posts, it may be kind of a nuanced distinction. He’s publicly saying he wants this to be pursued.

Americans are furious about the state of our healthcare system. 

A recent KFF poll found 60 percent of US adults worry about the cost of medical care — more than gasoline, food and groceries, or their rent or mortgage. One in three Americans say they worry every day or almost every day about their ability to afford healthcare, per a new survey from the Pew Research Center. There seems to be a growing appetite for reform, too: More than 65 percent of Americans say they support the government spending more tax dollars to lower healthcare costs. 

Democrats are trying to weaponize those frustrations against the Republicans who currently hold Congress and the White House. By a 2-to-1 margin, voters say they trust Democrats over Republicans on healthcare. That could mean single-payer Medicare-for-all or a new public insurance option or maybe something else. What all this energy leads to will depend on what happens in November. The candidates themselves are framing the stakes in those existential terms. 

“Medicare for all is where we need to go,” Abdul El-Sayed, the Democratic candidate in the Michigan Senate race whose support for the policy has been widely covered, said during an August interview with CNN. “And my hope is, both coming out of the 2026 midterms and then out of 2028, that we’re going to be on our way to a Senate majority to be able to get this done.”

Real change will have to wait for the 2028 presidential election and a new occupant in the White House. But this year’s midterms are still a make-or-break moment: The candidates who get elected this year, and how they shape the upcoming presidential primary debate and actions in Congress, will determine whether healthcare reform happens at all. 

If you’re fed up with the state of American healthcare, and you want to see a change, you should show up for the midterms on Tuesday, November 3.

Big midterm wins can beget big healthcare wins 

The classic pattern in American elections is that more voters go to the polls during presidential campaigns than during the midterm elections when only House and Senate seats are on the ballot. Turnout has started to tick up for the midterms in recent years, but it still trails behind presidential years. Midterms suffer from the perception that there’s not as much at stake if the White House is not on the line.

But that’s never been strictly true. 

Midterm elections are extraordinarily important in shaping the future of policymaking, even if the payoff is delayed. They help determine both the character of the Congress that could eventually pass a major bill after the next presidential election, and the kind of ideas and policies that are going to be prioritized.

“Voters should see 2026 and 2028 as the elections that will guide the next big change in our healthcare system,” said Natalie Davis, CEO and co-founder of the advocacy group United States of Care, in a statement to Vox. “These elections will be how voters’ demands are heard — and will tell us whether the next real window for change will come with serious reforms or missed opportunity.”

A walk through the recent history of healthcare reform should help make the stakes of the 2026 elections clear.

In 2006, the national mood looked similar to what we’re seeing today. A very unpopular Republican president was in office, and the country had soured on his agenda. George W. Bush’s foreign wars and his misguided attempt to overhaul Social Security gave Democrats an opportunity to win big in the 2006 midterms — and they did. Dems won more than 30 seats and secured a comfortable majority in the House. In the Senate, they won six seats and narrowly took control of that chamber too.

It was a resounding rejection of the Bush administration, and it set up the next decade of Democratic policymaking. At the highest level, the midterms gave energy to the progressive wing of the Democratic Party, united as they were around their opposition to the Iraq War, and that energy carried over to the presidential primary. Barack Obama defeated Hillary Clinton and won the presidency, springboarding off of the excitement that started with the 2006 elections.

Dems’ success in the midterms also helped put lowering healthcare costs at the forefront of the Democratic agenda. That encouraged both Obama and Clinton to develop detailed healthcare policy proposals during their primary campaigns and ultimately set the stage for the Democrats to pursue the Affordable Care Act once they had full control of the government in 2009.

And then there is the literal size of the congressional majorities that parties need to pass their agenda. Voters may not spend much time thinking about whip counts, but one or two elections in a midterm year can ultimately decide the fate of the next president’s agenda. 

Part of the reason Democrats were able to pass the ACA was that they built on their huge wins in 2006 with more wins in 2008 and held massive congressional majorities once Obama was sworn in. And once the debate over healthcare reform really got started, they needed every single vote. It was especially important in the Senate: Democrats had exactly 60 votes in 2009. That meant if all of them united together, they could pass filibuster-proof legislation — so long as nobody defected. That was only possible because in 2006 Mark Pryor won a Senate seat in Arkansas, Sherrod Brown triumphed in a Senate race in Ohio, and Jon Tester beat an incumbent Republican in Montana. 

Without those wins in 2006, the Democratic legislative agenda in 2009 would probably have looked different. They might’ve had to pursue a more limited healthcare reform plan; maybe the ACA wouldn’t have passed at all.

What kind of Democrats will be on the rise in 2028?

The 2006 midterms both created the opportunity for the ACA — and set the limits on what the legislation could actually achieve. Democrats had that 60-seat Senate majority, but within it were many more moderate members. Policies like the public option (which would have authorized the government to create its own health insurance plan to sell alongside private insurance) couldn’t get sufficient support. That is the dilemma of policymaking: You need those swing-seat members to win, which often means tacking to the center, but you also can’t pass anything they won’t get on board with. 

Nevertheless, that is a good kind of political problem to have, one which Democrats would be thrilled to face in January 2029. All of which brings us to 2026. What are we going to do now?

It all starts with the vote count. Most projections expect the Democrats to win between 10 and 20 House seats. But the difference between 10 and 20 could be substantial. The cushier the majority, the further you can push the policy agenda. More than 30 House Democrats actually voted against the ACA, but they could still narrowly pass the bill because of the huge majority that they had started building in 2006. 

If you live in one of the districts — like Arizona’s Sixth or Colorado’s Eighth or Florida’s 22nd, to name just a couple of the 21 toss-up races identified by the Cook Political Report this year — that forecasters say is competitive this year, you could have an outsized say in what the future of policymaking looks like. But even in safe districts, you should vote: Elections are the most reliable way we have to gauge public opinion, and strong victories for the candidates who prioritize healthcare send a message.

The same goes for the Senate. If Democrats sweep all of the competitive races, they could have up to 55 seats in the Senate in 2027 — with a chance to build on it in 2028. If you are a voter in Kansas, Michigan, Ohio, Texas, Alaska, Maine, New Hampshire, or Iowa, your ballot carries extra weight for the next steps in US healthcare reform. If the Democrats can reach 60 votes again in 2029, they would have much more flexibility about what to pass. Even if they fall short of that magic number, the more of a cushion they have above 50, the more likely that their Senate leaders can find support for altering Senate rules for the filibuster and get an ambitious bill approved.

The results of this year’s midterms will also set the terms of the debate among Democrats. We are likely to see “show” bills advanced by Dems next year that may have no chance of being signed by President Donald Trump, but that will give us a sense of what kind of policies the party wants to pursue and how much support there is for them. Believe it or not, the first Medicare prescription drug negotiations bill passed the House in 2007 after Democrats’ big wins in 2006 — even though the policy didn’t become law for another 15 years. The broader public may not pay much attention to this kind of doomed-to-fail legislation, but it is often a window into the future.

“One challenge for Democrats is finding the next big health care idea beyond the Affordable Care Act that will resonate with voters and respond to their affordability concerns,” said Larry Levitt, executive vice president for health policy at KFF. “One big difference between now and 2006 is that back then there was already a lot of coalescing around ideas that ultimately led to the ACA. All the major Democratic candidates for president in 2008 supported something like that. I’m not sure that’s true now, at least not yet.”

Democrats are already aligning on a wide range of healthcare ideas, from reviving the public option to free primary care to the full-blown Medicare-for-all supported by progressive candidates, some of whom are in competitive elections. If El-Sayed wins the Senate race in Michigan, for example, that could supercharge a debate around Medicare-for-all. It could also provide momentum to any progressives who run for president — Alexandria Ocasio-Cortez, to name one obvious example — and decide to make Medicare-for-all a pillar of their platform.

But if El-Sayed and other progressives were to fall short, that could make Democrats more timid about being ambitious in the 2028 campaign and afterward. Still, he’s far from the only candidate in a crucial race to put their support behind Medicare-for-all. There is Randy Villegas in an important California House race. Troy Jackson has bet on it as part of his bid to topple Sen. Susan Collins in Maine. All of these races will send a signal to the party about what the public wants and is willing to turn out for.

In some ways, winning elections is the easy part. Legislating is hard, and any eventual healthcare law will surely involve compromises and unexpected surprises. Who knows what will be happening in the world in 2029? 

“The bottom line is: 2026 is a healthcare election,” the leaders of the advocacy group Protect Our Care wrote in a campaign memo this month. “After November, it’s up to Democrats to keep up the fight to deliver relief to families and make healthcare affordable and accessible for every American.”

The harrowing allegations of rape at a Cornell University fraternity have been rippling out in both New York state and national politics.

Democrats have tended to voice sympathy with the accuser, saying that they stand with her and other victims. Rep. Alexandria Ocasio-Cortez (D-NY) said there was “a culture of rape, sexual assault, and pedophilia” in elite institutions across the country. Michigan Senate candidate Abdul El-Sayed said Cornell “protected her abusers, letting them off with a slap on the wrist.” 

New York Gov. Kathy Hochul said the accuser was “failed” by local police and county prosecutors who did not bring charges, so Hochul appointed state Attorney General Letitia James to take over the investigation. Days before that appointment, James posted on social media that “what this young woman has been forced to endure is horrific and unacceptable,” adding: “To her, and to all survivors: you’re not alone. We stand with you.” 

Some Republicans, meanwhile, are accusing Democrats of rushing to judgment. Saritha Komatireddy, who is running for attorney general of New York against James, said in a debate that James had “screwed this one up by prejudging it.” The investigation, Komatireddy said, “requires someone who approaches the case with fairness, impartiality and integrity.” And right-wing commentators like Megyn Kelly and Ben Shapiro have questioned the accuser’s story.

But beyond the procedural fight over this particular investigation, many Democrats have also called for changing the law to make cases like it that involve drugs or alcohol easier to prosecute in general. 

This might seem like a clean issue for the party, in line with prior progressive efforts to crack down on sexual assault via Title IX and expanding statute of limitations laws. 

However, it’s not so simple: According to my conversations with experts and advocates involved in these reform conversations, this is where the Democratic unity begins to fray, because of a divide between two key parts of the progressive coalition. 

The impulse to create stronger protections for victims has crashed into the left’s longstanding suspicion of the criminal justice system. And as a result, a coherent policy response has been hard to craft — and may end up being impossible to get agreement on.

On one side are advocacy groups for women and for victims of rape or sexual assault. They argue that current law — in New York and other states — makes it far too difficult to successfully prosecute perpetrators, and that it should be changed. They’ve advocated for closing what they call the “voluntary intoxication loophole,” which they say makes it harder to prosecute abusers of victims who have willingly consumed drugs or alcohol.

On the other side are various progressive or left constituencies that are deeply skeptical of the criminal justice system. These constituencies — which include key figures in New York’s Black political establishment, public defenders, supporters of criminal justice reform, and members of the Democratic Socialists of America — are united by a shared antipathy to mass incarceration and what they see as disproportionate police targeting of minority communities. 

The former camp argues that false rape and sexual assault allegations are vanishingly rare, that these crimes are hugely underpunished, and that the law needs to be updated to make these prosecutions easier. But the latter camp argues that Black and other nonwhite men are often falsely accused, and that it would be unwise to hand prosecutors another tool they could use to put men in jail in cases where ascertaining consent is more difficult.

It’s a fraught debate. Modern-day progressives have strongly backed the Me Too movement as well as campaigns for racial justice and criminal justice reform. Progressives want to be on the side of victims against the privileged and powerful — but sometimes, they have different ideas about who falls into which category.

The legal issues around “voluntary intoxication” and rape charges, explained

The current controversy in New York focuses on efforts to close what advocates call the “voluntary intoxication loophole” in rape and sexual assault law.

Every state says rape is a crime. Every state says it’s a crime to have sex with someone who is unconscious. And every state says it’s a crime to have sex with someone who is incapacitated due to unknowingly being dosed with drugs.

But what about someone who chooses to drink or take drugs, who remains conscious, and who doesn’t outright refuse consent? Should there be a standard by which the law deems that person incapable of meaningfully consenting, because they are too intoxicated? 

Many states have long had laws on the books saying yes — that someone who voluntarily drinks or does drugs can reach a state where they are too mentally impaired to consent to sex, even if they’re conscious and capable of communicating. But about half of states don’t have such a law, according to the Associated Press. And this hasn’t been an especially partisan issue to this point, with a mix of red and blue states adopting each standard.

The push to change the law in New York predates the Cornell case, and goes back to the late 2010s. At that time, the Me Too movement had put Manhattan District Attorney Cyrus Vance Jr. in the hot seat, with advocates criticizing him for not initially prosecuting Harvey Weinstein and arguing he was soft on rape and sex crimes generally. 

In the midst of pivoting on the issue (he had Weinstein indicted in 2018), Vance claimed that, in certain of these cases, his office was hamstrung by what he called a “loophole” in New York law involving intoxication. “Prosecutors cannot bring sex crime charges in cases where the victim became voluntarily intoxicated and was unable to consent,” he wrote in a letter. So really, Vance said, it was on the legislature to change the law.

Quickly, critics argued that Vance had misstated the law, saying it was not actually true that a loophole allowed people to rape voluntarily intoxicated New Yorkers with impunity. Vance’s office later acknowledged that his initial comments were “inartfully put.” 

The problematic cases, Vance’s team argued, were about victims who were “too intoxicated to consent” but who were also at least partially conscious and didn’t outright express their unwillingness — this, they said, was the “gap in the law.” “There’s a real problem that we have with people getting drunk and then being taken advantage of,” Vance said. 

So some Democrats and groups advocating for victims of sexual assault and rape kicked off an effort to change that law, in New York and elsewhere. Their favored bill says that lack of consent can be established if an alleged victim is “temporarily incapable of appraising or controlling their conduct” — and if the accused knew or reasonably should have known that.

Critics argue, though, that such bills go too far, and could make it easier to prosecute sexual encounters that, to the accused, seemed consensual. 

“The proposed legislation fails to provide any objective guidance about when a partner is too intoxicated to legally agree to engage in sexual conduct,” the New York State Association of Criminal Defense Lawyers said in an emailed statement.

Skeptics of the bill outlined several scenarios that concerned them, including scenarios where one person seems to consent but later decides that, in retrospect, they were too intoxicated for it to have truly been consensual. 

“You get all these scenarios where two people meet up at a bar and they both become voluntarily intoxicated,” said Yung-Mi Lee, a public defender and a former president of New York’s criminal defense lawyers association. “So then, if someone later says, ‘I was voluntarily incapable of appraising my conduct, I lost my inhibitions,’ they could say, ‘You committed a rape against me.’”

To advocates for victims’ rights, these concerns are overstated. “The burden that’s placed on a victim of sexual violence is such a large burden to bear in the first place that these changes to the law are really just slightly opening the door,” Rebecca Zipkin of the advocacy group World Without Exploitation told me.

“The current situation is not working to provide justice for survivors,” Stefan Turkheimer of RAINN, a network for rape and abuse survivors, told me. “The status quo is not okay.”

Why it hasn’t passed in New York

Versions of the voluntary intoxication bill have been signed into law in recent years in Minnesota, Michigan, and Texas. The bill has also repeatedly passed the New York state Senate by overwhelming margins. But it has never been brought to a vote in the lower chamber, the New York state Assembly.

That’s because, advocates for the bill told me, they’ve faced resistance from some influential parts of the Democratic Party and progressive coalition. 

Indeed, the skeptics are said to include two factions that are often at odds: New York’s Black political establishment and the Democratic Socialists of America. 

Assembly Speaker Carl Heastie controls which bills come to a vote in his chamber. He was an architect of the state’s sweeping bail reform law, a critic of what he called the existing “racist and classist system,” and has said he would be “a failure as a Black man” if he did not pass criminal justice reform. 

“It is generally known that Speaker Heastie does not believe in creating new crimes because he believes New York suffers from overincarceration,” Lizzie Asher, an advocate for changing the law and a co-founder of the Justice Without Exclusion Coalition, told me. (Heastie has said that he did not bring the bill to a vote because it lacked enough support among his chamber’s Democrats.)

Assembly member Latrice Walker is another champion of criminal justice reform; she even did a hunger strike in 2023 to protest rollbacks to the bail reform law. She spoke out about her concerns about the voluntary intoxication bill earlier this year, telling the New York Times that while she wanted survivors to get justice, she was “cautious about the creation of new laws and our duty to preserve due process protections.”

Zipkin and other advocates have also pointed to the six DSA-affiliated members of the assembly, who are associated with a general skepticism about the criminal justice system and incarceration, as a potential obstacle. None are currently listed as cosponsors of the bill. Back when Zohran Mamdani was in the assembly, he too declined to sign on, advocates noted. 

The DSA as an organization is very critical toward the police and prison system; many DSA members have called for defunding or abolishing the police in the past, and the DSA’s national platform still holds out “fully abolishing the police and prison system” as a long-term goal.

These objections may be harder to maintain amidst a wave of outrage around the Cornell case. Speaker Heastie announced he was creating a working group to reexamine the voluntary intoxication issue. The group includes Walker, whose office told Vox she would not comment on the law while “they undertake their important work.” Heastie told the group to give him recommendations by the end of the year, for consideration in New York’s 2027 legislative session. 

Is this a bigger divide among progressives?

The divide is coming into public view due to national attention on the Cornell case — but it’s long predated the current moment. 

Back in 2016, a California judge gave Brock Turner, a Stanford swimmer convicted of sexually assaulting an unconscious woman behind a dumpster, a six-month jail sentence. Advocates for victims’ rights were furious at what they deemed an inexcusably lenient punishment; nationwide outrage and an ultimately successful campaign to recall the judge ensued. 

But some progressive supporters of criminal justice reform felt queasy about the idea of punishing a judge for not locking up a defendant long enough. Skeptical of the criminal justice system and the value of incarceration, they worried this public fury would incentivize judges to be harsher across the board.

“What ultimately will happen is that the people that we represent — people of color, minorities, the disenfranchised, the poor in our communities that make up the people ensnared in our criminal justice system — they’re the ones that are going to bear the cost of this recall,” Sajid Khan, a public defender in Santa Clara County, California, said in 2018.

In practice, these two groups of advocates have generally managed to coexist in the progressive coalition. That’s in part because the Me Too cases that get the most attention have tended to be from white-collar work environments or college campuses, rather than in the dispossessed or marginalized populations that criminal justice reformers are more typically focused on.

But some argue that there’s a more fundamental tension here. Aya Gruber, a professor at the USC Gould School of Law, has written a book arguing that feminists’ efforts to ensure rape and domestic violence are punished more severely have, in practice, ended up contributing to racist mass incarceration. 

“I just think it is a really dangerous thing to start expanding the criminal law in ways that grant all this power to prosecutors,” Gruber told me. “This idea that somehow all this cultural power is going to be used against already privileged people and thus have some sort of egalitarian aspect to it makes it very tempting. But we can identify populations that are more heavily policed, and they are generally not privileged populations.”

Christina Applegate, the actor who has been one of the most visible faces of multiple sclerosis since her 2021 diagnosis, made a stunning revelation this week: She does not have MS after all. And her doctors still don’t know what is causing her debilitating symptoms.

“I’m back at square one,” Applegate told fellow actor Jamie Lynn Sigler, who does have MS, on Sigler’s podcast MeSsy. “I was not happy at all. Everybody else was so happy.”

It is a harrowing predicament for Applegate, and hopefully her medical team is able to get her the diagnosis and treatment she needs. But the fact is, her experience is not unique. Even as more and more Americans get diagnosed with multiple sclerosis, misdiagnosis remains all too common. According to one meta-analysis, roughly 15 percent of MS diagnoses may actually be false positives.

How could such a common medical condition — roughly 1 million Americans are living with the disease, about one in every 350 people — remain such a mystery? After Applegate’s announcement, I called some leading experts on MS to ask why diagnosing the disease is such a challenge, and what they want people to know. Here’s what I learned.

Why MS can be challenging to diagnose

Multiple sclerosis is an autoimmune condition: The body mistakenly attacks cells meant to protect your brain and spinal cord, and the resulting damage interrupts nerve signals and causes the disease’s telltale symptoms of motor impairment, tingling sensations, and vision problems. Some people experience a rollercoaster of relapses and remissions; others see the disease steadily progress, eventually leading to serious disability.

The reality is, scientists still don’t really know what causes MS to develop, said Dr. Andrew Solomon, a neurologist at the University of Vermont who specializes in MS. Smoking is a known risk factor. Obesity and metabolic problems play a role, but we need more research. Even the precise role of genetics remains something of a mystery. “We don’t really know what causes or triggers the autoimmune response in any given individual,” Solomon said. 

And that’s where the challenge in diagnosing it begins.

First, the testing can be imprecise; there is not a single test that reliably diagnoses MS. If a doctor suspects their patient may have MS, they usually undergo an MRI, which their physicians then scour for lesions that are typically associated with the disease. But those scans are still subject to interpretation: Other rare conditions sometimes resemble MS in imaging, as can diseases of blood vessels in the brain. You can also receive a spinal fluid analysis to check for abnormalities in your immune system, which the vast majority of MS patients have.

The nature of MS symptoms adds to the difficulty. They can often be vague early on: brain fog or fatigue or a general malaise. The tingling or vision problems can be similar to symptoms for other conditions that are not MS, and they are easily dismissed if they go into temporary remission, as often happens during the initial phases of the disease.

“Neurological symptoms sometimes can be vague — numbness, pins and needles — and it’s usually short-lived,” Dr. Saud Sadiq, chief research scientist and director of the Tisch Multiple Sclerosis Research Center of New York, told me. “Unless they’re taken seriously initially, they may be ignored because by the time the patient goes through the healthcare system and is actually referred to a neurologist, the symptoms have abated.”

If your doctor is diagnosing you with MS, ask directly: What’s the evidence?

One 2025 study by Solomon and his colleagues found that 40 percent of people who had later been diagnosed with multiple sclerosis were initially misdiagnosed with a different disease.

“Because it’s so heterogeneous, it doesn’t present in the same way in everybody and can have varying severity, it can be hard to diagnose sometimes,” Solomon said.

Lastly, when people are experiencing debilitating symptoms, there is pressure to deliver some diagnosis — and that may push some doctors to leap to MS even if they are not sure, Solomon said. The recent advent of effective treatments that help manage the disease’s symptoms, especially when it is caught early, may add to that pressure, even if the better course would be to continue monitoring the person before they start a medication.

“There may be a lot of clinicians who, if they can’t find a better explanation than MS, may be inclined to diagnose MS, even if they don’t really meet our diagnostic criteria, because they’re worried about missing a window of opportunity to treat somebody,” Solomon said.

There is reason to hope the MS misdiagnosis problem could get better. The National Multiple Sclerosis Society released new diagnostic criteria in 2024 that Solomon said more physicians should become familiar with to better distinguish MS from problems like migraines or vascular disease. And because imaging is involved in diagnosis, there is optimism that AI could be a powerful new tool in delivering more accurate results.

What everyone should know about MS symptoms and diagnosis

The good news is that MS, when diagnosed properly, is a treatable condition these days. “The prognosis with new drugs is extremely good for long-term care,” Sadiq told me. “If patients stick to treatment at a good MS center, you can look forward to a life without disability in 2026.”

So it is worth being vigilant and talking to your doctor if you experience any concerning symptoms. You should seek care if you have numbness or pins and needles that persists for more than 24 to 48 hours, Sadiq said, or have motor problems, like one hand won’t work as you try to play piano. Dr. Annette Langer-Gould, who develops and evaluates programs for MS care at Kaiser Permanente, said numbness in your abdomen, chest or back, as opposed to your extremities, is a particular cause for concern. If one eye has normal vision and the other is blurred, that’s another good reason to get checked out. 

If you do get tested, make sure the actual images of your MRIs end up being reviewed by an expert in MS. “The most common reasons the disease is still misdiagnosed are related to the providers’ lack of expertise usually in reading MRI scans,” Langer-Gould said. The spinal tap may sound scary, and doctors sometimes don’t recommend them because their insurance reimbursement is low — but they add to the confidence of a diagnosis. They are worth it, she said.

“American patients are very afraid of the spinal tap,” Langer-Gould said. “My message to patients is: Listen, just get the spinal. This way we’ll be sure.”

And do not be afraid to seek a second opinion for such a serious diagnosis, Sadiq added. Every state has a recognized MS center. If your doctor is diagnosing you with MS, ask directly: What’s the evidence? If your doctor is recommending that you start treatment, it could also be worth checking whether they have a relationship with a pharmaceutical company that affects how you perceive their judgment, Langer-Gould said.

People who have already been diagnosed may also be shaken by the Applegate news and question whether their own diagnosis might be wrong. Solomon said that folks should have a frank conversation with their physician about how exactly their case met the diagnostic criteria. With proper imaging and the spinal fluid tests, you can get to a confident diagnosis for the vast majority of people. But be your own advocate to make sure you’re satisfied.

“For many people, the diagnosis actually can be very straightforward,” Solomon said. “We really have no question about what it is.”

Wall Street is sending the public a dire warning: President Donald Trump has become a threat to the very foundation of American freedom — your frequent flier miles.

Okay, America’s big banks haven’t been using rhetoric quite that grandiose. But they are accusing Trump of imperiling Americans’ credit card rewards. 

The feud between Wall Street and the White House centers on the Credit Card Competition Act (CCCA). Long stalled in Congress, that legislation aims to drive down the “swipe fees” that merchants pay to banks when customers use credit cards. In theory, if those fees fall, retailers might pass on some of the savings to consumers, in the form of lower prices.

Trump first endorsed the bill in January. But he’s ramped up his advocacy for it recently, amid a broader (belated) push to address voters’ affordability concerns ahead of November’s midterms. Last week, the White House urged Congress to “put Main Street over Wall Street” by enacting the law. On Monday, Trump praised Kansas Sen. Roger Marshall for “working tirelessly to pass the Credit Card Competition Act, in order to stop the out of control Swipe Fee ripoff!”

The financial industry is used to taking fire from Trump right before Election Day, then receiving favorable treatment from him thereafter. But in this case, Trump’s threat is not entirely idle. Large retailers are lobbying hard to get the Credit Card Competition Act passed during December’s lame-duck congressional session. Banks have responded by issuing a “code red,” in the words of the Wall Street Journal. In recent days, their lobbyists have warned policymakers that, if swipe fees fall, credit cardholders’ cash rewards and travel points will go down with them.

In truth, the consequences of the Credit Card Competition Act are uncertain. But if the banks’ big-picture story is right — and the law cuts both swipe fees and credit card rewards — that would probably benefit the average American.

Poor people pay for your travel points

To see why, we need to first examine how the credit card system currently works — and whom it does and doesn’t benefit. 

Whenever you use a credit card to purchase a banana from Aldi, or volleyball from Dick’s, or an adult-sized Grape Fanta Can Halloween costume from Party City, the retailer must pay a fee to the bank that issued your card. The bank then uses that revenue to fund your rewards.

Critically, merchants don’t just eat the costs of swipe fees. Rather, they pass on part of the expense to consumers, in the form of higher prices. Some businesses concentrate these price hikes on card users (for example, barbershops often charge less if you pay with cash). But most retailers charge every customer the same price, regardless of their payment method. 

For this reason, shoppers who pay with cash or debit effectively subsidize those who pay with cards: The former face higher prices than they would in a world without credit cards, yet they receive no “cash back” or travel points in recompense. 

This arrangement seems unfair on its face. But it is especially troubling when one considers class disparities in the use of credit cards and receipt of rewards.

As a general rule, the higher a person’s income, the more they use credit cards. In 2024, US households who earned less than $25,000 a year put just 17 percent of their payments on credit cards; among households earning more than $150,000, that figure was 51 percent, according to Federal Reserve data.

What’s more, the rich are also more likely to qualify for premium cards that charge merchants exceptionally high fees, in order to fund extraordinarily lavish benefits. 

As a result of all this, swipe fees effectively redistribute money from poor and working-class people to affluent and wealthy ones. According to a 2026 working paper from the National Bureau of Economic Research, the credit card system takes, on average, $88 a year from households with annual incomes below $150,000, while delivering an average yearly benefit of $390 to households with incomes above that threshold.

American swipe fees are too damn high

To be sure, this does not mean that lower-income Americans would be better off in a world where credit cards didn’t exist. Such cards serve a variety of valuable economic purposes, from helping households weather unexpected expenses and irregular incomes to facilitating online commerce. And maintaining a credit card system costs money: Banks need to finance the loans they extend, while payment networks must maintain vast computer systems to process transactions and detect fraud. 

Yet America’s credit card system is needlessly expensive. Our nation’s merchants — and thus, consumers — pay far higher swipe fees than their counterparts in other rich countries. 

To take one illustrative example: When an American buys $100 worth of groceries using a standard Visa card, the supermarket must pay the issuing bank a minimum of $1.23. Some disfavored stores must pay as much as $1.57 on such a purchase. If a customer uses a premium “Visa Infinite” card, meanwhile, the grocer’s fee can run as high as $2.07.

By contrast, in Canada, a grocery purchase worth $100 US dollars would incur a fee worth 95 cents if the customer used a standard Visa card. 

In Australia and the European Union, meanwhile, government regulations would cap that fee at 30 cents (or .3 percent), no matter what kind of card was used. 

Suffice to say, Australia and the EU manage to sustain functional credit card systems, despite charging merchants a tiny fraction of the swipe fees absorbed by US businesses. And although retailers have pocketed some of these savings, research suggests that fee caps have also lowered consumer prices. 

This affordability gain does come at a cost; American cardholders do tend to reap higher rewards than Australian or European ones. But this is not a good trade from the standpoint of economic justice; few think it is fair to take money from the poor to give to the rich.

The Credit Card Competition Act might not work

All this said, whether the Credit Card Competition Act would actually yield those outcomes is uncertain. The bill does not directly regulate swipe fees. Instead, as the name suggests, it aims to give credit card companies greater competition. 

Today, each time you buy an adult-size Grape Fanta Can Halloween costume with a Visa, Party City is required to process your purchase using Visa’s network. Which means it needs to pay whatever swipe fee Visa decrees. The store can protest an exorbitant rate by refusing to accept Visa cards. But this would send a large number of customers into the hands of Spirit Halloween. So its leverage is limited.

Under the CCCA, however, Party City would be able to accept Visa on a transaction — without necessarily using Visa to process the payment. Instead, the bank that issued the customer’s Visa would need to provide Party City with at least one alternative payment processor — a different network that has no relationship with Visa and which might offer lower fees. 

The law’s authors hope — and the banking industry fears — that this mandatory competition will force down swipe fees. But it’s not clear how much of a difference the CCCA would actually make. 

After all, under the law, banks would still get to choose the alternative payment network available to retailers when their customers pay with Visa (or Mastercard, or American Express, etc.). Party City would no longer need to pony up whatever Visa asks when a shopper pays with a Visa-Bank of America card. But if the store did decline to use Visa’s network, it would then need to partner with Bank of America’s hand-selected alternative. And since banks benefit from high swipe fees, BofA would have an incentive to pick an expensive backup option.

Nevertheless, the banks and retailers both seem to believe that the CCCA will sharply reduce swipe fees. If they’re right, then Congress shouldn’t vote down the bill, merely to protect affluent Americans’ travel points. 

It doubtlessly feels nice to receive a free flight or hotel stay, as a reward for spending a lot of money on yourself. But the poor probably should not have to pay higher prices, just so the affluent can enjoy such satisfactions.

If you live in Colorado and buy your own health insurance, there’s a good chance you’re one of the 139,000 people enrolled in a public plan crafted by your state leaders. You’re paying $0 for primary care visits and certain mental health visits, $0 for prenatal and postnatal care, and you don’t have to meet your deductible first.

On average, enrollees in these plans pay an estimated $14 to $33 less a month in premiums than people in comparable plans, and their annual out-of-pocket spending has fallen about 15 percent while holding steady for everyone else on the marketplace. 

Colorado didn’t build a government insurance company, rather, it designed the plan itself, down to the copays, and then required private insurers to sell it alongside their own.

A public health insurance option was supposed to be part of the Affordable Care Act. President Barack Obama supported the idea throughout his time in office, endorsing a government plan that could, in his words, “keep insurance companies honest” by giving them a government-backed competitor. But the idea was stripped from the bill before passage, after it became clear Senate leaders couldn’t get garner enough votes. Joe Biden campaigned for president on reviving a public option in 2020, but he never prioritized it once in office, and the progressive activists who championed it under Obama largely turned their sights to single-payer health care, which would cover all Americans.

The problems a public option was intended to address — access, costs, reliability — have still not gone away and a growing number of policy wonks and elected officials have started to ask if the idea deserves a spot again on the national agenda. 

Healthcare costs are soaring, and voters tell pollsters it’s among their top economic concerns. Medicaid work requirements are set to take effect in January, which could leave millions of low-income Americans uncovered, and private insurers have asked to raise ACA marketplace premiums by a median of 15 percent next year, after a roughly 20 percent hike in 2026. Two-thirds of adults say they favor a national government health plan, and polls suggest most voters imagine proposals like Medicare-for-all as a competitor to private insurance, rather than a systemwide replacement.

While the debate around public options stalled in Congress, three states have gone ahead and built their own. Washington state launched a public option in 2021, Colorado in 2023, and Nevada earlier this year. They all built on a provision of the Affordable Care Act that lets states apply to run their own version of the law — one Sen. Bernie Sanders fought for in the hopes that Vermont would use it to build a single-payer system.

Their experience also shows the challenges involved: Not only in overcoming political objections from competing insurers, but medical providers as well, who may have to accept lower payments in order to keep the public option’s premiums affordable.

Colorado leaders say this push to control costs was critical to their success.

“The driving point behind what we were doing was to set hospital prices,” said Michael Conway, Colorado’s insurance commissioner and an architect behind the program. “That was what we were driving towards and that’s what we did.”

It’s not clear if other states, or the federal government, will be willing to pick those kinds of fights with the broader medical industry. But if ever there was a time for it to happen it would be now, with affordability a massive political issue, and the public seemingly eager for serious action on health care. Just as the ACA began with a state-level experiment in Massachusetts, the success or failure of these early public-option states could presage much bigger changes nationally.

What Colorado did

The motivation behind the public option in Colorado was simple enough: Healthcare was simply becoming too expensive.

Dylan Roberts, the Colorado state senator who sponsored the bill, represents mountain counties that had some of the highest individual-market premiums in the United States.

“Back then, the top issue on the minds of my constituents was the cost of healthcare and the cost of health insurance,” Roberts told the Century Foundation, which interviewed the officials and advocates behind the Washington and Colorado programs for a report last year.

Colorado Gov. Jared Polis made the issue a priority as well. One of his first acts in office was creating an Office of Saving People Money on Healthcare, run out of his lieutenant governor’s office.

When the state finally moved, it moved against unified opposition. Hospitals and insurers were lined up against essentially everything public officials proposed. Roberts described the opponents as “basically anybody in the status quo health care industry” — meaning insurers, doctors, hospitals, and pharmaceutical companies.

Colorado first introduced a bill for a state-run insurance plan, where the state itself would sell coverage. This is the kind of arrangement closest to Obama’s ACA vision, and what most people think of when they hear “public option.” 

“It was really in large part to scare the bejesus out of the insurance companies that we were going to really come in and truly be a state-run competitor against them,” Conway, the state’s insurance commissioner, said last month at a panel in Washington, DC.

But then in 2021, when Colorado officials mapped out what building a state-operated insurance company would involve, they concluded that a state-run plan would not have been able to sell a single policy until 2025 or 2026.

Officials decided that was too long given the urgent need, so they rewrote the bill before it passed, requiring the insurers already operating in Colorado to sell a marketplace plan the state would design. This coverage launched in 2023.

“We would just be starting today if we actually truly stood up a public option,” Conway said on the late September panel. He thinks this is what the federal debate around a public option keeps getting wrong. “People want action now. They’re pissed off, they’re hurting. … They don’t have four years to wait.”

Importantly, while hospitals in Colorado were not mandated to participate, the state gave itself the power to force them. Colorado gave private insurers a target: By 2025, the state-designed plans had to cost 15 percent less than that insurer’s plans had cost in 2021, adjusted for inflation. How they got there was up to them, but an insurer can only squeeze its own profits and overhead so far. So the rest effectively had to come out of the costs insurers paid to hospitals. And if an insurer missed the target, the commissioner could haul both the insurer and the hospitals responsible into a public hearing to defend their prices — and then order the hospitals to take less.

That threat of a hearing was a powerful enforcement mechanism. “No one wants to be called in front of a public hearing where press are going to be there,” Kyla Hoskins, Colorado’s deputy insurance commissioner, told the Century Foundation. The hospitals cared about that more than the insurers did, according to Conway. The state launched complaints against nearly every carrier in the individual market and then pulled hospitals in with them. After that, according to Adam Fox of the Colorado Consumer Health Initiative, the price negotiations started happening, meaning no enforcement hearing actually took place.

Doctors complained early, but Conway said hospitals were the harder fight. The state worried that a single large hospital system refusing to participate could sink the entire plan, but in the end, no hospital refused. 

The result is the Colorado Option, a standardized plan that every insurance company in the state’s individual and small-group markets has to sell. There are 36 of these plans on the individual market for 2026. 

And people are choosing it. Enrollment went from about 14 percent of the state marketplace’s customers in 2023, the first year, to a third in 2024, to roughly half today.

Researchers at Brown University found the savings weren’t limited to the public option. Across Colorado’s individual market, the cheapest silver plans — a benchmark middle-tier ACA plan — now cost more than $100 a month less than equivalent plans in similar states.

Not everyone is celebrating Colorado’s policy development. Two industry-funded groups, the Partnership for America’s Health Care Future and its state affiliate Colorado’s Health Care Future, have campaigned against the program for years, citing a 10 percent rise in individual market premiums in its first year, and a 2024 report they commissioned from Hoover Institution researchers, which estimated Coloradans in public option plans collectively paid $13.3 million more in 2023 than if they had chosen the cheapest nonpublic options plans. 

Andrew Shermeyer, a doctoral candidate in health policy at the University of Minnesota, found the program made coverage cheaper for people receiving federal subsidies but more expensive for those who don’t. Hoskins, who oversees the program, disputed that, pointing to the Brown analysis finding premiums fell across the state, including on private plans.

Cara Welch, a spokesperson for the Colorado Hospital Association, pointed to the looming Medicaid cuts with HR 1. “Public option plans that would further weaken the healthcare system and shut doors to care are the wrong solution,” she told me.

How the public option died in 2009, and where it went

While states are working to implement their own public options, a national version would still have to overcome the same barriers it faced the last time it was tried.

The original idea for a national public option was a government-run insurance plan that would be sold on the new Obamacare exchanges, next to the private plans. 

Jeanne Lambrew, who worked on the Affordable Care Act in the Obama administration and now directs health care reform at the Century Foundation, said on the DC panel that there were several reasons that made that particularly hard at the time, and that she doesn’t think those reasons have been resolved. 

The first challenge was determining who would end up in the plan, because if sick and expensive patients concentrated in the public option, then it would cost too much to run. But if sick people were concentrated in private plans instead, that could also make it too expensive for those insurers and they could pull out of the market. Something like that second scenario, what economists call “adverse selection,” played out in the early years of Obamacare, when insurers raised prices and pulled out of unprofitable areas, leaving some counties on the brink of having no insurer at all.

The second challenge Lambrew outlined is whether doctors and hospitals would take the public plan, and what they would get paid. In 2009 Democrats pitched participation in a public option as voluntary, which was a problem because it meant that in order to induce the most desirable doctors or the hospital everyone wants, the government would have to pay them high enough rates — which would make the savings effectively disappear. 

The third challenge was whether a government agency would sell insurance directly, or whether private companies would sell a plan the government designed, as Colorado later decided to do. 

While the public option was ultimately cut from the Affordable Care Act, what survived was a provision letting states apply for federal waivers to try their own designs, so long as coverage stayed as broad and affordable and didn’t cost the federal government more. 

That provision’s biggest champion was Sanders, who wanted Vermont to use it to build the first single-payer system in the country. Though Vermont tried and gave up in 2014, the clause instead became a legal opening for Washington, Colorado, and Nevada to later use. So although the ACA didn’t include a public option, Lambrew emphasized, it still built the path to the ones that exist now.

Washington state went first, passing its law in 2019, and made the opposite choice from Colorado on hospital mandates. Instead Washington asked hospitals to participate voluntarily, and many unsurprisingly didn’t. In the first year the plan was sold in 19 of the state’s 39 counties, cost about 11 percent more than the cheapest comparable plan, and drew roughly 1 percent of enrollees.

So the legislature went back and passed a second law in 2021, this time requiring hospitals to contract with at least one public option plan if one made them an offer. The requirement took effect for 2023, and enrollment has climbed every year since. By 2025 the plan was available in every county in the state. About 115,000 people signed up for a public option plan for 2026, or roughly 40 percent of Washington’s marketplace.

Nevada’s plans went on sale this year, and the state gave itself the least leverage of the three. It sets premium targets but cannot set hospital rates, and it suspended its provider participation requirement for the program’s first year. Enrollment has come in below projections. “The story is unfinished here,” Lambrew said of Nevada.

Taking the public option national

The hospital industry uses the plight of rural hospitals, which are often struggling financially, to argue against public options or the government getting involved more generally to lower costs. 

Healthcare reformers tend to respond by exempting rural hospitals from price caps, though Conway, Colorado’s insurance commissioner, says that is a mistake. Rural hospitals are generally paid far less by private insurers than large systems are, and at the price levels under discussion, he said, a cap would actually represent a raise for most of them. Tell a rural hospital it will get three times what Medicare pays and “they would think you were the savior,” he stressed.

Conway has been getting a lot of calls from other states interested in adopting what they’ve done. But in every conversation he’s blunt with the person on the phone, saying they’d have to be prepared to take on hospital prices. “When I bring that up with other states, the appetite isn’t there right now,” he said on the September panel.

Conway blames Medicaid cuts for the reticence. The Congressional Budget Office estimates 7.5 million Americans will lose their health insurance by 2034, and states bracing for that are not eager to pick fights with hospitals at the same time. Undoing those Medicaid cuts, Conway said, is “an incredibly important floor” and “the foundation to actually doing anything else past that.”

The federal government does have one tool that Colorado and other states lack: a public insurance program that already exists. Hannah Garden-Monheit, a former Federal Trade Commission official on the healthcare panel, pointed out that Medicare, unlike a private insurer, is “a price setter, not a price taker.” Meaning it can announce what it will pay rather than negotiate for it. Some public option proposals in Congress would let people buy into Medicaid through the marketplace, or create a new plan that pays what Medicare pays, instead of building something from scratch. 

Roberts, who sponsored the Colorado bill, told the Century Foundation that the goal should be saving customers money, getting more people insured, and getting them the care they need. He said what the public program “actually looks like at the end of the day doesn’t matter as much as the outcomes of the product that people have.”

Laura Kate Zaichkin, who runs competition and affordability at Washington’s exchange, says the path to a workable public option might not be easy, but the rewards are worth it.  

“It takes a lot of political will, collaboration with partners, thoughtful design and implementation,’ she told the Nation’s Health. “It is a long-term investment that states can make to lower healthcare premium costs.”

With Democrats potentially set to expand their statehouse presence after the midterms, there may be more room to act on healthcare in other states next year. Even if Democrats don’t end up enacting a public option at the federal level, they could boost states in their efforts by restoring Medicaid funding, which could give lawmakers more room to stand up to health providers on costs. If these public options continue to grow, they might end up an unexpected ACA legacy.

Twelve years ago, Vermont Democrats tried to make their state the first in the nation to have a single-payer government-financed healthcare system — a bold experiment to push the limits of American health coverage when Obamacare was just being launched.

Their plan failed, and rebooting it became politically impossible, even in Vermont: The Democrats lost the governorship to Republican Phil Scott for what turned out to be a decade.

This year, that could finally change. A progressive political newcomer named Amanda Janoo is taking on Scott in what polls show is a tight governor’s race.

And if she wins, the state could be poised to try a whole new national experiment: One of Janoo’s central campaign promises is to create a pioneering health system where the state pays the full tab for primary and preventive care, while leaving the rest to the existing system.

Janoo’s candidacy is an example of the policy experiments that are becoming possible nationwide in a projected “blue wave” year, when Democrats could sweep into power in a number of states. But in the healthcare universe, her plan is also an example of how even progressive policy idealists are trying to learn from past failures and focus on what they think can actually be achieved.

Compared to the sweeping ambition of Vermont’s 2014 effort, or Bernie Sanders’s signature “Medicare-for-all” idea, Janoo’s proposal for single-payer has very specific limits. Under Janoo’s proposal for “universal primary and preventive care” (she typically avoids the term “single-payer”), the state government would pay for Vermonters seeing primary care providers such as doctors and nurse practitioners. This government coverage would be universal and free for patients, and insurance companies would be cut out.

However, other parts of the health system — such as hospitals, specialists, and prescription drug companies — would remain under the existing insurance system, for now.

Every effort so far to enact full single-payer at the state level has failed — even in blue states, bills and ballot initiatives have regularly gone down to defeat. Vermont’s previous single-payer experiment made it the furthest — it was signed into law but abandoned before being implemented, when the governor concluded it was unworkable. Wherever it’s gained steam, politicians and voters have blanched at the high costs of moving their health systems onto state budgets, and the high taxes that would be necessary to fund them.

Now, Janoo is making an attempt to refurbish single-payer as something more achievable, by cutting off a smaller slice of it.

“I think it’s clear at this point that a profit-oriented healthcare system is a terrible idea,” Janoo told me in an interview on Monday. But after assessing that the state budget made it “unrealistic” to do single-payer immediately, she concluded, “we could do universal primary and preventive care,” financed by a tax on the wealthiest.

Indeed, single-payer for primary care seems more achievable precisely because primary care is a relatively less expensive part of the healthcare system. But Janoo hopes it will pay major dividends — that better preventive care will improve Vermonters’ health, reducing costs elsewhere in the system by, for instance, making some hospital visits unnecessary.

In speaking to health policy experts about this idea, I heard much sympathy for the goal of universal primary care, but many questions about the details. Would Janoo’s plan be sufficient to bring more primary care doctors to Vermont — and, not unrelatedly, would it pay them more? Would her hoped-for cost savings from preventive care actually materialize? Is picking up the tab for a relatively less expensive part of the healthcare system the best use of sparse state funding?

These questions are becoming national ones, as healthcare gains traction as a political issue again. It isn’t just Vermont where primary care reform ideas are gaining steam: Democrats in Minnesota, Washington state, and elsewhere have discussed them. “There is growing interest in a number of states across the country in doing a universal primary care for all program,” Kevin Grumbach, a family physician and a professor of family and community medicine at the University of California San Francisco, told me. Even Scott, Janoo’s opponent, signed a law calling for a study of universal primary care.

One dividing line emerging, though, is whether to keep insurers involved, or to clear them out with a single-payer system, as Janoo wants. Insurers are unpopular with the public, but they can be a formidable political opponent when they argue that the benefits voters currently enjoy might be lost. Scott has said that the idea of universal primary care is appealing — but that if universal is “just code for single payer, I’m not interested. We’ve already been through that.”

Yet Janoo is hoping that single-payer for primary care will be a stepping stone — a trial run for eventually making the rest of the state’s health system single-payer down the road.

“I think about this often,” Janoo told me. “How do you build the new system as you transition the old — or hospice the old?”

Amanda Janoo is tired of “corporate neoliberal bullshit”

Janoo has long been an unorthodox economic policy thinker. Her rise is part of a broader trend in which progressives and leftists are winning primaries and gaining influence in the Democratic Party — but she doesn’t fit the prototype of the democratic socialist candidates in New York City, Colorado, and elsewhere who’ve gotten much attention this year. Instead, she comes from a different strand of the left, a movement based on a dissident strain of economics and openly skeptical of the benefits of economic growth.

Dating back to when she graduated from college in 2010, in the aftermath of the financial crisis, she was part of a younger cohort rebelling against what seemed the glaring failures of the economic establishment. “The one thing coming out of university I was clear on was that neoliberalism was the worst,” Janoo said on a podcast last year. “This whole idea that governments should just take a hands-off approach to the economy and trust in sort of the disciplinary powers of the global free market to lead them to infinite growth seemed highly problematic and very anti-democratic.”

So for graduate school, Janoo attended Cambridge to study development economics under the “heterodox” economist Ha-Joon Chang. She then spent several years working abroad in international development for the United Nations and other organizations, before moving back to Vermont and working as an economic policy consultant.

In recent years, Janoo became deeply involved with the “well-being economy” movement: an international group of advocates, academics, and experts who criticize what they deem modern capitalism’s obsession with economic growth, and say the “well-being” of humans and the environment should be prioritized instead. They overlap with the “degrowth” movement, which outright argues economic growth should be reduced; last year, Janoo led a workshop at a DeGrowth Institute event on “Degrowth Policy Design.”

Trump’s return to power horrified Janoo. “I’m feeling angry about the rise of fascism and the growing threat of world war, because I feel like we don’t have time for this shit,” she said in a speech at an environmental event last year. ”The planet is on fire and ecosystems are collapsing, and that should really be the focus of all of our attention.” But, she said, “I believe I was born in this moment of history for a reason” and vowed “to fight for democracy — for life.”

So Janoo decided to jump in the race for governor of Vermont. While she is not running on a degrowth platform, her campaign is deeply informed by aspects of the movement’s thought: skepticism about growth’s benefits, a sense that untrammeled capitalism is leading the world to disaster, and that localism provides a better way. For instance, candidates for governor typically pledge that they’d help bring business investment in, but Janoo said in a July debate: “A lot of the problems we’re facing is because we focus so much on attracting external business.” 

“Our economy is not super-diversified, and it is not really centered in the most essential kinds of goods and services you want to make sure people have access to no matter what happens — because honestly, things are bad now and they’re going to get worse,” Janoo told me. “I feel a little bit like a collective prepper right now. My motto is, protect what we love, produce what we need.”

In the Democratic primary, Janoo’s opponent, Aly Richards, had closer ties to the party establishment and led in fundraising. But Janoo ran as a progressive outsider; she promised to advance a “more economically populist vision” instead of “corporate neoliberal bullshit.” Her health plan became a point of contrast with Richards, who said she wouldn’t run on “magical thinking,” and that she wanted a version of universal primary care that would keep insurance companies involved. Janoo won the primary by 2.5 percentage points.

Now, she’s facing Governor Scott, who’s long been viewed as politically untouchable in the state — in 2024, he won his fifth two-year term by a margin of 52 points. But polls show a much closer race this time around, and Janoo could have a national blue wave at her back. If that wave helps carry her into the governor’s mansion. And if she makes it there, Vermont will have its first Democratic trifecta in a decade — and with it, the opportunity for major progressive policy change.

Amanda Janoo’s plan: Single-payer for primary care

Advocates for primary care reform argue that it should be at the top of Democrats’ agenda, in Vermont and elsewhere, because the system is in crisis.

Primary care providers are overwhelmed and underfunded, they say — and, as a result, there aren’t enough. Grumbach, the family physician and UCSF professor, said “the workload, the lack of resources, and the gap in compensation” — as compared to more highly paid specialists — “has made it very hard to recruit people coming out of medical school to want to be family doctors like me.” 

Patients, then, are having trouble finding doctors they like, and aren’t getting sufficient access to preventive care that could help them be healthier. “The emergency rooms are functioning and doing a lot of the work that normally primary care would do,” Janoo told me. “People are waiting a really long time to see anyone, and so often health issues that could have been caught sooner become more serious and dangerous.” 

Finally, both providers and patients complain that insurance companies make the preceding problems worse, by adding administrative burdens and bureaucratic hassle. 

So what would Janoo’s plan do?

First, her plan would guarantee free, government-paid primary and preventive healthcare for all in the state, by cutting insurers out of that part of the system.

Second, she wants to phase out the “fee-for-service” model of care, where primary care providers are paid based on specific services. She’s suggested, instead, either government-paid annual salaries, or per-patient per-month payments.

Third, she wants to try and try and make sure there are more primary care providers in the state, via more spending. “We would need some relocation incentives, so maybe $100 grand if you want to move here, or a student loan repayment program,” she told me. “My hope would also be that we could be a place for foreign-trained medical professionals to come here and be safe and accepted and to bring some cultural diversity,” she added.

As for how it would be paid for, Janoo proposes an income tax increase on the wealthiest Vermonters that, she said, would be comparable to the tax break they got in President Trump’s One Big Beautiful Bill Act last year. Though she hasn’t settled on a final amount, she hopes these new taxes would raise hundreds of millions of dollars.

Would Janoo’s plan work in practice?

In speaking with health policy experts both inside and outside Vermont, though, I heard various questions and doubts about Janoo’s plan.

Some of the problems mix the practical and political. For instance, under this plan, primary care visits would be free, but tests such as MRIs would likely still require the existing insurance system, as would most prescription drugs. Janoo acknowledged to me that deciding how many things the government should pay for would “always be a challenge,” but said her first priority was access to getting people at least some healthcare.

There are also questions about whether this primary spending is really targeted at patients’ most urgent problems. Erasing the copay for your doctor visit might be nice, but those copays weren’t driving people into medical bankruptcy. Janoo’s reform plan leaves the bulk of hefty health spending from hospitals and treatments for very sick people untouched.

The core challenge to Janoo’s reform will be the one that has dogged single-payer reform attempts everywhere: money.

Other questions are about whether Janoo’s hoped-for benefits from better preventive care — she’s said the state could save as much as $300 million a year — will materialize.

“There’s no question that better access to primary and preventive care makes people healthier in the end,” Larry Levitt, executive vice president of the health policy nonprofit KFF, told me. “But advocates have long tried to sell prevention as saving money. I think it’s more likely that it costs money, but keeps people healthier.” One reason for this, he said, is that better preventive care could help identify more underlying illnesses and conditions in patients, and spur more spending to try and address them.

The shift to a salaried model for providers could bring other practical challenges. Though Janoo hopes that ditching fee-for-service will free up providers to see more patients, others suspect a guaranteed salary might incentivize them to see fewer, and wonder what role the government would play in trying to hold such providers accountable.

Finally, I also heard some disconnect between what providers said they wanted, and what Janoo thought they wanted. When we talked, she told me her impression was that primary care providers were most eager for changes in their work environment. “I’ve asked them, ‘If you could get paid a good annual salary — like, average for the nation — and you didn’t have to deal with insurance and the fee-for-service structure, would you do that?’ They say, ‘Absolutely.’”

Yet Grumbach told me that, for the primary care system, “Problem number one is not enough money, problem two is not enough money, and problem three is not enough money.” In his telling, it’s more money that’s the real key to incentivize more new doctors to practice primary care, and help pay other staff and health workers who could actually deliver good preventive care.

If so, the core challenge to Janoo’s reform will be the one that has dogged single-payer reform attempts everywhere: money.

If the government takes on the responsibility of paying primary care providers and setting salaries for them, providers will want those salaries to be high. If they aren’t high enough, the shortfall in primary care providers will worsen. But the higher such salaries are, the higher the taxes the state would need to raise to pay them. Essentially, taxpayers would be asked to shore up doctors’ salaries to keep them in the state — turning the healthcare argument from one kind of difficult political issue to another.

Getting the balance right would be a challenge for the government, with much at stake. But Janoo says her background in industrial policy has convinced her that it’s possible. Furthermore, she hopes, it will be just a starting point for the full single-payer system she still thinks is urgently needed.

“​​My hope is, when I’m governor, that I can start to work with some of our neighboring states,” Janoo said. “Because if we could create a New England-wide system, we could move to universal healthcare really quickly. “I think it’s a moment where people recognize we need a universal healthcare system.”

And, she added, “If we had done it previously, it would be much cheaper than it is now.”

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

Welcome to The Logoff: Donald Trump wants to deport a member of Congress. 

What’s happening? On Monday, Homeland Security officers raided the Washington, DC, home of US Rep. Ilhan Omar (D-MN) in an investigation reportedly tied to immigration paperwork filled out by her father when she was a minor.

That was, at the time, more than enough cause for alarm. Trump’s animosity toward Omar, who is Somali-American and an outspoken critic of the administration, is well-known, and the raid is an extraordinary violation of the Justice Department’s usual rule to avoid taking visible action around politically sensitive cases within 60 days of an election. 

On Wednesday evening, however, we learned more about the raid from the Wall Street Journal. The Omar investigation, the Journal reported, is explicitly aimed at stripping Omar of her citizenship — and thus her ability to hold office — and deporting her. 

How would they do that? Omar came to the US as a refugee when she was 12 and became a US citizen when she was 17. The Trump administration’s investigation is said to focus on whether she or her family misrecorded her age in order to more easily gain citizenship. 

The government cannot unilaterally denaturalize a citizen, however; it would have to ask a court to do so.

What’s the context? Historically, it’s rare for the US to strip citizenship from naturalized US citizens. But doing so at volume has been a major, if less visible, priority for the second Trump administration. 

As of earlier this year, NBC News reported, DOJ was targeting hundreds of people for possible denaturalization, and has reportedly hoped to put forward hundreds of new cases per month (though successfully stripping them of citizenship is another matter).

Why does this matter? Trump’s campaign to bend the traditionally nonpartisan DOJ into a tool to punish and harass his enemies has been one of the major stories of his second term. 

Even if it never advances beyond Monday’s raid, an investigation targeting Omar’s citizenship with the eventual goal of deporting her from the US represents a new and even more dangerous evolution of that effort — and it threatens to move the US to a far darker place, where citizenship and the rights it guarantees are predicated on the president’s goodwill.

And with that, it’s time to log off…

Hi readers — if you’ll allow me to depart a little from my normal approach to this section, I have a story about politics to share. It’s not, however, about the politics we’re currently dealing with, but about what could be: Democrats’ plan for a quietly ambitious “Project 2029” should they win the White House in 2028. You can read it with a gift link here.

Alternatively, if you’d prefer to just log off, here’s an adorable snow leopard cub with massive paws. Thanks for reading, have a great evening, and we’ll see you tomorrow!

The promise of GLP-1 drugs has always depended on people being able to afford them. These drugs still cost hundreds of dollars per month if you’re paying cash, at which point access becomes a privilege: The higher-income executive who wants to trim a few pounds might be able to afford them either way, but the low-income worker who needs the drug to lose significant weight might not be able to afford them — unless their health insurance covers it.

For a while, the trend lines for GLP-1 insurance coverage were positive. As of 2026, roughly two-thirds of private employer plans, which insure half of Americans, were covering GLP-1 medications for weight loss to treat obesity. Over the summer, Medicare launched a new $50-per-month prescription program. The US has struggled with an obesity epidemic for decades, but it looked like powerful drugs to treat it were finally starting to be more seamlessly integrated into the health system.

At least that’s how things appeared earlier this year. But now, private plans are pulling back from GLP-1 coverage. People are being left in the lurch, debating whether to try to pay for these drugs on their own or stop taking medicines they feel are making a real difference for their health.

The dilemma reveals one of the structural flaws in American healthcare. For working-age adults, your insurance depends on your job. Unfortunately, because people no longer stay at the same job for decades, there is not a strong financial incentive for employers to make investments that will benefit your health in the long term — but there is a strong incentive to minimize short-term costs as much as possible. It’s the kind of perverse rationale that could compel employer-sponsored health plans to stop covering a drug that, if taken over the full course of a person’s life, could help them not only lose weight but ultimately reduce their risk of heart disease, kidney disease and other chronic health problems, improving their health and saving all of us money as they get older.

“An employer or an insurer making coverage decisions doesn’t necessarily care if they’re saving Medicare money,” said Dan Sacks, a healthcare economist at the University of Wisconsin-Madison. “That’s a classic problem with the American health insurance system, and it’s certainly salient here.”

This mismatch between what’s good for people’s health and what’s good for the corporate bottom line has long been one of the underlying flaws in the US health system. Now access to GLP-1 drugs is shrinking just as these drugs were starting to make a real dent in the US obesity crisis. The stakes couldn’t be higher.

Why employer-sponsored health plans are suddenly dropping GLP-1 coverage

From the beginning, insurance coverage was the big question hanging over GLP-1s and their potential to revolutionize US healthcare. But recently, it looked like we’d turned a corner.

When I attended the Aspen Ideas: Health festival over the summer, pharmaceutical reps seemed visibly relieved that GLP-1 coverage had been picking up among private insurers. In 2026, about two out of every three employer-sponsored plans were covering some of these drugs for weight management, up from about 20 percent just the year before.

“They’re recognizing that this is an investment in their workforce,” said Laura Steele, who leads the cardiometabolic health unit at Eli Lilly, which manufactures Zepbound and Foundayo. “Yes, there is a budget, and there is a benefit design that every employer has. That’s real. That’s not going away. But they’re also recognizing the overall cost that they’re experiencing by not dealing with this too.”

But as employers and private insurers make coverage decisions for next year, they are suddenly pulling back. At least 10 percent of employer plans that currently cover GLP-1s for weight loss say they are likely to discontinue coverage in 2027, according to one survey by the Business Group on Health — and that number may still increase. A Mercer survey of large employers found that 6 percent had dropped coverage in 2026 and another 5 percent were planning to in 2027 or actively considering it. A separate report from the Health Policy Commission in Massachusetts found that the number of commercially insured people in the state taking a GLP-1 drug had fallen by 50 percent between 2025 and the first quarter of 2026 as private coverage started to drop off. 

Some of the biggest brands in the US are reportedly eliminating or reducing their coverage: PepsiCo, Starbucks, and Lowe’s among them. And their reasons are simple: It’s too expensive. The drugs still carry a high net price tag — $600 or more for a 30-day supply — and potential demand is high (two in every five American adults have obesity). 

When a lot of people start taking an expensive medication all at once, it’s going to raise costs for employer insurance plans — and they have to figure out how to adapt. Insurers set premiums at the start of each year, based on how many people are on the plan and how much healthcare they are expected to need. But if those estimates are off — say, if more people take an expensive GLP-1 drug than the insurer expected — they have to offset those costs somehow, and raising premiums the following year is a common solution. According to one estimate, premiums are projected to grow by 5 to 13 percent due to GLP-1 costs — and the burden of paying those higher premiums is likely to fall on the workers. The employer can also try to limit GLP-1 use by, for example, asking workers to pay more out of pocket for these drugs; according to Mercer, 27 percent of large US employers instituted some kind of utilization controls for GLP-1 drugs over the past year or plan to next year.

They also have the option to simply stop covering these drugs for weight loss altogether — and that’s the route more and more of them are deciding to take. The abrupt reversal has even caught economists like Sacks off guard.

“I was surprised that anyone would do an about-face because I thought they understood the trade-offs well,” Sacks said. “My guess is that it turned out to be more expensive than they anticipated: Take-up is higher, and possibly more people are sticking with it. That’s one reason that you might not want to continue to offer it.”

For employers, the short-term costs of covering a drug often outweigh the long-term benefits that medication may confer, at least from the employer’s POV. One analysis — notably produced by Blue Cross Blue Shield Kansas — concluded that covering GLP-1s for weight loss increased average employee health costs by $7,000 in the first year and another $4,200 in the second, largely due to the cost of the drugs themselves. And yet at the same time, there were no decreases in obesity-related medical events in that time period. Another study from Sacks and his colleagues at Indiana University and the University of South Carolina found that GLP-1 use did not lead to any cost savings over five years.

So in the short term, these employers are arguably making an economically rational decision — but one that may still come at their employees’ expense. “I’m completely screwed,” said one person on Reddit about Cigna’s plans to drop GLP-1 coverage for their own employees. They’re looking at at least $300 for one month’s supply at cash prices. 

They weren’t alone either: “I’m devastated,” said another person, commenting on Starbucks’s decision to stop covering GLP-1 drugs. They said they had an autoimmune condition that had made it difficult to lose weight — until this new class of medicines came along.

Where GLP-1 coverage goes from here

How could we end up here, where it makes good business sense for companies to make a decision that could potentially harm their workers’ health in the long term? It is at least in part a result of the haphazard way the US has ended up insuring people.

When employer-sponsored insurance started to arise in the mid-20th century, eventually becoming the primary way to cover the working-age population, people tended to stay at the same job for a long period of time. In theory, there was a synergy: Companies wanted their workers to stay productive, and so it was worth it for the company to invest in their long-term health via their insurance benefits. And research has found that people who stay with the same company — and the same insurance plan — tend to have better health than those who switch a lot.

But these days, people change jobs all the time or work various gigs to piece together an income. You probably don’t expect to stay at your job for 10 years — and your employer doesn’t expect you to either. Instead, they want to keep their own costs as low as possible in the short term. This leads them to cut GLP-1 coverage, even though doctors do believe that people could benefit tremendously long term from the weight loss these drugs help them achieve and all of its potential health benefits. 

“There are very real health benefits of these drugs,” Sacks told me. “The fact that we don’t find offsets or they’re even more expensive than we thought doesn’t necessarily mean that we shouldn’t cover them.”

In theory, the market is supposed to fix the price problem: Drug companies get a period of exclusivity for the drugs they develop, and then, once that time elapses, cheaper generic versions can come onto the market. But generic semaglutide won’t be available in the US until at least 2031 — and for some versions, the generic competitors aren’t going to debut until the 2040s. Offering GLP-1 coverage could become a competitive advantage for employers, a perk they can offer to entice potential workers as part of their benefits package.

Beyond that, though, the path to more affordable GLP-1s is not immediately obvious right now. A lot of people are already willing to pay cash for these drugs — and that may continue as long as people can afford to do it. But with inflation still steadily rising, these drugs could slip out of reach for more and more Americans.

The government could get involved, but, for now, the federal government’s negotiating authority only covers Medicare, not the private plans that are dropping coverage. Serious healthcare reform is probably off the table until at least 2028, and then only if Democrats win both Congress and the White House and decide to make a healthcare package their legislative priority.

But the lesson of these recent developments is that, at some point, the US may have to look seriously at the underlying problem creating this mess in the first place. A patchwork method of insuring people that privileges short-term cost-cutting over people’s long-term health isn’t a real healthcare system.