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The Affordable Care Act provides additional protections, because it requires most health insurers to fully cover all federally recommended preventive care.

Some insurers, including Aetna and certain Blue Cross Blue Shield plans, have already announced that they will not bill patients for the vaccine or its administration.

The federal government has used other levers to curtail surprise vaccine bills. When it offered enhanced Medicaid payment rates this spring, it required states to fully cover coronavirus vaccines for all their enrollees as a condition of receipt. All 50 states accepted the extra funding, and are now subject to those

requirements.

That’s different from the rules around coronavirus treatment, which regulated insurers’ cost sharing but did not take steps to curtail billing by doctors and hospitals. That meant some patients received bills they didn’t expect.

What makes the vaccine protections unique is that there are requirements on both the insurers and the providers,”

Experts also worry about uninsured Americans. The United States does not have a national program to cover vaccination costs for them. For coronavirus, it is instructing health providers to submit costs associated with vaccination to a $175 billion Provider Relief Fund created last spring.

Additional fees could accompany a vaccine. Some providers are accustomed to charging a visit fee for all in-person patients. Most emergency rooms charge “facility fees,” the price of coming in the door and seeking care, as do some hospital-based doctors.

Federal law is quite clear that patients should not have to pay for the vaccine and its administration. But there isn’t language that defines what counts as “vaccine administration,” and whether the visit fee makes the cut.

The question that I’m still not clear on is what happens if someone walks into an outpatient department that charges a facility fee and gets a vaccine,” said Kao-Ping Chua, an assistant professor of pediatrics at the University of Michigan who has studied coronavirus medical billing. “Is there a possibility they could get charged? I think the answer is yes.”

It’s the height of American exceptionalism that we are where we are. I have family in other parts of the world where health-care workers and vulnerable elderly people are begging to get the vaccine. And here, we’re sitting on stockpiles and begging people to take the vaccine.

Do you think verification and mandates could work in the U.S. with our notions of freedom, individual liberty?

I think we need to reframe freedom here, right? I don’t agree with the statement that some people have been putting out about vaccines, that this is just about personal choice. You can say that maybe eating unhealthy food is your personal choice. But in this case, nobody should have the right to carry an infectious disease that is able to endanger others and potentially kill them. I mean, I’ve got two little kids. I’m very upset thinking about how there are other people who are choosing not to be vaccinated. And as a result, they are choosing to endanger our children. I’m sure they’re not trying to do this intentionally, but that is the end result.

I hope that people see that by not being vaccinated, they’re actually impeding societal progress too. They’re making it harder for kids to get back in school. They’re making it harder for the economy to come back. And why are we allowed to make that kind of personal choice when we do not allow people to make the personal choice to go drunk driving?

How much do you worry about hesitancy, not just around the vaccine, but mistrust of science and mistrust of public health even?

I worry about this a lot. You’ve seen what happened in Tennessee with the vaccine director being fired for trying to promote covid vaccines to adolescents. And even more disturbing, I think is that now, Tennessee health officials are being prohibited from promoting vaccines to children. Not just covid vaccines, but all other childhood immunizations. I mean, public health is now under attack in a way that it has not been before.

Marvin Mallek, a doctor who treats covid patients from both sides of the river at Springfield Hospital in Vermont, said New Hampshire covid patients are now facing business as usual from insurers, suffering the same sort of financial stress that routinely affects patients with cancer, heart disease and other serious ailments.

“The inhumanity of our health-care system and the tragedies it creates will now resume and will now cover this one group that was exempted,'' he said. “The U.S. health-care system is sort of like a game of musical chairs where there are not enough chairs, and some people are going to get hurt and devastated financially.”

Hospitals also are in the position of having to resume billings and collections for individuals who may have been laid off because of the pandemic or been too sick to work, experts said.

“These waivers ended in January as we all had gained a better understanding of the virus, and people and communities became more familiar with best practices and protocols for limiting COVID-19 exposure and spread,” the company said in a statement. “Also, at this time vaccines, which are proven to be the safest and most effective way to protect oneself from COVID-19, were starting to become readily available.”Anthem took in $4.6 billion in profits in 2020, compared to $4.8 billion in 2019.

The reintroduction of cost-sharing mainly affects people with private or employer-based insurance. Patients with no insurance can have 100 percent of their expenses covered by the federal government, under a special program set up by the government for the pandemic, with hospitals reimbursed for care at Medicare rates.

Covid patients with Medicaid, the government plan for lower-income people that is paid for by states and the federal government, continue to be protected from cost-sharing, insurance specialists said

Patients on Medicare, the federal plan for the elderly, could face out-of-pocket costs if they do not have supplemental insurance.

Last year, according to the Kaiser Family Foundation, 88 percent of people covered by private insurance had their co-pays and deductibles for covid treatment waived. By August 2021, only 28 percent of the two largest plans in each state and D.C. still had the waivers in place, and another 10 percent planned to phase them out by the end of October,

general, a person with Azar’s type of plan would have an in-network deductible of $1,500 and an in-network out-of-pocket maximum of $4,000,

“We still don’t know where the numbers will land because the system makes the family wait for the bills,” s

Bills related to her stay at the out-of-network rehab hospital in Tennessee could climb as high as $10,000 more, her relatives have estimated, but they acknowledged they were uncertain this month what exactly to expect, even after asking UnitedHealthcare and the providers.

In 2020, as the pandemic took hold, U.S. health insurance companies declared they would cover 100 percent of the costs for covid treatment, waiving co-pays and expensive deductibles for hospital stays that frequently range into the hundreds of thousands of dollars.But this year, most insurers have reinstated co-pays and deductibles for covid patients, in many cases even before vaccines became widely available.

Over the past four decades, governments have slashed budgets and privatized basic services. This has two important consequences for public health

First, people are unlikely to trust institutions that do little for them.

second, public health is no longer viewed as a collective endeavor, based on the principle of social solidarity and mutual obligation. People are conditioned to believe they’re on their own and responsible only for themselves.

an important source of vaccine hesitancy is the erosion of the idea of a common good.

compared with white Americans, communities of color do experience the American health care system differently. But a closer look at the data reveals a more complicated picture.

Since the spring, when most American adults became eligible for Covid vaccines, the racial gap in vaccination rates between Black and white people has been halved. In September, a national survey found that vaccination rates among Black and white Americans were almost identical.

Other surveys have determined that a much more significant factor was college attendance: Those without a college degree were the most likely to go unvaccinated.

Education is a reliable predictor of socioeconomic status, and other studies have similarly found a link between income and vaccination.

It turns out that the real vaccination divide is class.

“People are thinking, ‘If the government isn’t going to do anything for us,’” said Elden, “‘then why should we participate in vaccines?’”

during the 1950s polio campaigns, for example, most people saw vaccination as a civic duty.

But as the public purse shrunk in the 1980s, politicians insisted that it’s no longer the government’s job to ensure people’s well-being; instead, Americans were to be responsible only for themselves and their own bodies

Entire industries, such as self-help and health foods, have sprung up on the principle that the key to good health lies in individuals making the right choices.

Without an idea of the common good, health is often discussed using the language of “choice.”

there are problems with reducing public health to a matter of choice. It gives the impression that individuals are wholly responsible for their own health.

This is despite growing evidence that health is deeply influenced by factors outside our control; public health experts now talk about the “social determinants of health,” the idea that personal health is never simply just a reflection of individual lifestyle choices, but also the class people are born into, the neighborhood they grew up in and the race they belong to.

food deserts and squalor are not easy problems to solve — certainly not by individuals or charities — and they require substantial government action.

Many medical schools teach “motivational interviewing,”

the deeper problem:

Being healthy is not cheap. Studies indicate that energy-dense foods with less nutritious value are more affordable, and low-cost diets are linked to obesity and insulin resistance.

Another problem with reducing well-being to personal choice is that this treats health as a commodity.

This isn’t surprising, since we shop for doctors and insurance plans the way we do all other goods and services

mothers devoted many hours to “researching” vaccines, soaking up parental advice books and quizzing doctors. In other words, they act like savvy consumers

When thinking as a consumer, people tend to downplay social obligations in favor of a narrow pursuit of self-interest. As one parent told Reich, “I’m not going to put my child at risk to save another child.”

Such risk-benefit assessments for vaccines are an essential part of parents’ consumer research.

Vaccine uptake is so high among wealthy people because Covid is one of the gravest threats they face. In some wealthy Manhattan neighborhoods, for example, vaccination rates run north of 90 percent.

For poorer and working-class people, though, the calculus is different: Covid-19 is only one of multiple grave threats.

When viewed in the context of the other threats they face, Covid no longer seems uniquely scary.

Most of the people we interviewed in the Bronx say they are skeptical of the institutions that claim to serve the poor but in fact have abandoned them.

he and his friends find reason to view the government’s sudden interest in their well-being with suspicion. “They are over here shoving money at us,” a woman told us, referring to a New York City offer to pay a $500 bonus to municipal workers to get vaccinated. “And I’m asking, why are you so eager, when you don’t give us money for anything else?”

These views reinforce the work of social scientists who find a link between a lack of trust and inequality. And without trust, there is no mutual obligation, no sense of a common good.

The experience of the 1960s suggests that when people feel supported through social programs, they’re more likely to trust institutions and believe they have a stake in society’s health.

While the reasons vary by country, the underlying causes are the same: a deep mistrust in local and international institutions, in a context in which governments worldwide have cut social services.

In one Syrian city, for example, the health care system now consists of one public hospital so underfunded that it is notorious for poor care, a few private hospitals offering high-quality care that are unaffordable to most of the population, and many unlicensed and unregulated private clinics — some even without medical doctors — known to offer misguided health advice. Under such conditions, conspiracy theories can flourish; many of the city’s residents believe Covid vaccines are a foreign plot.

In many developing nations, international aid organizations are stepping in to offer vaccines. These institutions are sometimes more equitable than governments, but they are often oriented to donor priorities, not community needs.

“We have starvation and women die in childbirth.” one tribal elder told us, “Why do they care so much about polio? What do they really want?”

In America, anti-vaccine movements are as old as vaccines themselves; efforts to immunize people against smallpox prompted bitter opposition in the turn of the last century. But after World War II, these attitudes disappeared. In the 1950s, demand for the polio vaccine often outstripped supply, and by the late 1970s, nearly every state had laws mandating vaccinations for school with hardly any public opposition.

What changed? This was the era of large, ambitious government programs like Medicare and Medicaid.

The anti-measles policy, for example, was an outgrowth of President Lyndon Johnson’s Great Society and War on Poverty initiatives.

Research shows that private systems not only tend to produce worse health outcomes than public ones, but privatization creates what public health experts call “segregated care,” which can undermine the feelings of social solidarity that are critical for successful vaccination drives

Only then do the ideas of social solidarity and mutual obligation begin to make sense.

The types of social programs that best promote this way of thinking are universal ones, like Social Security and universal health care.

If the world is going to beat the pandemic, countries need policies that promote a basic, but increasingly forgotten, idea: that our individual flourishing is bound up in collective well-being.

such a decline was both predictable and predicted, for example, in prepandemic projections from the Congressional Budget Office.

today’s labor force participation is actually higher than the budget office expected — which is truly remarkable given that Covid did push some workers into early retirement, while long Covid may have left a significant number of workers with persistent disabilities.

One way to look past demographic changes is to focus on labor force participation by Americans in their prime working years, which is higher now than it has been for 20 years.

if you adjust for age and sex, overall U.S. employment is now at its highest level in history — again, despite the lingering effects of the pandemic.

So much, then, for claims that Big Government has made Americans lazy, or even talk of a Great Resignation. Americans are working more than ever.

Where are these additional workers coming from? One answer is that in a tight labor market, employers are more willing to look at marginalized groups, many of whose members turn out to be perfectly capable of productive employment

Americans with disabilities.

We’ve also seen a surge in foreign-born workers. Whatever the likes of Ron DeSantis may think, immigrants are a big plus for the U.S. economy: They tend to be both working-age and highly motivated.

So what does America’s extraordinary success at getting people back to work tell us

One thing it tells us is that the sluggish recovery that followed the 2008 financial crisis — sluggish largely because Very Serious People were obsessed with debt rather than jobs — denied employment to millions of Americans who could and should have been working.

recent job gains also make Bidenomics look a lot better than it did a year ago.

The larger point is that despite what grumpy rich men may say, Americans haven’t become lazy. On the contrary, they’re willing, even eager, to take jobs if they’re available. And while economic policy in recent years has been far from perfect, one thing it did do — to the nation’s great benefit — was give work a chance.

But the federal rules do not dictate how poor a patient needs to be to qualify for free care

In exchange, the Internal Revenue Service requires Allina and thousands of other nonprofit hospital systems to benefit their local communities, including by providing free or reduced-cost care to patients with low incomes.

In 2020, thanks to its nonprofit status, Allina avoided roughly $266 million in state, local and federal taxes, according to the Lown Institute, a think tank that studies health care.

Doctors and patients described being unable to complete medical forms that children needed to enroll in day care or show proof of vaccination for school.

Allina is one of Minnesota’s largest health systems, having largely grown through acquisitions. Since 2013, its annual profits have ranged from $30 million to $380 million. Last year was the first in the past decade when it lost money, largely owing to investment losses.

The financial success has paid dividends. Allina’s president earned $3.5 million in 2021, the most recent year for which data is available. The health system recently built a $12 million conference center.

Allina sometimes plays hardball with patients. Doctors have become accustomed to seeing messages in the electronic medical record notifying them that a patient “will no longer be eligible to receive care” because of “unpaid medical balances.”

In 2020, Allina spent less than half of 1 percent of its expenses on charity care, well below the nationwide average of about 2 percent for nonprofit hospitals

Serena Gragert, who worked as a scheduler at an Allina clinic in Minneapolis until 2021, said the computer system simply wouldn’t let her book future appointments for some patients with outstanding balances.

Ms. Gragert and other Allina employees said some of the patients who were kicked out had incomes low enough to qualify for Medicaid, the federal-state insurance program for poor people. That also means those patients would be eligible for free care under Allina’s own financial assistance policy — something many patients are unaware exists when they seek treatment.

Allina says the policy applies only to debts related to care provided by its clinics, not its hospitals. But patients said in interviews that they got cut off after falling into debt for services they received at Allina’s hospitals.

Jennifer Blaido lives in Isanti, a small town outside Minneapolis, and Allina owns the only hospital there. Ms. Blaido, a mechanic, said she racked up nearly $200,000 in bills from a two-week stay at Allina’s Mercy Hospital in 2009 for complications from pneumonia, along with several visits to the emergency department for asthma flare-ups

Ms. Blaido, a mother of four, said most of the hospital stay was not covered by her health insurance and she was unable to scrounge together enough money to make a dent in the debt.

Last year, Ms. Blaido had a cancer scare and said she couldn’t get an appointment with a doctor at Mercy Hospital. She had to drive more than an hour to get examined at a health system unconnected to Allina

In court filings, the couple described how Allina canceled Ms. Anderson’s appointments and told her that she could not book new ones until she had set up three separate payment plans — one with the health system and two with its debt collectors.Even after setting up those payment plans, which totaled $580 a month, the canceled appointments were never restored. Allina allows patients to come back only after they have paid the entire debt.

When the Andersons asked in court for a copy of Allina’s policy of barring patients with unpaid bills, the hospital’s lawyers responded: “Allina does not have a written policy regarding the canceling of services or termination of scheduled and/or physician referral services or appointments for unpaid debts.”In fact, Allina’s policy, which was created in 2006, instructs employees on how to do exactly that. Among other things, it tells staff to “cancel any future appointments the patient has scheduled at any clinic.”

It does provide a few ways for patients to continue being seen despite their unpaid bills. One is by getting approved for a loan through the hospital. Another is by filing for bankruptcy.

“People have faced higher prices and that is difficult, but that doesn’t explain why people have not cut back,” she said of a phenomenon known as revealed preference. “They have spent as if they see nothing but good times in front of them. So why are their actions so out of whack with their words?”

Many said their own finances were good enough — they had jobs, owned houses, made ends meet. But they felt as if they were “just getting by,” with “nothing left over.” Many felt angry and anxious over prices and the pandemic and politics.

Also, economists said, wages have increased alongside prices. Real median earnings for full-time workers are slightly higher than at the end of 2019, and for many low earners, their raises have outpaced inflation. But it’s common for people to think about prices at face value, rather than relative to their income, a habit economists call money illusion.

“The pandemic shattered a lot of illusions of control,” Professor Stevenson said. “I wonder how much that has made us more aware of all the places we don’t have control, over prices, over the housing market.”

Inflation weighed heavily on voters — nearly all of them mentioned frustration at the price of something they buy regularly.

Consumer prices were up 3.2 percent in October from the year before, a decline in the year-over-year inflation rate from more than 8 percent in mid-2022. But inflation “casts a long shadow on how people evaluate things,” said Lawrence Katz, an economist at Harvard. Some people may expect prices to return to what they were before — something that rarely happens

Those feelings may be driving attitudes about the economy, economists speculated, sounding more like their colleagues from another branch of social science, psychology.

Younger people — who were a key to President Biden’s win in 2020 but showed less support for him in the new poll — had concerns specific to their phase of life. In the poll, 93 percent of them rated the economy unfavorably, more than any other age group.

“Everyone thinks a wage increase is something they deserve, and a price increase is imposed by the economy on them,” Professor Katz said.

There’s a sense that it’s become harder to achieve the things their parents did, like buying a home. Houses are less affordable than at the height of the 2006 bubble, and less than half of Americans can afford one.

“More than likely, half my income will go toward rent,” he said. “I was really hoping on that student loan forgiveness.”

Yet overall, economists said, data shows that more people are quitting jobs to start better ones, moving to more desirable places because they can work remotely, and starting new businesses.

He said he makes almost $80,000, serving in the military and working as a DoorDash deliverer, yet feels he had more spending money a decade ago, when he was two pay grades lower.

he uncertainty Mr. Blanck and Ms. Linn share about the future ran through many voters’ stories, darkening their economic outlook.

“The degree of volatility that we’ve experienced from different events — from the pandemic, from inflation — leaves them not confident that even if objectively good things are going on, it’s going to persist,”

In response to the pandemic, the United States built an extensive welfare state, and it has since been dismantled. While wealth has increased for families across the income spectrum, data shows, and there are indications that inequality could be shrinking, the changes have been small relative to decades of growing inequality, leading to a sense for some that the system is rigged.

“When things are going well, that means rich people are getting richer and all of us are pretty much second,” said Manuel Zimberoff, 26, a manufacturing engineer in Philadelphia. “And if things are going poorly, rich people are still getting richer, and all of us are screwed.”

For roughly two decades, partisanship has increasingly been correlated with views about the economy: Research has shown that people rate the economy more poorly when their party is not in power. Nearly every Republican in the poll rated the economy unfavorably, and 59 percent of Democrats did.

He brought up U.S. funding in Ukraine and the Middle East. He wanted to know: Is that the reason our economy is “slowing down?” He wasn’t sure, but he thought it might be. He plans to vote for “the Republican, any Republican,” he said. “Democrats have disappointed me.”

But to understand why Republicans have died at higher rates, you can’t look at vaccine status alone. Congressional districts controlled by a trifecta of Republican leaders—state governor, Senate, and House—had an 11 percent higher death rate, according to the Lancet study. A likely explanation, the authors write, could be that in the post-vaccine era, those leaders chose policies and conveyed public-health messages that made their constituents more likely to die. Although we still can’t say these decisions led to higher death rates, the association alone is jarring.

One of the most compelling studies comes from researchers at Yale, who published their findings as a working paper in November. They link political party and excess-death rate—the percent increase in deaths above pre-COVID levels—among those registered as either Democrats or Republicans, providing a more granular view. They chose to analyze data from Florida and Ohio from before and after vaccines were available. Looking at the period before the vaccine,  researchers found a 1.6 percentage-point difference in excess death rate among Republicans and Democrats, with a higher rate among Republicans. But after vaccines became available, that gap widened dramatically to 10.4 percentage points, again with a higher Republican excess death rate. “When we compare individuals who are of the same age, who live in the same county in the same month of the pandemic, there are differences correlated with your political-party affiliation that emerge after vaccines are available,”

What’s most concerning about all of this is that partisan disparities in death rates were also apparent before COVID. People living in Republican jurisdictions have been at a health disadvantage for more than 20 years. From 2001 to 2019, the death rate in Democratic counties decreased by 22 percent, according to a recent study; in Republican counties, it declined by only 11 percent. In the same time period, the political gap in death rates increased sixfold.

over the decades, state policy decisions on health issues such as Medicaid, gun legislation, tobacco taxes, and, indeed, vaccines have likely had a stronger impact on state health trajectories than other factors

the long-term decline of health in red states indicates that there is an ongoing problem at a high level in Republican-led places, and that something has gone awry. “If you happen to live in certain states, your chances for living a long life are going to be much higher than if you’re an American living in a different state,”

o acknowledge how many Republicans didn’t have to die would mean giving credence to scientific and medical expertise. So long as America remains locked in a poisonous partisan battle in which science is wrongly dismissed as being associated with the left, the death toll will only rise.

The ordinary fixes—the kind that draw on people’s will, and require eating less and moving more—rarely have a large or lasting effect. Indeed, America itself has suffered through a long, maddening history of failed attempts to change its habits on a national scale: a yo-yo diet of well-intentioned treatments, policies, and other social interventions that only ever lead us back to where we started

Through it all, obesity rates keep going up; the diabetes epidemic keeps worsening.

The most recent miracle, for Barb as well as for the nation, has come in the form of injectable drugs. In early 2021, the Danish pharmaceutical company Novo Nordisk published a clinical trial showing remarkable results for semaglutide, now sold under the trade names Wegovy and Ozempic.

Patients in the study who’d had injections of the drug lost, on average, close to 15 percent of their body weight—more than had ever been achieved with any other drug in a study of that size. Wadden knew immediately that this would be “an incredible revolution in the treatment of obesity.”

Many more drugs are now racing through development: survodutide, pemvidutide, retatrutide. (Among specialists, that last one has produced the most excitement: An early trial found an average weight loss of 24 percent in one group of participants.

In the United States, an estimated 189 million adults are classified as having obesity or being overweight

The drugs don’t work for everyone. Their major side effects—nausea, vomiting, and diarrhea—can be too intense for many patients. Others don’t end up losing any weight

For the time being, just 25 percent of private insurers offer the relevant coverage, and the cost of treatment—about $1,000 a month—has been prohibitive for many Americans.

The drugs have already been approved not just for people with diabetes or obesity, but for anyone who has a BMI of more than 27 and an associated health condition, such as high blood pressure or cholesterol. By those criteria, more than 140 million American adults already qualify

if this story goes the way it’s gone for other “risk factor” drugs such as statins and antihypertensives, then the threshold for prescriptions will be lowered over time, inching further toward the weight range we now describe as “normal.”

How you view that prospect will depend on your attitudes about obesity, and your tolerance for risk

The first GLP-1 drug to receive FDA approval, exenatide, has been used as a diabetes treatment for more than 20 years. No long-term harms have been identified—but then again, that drug’s long-term effects have been studied carefully only across a span of seven years

the data so far look very good. “These are now being used, literally, in hundreds of thousands of people across the world,” she told me, and although some studies have suggested that GLP-1 drugs may cause inflammation of the pancreas, or even tumor growth, these concerns have not borne out.

adolescents are injecting newer versions of these drugs, and may continue to do so every week for 50 years or more. What might happen over all that time?

“All of us, in the back of our minds, always wonder, Will something show up?  ” Although no serious problems have yet emerged, she said, “you wonder, and you worry.”

in light of what we’ve been through, it’s hard to see what other choices still remain. For 40 years, we’ve tried to curb the spread of obesity and its related ailments, and for 40 years, we’ve failed. We don’t know how to fix the problem. We don’t even understand what’s really causing it. Now, again, we have a new approach. This time around, the fix had better work.

The fen-phen revolution arrived at a crucial turning point for Wadden’s field, and indeed for his career. By then he’d spent almost 15 years at the leading edge of research into dietary interventions, seeing how much weight a person might lose through careful cutting of their calories.

But that sort of diet science—and the diet culture that it helped support—had lately come into a state of ruin. Americans were fatter than they’d ever been, and they were giving up on losing weight. According to one industry group, the total number of dieters in the country declined by more than 25 percent from 1986 to 1991.

Rejecting diet culture became something of a feminist cause. “A growing number of women are joining in an anti-diet movement,” The New York Times reported in 1992. “They are forming support groups and ceasing to diet with a resolve similar to that of secretaries who 20 years ago stopped getting coffee for their bosses.

Now Wadden and other obesity researchers were reaching a consensus that behavioral interventions might produce in the very best scenario an average lasting weight loss of just 5 to 10 percent

National surveys completed in 1994 showed that the adult obesity rate had surged by more than half since 1980, while the proportion of children classified as overweight had doubled. The need for weight control in America had never seemed so great, even as the chances of achieving it were never perceived to be so small.

Wadden wasn’t terribly concerned, because no one in his study had reported any heart symptoms. But ultrasounds revealed that nearly one-third of them had some degree of leakage in their heart valves. His “cure for obesity” was in fact a source of harm.

In December 1994, the Times ran an editorial on what was understood to be a pivotal discovery: A genetic basis for obesity had finally been found. Researchers at Rockefeller University were investigating a molecule, later named leptin, that gets secreted from fat cells and travels to the brain, and that causes feelings of satiety. Lab mice with mutations in the leptin gene—importantly, a gene also found in humans—overeat until they’re three times the size of other mice. “The finding holds out the dazzling hope,”

In April 1996, the doctors recommended yes: Dexfenfluramine was approved—and became an instant blockbuster. Patients received prescriptions by the hundreds of thousands every month. Sketchy wellness clinics—call toll-free, 1-888-4FEN-FEN—helped meet demand. Then, as now, experts voiced concerns about access. Then, as now, they worried that people who didn’t really need the drugs were lining up to take them. By the end of the year, sales of “fen” alone had surpassed $300 million.

It was nothing less than an awakening, for doctors and their patients alike. Now a patient could be treated for excess weight in the same way they might be treated for diabetes or hypertension—with a drug they’d have to take for the rest of their life.

the article heralded a “new understanding of obesity as a chronic disease rather than a failure of willpower.”

News had just come out that, at the Mayo Clinic in Minnesota, two dozen women taking fen-phen—including six who were, like Barb, in their 30s—had developed cardiac conditions. A few had needed surgery, and on the operating table, doctors discovered that their heart valves were covered with a waxy plaque.

Americans had been prescribed regular fenfluramine since 1973, and the newer drug, dexfenfluramine, had been available in France since 1985. Experts took comfort in this history. Using language that is familiar from today’s assurances regarding semaglutide and other GLP-1 drugs, they pointed out that millions were already on the medication. “It is highly unlikely that there is anything significant in toxicity to the drug that hasn’t been picked up with this kind of experience,” an FDA official named James Bilstad would later say in a Time cover story headlined “The Hot New Diet Pill.

“I know I can’t get any more,” she told Williams. “I have to use up what I have. And then I don’t know what I’m going to do after that. That’s the problem—and that is what scares me to death.” Telling people to lose weight the “natural way,” she told another guest, who was suggesting that people with obesity need only go on low-carb diets, is like “asking a person with a thyroid condition to just stop their medication.”

She’d gone off the fen-phen and had rapidly regained weight. “The voices returned and came back in a furor I’d never heard before,” Barb later wrote on her blog. “It was as if they were so angry at being silenced for so long, they were going to tell me 19 months’ worth of what they wanted me to hear. I was forced to listen. And I ate. And I ate. And ate.”

For Barb, rapid weight loss has brought on a different metaphysical confusion. When she looks in the mirror, she sometimes sees her shape as it was two years ago. In certain corners of the internet, this is known as “phantom fat syndrome,” but Barb dislikes that term. She thinks it should be called “body integration syndrome,” stemming from a disconnect between your “larger-body memory” and “smaller-body reality.

In 2003, the U.S. surgeon general declared obesity “the terror within, a threat that is every bit as real to America as the weapons of mass destruction”; a few months later, Eric Finkelstein, an economist who studies the social costs of obesity, put out an influential paper finding that excess weight was associated with up to $79 billion in health-care spending in 1998, of which roughly half was paid by Medicare and Medicaid. (Later he’d conclude that the number had nearly doubled in a decade.

In 2004, Finkelstein attended an Action on Obesity summit hosted by the Mayo Clinic, at which numerous social interventions were proposed, including calorie labeling in workplace cafeterias and mandatory gym class for children of all grades.

he message at their core, that soda was a form of poison like tobacco, spread. In San Francisco and New York, public-service campaigns showed images of soda bottles pouring out a stream of glistening, blood-streaked fat. Michelle Obama led an effort to depict water—plain old water—as something “cool” to drink.

Soon, the federal government took up many of the ideas that Brownell had helped popularize. Barack Obama had promised while campaigning for president that if America’s obesity trends could be reversed, the Medicare system alone would save “a trillion dollars.” By fighting fat, he implied, his ambitious plan for health-care reform would pay for itself. Once he was in office, his administration pulled every policy lever it could.

Michelle Obama helped guide these efforts, working with marketing experts to develop ways of nudging kids toward better diets and pledging to eliminate “food deserts,” or neighborhoods that lacked convenient access to healthy, affordable food. She was relentless in her public messaging; she planted an organic garden at the White House and promoted her signature “Let’s Move!” campaign around the country.

An all-out war on soda would come to stand in for these broad efforts. Nutrition studies found that half of all Americans were drinking sugar-sweetened beverages every day, and that consumption of these accounted for one-third of the added sugar in adults’ diets. Studies turned up links between people’s soft-drink consumption and their risks for type 2 diabetes and obesity. A new strand of research hinted that “liquid calories” in particular were dangerous to health.

when their field lost faith in low-calorie diets as a source of lasting weight loss, the two friends went in opposite directions. Wadden looked for ways to fix a person’s chemistry, so he turned to pharmaceuticals. Brownell had come to see obesity as a product of our toxic food environment: He meant to fix the world to which a person’s chemistry responded, so he started getting into policy.

The social engineering worked. Slowly but surely, Americans’ lamented lifestyle began to shift. From 2001 to 2018, added-sugar intake dropped by about one-fifth among children, teens, and young adults. From the late 1970s through the early 2000s, the obesity rate among American children had roughly tripled; then, suddenly, it flattened out.

although the obesity rate among adults was still increasing, its climb seemed slower than before. Americans’ long-standing tendency to eat ever-bigger portions also seemed to be abating.

sugary drinks—liquid candy, pretty much—were always going to be a soft target for the nanny state. Fixing the food environment in deeper ways proved much harder. “The tobacco playbook pretty much only works for soda, because that’s the closest analogy we have as a food item,

that tobacco playbook doesn’t work to increase consumption of fruits and vegetables, he said. It doesn’t work to increase consumption of beans. It doesn’t work to make people eat more nuts or seeds or extra-virgin olive oil.

Careful research in the past decade has shown that many of the Obama-era social fixes did little to alter behavior or improve our health. Putting calorie labels on menus seemed to prompt at most a small decline in the amount of food people ate. Employer-based wellness programs (which are still offered by 80 percent of large companies) were shown to have zero tangible effects. Health-care spending, in general, kept going up.

From the mid-1990s to the mid-2000s, the proportion of adults who said they’d experienced discrimination on account of their height or weight increased by two-thirds, going up to 12 percent. Puhl and others started citing evidence that this form of discrimination wasn’t merely a source of psychic harm, but also of obesity itself. Studies found that the experience of weight discrimination is associated with overeating, and with the risk of weight gain over time.

obesity rates resumed their ascent. Today, 20 percent of American children have obesity. For all the policy nudges and the sensible revisions to nutrition standards, food companies remain as unfettered as they were in the 1990s, Kelly Brownell told me. “Is there anything the industry can’t do now that it was doing then?” he asked. “The answer really is no. And so we have a very predictable set of outcomes.”

she started to rebound. The openings into her gastric pouch—the section of her stomach that wasn’t bypassed—stretched back to something like their former size. And Barb found ways to “eat around” the surgery, as doctors say, by taking food throughout the day in smaller portions

Bariatric surgeries can be highly effective for some people and nearly useless for others. Long-term studies have found that 30 percent of those who receive the same procedure Barb did regain at least one-quarter of what they lost within two years of reaching their weight nadir; more than half regain that much within five years.

if the effects of Barb’s surgery were quickly wearing off, its side effects were not: She now had iron, calcium, and B12 deficiencies resulting from the changes to her gut. She looked into getting a revision of the surgery—a redo, more or less—but insurance wouldn’t cover it

She found that every health concern she brought to doctors might be taken as a referendum, in some way, on her body size. “If I stubbed my toe or whatever, they’d just say ‘Lose weight.’ ” She began to notice all the times she’d be in a waiting room and find that every chair had arms. She realized that if she was having a surgical procedure, she’d need to buy herself a plus-size gown—or else submit to being covered with a bedsheet when the nurses realized that nothing else would fit.

Barb grew angrier and more direct about her needs—You’ll have to find me a different chair, she started saying to receptionists. Many others shared her rage. Activists had long decried the cruel treatment of people with obesity: The National Association to Advance Fat Acceptance had existed, for example, in one form or another, since 1969; the Council on Size & Weight Discrimination had been incorporated in 1991. But in the early 2000s, the ideas behind this movement began to wend their way deeper into academia, and they soon gained some purchase with the public.

“Our public-health efforts to address obesity have failed,” Eric Finkelstein, the economist, told me.

Others attacked the very premise of a “healthy weight”: People do not have any fundamental need, they argued, morally or medically, to strive for smaller bodies as an end in itself. They called for resistance to the ideology of anti-fatness, with its profit-making arms in health care and consumer goods. The Association for Size Diversity and Health formed in 2003; a year later, dozens of scholars working on weight-related topics joined together to create the academic field of fat studies.

As the size-diversity movement grew, its values were taken up—or co-opted—by Big Business. Dove had recently launched its “Campaign for Real Beauty,” which included plus-size women. (Ad Age later named it the best ad campaign of the 21st century.) People started talking about “fat shaming” as something to avoid

By 2001, Bacon, who uses they/them pronouns, had received their Ph.D. and finished a rough draft of a book, Health at Every Size, which drew inspiration from a broader movement by that name among health-care practitioners

But something shifted in the ensuing years. In 2007, Bacon got a different response, and the book was published. Health at Every Size became a point of entry for a generation of young activists and, for a time, helped shape Americans’ understanding of obesity.

Some experts were rethinking their advice on food and diet. At UC Davis, a physiologist named Lindo Bacon who had struggled to overcome an eating disorder had been studying the effects of “intuitive eating,” which aims to promote healthy, sustainable behavior without fixating on what you weigh or how you look

The heightened sensitivity started showing up in survey data, too. In 2010, fewer than half of U.S. adults expressed support for giving people with obesity the same legal protections from discrimination offered to people with disabilities. In 2015, that rate had risen to three-quarters.

In Bacon’s view, the 2000s and 2010s were glory years. “People came together and they realized that they’re not alone, and they can start to be critical of the ideas that they’ve been taught,” Bacon told me. “We were on this marvelous path of gaining more credibility for the whole Health at Every Size movement, and more awareness.”

that sense of unity proved short-lived; the movement soon began to splinter. Black women have the highest rates of obesity, and disproportionately high rates of associated health conditions. Yet according to Fatima Cody Stanford, an obesity-medicine physician at Harvard Medical School, Black patients with obesity get lower-quality care than white patients with obesity.

That system was exactly what Bacon and the Health at Every Size movement had set out to reform. The problem, as they saw it, was not so much that Black people lacked access to obesity medicine, but that, as Bacon and the Black sociologist Sabrina Strings argued in a 2020 article, Black women have been “specifically targeted” for weight loss, which Bacon and Strings saw as a form of racism

But members of the fat-acceptance movement pointed out that their own most visible leaders, including Bacon, were overwhelmingly white. “White female dietitians have helped steal and monetize the body positive movement,” Marquisele Mercedes, a Black activist and public-health Ph.D. student, wrote in September 2020. “And I’m sick of it.”

Tensions over who had the standing to speak, and on which topics, boiled over. In 2022, following allegations that Bacon had been exploitative and condescending toward Black colleagues, the Association for Size Diversity and Health expelled them from its ranks and barred them from attending its events.

As the movement succumbed to in-fighting, its momentum with the public stalled. If attitudes about fatness among the general public had changed during the 2000s and 2010s, it was only to a point. The idea that some people can indeed be “fit but fat,” though backed up by research, has always been a tough sell.

Although Americans had become less inclined to say they valued thinness, measures of their implicit attitudes seemed fairly stable. Outside of a few cities such as San Francisco and Madison, Wisconsin, new body-size-discrimination laws were never passed.

In the meantime, thinness was coming back into fashion

In the spring of 2022, Kim Kardashian—whose “curvy” physique has been a media and popular obsession—boasted about crash-dieting in advance of the Met Gala. A year later, the model and influencer Felicity Hayward warned Vogue Business that “plus-size representation has gone backwards.” In March of this year, the singer Lizzo, whose body pride has long been central to her public persona, told The New York Times that she’s been trying to lose weight. “I’m not going to lie and say I love my body every day,” she said.

Among the many other dramatic effects of the GLP-1 drugs, they may well have released a store of pent-up social pressure to lose weight.

If ever there was a time to debate that impulse, and to question its origins and effects, it would be now. But Puhl told me that no one can even agree on which words are inoffensive. The medical field still uses obesity, as a description of a diagnosable disease. But many activists despise that phrase—some spell it with an asterisk in place of the e—and propose instead to reclaim fat.

Everyone seems to agree on the most important, central fact: that we should be doing everything we can to limit weight stigma. But that hasn’t been enough to stop the arguing.

Things feel surreal these days to just about anyone who has spent years thinking about obesity. At 71, after more than four decades in the field, Thomas Wadden now works part-time, seeing patients just a few days a week. But the arrival of the GLP-1 drugs has kept him hanging on for a few more years, he said. “It’s too much of an exciting period to leave obesity research right now.”

When everyone is on semaglutide or tirzepatide, will the soft-drink companies—Brownell’s nemeses for so many years—feel as if a burden has been lifted? “My guess is the food industry is probably really happy to see these drugs come along,” he said. They’ll find a way to reach the people who are taking GLP‑1s, with foods and beverages in smaller portions, maybe. At the same time, the pressures to cut back on where and how they sell their products will abate.

the triumph in obesity treatment only highlights the abiding mystery of why Americans are still getting fatter, even now

Perhaps one can lay the blame on “ultraprocessed” foods, he said. Maybe it’s a related problem with our microbiomes. Or it could be that obesity, once it takes hold within a population, tends to reproduce itself through interactions between a mother and a fetus. Others have pointed to increasing screen time, how much sleep we get, which chemicals are in the products that we use, and which pills we happen to take for our many other maladies.

“The GLP-1s are just a perfect example of how poorly we understand obesity,” Mozaffarian told me. “Any explanation of why they cause weight loss is all post-hoc hand-waving now, because we have no idea. We have no idea why they really work and people are losing weight.”

The new drugs—and the “new understanding of obesity” that they have supposedly occasioned—could end up changing people’s attitudes toward body size. But in what ways

When the American Medical Association declared obesity a disease in 2013, Rebecca Puhl told me, some thought “it might reduce stigma, because it was putting more emphasis on the uncontrollable factors that contribute to obesity.” Others guessed that it would do the opposite, because no one likes to be “diseased.”

why wasn’t there another kind of nagging voice that wouldn’t stop—a sense of worry over what the future holds? And if she wasn’t worried for herself, then what about for Meghann or for Tristan, who are barely in their 40s? Wouldn’t they be on these drugs for another 40 years, or even longer? But Barb said she wasn’t worried—not at all. “The technology is so much better now.” If any problems come up, the scientists will find solutions.

It’s dropping in developing countries, too. India surpassed China as the most populous country last year, yet its fertility is now below replacement.

“The demographic winter is coming,”

Smaller populations come with diminished global clout, raising questions in the U.S., China and Russia about their long-term standings as superpowers.

Some demographers think the world’s population could start shrinking within four decades—one of the few times it’s happened in history.

A year ago Japanese Prime Minister Fumio Kishida declared that the collapse of the country’s birthrate left it “standing on the verge of whether we can continue to function as a society.”

Had fertility stayed near 2.1, where it stood in 2007, the U.S. would have welcomed an estimated 10.6 million more babies since

In 2017, when the global fertility rate—a snapshot of how many babies a woman is expected to have over her lifetime—was 2.5, the United Nations thought it would slip to 2.4 in the late 2020s. Yet by 2021, the U.N. concluded, it was already down to 2.3—close to what demographers consider the global replacement rate of about 2.2

He has found that national birth registries are typically reporting births 10% to 20% below what the U.N. projected.

China reported 9 million births last year, 16% less than projected in the U.N.’s central scenario. In the U.S., 3.59 million babies were born last year, 4% less than the U.N. projected. In other countries, the undershoot is even larger: Egypt reported 17% fewer births last year. In 2022, Kenya reported 18% fewer.

In 2017 the U.N. projected world population, then 7.6 billion, would keep climbing to 11.2 billion in 2100. By 2022 it had lowered and brought forward the peak to 10.4 billion in the 2080s. That, too, is likely out of date

the University of Washington now thinks it will peak around 9.5 billion in 2061 then start declining. 

The falling birthrates come with huge implications for the way people live, how economies grow and the standings of the world’s superpowers.

In the U.S., a short-lived pandemic baby boomlet has reversed. The total fertility rate fell to 1.62 last year, according to provisional government figures, the lowest on record.

In 2017, when the fertility rate was 1.8, the Census Bureau projected it would converge over the long run to 2.0. It has since revised that down to 1.5. “It has snuck up on us,”

Historians refer to the decline in fertility that began in the 18th century in industrializing countries as the demographic transition. As lifespans lengthened and more children survived to adulthood, the impetus for bearing more children declined. As women became better educated and joined the workforce, they delayed marriage and childbirth, resulting in fewer children. 

Some demographers see this as part of a “second demographic transition,” a societywide reorientation toward individualism that puts less emphasis on marriage and parenthood, and makes fewer or no children more acceptable. 

In research published in 2021, the University of Maryland’s Kearney and two co-authors looked for possible explanations for the continued drop. They found that state-level differences in parental abortion notification laws, unemployment, Medicaid availability, housing costs, contraceptive usage, religiosity, child-care costs and student debt could explain almost none of the decline

“We suspect that this shift reflects broad societal changes that are hard to measure or quantify,” they conclude.

while raising children is no more expensive than before, parents’ preferences and perceived constraints have changed

“If people have a preference for spending time building a career, on leisure, relationships outside the home, that’s more likely to come in conflict with childbearing.” 

Once a low fertility cycle kicks in, it effectively resets a society’s norms and is thus hard to break, said Jackson. “The fewer children you see your colleagues and peers and neighbors having, it changes the whole social climate,”

Fertility is below replacement in India even though the country is still poor and many women don’t work—factors that usually sustain fertility.

Urbanization and the internet have given even women in traditional male-dominated villages a glimpse of societies where fewer children and a higher quality of life are the norm. “People are plugged into the global culture,

mothers and fathers, especially those that are highly educated, spend more time with their children than in the past. “The intensity of parenting is a constraint,”

Sub-Saharan Africa once appeared resistant to the global slide in fertility, but that too is changing. The share of all women of reproductive age using modern contraception grew from 17% in 2012 to 23% in 2022

Jose Rimon, a professor of public health at Johns Hopkins University, credits that to a push by national leaders in Africa which, he predicted, would drive fertility down faster than the U.N. projects. 

Mae Mariyam Thomas, 38, who lives in Mumbai and runs an audio production company, said she’s opted against having children because she never felt the tug of motherhood. She sees peers struggling to meet the right person, getting married later and, in some instances, divorcing before they have kids. At least three of her friends have frozen their eggs,

Danielle Vermeer grew up third in a family of four children on Chicago’s North Side, where her neighborhood was filled with Catholics of Italian, Irish and Polish descent and half her close friends had as many siblings as her or more.

Her Italian-American father was one of four children who produced 14 grandchildren. Now her parents have five grandchildren, including Vermeer’s two children, ages 4 and 7.

The 35-year-old, who is the co-founder of a fashion thrifting app, said that before setting out to have children, she consulted dozens of other couples and her Catholic church and read at least eight books on the subject, including one by Pope Paul VI. She and her husband settled on two as the right number.“The act of bringing a child into this world is an incredible responsibility,” she said.

Perhaps no country has been trying longer than Japan. After fertility fell to 1.5 in the early 1990s, the government rolled out a succession of plans that included parental leave and subsidized child care. Fertility kept falling.

In 2005, Kuniko Inoguchi was appointed the country’s first minister responsible for gender equality and birthrate. The main obstacle, she declared, was money: People couldn’t afford to get married or have children. Japan made hospital maternity care free and introduced a stipend paid upon birth of the child. 

Japan’s fertility rate climbed from 1.26 in 2005 to 1.45 in 2015. But then it started declining again, and in 2022 was back to 1.26.

This year, Prime Minister Fumio Kishida rolled out yet another program to increase births that extends monthly allowances to all children under 18 regardless of income, free college for families with three children, and fully paid parental leave.

noguchi, now a member of parliament’s upper house, said the constraint on would-be parents is no longer money, but time. She has pressed the government and businesses to adopt a four-day workweek

If you’re a government official or manager of a big corporation, you should not worry over questions of salary now, but that in 20 years time you will have no customers, no clients, no applicants to the Self-Defense Forces.”

Hungarian Prime Minister Viktor Orban has pushed one of Europe’s most ambitious natality agendas. Last year he expanded tax benefits for mothers so that women under the age of 30 who have a child are exempt from paying personal income tax for life. That’s on top of housing and child-care subsidies as well as generous maternity leaves. 

Hungary’s fertility rate, though still well below replacement, has risen since 2010. But the Vienna Institute of Demography attributed this primarily to women delaying childbirth because of a debt crisis that hit around 2010. Adjusted for that, fertility has risen only slightly, it concluded.

The usual prescription in advanced countries is more immigration, but that has two problems.

With no reversal in birthrates in sight, the attendant economic pressures are intensifying. Since the pandemic, labor shortages have become endemic throughout developed countries. That will only worsen in coming years as the postcrisis fall in birthrates yields an ever-shrinking inflow of young workers, placing more strain on healthcare and retirement systems.

worsening demographics could make this a second consecutive “lost decade” for global economic growth.

The Institute for Health Metrics and Evaluation found little evidence that pronatalist policies lead to sustained rebounds in fertility. A woman may get pregnant sooner to capture a baby bonus, researchers say, but likely won’t have more kids over the course of her lifetime.

As more countries confront stagnant population, immigration between them is a zero-sum gam

Historically, host countries have sought skilled migrants who enter through formal, legal channels, but recent inflows have been predominantly unskilled migrants often entering illegally and claiming asylum.

High levels of immigration have also historically aroused political resistance,

Many of the leaders keenest to raise birthrates are most resistant to immigratio

As birthrates fall, more regions and communities experience depopulation, with consequences ranging from closed schools to stagnant property values. Less selective colleges will soon struggle to fill classrooms because of the plunge in birthrates that began in 2007, said Fernández-Villaverde. Vance said rural hospitals can’t stay open because of the falling local population.

An economy with fewer children will struggle to finance pensions and healthcare for growing ranks of elderly. South Korea’s national pension fund, one of the world’s largest, is on track to be depleted by 2055

There’s been little public pressure to act, said Sok Chul Hong, an economist at Seoul National University. “The elderly are not very interested in pension reform, and the youth are apathetic towards politics,” he said. “It is truly an ironic situation.”

“devastating” because the hardship of rural Americans is real, “terrifying” because the political backlash to this hardship poses a clear and present danger to our democracy, and “baffling” because at some level I still don’t get the politics.

Technology is the main driver of rural decline, Schaller and Waldman argue. Indeed, American farms produce more than five times as much as they did 75 years ago, but the agricultural work force declined by about two-thirds over the same period, thanks to machinery, improved seeds, fertilizers and pesticides

Coal production has been falling recently, but thanks partly to technologies like mountaintop removal, coal mining as a way of life largely disappeared long ago, with the number of miners falling 80 percent even as production roughly doubled.

The decline of small-town manufacturing is a more complicated story, and imports play a role, but it’s also mainly about technological change that favors metropolitan areas with large numbers of highly educated workers.

Technology, then, has made America as a whole richer, but it has reduced economic opportunities in rural areas. So why don’t rural workers go where the jobs are? Some have

But some cities have become unaffordable, in part because of restrictive zoning — one thing blue states get wrong — while many workers are also reluctant to leave their families and communities.

So shouldn’t we aid these communities? We do. Federal programs — Social Security, Medicare, Medicaid and more — are available to all Americans, but are disproportionately financed from taxes paid by affluent urban areas. As a result there are huge de facto transfers of money from rich, urban states like New Jersey to poor, relatively rural states like West Virginia.

While these transfers somewhat mitigate the hardship facing rural America, they don’t restore the sense of dignity that has been lost along with rural jobs.

And maybe that loss of dignity explains both white rural rage and why that rage is so misdirected — why it’s pretty clear that this November a majority of rural white Americans will again vote against Joe Biden, who as president has been trying to bring jobs to their communities, and for Donald Trump, a huckster from Queens who offers little other than validation for their resentment.

This feeling of a loss of dignity may be worsened because some rural Americans have long seen themselves as more industrious, more patriotic and maybe even morally superior to the denizens of big cities — an attitude still expressed in cultural artifacts like Jason Al

In the crudest sense, rural and small-town America is supposed to be filled with hard-working people who adhere to traditional values, not like those degenerate urbanites on welfare, but the economic and social reality doesn’t match this self-image.

Prime working-age men outside metropolitan areas are substantially less likely than their metropolitan counterparts to be employed — not because they’re lazy, but because the jobs just aren’t there.

Quite a few rural states also have high rates of homicide, suicide and births to single mothers — again, not because rural Americans are bad people, but because social disorder is, as the sociologist William Julius Wilson argued long ago about urban problems, what happens when work disappears.

Draw attention to some of these realities and you’ll be accused of being a snooty urban elitist

The result — which at some level I still find hard to understand — is that many white rural voters support politicians who tell them lies they want to hear. It helps explain why the MAGA narrative casts relatively safe cities like New York as crime-ridden hellscapes while rural America is the victim not of technology but of illegal immigrants, wokeness and the deep state.

while white rural rage is arguably the single greatest threat facing American democracy, I have no good ideas about how to fight it.