Public health and access to lifesaving vaccines are on the line in a high-stakes leadership battle at the Centers for Disease Control and Prevention.

Health and Human Services Secretary Robert F. Kennedy Jr.’s push to fire CDC director Susan Monarez is more than an administrative shake-up. The firing marks a major offensive by Kennedy to seize control of the agency and impose an anti-vaccine, anti-science agenda that will have profound effects on the lives and health of all Americans, public health leaders say.

Kennedy wants to see the Pfizer and Moderna messenger RNA-based covid-19 vaccines pulled from the market, according to two people familiar with the planning who asked not to be identified because they’re not authorized to speak to the press. He’s also set his sights on restricting or halting access to some pediatric immunizations, some public health leaders say.

His actions have already reduced federal help to states, creating the potential for more infectious disease outbreaks and incidences of foodborne illness. Some public health leaders say they expect Kennedy will use the CDC to publicize health information that isn’t grounded in science.

“It’s crazy season,” said Richard Besser, former acting CDC director during the Obama administration. “People want information they can trust to make critical decisions about their health. Until now, we’ve been able to say look at the CDC. Unfortunately, we’re not able to do that anymore.”

HHS spokesperson Emily Hilliard disputed the criticism.

“Secretary Kennedy remains firmly committed to delivering on President Trump’s promise to Make America Healthy Again, dismantling the failed status quo that fueled a nationwide chronic disease epidemic and eroded public trust in our public health institutions,” Hilliard said in a statement.

White House spokesperson Kush Desai said Kennedy and Commissioner of Food and Drugs Marty Makary have reiterated that covid shots will remain available for Americans who need and want them.

“The Trump administration is restoring Gold Standard Science as the sole guiding principle of health decision-making,” Desai said in an email. “Only the Fake News could ignore these facts to continue pushing Democrat talking points and hysteria.”

Behind the Ouster

The shake-up began last week, when Kennedy sought to fire Monarez, a microbiologist who’d just been confirmed by the Senate in July. She refused to leave the position, and her lawyers said Kennedy sought to oust her because she wouldn’t fire senior staff or follow unscientific directives. Four top career officials at the CDC resigned on Aug. 27 in protest.

Career staffers at the CDC and some public health groups had hoped President Donald Trump would intervene and put the brakes on Kennedy. Instead, the White House backed Kennedy, saying Monarez was fired.

Trump on Sept. 1 demanded that drug companies show that covid vaccines work, in a further sign he’s not set on defending the shots.

“I hope OPERATION WARP SPEED was as ‘BRILLIANT’ as many say it was. If not, we all want to know about it, and why???” Trump said on Truth Social.

Operation Warp Speed was the initiative that Trump himself announced in 2020 to accelerate the development of covid vaccines, including the Pfizer and Moderna shots. The vaccines have proved safe and effective in multiple clinical trials; a study published in JAMA Health Forum estimated that they saved about 2.5 million lives worldwide.

CDC staffers are worried the agency’s next director won’t fight for science, according to an employee who asked not to be identified for fear of professional retaliation.

Trump’s support for Monarez’s ouster was a watershed moment that signaled there are no checks on Kennedy and his agenda, public health advocates say. Leading congressional Democrats such as Senate Minority Leader Chuck Schumer called for Kennedy’s firing. Hundreds of HHS staffers have also implored Congress to intervene, saying Kennedy threatens science and public health. He is slated to testify Sept. 4 before the Senate Finance Committee.

Kennedy said in a message to CDC staff that his focus is on boosting the agency’s reputation and leadership. The Atlanta-based agency was already reeling after the Trump administration pushed out thousands of its staff and a gunman who reportedly believed the covid vaccine had caused him health problems fired hundreds of rounds at its campus last month, killing a police officer.

“The CDC must once again be the world’s leader in communicable disease prevention. Together, we will restore trust,” Kennedy wrote. “Together, we will rebuild this institution into what it was always meant to be: a guardian of America’s health and security.” He said his deputy, Jim O’Neill, would serve as acting CDC director.

Nine former CDC directors or acting directors who served under both Republicans and Democrats criticized Kennedy in the aftermath of the Monarez firing, saying in an op-ed in The New York Times that the impact on public health is “unacceptable, and it should alarm every American, regardless of political leanings.”

HHS spokesperson Hilliard took exception with this point, listing four covid vaccines that continue to get the nod for use.

However, the Food and Drug Administration last

week approved updated covid mRNA boosters only for people 65 or older and others at high risk of complications. The CDC has also stopped recommending the shots for healthy children and pregnant women. Previously, the shots had been advised for anyone 6 months or older.

As a result, many people who don’t meet the criteria but want the vaccine will have to get prescriptions or consult with their doctors. Insurance may not always cover the shots, which can run around $200. Major drugstores such as Walgreens and CVS have said the shots may not be available at all pharmacies and may require a prescription.

The American Academy of Pediatrics on Aug. 19 broke with the administration, recommending that all young children get the covid vaccine. Insurance still may not cover the cost in some cases and parents could face obstacles in getting the vaccines without a prescription.

Next Move: The Advisory Committee

Kennedy and his team changed official covid vaccine recommendations even though there have been no new safety issues. A dose of the 2023-24 covid mRNA vaccine prevented significant illness and death across all age groups, according to a study published in August led by a University of Michigan researcher. The virus killed about 1,000 people a week in the U.S. in mid-January, and cases are rising again and expected to accelerate this winter.

Kennedy has handpicked a vaccine advisory committee for the CDC that is reviewing mRNA-based covid vaccines, which he falsely claimed in 2021 were “the deadliest vaccine ever made.” The covid vaccine review is being led by Retsef Levi, a professor of operations management at the Massachusetts Institute of Technology who has said without evidence that the shots cause serious harm, including death. If the committee recommends against them, Kennedy and the FDA could then begin the process of removing them from the market.

Taking mRNA-based covid shots off the market would leave consumers with fewer options for protection. Paxlovid, an antiviral medication that treats the infection in high-risk adults, would be available.

The CDC advisory committee reviewing the covid shots is also probing a long-debunked link between aluminum, used in many childhood immunizations such as those for hepatitis A and pneumonia, and autism or allergies.

The group’s findings are expected to support the erroneous link, some public health officials say. HHS could then require drugmakers to undertake costly reformulations of the shots or stop manufacturing them altogether.

“That would set up the elimination of all childhood vaccines,” Besser said.

The advisory group’s next meeting is set for Sept. 18, although Sen. Bill Cassidy (R-La.) has called for the meeting to be indefinitely delayed. Cassidy, a physician who chairs the Senate Health, Education, Labor and Pensions Committee, voted for Kennedy’s confirmation as HHS secretary after receiving assurances, he said, that the longtime vaccine opponent wouldn’t disrupt the U.S. vaccination system. Kennedy’s promises, Cassidy said, included that he wouldn’t change the CDC’s Advisory Committee on Immunization Practices.

Kennedy removed all of the panel’s members in June and replaced them with his own appointees, including anti-vaccine activists.

Kennedy’s move to put his stamp on the CDC means states that have long relied on the agency’s expertise and help in crises such as disease outbreaks will largely be left to fend for themselves, said Ashish Jha, who served as President Joe Biden’s covid response coordinator from 2022 to 2023.

“States are going to be left on their own,” Jha said. “States will struggle with the CDC incapable and dysfunctional. Our system is not designed for states to go it alone.”

The CDC typically plays a critical role by assisting states with disease surveillance, public health interventions, and outbreak response, especially when a crisis spills across state lines. An outbreak of measles this year led to more than 1,400 cases nationwide, and states including Texas, where the outbreak was identified, struggled to get help from the CDC.

A CDC program that has long tracked pathogens in food has already reduced the number of hazards it looks for from eight to two, which public health leaders say is making it harder to identify outbreaks. Staff overseeing a CDC program that tracks outdoor pollution that can exacerbate asthma also have been cut.

The agency runs a hotline that doctors around the country can call to get treatment and other types of advice. Under Kennedy’s watch, the CDC has had to pare assistance because of staffing reductions, said Wendy Armstrong, vice president at the Infectious Diseases Society of America.

“Lives are 100% at stake, no question about it,” Armstrong said. “That you can no longer trust the recommendations out of the CDC is just devastating. It’s appalling to think we can’t trust that information is science-based anymore.”

Kennedy wants to shake up CDC leadership because he sees the agency as the heart of corruption and resistance within the federal health bureaucracy, according to people familiar with his planning. Kennedy has said the agency suffers from malaise and bias.

Many public health leaders, however, view the CDC as under siege by an administration they say is corrupting science for its own ends. HHS staffers signed onto a letter that now has more than 6,800 signatures, saying Kennedy is “endangering the nation’s health by repeatedly spreading inaccurate health information.”

Kennedy has also been fending off mounting criticism of his response to the shooting at the CDC’s headquarters. He responded to the attack on social media, hours later, after first posting pictures of himself fly-fishing.

Some younger staffers are considering leaving and some workers feel like the shooting accelerated Kennedy’s overhaul of the agency, the CDC employee said.

With the battle for control of the CDC still raging, public health leaders are now looking to Congress to put the brakes on Kennedy. Some Republican lawmakers have called for a review of Kennedy’s actions.

“These high profile departures will require oversight by the HELP Committee,” Cassidy said Aug. 27 on the social platform X. Cassidy had backed Monarez to lead the agency.

Doctors, hospitals, and health insurers for weeks issued dire warnings to Republican lawmakers that millions of people would lose health coverage and hospitals would close if they cut Medicaid funding to help pay for President Donald Trump’s big tax and spending bill.

But Republicans ignored those pleas, made even deeper cuts, and sent the legislation on July 3 to the White House, where Trump signed it the next day.

The law’s passage marked a rare political loss for some of the health industry’s biggest players. When unified, doctors, hospitals, and insurers have stood among the most powerful lobbying forces in Washington and have a long track record of blocking or forcing changes to legislation that could hurt them financially.

But health industry lobbyists are catching their breath and assessing the damage after Trump’s massive bill raced through Congress in less than two months with only Republican votes.

Several lobbyists offered various reasons for being unable to stave off big cuts to Medicaid, a $900 billion state-federal health insurance program that covers an estimated 72 million low-income and disabled people nationally and accounts for 19% of all spending on hospital care, about $283 billion a year, according to the latest data. But nearly all agreed that GOP lawmakers were more worried about angering Trump than facing backlash from local hospitals and constituents back home.

“Members were more scared of Trump issuing a primary challenge than disappointing local voters who may find their hospital has to close or their insurance premium may go up,” said Bob Kocher, a partner with venture capital firm Venrock who served in the Obama administration, referring to election primaries leading into the midterms.

Consider what happened to Sen. Thom Tillis (R-N.C.). After he took to the Senate floor to announce his opposition to the bill because of its cuts to Medicaid, Trump threatened to support a challenger to run against Tillis next year. Shortly thereafter, Tillis announced his retirement from politics.

But other factors were at work.

The health industry’s warnings to lawmakers may have been dismissed because hospitals, health centers, and other health care provider groups are seen by Republicans as strong backers of the Affordable Care Act, the law known as Obamacare that’s considered Democrats’ biggest domestic achievement in decades.

The ACA expanded government health insurance coverage to millions of people previously not eligible. And no Republicans voted for it.

“Hospitals’ support of the ACA has frustrated Republicans, and as a result there is less a reservoir of goodwill to hospitals than in the past,” Kocher said.

Ceci Connolly, chief executive of the Alliance of Community Health Plans, said her lobbying team spent extra time on Capitol Hill with lawmakers and their staffers, raising concerns about how the legislation would imperil health care coverage.

“There was almost an overriding sense on the part of Republicans in Congress to deliver a major victory for President Trump,” she said. Her group represents health plans that provide coverage in about 40 states. “That superseded some of their concerns, reluctance, and hesitation.”

Connolly said she repeatedly heard from GOP lawmakers that the focus was on delivering on Trump’s campaign promise to extend his 2017 tax cuts.

She said the concerns of some moderate members helped lead to one concession: a $50 billion fund to help rural hospitals and other health providers.

The money, she said, may have made it easier for some lawmakers to support a bill that, in total, cuts more than $1 trillion from Medicaid over a decade.

Another twist: Many new lawmakers were clearly still learning about Medicaid, she said.

Republicans also seemed eager to reduce the scope of Medicaid and Affordable Care Act marketplace coverage after enrollment in both programs soared to record levels during the pandemic and the Biden administration, she said. Trump’s law requires states to verify eligibility for Medicaid at least every six months and ends auto-enrollment into marketplace plans — steps health policy experts says will reverse some of those gains.

Charles “Chip” Kahn, a longtime health lobbyist and CEO of the Federation of American Hospitals, which represents for-profit hospitals, said the industry’s message was heard on Capitol Hill. But because the bill dealt with so many other issues, including tax cuts, border security, and energy, lawmakers had to decide whether potential health coverage losses were more important.

It was very different than in 2017, when Republicans tried to repeal Obamacare but failed. Trump’s 2025 measure, Kahn said, isn’t a health reform bill or a health bill.

It “left us with an outcome that was unfortunate.”

There were some successes, however, Kahn said.

Industry lobbying did prevent the federal government from reducing its share of spending for states that expanded Medicaid under the ACA. Hospitals and other Medicaid advocates also persuaded Congress not to cap the program’s open-ended federal funding to states. Both measures would have tallied billions more in additional Medicaid funding cuts.

The new law doesn’t change eligibility rules for Medicaid or change its benefits. But it does stipulate that states require most Medicaid enrollees who gained coverage via the ACA’s expansion to document that they work or volunteer 80 hours a month, a provision the Congressional Budget Office predicts will lead to about 5 million people losing coverage by 2034.

The law also limits states’ use of a decades-old system of taxing health providers to leverage extra federal Medicaid funding. This was another loss for the hospital industry, which has supported the practice because it led to higher payments from Medicaid.

Medicaid generally pays lower fees for care than private insurance and Medicare, the program for people 65 and older as well as those with disabilities. But due to provider taxes, some hospitals are paid more under Medicaid than Medicare, according to the Commonwealth Fund, a health research nonprofit.

Kahn credits the Paragon Health Institute, a conservative think tank, and its CEO Brian Blase for pushing the argument that provider taxes amounted to legalized “money laundering.” Blase advised Trump on health policy in his first term.

One hospital executive who asked for his name to be withheld to avoid professional retribution said the message — that some facilities had used this play to increase their profits — resonated with GOP lawmakers. “They thought some hospitals were doing fine financially and did not want to reward them,” he said.

Still, Kahn, who is retiring at the end of the year, said he was pleased the Senate delayed implementation of the provider tax cuts until 2028. That will give the health industry a chance to revise the law, he speculated, possibly after the 2026 midterm election changes the balance of power in Congress.

In rural northeastern Louisiana, Todd Eppler, CEO of Desoto Regional Medical Center, had hoped Congress would pass the initial House version of the bill, which didn’t include cuts to provider-tax funding. But he said any impact on his hospital in Mansfield, located in House Speaker Mike Johnson’s district, will be offset by the $50 billion rural health fund.

“I am happy where we ended up,” Eppler said. “I think they listened to rural hospitals.”

Hospitals have argued for decades that any cuts in federal funding to Medicaid or Medicare would harm patients and lead to service reductions. Because hospitals are usually one of the largest employers in a congressional district, the industry often also warns of potential job losses. Such arguments typically give lawmakers pause.

But this time around, that message had little traction.

One health industry lobbyist, who asked not to be identified to speak candidly without risking professional repercussions, said there was a sense on Capitol Hill that hospitals could withstand the funding cuts.

But there’s also a belief that trade groups including the American Hospital Association, the largest hospital industry lobbying organization, could have been more effective. “There is lot of concern that AHA statements were too soft, too little, and too late,” he said.

AHA helped lead a coalition of hospital organizations that spent millions of dollars on television advertising against the GOP bill. Its president and CEO, Rick Pollack, said in a statement before the House voted on the legislation that the cuts to Medicaid would be a “devastating blow to the health and well-being of our nation’s most vulnerable citizens and communities.”

Pollack said in a statement to KFF Health News that the appeal of tax cuts drove Republican lawmakers to pass the law.

“Hospitals and health systems have tirelessly advocated to protect coverage and access for millions of people,” he said. “We will continue to raise these critical issues to mitigate the effects of these proposals.”

The nation’s largest trade group for doctors, the American Medical Association, also opposed the funding cuts to Medicaid and other federal health programs. Its president, Bobby Mukkamala, said in a July 1 statement that the changes “will shift costs to the states and specifically to physicians and hospitals to provide uncompensated care at a time when rural hospitals and physician practices are struggling to keep their doors open.”

But the AMA was also focused on securing higher Medicare fees for doctors. The law ultimately included a one-time 2.5% Medicare pay bump for doctors in 2026. This wasn’t a victory because it left out the House version’s permanent payment fix that would have tied doctor pay to the medical inflation rate. Mukkamala noted the temporary lift but described it as falling “far short of what is needed to preserve access to care for America’s seniors.”

Joe Dunn, chief policy officer at the National Association of Community Health Centers, said his organization worked relentlessly this year to prevent deeper Medicaid cuts that would financially hurt nonprofit clinics. Health center administrators visited Washington in February, made thousands of phone calls, and sent emails to members of Congress.

One payoff was that the health centers were exempted from the law’s requirement that providers charge some Medicaid enrollees up to $35 copayments for services.

But at the end of the day, Dunn said, many GOP House and Senate members simply wanted to finish the bill. “They went in a direction that satisfied the president’s timelines and goals,” he said.

Chief Washington correspondent Julie Rovner contributed to this report.

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This article first appeared on KFF Health News and is republished here under a Creative Commons license.

Colton George felt sick. The 9-year-old Indiana boy told his parents his stomach hurt. He kept running to the bathroom and felt too ill to finish a basketball game.

Days later, he lay in a hospital bed, fighting for his life. He had eaten tainted salad, according to a lawsuit against the lettuce grower filed by his parents on April 17 in federal court for the Southern District of Indiana.

The E. coli bacteria that ravaged Colton’s kidneys was a genetic match to the strain that killed one person and sickened nearly 90 people in 15 states last fall. Federal health agencies investigated the cases and linked them to a farm that grew romaine lettuce.

But most people have never heard about this outbreak, which a Feb. 11 internal FDA memo linked to a single lettuce processor and ranch as the source of the contamination. In what many experts said was a break with common practice, officials never issued public communications after the investigation or identified the grower who produced the lettuce.

From failing to publicize a major outbreak to scaling back safety alert specialists and rules, the Trump administration’s anti-regulatory and cost-cutting push risks unraveling a critical system that helps ensure the safety of the U.S. food supply, according to consumer advocates, researchers and former employees at the FDA and U.S. Department of Agriculture.

The investigation into the illnesses began near the end of the Biden administration but work on the lettuce outbreak wasn’t completed until Feb. 11. At that time, the decision was made by the Trump administration not to release the names of the grower and processor because the FDA said no product remained on the market.

The administration also has withdrawn a proposed regulation to reduce the presence of salmonella in raw poultry, according to an April USDA alert. It was projected to save more than $13 million annually by preventing more than 3,000 illnesses, according to the proposal.

Officials from the Department of Health and Human Services have said that food safety is a priority, and FDA Commissioner Marty Makary said in an April 29 interview with the newsletter Inside Medicine that the recent job cuts would not affect agency operations.

“The FDA had 9,500 employees in 2007. Last year it was nearly 19,000. Has the 100% increase in employees increased approval times, innovation, AI, food safety, or agency morale?” Makary asked. “No, it hasn’t. In fact, it’s increased regulatory creep.”

The FDA referred questions to HHS, which declined to comment or make Makary available for an interview. In a statement, the agency said “protecting public health and insuring food safety remain top priorities for HHS. FDA inspectors were not impacted [by job cuts] and this critical work will continue.”

Public health advocates warn companies and growers will face less regulatory oversight and fewer consequences for selling tainted food products as a result of recent FDA actions.

The administration is disbanding a Justice Department unit that pursues civil and criminal actions against companies that sell contaminated food and is reassigning its attorneys. Some work will be assumed by other divisions, according to a publicly posted memo from the head of the department’s criminal division and a white paper by the law firm Gibson Dunn.

The Justice Department did not respond to an email requesting comment.

“They need the DOJ to enforce the law,” said Sarah Sorscher, director of regulatory affairs at the Center for Science in the Public Interest, a nonprofit consumer advocacy group. “For an executive investing in food safety, the knowledge they could go to jail if they don’t is a really strong motivator.”

Federal regulators also want states to conduct more inspections, according to two former FDA officials, who spoke on the condition of anonymity out of fear of retaliation. But some Democratic lawmakers say states lack the resources to take over most food safety inspections.

“Handing that duty to state and local agencies is really troubling,” said Rep. Shontel M. Brown (D-Ohio). “They don’t have the resources, and it creates a potentially unsafe situation that puts families in Ohio and America at risk.”

The High Cost of Foodborne Illnesses

Foodborne illnesses exact a major economic toll in the United States, according to federal data, and cost thousands of lives each year. The U.S. Department of Agriculture estimates the deaths, chronic illness, medical treatment, and lost productivity from food-related illnesses amounted to $75 billion in 2023.

Each year, about 48 million people in the U.S. get sick with foodborne illnesses, 128,000 are hospitalized, and 3,000 die, according to the Centers for Disease Control and Prevention.

In its first few months, the administration has suspended a program known as the Food Emergency Response Network Proficiency Testing that ensures food-testing labs accurately identify pathogens that can sicken or kill, according to a former FDA official.

In March, the agency said it would delay from January 2026 to July 2028 compliance with a Biden-era rule that aims to speed up the identification and removal of potentially contaminated food from the market.

However, the FDA is taking aim at foreign food manufacturing, saying in a May 6 notice that it would expand unannounced inspections overseas. “This expanded approach marks a new era in FDA enforcement — stronger, smarter, and unapologetically in support of the public health and safety of Americans,” the notice said.

Some former FDA and USDA officials said that goal isn’t realistic, because U.S. inspectors often need to obtain travel visas that can wind up alerting companies to their arrival.

“It’s really, really difficult to do surprise inspections,” said Brian Ronholm, director of food policy for Consumer Reports and a former USDA deputy undersecretary for food safety. “The visa process can alert the local authority.”

HHS declined to address Ronholm’s concerns.

The FDA hasn’t met the mandated targets for inspecting food facilities in the U.S. since fiscal year 2018, and the agency has consistently fallen short of meeting its annual targets for foreign inspections, according to a January report by the U.S. Government Accountability Office.

Foodborne illness can turn serious. Listeria bacteria in cucumbers sickened dozens of people in April and May and left at least nine people hospitalized, according to the FDA. Salmonella in peanut butter killed nine in 2008 and 2009, resulting in criminal charges against company executives. And E. coli in cookie dough sickened more than 70 people in 2009, including a Nevada mother who died of complications from eating the raw dough.

‘Life or Death for Our Son’

E. coli, commonly found in feces, can be especially dangerous to children like Colton, the boy from Avon, Indiana, who ate contaminated lettuce. The bacteria can damage blood vessels and cause clots that destroy the kidneys, leading to strokes and comas. Consumers sickened by E. coli can pass it along to others, and, in some cases, the bacteria end up killing victims who never consumed the contaminated food.

By the time Colton’s mother brought him to the emergency room that November day, the bacteria were releasing toxins and damaging his blood cells and kidneys, according to his father, Chris George.

Colton was sent to Riley Hospital for Children in Indianapolis. Chris said doctors told him and his wife, Amber George, that their son was in kidney failure and the next 24 to 72 hours would determine whether he would survive, the father recalled.

“They said it was life or death for our son, and I was like, wait, he was just playing basketball,” said Chris, a firefighter. “I told them, ‘You do what you need to do to save my son.’”

Usually, the FDA alerts the public and identifies growers and food manufacturers when there are outbreaks like the one that sickened Colton. The FDA said in its February internal summary that the grower wasn’t named because no product remained on the market.

But Bill Marler, a Seattle lawyer who specializes in food-safety litigation and represents the George family, said the information is still important because it can prevent more cases, pressure growers to improve sanitation, and identify repeat offenders.

It also gives victims an explanation for their illnesses and helps them determine whom they might take legal action against, he said.

“Normally we would see the information on their websites,” Marler said, adding that the agency’s investigatory findings on the outbreak were “all redacted” and he obtained them through a Freedom of Information Act request.

The FDA, USDA, and CDC play central roles in overseeing food safety, including inspections and investigations. The FDA and CDC have been rocked by job cuts that are part of a reduction of 20,000 staff at HHS, their parent agency. The Agriculture Department has also shrunk its workforce.

Staffing cuts mean delays in publicizing deadly outbreaks, said Susan Mayne, an adjunct professor at Yale School of Public Health who retired from the FDA in 2023.

“Consumers are being notified with delays about important food safety notifications,” she said, referring to a recent outbreak in cucumbers. “People can die if there are pathogens like listeria, which can have a 30% fatality rate.”

Makary has said the cuts wouldn’t touch inspectors, reviewers, or scientists at the agency.

But the FDA laid off scientists in April who worked at food safety labs in Chicago and San Francisco, where they performed specialized analysis for food inspectors, former FDA officials said. The FDA later restored some positions.

“No scientists were fired? That was incorrect,” Mayne said.

Siobhan DeLancey, who worked in the agency’s Office of Foods and Veterinary Medicine for more than 20 years before she also was laid off in April, said new requirements for reviewing agency announcements became so arduous that it took weeks to get approval for alerts that should have been going out much sooner.

She said some employees who were laid off include communications specialists and web staff who do consumer outreach aimed at preventing illness. The USDA and FDA have been bringing some workers back or are asking some who accepted deferred resignations to take back their decisions.

“It’s all about destruction and not about efficiency,” DeLancey said. “We’re going to see the effects for years. It will cost lives.”

HHS did not respond to an email seeking a response to DeLancey’s comments.

For 13 days, Colton stayed on dialysis at the hospital, initially unable to eat or drink. His mother wet a sponge to moisten his lips and tongue.

He turned 10 in the hospital. Chris George bought paint markers to make signs on the windows of his son’s room.

“I am not happy with the CDC and FDA,” Chris George said. “Victims have a right to know who made them sick. This is my kid. He’s my life.”

Colton was able to leave the hospital almost three weeks after first eating the contaminated lettuce but still has nightmares about the ordeal and is seeing a therapist.

“The whole ‘Make America Healthy Again,’ the focus on taking food color dyes out of cereal?” said Chris George, who objects to the Trump administration’s decision to redact information about the grower in the February report. “How about we take E. coli out of our lettuce, so it doesn’t kill our kids?”

This article first appeared on KFF Health News and is republished here under a Creative Commons license.

After the Senate voted to confirm Robert F. Kennedy Jr. as Health and Human Services secretary, supporters of his “Make America Healthy Again” movement cheered at having a champion in the federal government.

Now the grumbling has begun. Some of Kennedy’s allies say he’s become almost inaccessible since his confirmation and complain that he’s made glacial progress advancing MAHA goals, such as halting mRNA-based covid shots and removing fluoride from drinking water.

The fractures underscore the clash between Kennedy’s movement and President Donald Trump’s “Make America Great Again” agenda. Kennedy is pulled between his supporters who want swift action to disrupt traditional health care and Trump, who is focused more on tariffs and increasing deportations than on disease, according to four people close to Kennedy who asked not to be identified because they weren’t authorized to speak to the press. Many of the priorities driving Kennedy’s MAHA program are not top priorities of his boss.

Kennedy’s capacity to navigate those tensions has been further strained by a measles outbreak and the threat of a bird flu pandemic, the people said.

Some of his deputies are still being vetted and other key positions remain unfilled. That, along with resignations of top HHS leaders and sweeping staffing reductions, has created a gap in expertise. Kennedy sometimes calls close informal advisers on the run before meetings, and the crises have put him in a reactionary stance, working on weekends and marshaling staff for Sunday meetings, according to the people.

More churn is coming because of an HHS reorganization set to eliminate about 20,000 jobs, including a 19% cut to the workforce at the FDA, which oversees food, nutrition, and vaccines.

HHS spokespeople didn’t respond to emails seeking comment.

To be sure, Kennedy’s ascendance represents a breakthrough for the MAHA movement, a broad collection of gadflies, groups, and wellness influencers who extol raw milk, metabolic health, and sustainable farming while lambasting Big Pharma, vaccines, and processed foods.

The coming months will test Kennedy’s ability to juggle the challenges and achieve Trump’s goals without losing the support of MAHA adherents, especially special interest and advocacy groups that helped him reach his influential perch overseeing one of the nation’s largest federal agencies. HHS, with a budget of almost $2 trillion, includes the Centers for Disease Control and Prevention, the National Institutes of Health, and the Centers for Medicare & Medicaid Services.

But the MAHA goals aren’t top agenda items for GOP voters, who tend to be focused more on the price of eggs than whether they’re organic.

The MAHA faithful “expect action” but their to-do list is not necessarily a high priority for voters or lawmakers, said Robert Blendon, a professor emeritus of health policy and political analysis at Harvard. “And should there be a big measles outbreak or avian flu, it would hurt the White House if there was a big conflict over vaccines going on,” he said.

An additional challenge for Kennedy is that not all MAHA and MAGA goals overlap. Trump wants to slash the workforce, which Kennedy has embraced. But fulfilling MAHA wishes will require more regulation, which runs counter to MAGA dogma favoring a smaller federal government.

MAHA wants fluoride out of water because followers say it leads to lower IQ levels in children, as well as arthritis and bone cancer. Kennedy said on X that fluoride is dangerous and that the Trump administration would recommend it be removed from America’s drinking water. Fluoridated water is credited for vastly reducing rates of tooth decay in the U.S. In 2015, the CDC called water fluoridation one of the 10 greatest public health achievements of the 20th century, and only 15% of Americans think fluoride is harmful or detrimental to the public, based on a poll in January by market research company Ipsos.

MAHA adherents believe in the debunked claim that vaccines cause autism, and Kennedy just tapped a vaccine opponent to work on a study on possible connections. In fact, HHS has launched an effort that Kennedy said will determine by September what has caused the “autism epidemic.” Many autism researchers say this timeline sows doubts about the study’s seriousness. Most voters support vaccines and believe in their benefits. Eight in 10 parents with children under age 18 say they normally keep them up to date with recommended childhood vaccines, according to a KFF poll in January.

And MAHA wants to replace seed oils, which the movement’s followers claim without evidence are unhealthy, with animal fats such as beef tallow, which is high in saturated fat, which can contribute to high cholesterol and heart disease. Only 13% of Americans believe seed oils are unhealthy to consume, based on a poll by the industry-backed International Food Information Council.

Perhaps no goal is more important to many MAHA followers, however, than banning the mRNA technology behind covid vaccines by Moderna and Pfizer.

“The big threat is that we still have covid-19 vaccines on the market,” said Peter McCullough, a former cardiologist who has been criticized for spreading covid misinformation and has informally advised Kennedy. “It’s horrendous. I would not hesitate; I would just pull it. What’s he waiting for?”

The FDA says covid shots are safe. They are credited for saving millions of lives worldwide during the pandemic, and two NIH-funded scientists who advanced mRNA technology were awarded the Nobel Prize in physiology or medicine in 2023.

Yanking authority for mRNA-based covid vaccines could backfire because Trump sees “Operation Warp Speed,” the federal effort to develop the shots, as one of his signature achievements, according to one of the people close to Kennedy. And it would have been impolitic to take action before the confirmation of an FDA commissioner, the person said. Marty Makary, a Johns Hopkins University researcher, was confirmed on March 25 to the post.

Kennedy also isn’t calling all the shots. He was initially unaware of the appointment of Gerald Parker, a veterinarian who recently chaired an NIH advisory board, to head the White House’s pandemic office, according to one of the people.

Kennedy did choose Susan Monarez, a former deputy director of the Advanced Research Projects Agency for Health, as acting CDC director. Trump nominated her for Senate confirmation to lead the agency on March 24. Kennedy felt she had worked well with Trump’s job-cutting Department of Government Efficiency and did a great job in her acting director position, one of the people close to him said.

Kennedy is also in a difficult position regarding Trump’s Make America Healthy Again commission, which Kennedy chairs. The panel’s charge to investigate and deliver an action plan on the nation’s decades-long increase in chronic illness, with a special emphasis on children, is a clear pitch to the MAHA movement. But Trump has told Kennedy, according to one of the people, that he wants to see measurable progress in a year to 18 months — which is hard both to define and to achieve.

While Kennedy is a scion of the country’s most famous Democratic family, he is widely distrusted in the medical community because of his fringe views on vaccines and his rejection of established science. Since taking office, he has tried to cultivate relationships with MAGA-leaning state officials, including West Virginia’s governor, Republican Patrick Morrisey. And his alliance with Trump is new. When Kennedy was running for president in 2024, Trump took to his Truth Social platform to say, “Kennedy is a Radical Left Democrat, and always will be!!!” — though Trump’s administration includes other onetime adversaries such as Secretary of State Marco Rubio.

Many of Kennedy’s nutrition and health goals would require regulation, which clash with Trump’s anti-regulatory agenda and his focus on a lean federal government.

Meanwhile, he’s relied on his principal deputy chief of staff, Stefanie Spear, a longtime Kennedy aide who has taken on the role of traffic cop in the department. He’s also leaned on HHS chief of staff Heather Flick Melanson for expertise. She was a senior adviser to former HHS Secretary Alex Azar in Trump’s first term.

Kennedy’s close circle of informal advisers includes nontraditional doctors, fellow vaccine opponents, media personalities, and self-appointed health gurus. Some have gained unprecedented influence and access to the innermost workings of federal health agencies.

Calley Means, for example, is a Kennedy ally whose business sells wellness products such as saunas and supplements. His statements have dismayed some scientists, such as when he called covid vaccine mandates for children a “war crime” and said without evidence that “metabolically healthy” people don’t die from covid. In March, Means joined the White House as a special government employee and MAHA adviser.

Others in Kennedy’s orbit include Del Bigtree, a television producer who founded the anti-vaccination group Informed Consent Action Network, and some officials from the previous Trump administration. Aaron Siri, a lawyer for Kennedy, is no longer involved in vetting candidates for HHS positions, one of the people said.

“‘Nontraditional’ as a description for these people is not enough. We’re talking about beyond the outer fringes of medicine,” said Irwin Redlener, senior adviser for the National Center for Disaster Preparedness at Columbia University, of Kennedy’s inner circle. “This faux expertise is really dangerous.”

Even as some MAHA adherents press for swifter action, Kennedy’s recent comments and actions suggest public health ideas once dismissed as fringe or unscientific now have an advocate at HHS.

Kennedy claimed without evidence that cod liver oil is an effective treatment for measles. He’s suggested letting the bird flu virus rip unchecked through infected chicken flocks even though scientists say that could unleash dangerous mutations.

And he’s backed cellphone bans in schools, saying phones cause cancer in kids. Most studies have found no such link.

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Researchers racing to develop bird flu vaccines for humans have turned to a cutting-edge technology that enabled the rapid development of lifesaving covid shots.

There’s a catch: The mRNA technology faces growing doubts among Republicans, including people around President Donald Trump.

Legislation aimed to ban or limit mRNA vaccines was introduced this year by GOP lawmakers in at least seven states. In some cases, the measures would hit doctors who give the injections with criminal penalties, fines, and possible revocation of their licenses.

Some congressional Republicans are also pressing regulators to revoke federal approval for mRNA-based covid shots, which President Donald Trump touted as one of the signature achievements of his first term.

The opposition comes at a critical juncture because vaccines using mRNA have applications well beyond avian flu and covid. They hold the promise of lifesaving breakthroughs to treat many diseases, from melanoma to HIV to Zika, according to clinical trials. The proposed bans could block access to these advances.

MRNA is found naturally in human cells. It is a molecule that carries genetic material and, in a vaccine, trains the body’s immune system to fight viruses, cancer cells, and other conditions. An advantage of mRNA technology is that it can be developed more quickly to target specific variants and is safer than developing a vaccine made from inactivated virus.

“Right now, if we had a bird flu pandemic, we would have a shortage of the vaccine we need,” said Michael Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy. “The one thing that could save us is mRNA vaccine. The challenge would be if mRNA is banned. This is truly dangerous policy.”

The pushback conflicts with innovations championed by Trump. He assembled tech tycoons at the White House just after his inauguration to announce Stargate, a $500 billion artificial intelligence initiative that could help transform cancer treatment by creating tumor-targeting mRNA vaccines. The fledging partnership between Oracle, SoftBank Corp., and OpenAI, co-founded by Elon Musk, envisions leveraging AI in part to improve health outcomes. Patients would undergo blood tests and AI would be used to find cancer.

Scientists would examine the DNA and RNA (RNA and mRNA serve different functions in a cell) of a specific patient’s tumor to create a vaccine to teach that person’s immune system to target and destroy cells driving cancer growth.

“Imagine early cancer detection, the development of a cancer vaccine for your particular cancer aimed at you, and have that vaccine available in 48 hours,” Oracle co-founder Larry Ellison said at the White House event.

Scores of mRNA clinical trials for cancer vaccines are underway and some have shown dramatic results, cutting the risk of death and recurrence roughly in half for certain patients. In research led by the Yale School of Medicine, for example, patients with advanced kidney cancer remained cancer-free about three years after an mRNA-based treatment in an early-phase trial.

But some politically conservative doctors, lawmakers, and researchers question the safety of mRNA vaccines, especially covid shots made with the technology. Robert F. Kennedy Jr. unsuccessfully petitioned the FDA in 2021 to rescind approval for covid shots and called them “the deadliest vaccine ever made” — a controversial statement that has been refuted.

Now that he’s newly confirmed as Health and Human Services secretary, Kennedy is poised to oversee federal approvals of vaccines, with the power to shape policy such as immunization schedules and appoint vaccine opponents to committees that advise on the approval of shots.

Bloomberg reported late last month that Trump administration health officials were reevaluating a $590 million contract for bird flu shots that the Biden administration awarded to Moderna as part of its push to examine spending on mRNA vaccines.

HHS and White House spokespeople didn’t return emails seeking comment.

Support for an mRNA ban is coming from other sources too. Florida Gov. Ron DeSantis on March 5 urged the Centers for Disease Control and Prevention to stop recommending the covid-19 vaccine for children and called for a state ban on mRNA vaccine mandates. In February, Rep. Thomas Massie (R-Ky.) said on X that the “FDA should immediately revoke approval of these shots,” and Sen. Ron Johnson (R-Wis.) is leading an investigation into the safety of the vaccines. Trump in February signed an order to strip federal funds from schools that require covid shots for attendance.

Vaccine skepticism has become pronounced among Republicans since the pandemic. Four in 10 Republicans who responded to a KFF poll published in January said it was “probably” or “definitely true” that “more people have died from covid-19 vaccines than from the virus itself.” Just a quarter of Republicans reported holding that view in 2023.

The effort is also finding traction at the local level. A district health department outside Boise, Idaho, last year banned its health department from administering covid-19 vaccines, and local lawmakers in Franklin County, Washington, passed a resolution in February against mRNA vaccines.

The ABCs of mRNA

The CDC recommends covid vaccines for anyone 6 months and older, especially seniors and people who are immunocompromised. About 29 million doses had been administered to adults in the 2024-25 season in retail pharmacies and doctors’ offices through Feb. 8, based on federal data.

Given as a shot, mRNA enters muscle cells and teaches them to produce a spike protein found on the surface of a virus. The body’s immune system then targets the spike protein, priming it to identify and fight the virus — in this case, the coronavirus that causes covid. The body’s cells then break down the mRNA and remove it, according to federal health researchers.

More than 13 billion covid vaccines had been administered worldwide as of August 2024.

Researchers say the vaccinations saved countless lives — estimates for the first year alone go as high as 19.8 million — in the throes of a pandemic that had hospitals ordering refrigerated mobile morgues and deliberating over which patients to put on ventilators. Two University of Pennsylvania scientists credited with developing the mRNA technology behind the shots were awarded the Nobel Prize for medicine in 2023.

The FDA says the covid vaccines are safe, with fewer than 1 in 200,000 vaccinated individuals experiencing a severe allergic reaction or heart problems like myocarditis or pericarditis, and the agency notes that “inaccurate information about these vaccines, particularly the mRNA COVID-19 vaccines, continues to circulate.”

While many people hadn’t heard of the mRNA platform until the covid shots were rolled out, it was discovered in the 1960s. The first mRNA flu vaccines were tested in mice in the 1990s. A clinical trial involving direct injection of mRNA to fight cancer occurred in 2008. Clinical trials involving the covid mRNA vaccines involved tens of thousands of volunteers.

Reviews of mortality data showed “no unusual patterns of death were detected that might suggest a potential safety concern,” based on a September 2024 report by a technical working group that provided guidance to the CDC.

But those calling for a ban on all mRNA vaccines say there is a dearth of long-term safety data, and they say covid vaccines by Pfizer-BioNTech and Moderna were hastily approved without proper vetting. They assert without strong evidence that the vaccines cause serious injuries to the heart, nerves, and immune and reproductive systems, and can lead to cancer.

The vaccine has been linked to rare cases of heart inflammation and inflammation of the sac surrounding the heart, although the severity has varied and most patients fully recovered, the CDC says.

“The allegations are beyond reason,” said Anne Schuchat, a career scientist who worked on covid and who twice served stints as acting director of the CDC. “The mRNA covid vaccines were extensively studied after use and do not have those problems.”

“I’m concerned about the whole mRNA technology. I don’t trust anything that fools the body,” said Stephanie Seneff, a computer scientist and anti-vaccine activist at the Massachusetts Institute of Technology. “I’m really glad people are waking up and realizing it’s not the thing to do anymore.”

Vaccines generally work by tricking the body into producing antibodies to fight illnesses.

Pfizer spokespeople didn’t return an email seeking comment. A Moderna spokesperson, Chris Ridley, said legislative efforts to ban or restrict mRNA medicines are largely driven by misunderstandings about their safety profile and mechanism of action. While mRNA-based shots do not modify DNA, for example, that misconception is frequently cited in support of restrictions, Ridley said.

“If enacted, these measures could hinder important research and limit patient access to innovative treatments, potentially delaying life-changing medical advancements,” Ridley said in a written statement.

Networks of Opposition

Groups opposed to the mRNA technology have built a vast and well-funded legal, marketing, and social media network. Members hold conferences to discuss strategies, fund lawsuits against vaccine mandates, and produce reports on the covid vaccines.

As for state legislative efforts, measures introduced this year have varied and their progress has been mixed. Montana’s measure, for instance, was blocked. Idaho lawmakers in February held a hearing on its bill, which calls for a 10-year moratorium on mRNA vaccines. Idaho’s proposal, likely to be amended, as well as Iowa’s and Montana’s have featured criminal penalties for providers who administer all or certain mRNA vaccines. In addition, some state bills, such as legislation in Pennsylvania and Tennessee, focused on the use of the vaccine in livestock and food production.

Various bills are pending in the Texas Legislature to restrict mRNA vaccines in both livestock and humans. South Carolina’s pending bill would require anyone administering certain covid mRNA vaccines to inform patients that the shot is contaminated with fragments of “bacterial plasmid DNA.”

Covid mRNA shots may have minute amounts of residual DNA from production processes but they are heavily degraded and pose no risk, according to the Global Vaccine Data Network, which evaluates vaccine safety concerns.

Speakers at some legislative proceedings have included representatives from Children’s Health Defense, an activist, anti-vaccine group founded by Kennedy.

The Florida surgeon general in January 2024 called for a halt in the use of covid mRNA vaccines. And in Texas, Attorney General Ken Paxton in January moved to appeal a lawsuit he filed claiming Pfizer misrepresented the safety of its mRNA shot.

Efforts to restrict the shots have raised the profile of groups such as the Independent Medical Alliance, which advocates for mRNA-based covid vaccines to be withdrawn from the market.

“We should stop it and test it more before we move forward,” said pediatric cardiologist Kirk Milhoan, a senior fellow at the alliance.

Groups opposed to mRNA shots are pointing to a recent study to urge more caution. Yale University researchers reported in February that they found spike protein still circulating in a subset of individuals with a debilitating, post-vaccination condition. Some of the individuals who experienced chronic illness after getting the shots had detectable levels of spike protein more than 700 days after vaccination. This study was small — 42 participants — and not peer-reviewed.

Its findings also don’t show the spike protein is a health risk or a cause of vaccine injury.

“It’s an initial, provocative study in which you can’t draw conclusions,” said William Schaffner, past medical director of National Foundation for Infectious Diseases. “This is one of the most widely used vaccines around the globe. It’s the furthest thing from an experimental vaccine.”

But what this growing pushback shows, according to some researchers, is that distrust isn’t coming only from fringe groups anymore.

“There are truly amazing mRNA cancer vaccines out there,” said Kate Broderick, chief innovation officer at Maravai LifeSciences, which works on vaccine development. “My fear as a scientist is that it’s been tainted in the public.”

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Few voters likely expected President Donald Trump in the first weeks of his administration to slash billions of dollars from the nation’s premier federal cancer research agency.

But funding cuts to the National Institutes of Health were presaged in Project 2025’s “Mandate for Leadership,” a conservative plan for governing that Trump said he knew nothing about during his campaign. Now, his administration has embraced it.

The 922-page playbook compiled by the Heritage Foundation, a conservative research group in Washington, says “the NIH monopoly on directing research should be broken” and calls for capping payments to universities and their hospitals to “help reduce federal taxpayer subsidization of leftist agendas.”

Universities, now slated to face sweeping cuts in agency grants that cover these overhead costs, say the policy will destroy ongoing and future biomedical science. A federal judge temporarily halted the cuts to medical research on Feb. 10 after they drew legal challenges from medical institutions and 22 states.

Project 2025 as Prologue

The rapid-fire adoption of many of Project 2025’s objectives indicates that Trump acolytes — many of its contributors were veterans of his first term, and some have joined his second administration — have for years quietly laid the groundwork to disrupt the national health system. That runs counter to Trump’s insistence on the campaign trail, after Democrats made Project 2025 a potent attack line, that he was ignorant of the document.

“I have no idea what Project 2025 is,” Trump said Oct. 31 at a rally in Albuquerque, New Mexico, one of many times he disclaimed any knowledge of the plan. “I’ve never read it, and I never will.”

But because his administration is hewing to the Heritage Foundation-compiled playbook so closely, opposition groups and some state Democratic leaders say they’re able to act swiftly to counter Trump’s moves in court.

They’re now preparing for Trump to act on Project 2025 recommendations for some of the nation’s largest and most important health programs, including Medicaid and Medicare, and for federal health agencies.

“There has been a lot of planning on the litigation side to challenge the executive orders and other early actions from a lot of different organizations,” said Noah Bookbinder, president of Citizens for Responsibility and Ethics in Washington, a watchdog group. “Project 2025 allowed for some preparation.”

The plan, for example, calls for state flexibility to impose premiums for some beneficiaries, work requirements, and lifetime caps or time limits on Medicaid coverage for some enrollees in the program for low-income and disabled Americans, which could lead to a surge in the number of uninsured after the Biden administration vastly expanded the program’s coverage.

“These proposals don’t directly alter eligibility for Medicaid or the benefits provided, but the ultimate effect would be fewer people with health coverage,” said Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes KFF Health News. “When you erect barriers to people enrolling in Medicaid, like premiums or documenting work status, you end up rationing coverage by complexity and ability to pay.”

Congressional Republicans are contemplating a budget plan that could result in hundreds of billions of dollars being trimmed from Medicaid over 10 years.

Project 2025 called for expanding access to health plans that don’t comply with the Affordable Care Act’s strongest consumer protections. That may lead to more choice and lower monthly premiums for buyers, but unwitting consumers may face potentially massive out-of-pocket costs for care the plans won’t cover.

And Project 2025 called for halting Medicaid funding to Planned Parenthood affiliates. The organization, an important health care provider for women across the country, gets roughly $700 million annually from Medicaid and other government programs, based on its 2022-23 report. Abortion made up about 4% of services the organization provided to patients, the report says.

The administration’s steps to scrub words such as “equity” from federal documents, erase transgender identifiers, and curtail international medical aid — all part of the Project 2025 wish list — have already had sweeping ramifications, hobbling access to health care and eviscerating international programs that aim to prevent disease and improve maternal health outcomes.

Under a memorandum issued in January, for example, Trump reinstated and expanded a ban on federal funds to global organizations that provide legal information on abortions.

Studies have found that the ban, known as the “global gag rule” or “Mexico City Policy,” has stripped millions of dollars away from foreign aid groups that didn’t abide by it. It’s also had a chilling effect: In Zambia, one group removed information in brochures on contraception, and in Turkey, some providers stopped talking with patients about menstrual regulation as a form of family planning.

Project 2025 called on the next president to reinstate the gag rule, saying it “should be drafted broadly to apply to all foreign assistance.”

Trump also signed an executive order rolling back transgender rights by banning federal funds for transition-related care for people under age 19. An order he signed also directed the federal government to recognize only two sexes, male and female, and use the term “sex” instead of “gender.”

The Project 2025 document calls for deleting the term “gender identity” from federal rules, regulations, and grants and for unwinding policies and procedures that its authors say are used to advance a “radical redefinition of sex.” In addition, it states that Department of Health and Human Services programs should “protect children’s minds and bodies.”

“Radical actors inside and outside government are promoting harmful identity politics that replaces biological sex with subjective notions of ‘gender identity,’” the Project 2025 road map reads.

Data Disappears

As a result of Trump’s order on gender identity, health researchers say, the Centers for Disease Control and Prevention took down online information about transgender health and removed data on LGBTQ+ health. A federal judge on Feb. 11 ordered that much of the information be restored; the administration complied but added notices to some webpages labeling them “extremely inaccurate” and claiming they don’t “reflect biological reality.”

The CDC also delayed the release of information and findings on bird flu in the agency’s Morbidity and Mortality Weekly Report. Federal workers have said they were told to retract papers that contain words such as “nonbinary” or “transgender.” And some hospitals suspended gender-affirming care such as hormone therapy and puberty blockers for youths.

Advocacy groups say the orders discriminate and pose barriers to medically necessary care, and transgender children and their families have filed a number of court challenges.

Lawyers, advocates, and researchers say implementation of many of Project 2025’s health policy goals poses a threat.

“The playbook presents an antiscience, antidata, and antimedicine agenda,” according to a piece last year by Boston University researchers in JAMA.

The Project 2025 blueprint sets out goals to curb access to medication abortion, restructure public health agencies, and weaken protections against sex-based discrimination. It would have seniors enroll by default in Medicare Advantage plans run by commercial insurers, in essence privatizing the health program for older Americans. And it calls for eliminating coverage requirements for Affordable Care Act plans that people buy without federal subsidies, which, insurance experts say, risks leaving people underinsured.

“It’s the agenda of the Trump administration,” said Robert Weissman, a co-president of Public Citizen, a progressive consumer rights advocacy group. “It’s to minimize access to care under the guise of strict work requirements in Medicaid, privatizing Medicare, and rolling back consumer protections and subsidies in the Affordable Care Act.”

The White House didn’t respond to a message seeking comment. Conservatives have said implementation of the project’s proposals would curb waste and fraud in federal health programs and free health systems from the clutches of a radical “woke” agenda.

“Americans are tired of their government being used against them,” Paul Dans, a lawyer and former director of Project 2025, said last year in a statement. “The administrative state is, at best, completely out of touch with the American people and, at worst, is weaponized against them.”

Dans did not return messages seeking comment for this article.

The Heritage Foundation has sought to separate itself and Project 2025 from Trump’s executive orders and other initiatives on health.

“This isn’t about our recommendations in Project 2025 – something we’ve been doing for more than 40 years. This is about President Trump delivering on his promises to make America safer, stronger, and better than ever before, and he and his team deserve the credit,” Ellen Keenan, a spokesperson for Heritage, said in a statement.

Versions of the document have been produced roughly every four years since the 1980s and have influenced other GOP presidents. Former President Ronald Reagan adopted about two-thirds of the recommendations from an earlier Heritage guide, the group says.

In some instances, the Trump administration hasn’t just followed Project 2025’s proposals but has gone beyond them.

The document called on the next president to scale back and “deradicalize” the U.S. Agency for International Development, an independent federal agency that provides foreign aid and assistance, including for many international health programs. The administration hasn’t just scaled back USAID. Trump adviser Elon Musk bragged on his social media platform, X, that his “Department of Government Efficiency” fed the agency “into the wood chipper,” physically closing its offices and putting nearly all its staff on administrative leave while ending funding for its programs and disseminating misinformation about them.

But the administration risks waning public support if it adopts the project’s goals to upend U.S. health care and health policy. Almost 60% of voters said they felt negatively about Project 2025 in a September poll by NBC News.

“Project 2025 was never a thought exercise; it was always a blueprint,” said Ally Boguhn, a spokesperson for Reproductive Freedom for All, an abortion rights group. “We’re only a few weeks into his presidency, and it’s setting the groundwork for even more.”

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In summertime, cows wait under a canopy to be milked at Mark McAfee’s farm in Fresno, California. From his Cessna 210 Centurion propeller plane, the 63-year-old can view grazing lands of the dairy company he runs that produces products such as unpasteurized milk and cheese for almost 2,000 stores.

Federal regulators say it’s risky business. Samples of raw milk can contain bird flu virus and other pathogens linked to kidney disease, miscarriages, and death.

McAfee, founder and CEO of the Raw Farm, who also leads the Raw Milk Institute, says he plans to soon be in a position to change that message.

Robert F. Kennedy Jr., the anti-vaccine activist President Donald Trump has tapped to run the Department of Health and Human Services, recruited McAfee to apply for a job as the FDA’s raw milk standards and policy adviser, McAfee said. McAfee has already written draft proposals for possible federal certification of raw dairy farms, he said.

Virologists are alarmed. The Centers for Disease Control and Prevention recommends against unpasteurized dairy that hasn’t been heated to kill pathogens such as bird flu. Interstate raw milk sales for human consumption are banned by the FDA. A Trump administration that weakens the ban or extols raw milk, the scientists say, could lead to more foodborne illness. It could also, they say, raise the risk of the highly pathogenic H5N1 bird flu virus evolving to spread more efficiently, including between people, possibly fueling a pandemic.

“If the FDA says raw milk is now legal and the CDC comes through and says it advises drinking raw milk, that’s a recipe for mass infection,” said Angela Rasmussen, a virologist and co-editor-in-chief of the medical journal Vaccine and an adjunct professor at Stony Brook University in New York.

The raw milk controversy reflects the broader tensions President Donald Trump will confront when pursuing his second-administration agenda of rolling back regulations and injecting more consumer choice into health care.

Many policies Kennedy has said he wants to revisit — from the fluoridation of tap water to nutrition guidance to childhood vaccine requirements — are backed by scientific research and were established to protect public health. Some physician groups and Democrats are gearing up to fight initiatives they say would put people at risk.

Raw milk has gained a following among anti-regulatory conservatives who are part of a burgeoning health freedom movement.

“The health freedom movement was adopted by the tea party, and conspiracy websites gave it momentum,” said Paul Offit, director of the Vaccine Education Center at Children’s Hospital of Philadelphia, who has studied the history of the anti-vaccine movement.

Once-fringe ideas are edging into the mainstream. Vaccine hesitancy is growing.

Arkansas, Utah, and Kentucky are weighing legislation that would relax or end requirements for fluoride in public water. And 30 states now allow for the sale of raw milk in some form within their borders.

While only an estimated 3% of the U.S. population consumes raw milk or cheese, efforts to try to restrict its sales have riled Republicans and provided grist for conservative podcasts.

Many conservatives denounced last year’s execution of a search warrant when Pennsylvania agriculture officials and state troopers arrived at an organic farm tucked off a two-lane road on Jan. 4, 2024. State inspectors were investigating cases of two children sickened by E. coli bacteria and sales of raw dairy from the operation owned by Amish farmer Amos Miller, according to a complaint filed by the state’s agricultural department.

Bundled in flannel shirts and winter jackets, the inspectors put orange stickers on products detaining them from sale, and they left toting product samples in large blue-and-white coolers, online videos show. The 2024 complaint against Miller alleged that he and his wife sold dairy products in violation of state law.

The farm was well known to regulators. They say in the complaint that a Florida consumer died after being sickened in 2014 with listeria bacteria found in raw dairy from Miller’s farm. The FDA said a raw milk sample from the farm indicates it was the “likely source” of the infection, based on the complaint.

Neither Miller’s farm nor his lawyer returned calls seeking comment.

The Millers’ attorney filed a preliminary objection that said “shutting down Defendants would cause inequitable harm, exceed the authority of the agency, constitute an excessive fine as well as disparate, discriminatory punishment, and contravene every essential Constitutional protection and powers reserved to the people of Pennsylvania.”

Regulators in Pennsylvania said in a press release they must protect the public, and especially children, from harm. “We cannot ignore the illnesses and further potential harm posed by distribution of these unregulated products,” the Pennsylvania agricultural department and attorney general said in a joint statement.

Unpasteurized dairy products are responsible for almost all the estimated 761 illnesses and 22 hospitalizations in the U.S. that occur annually because of dairy-related illness, according to a study published in the June 2017 issue of Emerging Infectious Diseases.

But conservatives say raiding an Amish farm is government overreach. They’re “harassing him and trying to make an example of him. Our government is really out of control,” Pennsylvania Republican Sen. Doug Mastriano said in a video he posted to Facebook.

Videos show protesters at a February 2024 hearing on Miller’s case included Amish men dressed in black with straw hats and locals waving homemade signs with slogans such as “FDA Go Away.” A court in March issued a preliminary injunction that barred Miller from marketing and selling raw dairy products within the commonwealth pending appeal, but the order did not preclude sales of raw milk to customers out of state. The case is ongoing.

With Kennedy, the raw milk debate is poised to go national. Kennedy wrote on X in October that the “FDA’s war on public health is about to end.” In the post, he pointed to the agency’s “aggressive suppression” of raw milk, as one example.

McAfee is ready. He wants to see a national raw milk ordinance, similar to one that exists for pasteurized milk, that would set minimal national standards. Farmers could attain certification through training, continuing education, and on-site pathogen testing, with one standard for farms that sell to consumers and another for retail sales.

The Trump administration didn’t return emails seeking comment.

McAfee has detailed the system he developed to ensure his raw dairy products are safe. He confirmed the process for KFF Health News: cows with yellow-tagged ears graze on grass pastures and are cleansed in washing pens before milking. The raw dairy is held back from consumer sale until it’s been tested and found clear of pathogens.

His raw dairy products, such as cheese and milk, are sold by a variety of stores, including health, organic, and natural grocery chains, according to the company website, as well as raw dairy pet products, which are not for human consumption.

He said he doesn’t believe the raw milk he sells could contain or transmit viable bird flu virus. He also said he doesn’t believe regulators’ warnings about raw milk and the virus.

“The pharmaceutical industry is trying to create a new pandemic from bird flu to get their stock back up,” said McAfee, who says he counts Kennedy as a customer. His view is not shared by leading virologists.

In December, the state of California secured a voluntary recall of all his company’s raw milk and cream products due to possible bird flu contamination.

Five indoor cats in the same household died or were euthanized in December after drinking raw milk from McAfee’s farm, and tests on four of the animals found they were infected with bird flu, according to the Los Angeles County Department of Health.

In an unrelated case, Joseph Journell, 56, said three of his four indoor cats drank McAfee’s raw milk. Two fell sick and died, he said. His third cat, a large tabby rescue named Big Boy, temporarily lost the use of his hind legs and had to use a specialized wheelchair device, he said. Urine samples from Big Boy were positive for bird flu, according to a copy of the results from Cornell University and the U.S. Department of Agriculture.

McAfee dismissed connections between the cats’ illnesses and his products, saying any potential bird flu virus would no longer be viable by the time his raw milk gets to stores. He also said he believes that any sick cats got bird flu from recalled pet food.

Journell said he has hired a lawyer to try to recover his veterinary costs but remains a staunch proponent of raw milk.

“Raw milk is good for you, just not if it has bird flu in it,” he said. “I do believe in its healing powers.”

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Former President Donald Trump’s election victory and looming return to the White House will likely bring changes that scale back the nation’s public health insurance programs — increasing the uninsured rate, while imposing new barriers to abortion and other reproductive care.

The reverberations will be felt far beyond Washington, D.C., and could include an erosion of the Affordable Care Act’s consumer protections, the imposition of work requirements in Medicaid and funding cuts to the safety net insurance, and challenges to federal agencies that safeguard public health. Abortion restrictions may tighten nationwide with a possible effort to restrict the mailing of abortion medications.

And with the elevation of vaccine skeptic Robert F. Kennedy Jr. to Trump’s inner circle of advisers, public health interventions with rigorous scientific backing — whether fluoridating public water supplies or inoculating children — could come under fire.

Trump defeated Vice President Kamala Harris with 277 Electoral College votes, The Associated Press declared at 5:34 a.m. ET on Wednesday. He won 51% of the vote nationally to Harris’ 47.5%, the AP projected.

Trump’s victory will give a far broader platform to skeptics and critics of federal health programs and actions. Worst case, public health authorities worry, the U.S. could see increases in preventable illnesses; a weakening of public confidence in established science; and debunked notions — such as a link between vaccines and autism — adopted as policy. Trump said in an NBC News interview on Nov. 3 that he would “make a decision” about banning some vaccines, saying he would consult with Kennedy and calling him “a very talented guy.”

While Trump has said he will not try again to repeal the Affordable Care Act, his administration will face an immediate decision next year on whether to back an extension of enhanced premium subsidies for Obamacare insurance plans. Without the enhanced subsidies, steep premium increases causing lower enrollment are projected. The current uninsured rate, about 8%, would almost certainly rise.

Policy specifics have not moved far beyond the “concepts of a plan” Trump said he had during his debate with Harris, though Vice President-elect JD Vance later said the administration would seek to inject more competition into ACA marketplaces.

Republicans were projected to claim a Senate majority, in addition to the White House, while control of the House was not yet resolved early Wednesday.

Polls show the ACA has gained support among the public, including provisions such as preexisting condition protections and allowing young people to stay on family health plans until they are 26.

Trump supporters and others who have worked in his administration say the former president wants to improve the law in ways that will lower costs. They say he has already shown he will be forceful when it comes to lowering high health care prices, pointing to efforts during his presidency to pioneer price transparency in medical costs.

“On affordability, I’d see him building on the first term,” said Brian Blase, who served as a Trump health adviser from 2017 to 2019. Relative to a Democratic administration, he said, there will be “much more focus” on “minimizing fraud and waste.”

Efforts to weaken the ACA could include slashing funds for enrollment outreach, enabling consumers to purchase more health plans that don’t comply with ACA consumer protections, and allowing insurers to charge sicker people higher premiums.

Democrats say they expect the worst.

“We know what their agenda is,” said Leslie Dach, executive chair of Protect Our Care, a health care policy and advocacy organization in Washington, D.C. He worked in the Obama administration helping to implement the ACA. “They’re going to raise costs for millions of Americans and rip coverage away from millions and, meanwhile, they will give tax breaks to rich people.”

Theo Merkel, director of the Private Health Reform Initiative at the right-leaning Paragon Health Institute, which Blase leads, said the enhanced ACA subsidies extended by the Inflation Reduction Act in 2022 do nothing to improve plans or lower premiums. He said they paper over the plans’ low value with larger government subsidies.

Other Trump supporters say the president-elect may support preserving Medicare’s authority to negotiate drug prices, another provision of the IRA. Trump has championed reducing drug prices, and in 2020 advanced a test model that would have tied the prices of some drugs in Medicare to lower costs overseas, said Merkel, who worked in Trump’s first White House. The drug industry successfully sued to block the program.

Within Trump’s circles, some names have already been floated as possible leaders for the Department of Health and Human Services. They include former Louisiana Gov. Bobby Jindal and Seema Verma, who ran the Centers for Medicare & Medicaid Services during the Trump administration.

Kennedy, who suspended his independent presidential run and endorsed Trump, has told his supporters that Trump promised him control of HHS. Trump said publicly before Election Day that he would give Kennedy a big role in his administration, but he may have difficulty winning Senate confirmation for a Cabinet position.

While Trump has vowed to protect Medicare and said he supports funding home care benefits, he’s been less specific about his intentions for Medicaid, which provides coverage to lower-income and disabled people. Some health analysts expect the program will be especially vulnerable to spending cuts, which could help finance the extension of tax breaks that expire at the end of next year.

Possible changes include the imposition of work requirements on beneficiaries in some states. The administration and Republicans in Congress could also try to revamp the way Medicaid is funded. Now, the federal government pays states a variable percentage of program costs. Conservatives have long sought to cap the federal allotments to states, which critics say would lead to draconian cuts.

“Medicaid will be a big target in a Trump administration,” said Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes KFF Health News.

Less clear is the potential future of reproductive health rights.

Trump has said decisions about abortion restrictions should be left to the states. Thirteen states ban abortion with few exceptions, while 28 others restrict the procedure based on gestational duration, according to the Guttmacher Institute, a research and policy organization focused on advancing reproductive rights. Trump said before the election that he would not sign a national abortion ban.

State ballot measures to protect abortion rights were adopted in four states, including Missouri, which Trump won by about 18 points, according to preliminary AP reports. Abortion rights measures were rejected by voters in Florida and South Dakota.

Trump could move to restrict access to abortion medications, used in more than half of abortions, either by withdrawing the FDA’s authorization for the drugs or by enforcing a 19th-century law, the Comstock Act, that abortion opponents say bans their shipment. Trump has said he generally would not use the law to ban mail delivery of the drugs.

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On the campaign trail, both former President Donald Trump and Vice President Kamala Harris are eager to portray themselves as guardians of Medicare. Each presidential candidate accuses the other of backing spending cuts and other policies that would damage the health insurance program for older Americans.

But the election’s outcome could alter the very nature of the nearly 60-year-old federal program. More than half of Medicare beneficiaries are already enrolled in plans, called Medicare Advantage, run by commercial insurers, and if Trump wins, that proportion is expected to grow — perhaps dramatically.

Trump and many congressional Republicans have already taken steps to aggressively promote Medicare Advantage. And Project 2025, a political wish list produced by the conservative Heritage Foundation for the next presidency, calls for making insurer-run plans the default enrollment option for Medicare.

Such a change would effectively privatize the program, because people tend to stick with the plans they’re initially enrolled in, health analysts say. Trump has repeatedly tried to distance himself from Project 2025, though the document’s authors include numerous people who worked in his first administration.

Conservatives say Medicare beneficiaries are better off in the popular Advantage plans, which offer more benefits than the traditional, government-run program. Critics say increasing insurers’ control of the program would trap consumers in health plans that are costlier to taxpayers and that can restrict their care, including by imposing onerous prior authorization requirements for some procedures.

“Traditional Medicare will wither on the vine,” said Robert Berenson, a former official in the Jimmy Carter and Bill Clinton administrations who’s now a senior fellow at the Urban Institute, a left-leaning research group.

While the fate of Medicare has gotten scant attention so far in the campaign, the different visions under Trump versus Harris indicate the high stakes.

A candidate’s position on protecting Medicare and Social Security is the most important health care issue, or among the most important, in determining 63% of Americans’ vote in the presidential election, according to a September poll by Gallup and West Health, a family of nonprofit and nonpartisan organizations focused on health care and aging.

Medicare, which covers about 66 million people, is funded largely by payroll taxes. At age 65, most Americans are automatically enrolled in Medicare coverage for hospitalization and doctor visits, known as Part A and Part B, though others must sign up. Consumers must also sign up for other aspects of Medicare, specifically drug coverage (Part D) and supplemental plans from insurers that pay for costs that aren’t covered by traditional Medicare, such as extended stays in skilled nursing facilities and cost sharing.

People on Medicare pay premiums plus as much as 20% of the cost of their care.

Medicare Advantage plans typically combine coverage for hospital and outpatient care and prescriptions, while eliminating the 20% coinsurance requirement and capping customers’ annual out-of-pocket costs. Many of the plans don’t charge an extra monthly premium, though some carry a deductible — an amount patients must pay each year before coverage kicks in.

Sometimes the plans throw in extras like coverage for eye exams and glasses or gym memberships.

However, they control costs by limiting patients to networks of approved doctors and hospitals, with whom the plans negotiate payment rates. Some hospitals and doctors refuse to do business with some or all Medicare Advantage plans, making those networks narrow or limited. Traditional Medicare, in comparison, is accepted by nearly every hospital and doctor.

Medicare’s popularity is one reason both candidates are pledging to enhance it. Last month, Harris released a plan that would add benefits including care for hearing and vision, and long-term in-home health care. The costs would be covered by savings from expanding Medicare’s negotiations with drugmakers, reducing fraud, and increasing discounts drugmakers pay for certain brand-name drugs in the program, according to Harris’ campaign.

Trump’s campaign said he would prioritize home care benefits and support unpaid family caregivers through tax credits and reduced red tape.

The Trump campaign also noted enhancements to Medicare Advantage plans during his tenure as president, such as increasing access to telehealth and expanding supplemental benefits for seniors with chronic diseases.

But far less attention has been paid to whether to give even more control of Medicare to private insurers. Joe Albanese, a senior policy analyst at Paragon Health Institute, a right-leaning research group, said “a Trump administration and GOP Congress would be more friendly” to the idea.

The concept of letting private insurers run Medicare isn’t new. Former House Speaker Newt Gingrich, a Republican, asserted in 1995 that traditional Medicare would fade away if its beneficiaries could pick between the original program and private plans.

The shift to Medicare Advantage was accelerated by legislation in 2003 that created Medicare’s drug benefit and gave private health plans a far greater role in the program.

Lawmakers thought private insurers could better contain costs. Instead, the plans have cost more. In 2023, Medicare Advantage plans cost the government and taxpayers about 6% — or $27 million — more than original Medicare, though some research shows they provide better care.

The Trump administration promoted Medicare Advantage in emails during the program’s open enrollment period each year, but support for the privately run plans has become bipartisan as they have grown.

“It helps inject needed competition into a government-run program and has proven to be more popular with those who switch,” said Roger Severino, lead architect of Project 2025’s section on the Department of Health and Human Services. He served as director of HHS’ civil rights office during the Trump administration.

But enrollees who want to switch back to traditional Medicare may not be able to. If they try to buy supplemental coverage for the 20% of costs Medicare doesn’t cover, they may find they have to pay an unaffordable premium. Unless they enroll in the plans close to the time they first become eligible for Medicare, usually at age 65, insurers selling those supplemental plans can deny coverage or charge higher premiums because of preexisting conditions.

“More members of Congress are hearing from constituents who are horrified and realize they are trapped in these plans,” said Andrea Ducas, vice president of health policy at the Center for American Progress, a liberal public policy organization.

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Health care is suddenly front and center in the final sprint to the presidential election, and the outcome will shape the Affordable Care Act and the coverage it gives to more than 40 million people.

Besides reproductive rights, health care for most of the campaign has been an in-the-shadows issue. However, recent comments from former President Donald Trump and his running mate, Ohio Sen. JD Vance, about possible changes to the ACA have opened Republicans up to heavier scrutiny.

More than 1,500 doctors across the country recently released a letter calling on Trump to reveal details about how he would alter the ACA, saying the information is needed so voters can make an informed decision. The letter came from the Committee to Protect Health Care, a national advocacy group of physicians.

“It’s remarkable that a decade and a half after the ACA passed, we are still debating these fundamental issues,” said Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes KFF Health News. “Democrats want to protect people with preexisting conditions, which requires money and regulation. Republicans have looked to scale back federal regulation, and the byproduct is fewer protections.”

The two parties’ tickets hold starkly different goals for the ACA, a sweeping law passed under former President Barack Obama that set minimum benefit standards, made more people eligible for Medicaid, and ensured consumers with preexisting health conditions couldn’t be denied health coverage.

Vice President Kamala Harris, who previously backed a universal health care plan, wants to expand and strengthen the health law, popularly known as Obamacare. She supports making permanent temporary enhanced subsidies that lower the cost of premiums. And she’s expected to press Congress to extend Medicaid coverage to more people in the 10 states that have so far not expanded the program.

Trump, who repeatedly tried and failed to repeal the ACA, said in the September presidential debate that he has “concepts of a plan” to replace or change the legislation. Although that sound bite became a bit of a laugh line because Trump had promised an alternative health insurance plan many times during his administration and never delivered, Vance later provided more details.

He said the next Trump administration would deregulate insurance markets — a change that some health analysts say could provide more choice but erode protections for people with preexisting conditions. He seemed to adjust his position during the vice presidential debate, saying the ACA’s protections for preexisting conditions should be left in place.

Such health policy changes could be advanced as part of a large tax measure in 2025, Sen. Tom Cotton (R-Ark.) told NBC News. That could also open the door to changes in Medicaid. Conservatives have long sought to remake the health insurance program for low-income or disabled people from the current system, in which the federal government contributes a formula-based percentage of states’ total Medicaid costs, to one that caps federal outlays through block grants or per capita funding limits. ACA advocates say that would shift significant costs to states and force most or all states to drop the expansion of the program over time.

Democrats are trying to turn the comments into a political liability for Trump, with the Harris campaign running ads saying Trump doesn’t have a health plan to replace the ACA. Harris’ campaign also released a 43-page report, “The Trump-Vance ‘Concept’ on Health Care,” asserting that her opponents would “rip away coverage from people with preexisting conditions and raise costs for millions.”

Republicans were tripped up in the past when they sought unsuccessfully to repeal the ACA. Instead, the law became more popular, and the risk Republicans posed to preexisting condition protections helped Democrats retake control of the House in 2018.

In a KFF poll last winter, two-thirds of the public said it is very important to maintain the law’s ban on charging people with health problems more for health insurance or rejecting their coverage.

“People in this election are focused on issues that affect their family,” said Robert Blendon, a professor emeritus of health policy and political analysis at Harvard. “If people believe their own insurance will be affected by Trump, it could matter.”

Vance, in a Sept. 15 interview on NBC’s “Meet the Press,” tried to minimize this impact.

“You want to make sure that preexisting coverage — conditions — are covered, you want to make sure that people have access to the doctors that they need, and you also want to implement some deregulatory agenda so that people can choose a health care plan that fits them,” he said.

Vance went on to say that the best way to ensure everyone is covered is to promote more choice and not put everyone in the same insurance risk pool.

Risk pools are fundamental to insurance. They refer to a group of people who share the burdens of health costs.

Under the ACA, enrollees are generally in the same pool regardless of their health status or preexisting conditions. This is done to control premium costs for everyone by using the lower costs incurred by healthy participants to keep in check the higher costs incurred by unhealthy participants. Separating sicker people into their own pool can lead to higher costs for people with chronic health conditions, potentially putting coverage out of financial reach for them.

The Harris campaign has seized on the threat, saying in its recent report that “health insurers will go back to discriminating on the basis of how healthy or unhealthy you are.”

But some ACA critics think there are ways to separate risk pools without undermining coverage.

“Unsurprisingly, it’s been blown out of proportion for political purposes,” said Theo Merkel, a former Trump aide who now is a senior research fellow at the Paragon Health Institute, a right-leaning organization that produces health research and market-based policy proposals.

Adding short-term plans to coverage options won’t hurt the ACA marketplace and will give consumers more affordable options, said Merkel, who is also a senior fellow at the Manhattan Institute. The Trump administration increased the maximum duration of these plans, then Biden rolled it back to four months.

People eligible for subsidies would likely buy comprehensive ACA plans because — with the financial help — they would be affordable. Thus, the ACA market and its protections for preexisting conditions would continue to function, Merkel said. But offering short-term plans, too, would provide a more affordable option for people who don’t qualify for subsidies and who would be more likely to buy the noncompliant plans.

He also said that in states that allowed people to buy non-ACA-compliant plans outside the exchange, the exchanges performed better than in states that prohibited it. Another option, Merkel said, is a reinsurance program similar to one that operates in Alaska. Under the plan, the state pays insurers back for covering very expensive health claims, which helps keep premiums affordable.

But advocates of the ACA say separating sick and healthy people into different insurance risk pools will make health coverage unaffordable for people with chronic conditions, and that letting people purchase short-term health plans for longer durations will backfire.

“It uninsures people when they get sick,” said Leslie Dach, executive chair of Protect Our Care, which advocates for the health law. “There’s no reason to do this. It’s unconscionable and makes no economic sense. They will hide behind saying ‘we’re making it better,’ but it’s all untrue.”

Harris, meanwhile, wants to preserve the temporary expanded subsidies that have helped more people get lower-priced health coverage under the ACA. These expanded subsidies that help about 20 million people will expire at the end of 2025, setting the stage for a pitched battle in Congress between Republicans who want to let them run out and Democrats who say they should be made permanent.

Democrats in September introduced a bill to make them permanent. One challenge: The Congressional Budget Office estimated doing so would increase the federal deficit by more than $330 billion over 10 years.

In the end, the ability of either candidate to significantly grow or change the ACA rests with Congress. Polls suggest Republicans are in a good position to take control of the Senate, with the outcome in the House more up in the air. The margins, however, will likely be tight. In any case, many initiatives, such as expanding or restricting short-term health plans, also can be advanced with executive orders and regulations, as both Trump and Biden have done.

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