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With respect to crime, poverty and homelessness, Brown argued,One thing that may occur is that disinvestment in city downtowns will alter the spatial distribution of these elements in cities — i.e. in which neighborhoods or areas of a city is crime more likely, and homelessness more visible. Urban downtowns are often policed such that these visible elements of poverty are pushed to other parts of the city where they will not interfere with commercial activities. But absent these activities, there may be less political pressure to maintain these areas. This is not to say that the overall crime rate or homelessness levels will necessarily increase, but their spatial redistribution may further alter the trajectory of commercial downtowns — and the perception of city crime in the broader public.

“The more dramatic effects on urban geography,” Brown continued,may be how this changes cities in terms of economic and racial segregation. One urban trend from the last couple of decades is young white middle- and upper-class people living in cities at higher rates than previous generations. But if these groups become less likely to live in cities, leaving a poorer, more disproportionately minority population, this will make metropolitan regions more polarized by race/class.

the damage that even the perception of rising crime can inflict on Democrats in a Nov. 27 article, “Meet the Voters Who Fueled New York’s Seismic Tilt Toward the G.O.P.”: “From Long Island to the Lower Hudson Valley, Republicans running predominantly on crime swept five of six suburban congressional seats, including three that President Biden won handily that encompass some of the nation’s most affluent, well-educated commuter towns.

In big cities like New York and San Francisco we estimate large drops in retail spending because office workers are now coming into city centers typically 2.5 rather than 5 days a week. This is reducing business activity by billions of dollars — less lunches, drinks, dinners and shopping by office workers. This will reduce city hall tax revenues.

Public transit systems are facing massive permanent shortfalls as the surge in working from home cuts their revenues but has little impact on costs (as subway systems are mostly a fixed cost. This is leading to a permanent 30 percent drop in transit revenues on the New York Subway, San Francisco Bart, etc.

These difficulties for cities will not go away anytime soon. Bloom provided data showing strong economic incentives for both corporations and their employees to continue the work-from-home revolution if their jobs allow it:

First, “Saved commute time working from home averages about 70 minutes a day, of which about 40 percent (30 minutes) goes into extra work.” Second, “Research finds hybrid working from home increases average productivity around 5 percent and this is growing.” And third, “Employees also really value hybrid working from home, at about the same as an 8 percent pay increase on average.

three other experts in real estate economics, Arpit Gupta, of N.Y.U.’s Stern School of Business, Vrinda Mittal, both of the Columbia Business School, and Van Nieuwerburgh. They anticipate disaster in their September 2022 paper, “Work From Home and the Office Real Estate Apocalypse.”

“Our research,” Gupta wrote by email,emphasizes the possibility of an ‘urban doom loop’ by which decline of work in the center business district results in less foot traffic and consumption, which adversely affects the urban core in a variety of ways (less eyes on the street, so more crime; less consumption; less commuting) thereby lowering municipal revenues, and also making it more challenging to provide public goods and services absent tax increases. These challenges will predominantly hit blue cities in the coming years.

the three authors “revalue the stock of New York City commercial office buildings taking into account pandemic-induced cash flow and discount rate effects. We find a 45 percent decline in office values in 2020 and 39 percent in the longer run, the latter representing a $453 billion value destruction.”

Extrapolating to all properties in the United States, Gupta, Mittal and Van Nieuwerburgh write, the “total decline in commercial office valuation might be around $518.71 billion in the short-run and $453.64 billion in the long-run.”

the share of real estate taxes in N.Y.C.’s budget was 53 percent in 2020, 24 percent of which comes from office and retail property taxes. Given budget balance requirements, the fiscal hole left by declining central business district office and retail tax revenues would need to be plugged by raising tax rates or cutting government spending.

Since March 2020, Manhattan has lost 200,000 households, the most of any county in the U.S. Brooklyn (-88,000) and Queens (-51,000) also appear in the bottom 10. The cities of Chicago (-75,000), San Francisco (-67,000), Los Angeles (-64,000 for the city and -136,000 for the county), Washington DC (-33,000), Seattle (-31,500), Houston (-31,000), and Boston (-25,000) make up the rest of the bottom 10.

Prior to the pandemic, these ecosystems were designed to function based on huge surges in their daytime population from commuters and tourists. The shock of the sudden loss of a big chunk of this population caused a big disruption in the ecosystem.

Just as the pandemic has caused a surge in telework, Loh wrote, “it also caused a huge surge in unsheltered homelessness because of existing flaws in America’s housing system, the end of federally-funded relief measures, a mental health care crisis, and the failure of policies of isolation and confinement to solve the pre-existing homelessness crisis.”

The upshot, Loh continued,is that both the visibility and ratio of people in crisis relative to those engaged in commerce (whether working or shopping) has changed in a lot of U.S. downtowns, which has a big impact on how being downtown ‘feels’ and thus perceptions of downtown.

The nation, Glaeser continued, isat an unusual confluence of trends which poses dangers for cities similar to those experienced in the 1970s. Event#1 is the rise of Zoom, which makes relocation easier even if it doesn’t mean that face-to-face is going away. Event#2 is a hunger to deal with past injustices, including police brutality, mass incarceration, high housing costs and limited upward mobility for the children of the poor.

Progressive mayors, according to Glaeser,have a natural hunger to deal with these problems at the local level, but if they try to right injustices by imposing costs on businesses and the rich, then those taxpayers will just leave. I certainly remember New York and Detroit in the 1960s and 1970s, where the dreams of progressive mayors like John Lindsay and Jerome Patrick Cavanagh ran into fiscal realities.

Richard Florida, a professor of economic analysis and policy at the University of Toronto, stands out as one of the most resolutely optimistic urban scholars. In his August 2022 Bloomberg column, “Why Downtown Won’t Die,”

His answer:

Great downtowns are not reducible to offices. Even if the office were to go the way of the horse-drawn carriage, the neighborhoods we refer to today as downtowns would endure. Downtowns and the cities they anchor are the most adaptive and resilient of human creations; they have survived far worse. Continual works in progress, they have been rebuilt and remade in the aftermaths of all manner of crises and catastrophes — epidemics and plagues; great fires, floods and natural disasters; wars and terrorist attacks. They’ve also adapted to great economic transformations like deindustrialization a half century ago.

Florida wrote that many urban central business districts are “relics of the past, the last gasp of the industrial age organization of knowledge work the veritable packing and stacking of knowledge workers in giant office towers, made obsolete and unnecessary by new technologies.”

“Downtowns are evolving away from centers for work to actual neighborhoods. Jane Jacobs titled her seminal 1957 essay, which led in fact to ‘The Death and Life of Great American Cities,’ ‘Downtown Is for People’ — sounds about right to me.”

Despite his optimism, Florida acknowledged in his email thatAmerican cities are uniquely vulnerable to social disorder — a consequence of our policies toward guns and lack of a social safety net. Compounding this is our longstanding educational dilemma, where urban schools generally lack the quality of suburban schools. American cities are simply much less family-friendly than cities in most other parts of the advanced world. So when people have kids they are more or less forced to move out of America’s cities.

What worries me in all of this, in addition to the impact on cities, is the impact on the American economy — on innovation. and competitiveness. Our great cities are home to the great clusters of talent and innovation that power our economy. Remote work has many advantages and even leads to improvements in some kinds of knowledge work productivity. But America’s huge lead in innovation, finances, entertainment and culture industries comes largely from its great cities. Innovation and advance in. these industries come from the clustering of talent, ideas and knowledge. If that gives out, I worry about our longer-run economic future and living standards.

The risk that comes with fiscal distress is clear: If city governments face budget shortfalls and begin to cut back on funding for public transit, policing, and street outreach, for the maintenance of parks, playgrounds, community centers, and schools, and for services for homelessness, addiction, and mental illness, then conditions in central cities will begin to deteriorate.

There is reason for both apprehension and hope. Cities across time have proven remarkably resilient and have survived infectious diseases from bubonic plague to cholera to smallpox to polio. The world population, which stands today at eight billion people, is 57 percent urban, and because of the productivity, innovation and inventiveness that stems from the creativity of human beings in groups, the urbanization process is quite likely to continue into the foreseeable future. There appears to be no alternative, so we will have to make it work.

I had other doubts, too. It seemed hubristic, or worse, to make multitrillion-dollar policy bets based on computer models trying to forecast climate patterns decades into the future. Climate activists kept promoting policies based on technologies that were either far from mature (solar energy) or sometimes actively harmful (biofuels).

Expensive efforts to curb greenhouse gas emissions in Europe and North America seemed particularly fruitless when China, India and other developing countries weren’t about to curb their own appetite for fossil fuels

just how fast is Greenland’s ice melting right now? Is this an emergency for our time, or is it a problem for the future?

His pitch was simple: The coastline we have taken for granted for thousands of years of human history changed rapidly in the past on account of natural forces — and would soon be changing rapidly and disastrously by man-made ones. A trip to Greenland, which holds one-eighth of the world’s ice on land (most of the rest is in Antarctica) would show me just how drastic those changes have been. Would I join him?

Greenland is about the size of Alaska and California combined and, except at its coasts, is covered by ice that in places is nearly two miles thick. Even that’s only a fraction of the ice in Antarctica, which is more than six times as large

Greenland’s ice also poses a nearer-term risk because it is melting faster. If all its ice were to melt, global sea levels would rise by some 24 feet. That would be more than enough to inundate hundreds of coastal cities in scores of nations, from Jakarta and Bangkok to Copenhagen and Amsterdam to Miami and New Orleans.

There was also a millenarian fervor that bothered me about climate activism, with its apocalyptic imagery (the Statue of Liberty underwater) and threats of doom unless we were willing to live far more frugally.

“We haven’t had a good positive mass balance year since the late 1990s,” he told me in a follow-on email when I asked him to explain the data for me. The losses can vary sharply by year. The annualized average over the past 30 years, he added, is 170 gigatons per year. That’s the equivalent of about 5,400 tons of ice loss per second. That “suggests that Greenland ice loss has been tracking the I.P.P.C. worse-case, highest-carbon-emission scenario.

The data shows unmistakably that Greenland’s ice is not in balance. It is losing far more than it is gaining.

scientists have been drilling ice-core samples from Greenland for decades, giving them a very good idea of climatic changes stretching back thousands of years. Better yet, a pair of satellites that detect anomalies in Earth’s gravity fields have been taking measurements of the sheet regularly for nearly 20 years, giving scientists a much more precise idea of what is happening.

it’s hard to forecast with any precision what that means. “Anyone who says they know what the sea level is going to be in 2100 is giving you an educated guess,” said NASA’s Willis. “The fact is, we’re seeing these big ice sheets melt for the first time in history, and we don’t really know how fast they can go.”

His own educated guess: “By 2100, we are probably looking at more than a foot or two and hopefully less than seven or eight feet. But we are struggling to figure out just how fast the ice sheets can melt. So the upper end of range is still not well known.”

On the face of it, that sounds manageable. Even if sea levels rise by eight feet, won’t the world have nearly 80 years to come to grips with the problem, during which technologies that help us mitigate the effects of climate change while adapting to its consequences are likely to make dramatic advances?

Won’t the world — including countries that today are poor — become far richer and thus more capable of weathering the floods, surges and superstorms?

The average rate at which sea level is rising around the world, he estimates, has more than tripled over the past three decades, to five millimeters a year from 1.5 millimeters. That may still seem minute, yet as the world learned during the pandemic, exponential increases have a way of hitting hard.

“When something is on a straight line or a smooth curve, you can plot its trajectory,” Englander said. “But sea level, like earthquakes and mudslides, is something that happens irregularly and can change rather quickly and surprise us. The point is, you can no longer predict the future by the recent past.”

In The Wall Street Journal’s editorial pages, where I used to work, the theoretical physicist Steven Koonin, a former under secretary for science in the Obama administration’s Energy Department, cast doubt on the threat from Thwaites in a voice that could have once been mine. He also thinks the risks associated with Greenland’s melting are less a product of human-induced global warming than of natural cycles in North Atlantic currents and temperatures, which over time have a way of regressing to the mean.

Even the poorest countries, while still unacceptably vulnerable, are suffering far fewer human and economic losses to climate-related disasters.

Another climate nonalarmist is Roger Pielke Jr., a professor of environmental studies at the University of Colorado Boulder. I call Pielke a nonalarmist rather than a skeptic because he readily acknowledges that the challenges associated with climate change, including sea-level rise, are real, serious and probably unstoppable, at least for many decades.

“If we have to have a problem,” he told me when I reached him by phone, “we probably want one with a slow onset that we can see coming. It’s not like an asteroid coming from space.”

“Since the 1940s, the impact of floods as a proportion of U.S. gross domestic product has dropped by 70 percent-plus,” Pielke said. “We see this around the world, across phenomena. The story is that fewer people are dying and we are having less damage proportional to G.D.P.”

“Much climate reporting today highlights short-term changes when they fit the narrative of a broken climate but then ignores or plays down changes when they don’t, often dismissing them as ‘just weather,’” he wrote in February.

Global warming is real and getting worse, Pielke said, yet still it’s possible that humanity will be able to adapt to, and compensate for, its effects.

A few years ago, I would have found voices like Koonin’s and Pielke’s persuasive. Now I’m less sure. What intervened was a pandemic.

That’s what I thought until the spring of 2020, when, along with everyone else, I experienced how swiftly and implacably nature can overwhelm even the richest and most technologically advanced societies. It was a lesson in the sort of intellectual humility I recommended for others

It was also a lesson in thinking about risk, especially those in the category known as high-impact, low-probability events that seem to be hitting us with such regularity in this century: the attacks of Sept. 11, 2001; the tsunamis of 2004 and 2011, the mass upheavals in the Arab world

What if the past does nothing to predict the future? What if climate risks do not evolve gradually and relatively predictably but instead suddenly soar uncontrollably? How much lead time is required to deal with something like sea-level rise? How do we weigh the risks of underreacting to climate change against the risks of overreacting to it?

I called Seth Klarman, one of the world’s most successful hedge-fund managers, to think through questions of risk. While he’s not an expert on climate change, he has spent decades thinking deeply about every manner of risk

And we will almost certainly have to do it from sources other than Russia, China, the Democratic Republic of Congo and other places that pose unacceptable strategic, environmental or humanitarian risks

“If you face something that is potentially existential,” he explained, “existential for nations, even for life as we know it, even if you thought the risk is, say, 5 percent, you’d want to hedge against it.”

“One thing we try to do,” he said, “is we buy protection when it’s really inexpensive, even when we think we may well not need it.” The forces contributing to climate change, he noted, echoing Englander, “might be irreversible sooner than the damage from climate change has become fully apparent. You can’t say it’s far off and wait when, if you had acted sooner, you might have dealt with it better and at less cost. We have to act now.”

In other words, an ounce of prevention is worth a pound of cure. That’s particularly true if climate change is akin to cancer — manageable or curable in its earlier stages, disastrous in its later ones.

As I’ve always believed, knowing there is grave risk to future generations — and expecting current ones to make immediate sacrifices for it — defies most of what we know about human nature. So I began to think more deeply about that challenge, and others.

For the world to achieve the net-zero goal for carbon dioxide emissions by 2050, according to the International Energy Agency, we will have to mine, by 2040, six times the current amounts of critical minerals — nickel, cobalt, copper, lithium, manganese, graphite, chromium, rare earths and other minerals and elements — needed for electric vehicles, wind turbines and solar panels.

The poster child for this kind of magical thinking is Germany, which undertook a historic Energiewende — “energy revolution” — only to come up short. At the turn of the century, Germany got about 85 percent of its primary energy from fossil fuels. Now it gets about 78 percent, a puny reduction, considering that the country has spent massive sums on renewables to increase the share of electricity it generates from them.

As in everything else in life, so too with the environment: There is no such thing as a free lunch. Whether it’s nuclear, biofuels, natural gas, hydroelectric or, yes, wind and solar, there will always be serious environmental downsides to any form of energy when used on a massive scale. A single industrial-size wind turbine, for instance, typically requires about a ton of rare earth metals as well as three metric tons of copper, which is notoriously destructive and dirty to mine.

no “clean energy” solution will easily liberate us from our overwhelming and, for now, inescapable dependence on fossil fuels.

Nobody brings the point home better than Vaclav Smil, the Canadian polymath whose most recent book, “How the World Really Works,” should be required reading for policymakers and anyone else interested in a serious discussion about potential climate solutions.

“I’ve talked to so many experts and seen so much evidence,” he told me over Zoom, “I’m convinced the climate is changing, and addressing climate change has become a philanthropic priority of mine.”

Things could turn a corner once scientists finally figure out a technical solution to the energy storage problem. Or when governments and local actors get over their NIMBYism when it comes to permitting and building a large energy grid to move electricity from Germany’s windy north to its energy-hungry south. Or when thoughtful environmental activists finally come to grips with the necessity of nuclear energy

Till then, even as I’ve come to accept the danger we face, I think it’s worth extending the cancer metaphor a little further: Just as cancer treatments, when they work at all, can have terrible side effects, much the same can be said of climate treatments: The gap between an accurate diagnosis and effective treatment remains dismayingly wide

Only when countries like Vietnam and China turned to a different model, of largely bottom-up, market-driven development, did hundreds of millions of people get lifted out of destitution.

the most important transformation has come in agriculture, which uses about 70 percent of the world’s freshwater supply.

Farmers gradually adopted sprinkler and drip irrigation systems, rather than more wasteful flood irrigation, not to conserve water but because the technology provided higher crop yields and larger profit margins.

Water shortages “will spur a revolutionary, aggressive approach to getting rid of flood irrigation,” said Seth Siegel, the chief sustainability officer of the Israeli AgTech company N-Drip. “Most of this innovation will be driven by free-market capitalism, with important incentives from government and NGOs.

meaningful environmental progress has been made through market forces. In this century, America’s carbon dioxide emissions across fuel types have fallen to well below 5,000 million metric tons per year, from a peak of about 6,000 million in 2007, even as our inflation-adjusted G.D.P. has grown by over 50 percent and total population by about 17 percent.

1) Engagement with critics is vital. Insults and stridency are never good tools of persuasion, and trying to cow or censor climate skeptics into silence rarely works

the biggest single driver in emissions reductions from 2005 to 2017 was the switch from coal to natural gas for power generation, since gas produces roughly half the carbon dioxide as coal. This, in turn, was the result of a fracking revolution in the past decade, fiercely resisted by many environmental activists, that made the United States the world’s largest gas producer.

In the long run, we are likelier to make progress when we adopt partial solutions that work with the grain of human nature, not big ones that work against it

Renewables, particularly wind power, played a role. So did efficiency mandates.

The problem with our civilization isn’t overconfidence. It’s polarization, paralysis and a profound lack of trust in all institutions, including the scientific one

Devising effective climate policies begins with recognizing the reality of the social and political landscape in which all policy operates. Some thoughts on how we might do better:

They may not be directly related to climate change but can nonetheless have a positive impact on it. And they probably won’t come in the form of One Big Idea but in thousands of little ones whose cumulative impacts add up.

2) Separate facts from predictions and predictions from policy. Global warming is a fact. So is the human contribution to it. So are observed increases in temperature and sea levels. So are continued increases if we continue to do more of the same. But the rate of those increases is difficult to predict even with the most sophisticated computer modeling

3) Don’t allow climate to become a mainly left-of-center concern. One reason the topic of climate has become so anathema to many conservatives is that so many of the proposed solutions have the flavor, and often the price tag, of old-fashioned statism

4) Be honest about the nature of the challenge. Talk of an imminent climate catastrophe is probably misleading, at least in the way most people understand “imminent.”

A more accurate description of the challenge might be a “potentially imminent tipping point,” meaning the worst consequences of climate change can still be far off but our ability to reverse them is drawing near. Again, the metaphor of cancer — never safe to ignore and always better to deal with at Stage 2 than at Stage 4 — can be helpful.

5) Be humble about the nature of the solutions. The larger the political and financial investment in a “big fix” response to climate change on the scale of the Energiewende, the greater the loss in time, capital and (crucially) public trust when it doesn’t work as planned

6) Begin solving problems our great-grandchildren will face. Start with sea-level rise

We can also stop providing incentives for building in flood-prone areas by raising the price of federal flood insurance to reflect the increased risk more accurately.

7) Stop viewing economic growth as a problem. Industrialization may be the leading cause of climate change. But we cannot and will not reverse it through some form of deindustrialization, which would send the world into poverty and deprivation

8) Get serious about the environmental trade-offs that come with clean energy. You cannot support wind farms but hinder the transmission lines needed to bring their power to the markets where they are needed.

9) A problem for the future is, by its very nature, a moral one. A conservative movement that claims to care about what we owe the future has the twin responsibility of setting an example for its children and at the same time preparing for that future.

In a few short years, effective altruism has become the giving philosophy for many Silicon Valley programmers, hedge funders and even tech billionaires. That includes not just Mr. Bankman-Fried but also the Facebook and Asana co-founder Dustin Moskovitz and his wife, Cari Tuna, who are devoting much of their fortune to the cause.

“If I can help encourage people who do have enormous resources to not buy yachts and instead put that money toward pandemic preparedness and A.I. safety and bed nets and animal welfare that’s just like a really good thing to do,” Mr. MacAskill said.

Mr. Musk has not officially joined the movement but he and Mr. MacAskill have known each other since 2015, when they met at an effective altruism conference. Mr. Musk has also said on Twitter that Mr. MacAskill’s giving philosophy is similar to his own.

Mr. MacAskill was one of the founders of the group Giving What We Can, started at Oxford in 2009. Members promised to give away at least 10 percent of what they earned to the most cost-effective charities possible.

The rise of this kind of thinking, known as longtermism, has meant the Effective Altruists are increasingly associated with causes that have the ring of science fiction to them — like preventing artificial intelligence from running amok or sending people to distant planets to increase our chances of survival as a species

Traditionally, effective altruism was focused on finding the lowest-cost interventions that did the most good. The classic example is insecticide-treated bed nets to prevent mosquitoes from giving people malaria.

Mr. MacAskill argues that people living today have a responsibility not just to people halfway around the world but also those in future generations.

If the movement has an ur-text, it is the Australian philosopher Peter Singer’s article, “Famine, Affluence and Morality,” published in 1972. The essay, which argued that there was no difference morally between the obligation to help a person dying on the street in front of your house and the obligation to help people who were dying elsewhere in the world, emerged as a kind of “sleeper hit” for young people in the past two decades,

The two men first met in 2012, when Mr. Bankman-Fried was a student at M.I.T. with an interest in utilitarian philosophy.

Over lunch, Mr. Bankman-Fried said that he was interested in working on issues related to animal welfare. Mr. MacAskill suggested that he might do more good by entering a high-earning field and donating money to the cause than by working for it directly.

Mr. Bankman-Fried contacted the Humane League and other charities, asking if they would prefer his time or donations based on his expected earnings if he went to work in tech or finance. They opted for the money, and he embarked on a remunerative career, eventually founding the cryptocurrency exchange FTX in 2019.

Bloomberg recently estimated that Mr. Bankman-Fried was worth $10.5 billion, even after the recent crash in crypto prices. That puts Mr. Bankman-Fried in the unusual position of having earned his enormous fortune on behalf of the effective altruism cause, rather than making the money and then searching for a sense of purpose in donating it.

Mr. Bankman-Fried said he expected to give away the bulk of his fortune in the next 10 to 20 years.

Mr. Moskovitz and Ms. Tuna’s net worth is estimated at $12.7 billion. They founded their own group, Good Ventures, in 2011. The group said it had given $1.96 billion in donations

Those two enormous fortunes, along with giving by scores of highly paid engineers at tech companies, mean the community is exceptionally well funded.

Mr. MacAskill said that he got to know Mr. Musk better through Igor Kurganov, a professional poker player and effective altruist, who briefly advised Mr. Musk on philanthropy.

In August, Mr. Musk retweeted Mr. MacAskill’s book announcement to his 108 million followers with the observation: “Worth reading. This is a close match for my philosophy.” Yet instead of wholeheartedly embracing that endorsement as many would, Mr. MacAskill posted a typically earnest and detailed thread in response about some of the places he agreed — and many areas where he disagreed — with Mr. Musk. (They did not see eye to eye on near-term space settlement, for one.)

Mr. MacAskill accepts responsibility for what he calls misconceptions about the community. “I take a significant amount of blame,” he said, “for being a philosopher who was unprepared for this amount of media attention.”

But the diagnoses had a lucrative side effect: They let the insurers collect more money from the federal government’s Medicare Advantage program.

Medicare Advantage, a private-sector alternative to traditional Medicare, was designed by Congress two decades ago to encourage health insurers to find innovative ways to provide better care at lower cost.

by next year, more than half of Medicare recipients will be in a private plan.

a New York Times review of dozens of fraud lawsuits, inspector general audits and investigations by watchdogs shows how major health insurers exploited the program to inflate their profits by billions of dollars.

The government pays Medicare Advantage insurers a set amount for each person who enrolls, with higher rates for sicker patients. And the insurers, among the largest and most prosperous American companies, have developed elaborate systems to make their patients appear as sick as possible, often without providing additional treatment, according to the lawsuits.

As a result, a program devised to help lower health care spending has instead become substantially more costly than the traditional government program it was meant to improve.

Eight of the 10 biggest Medicare Advantage insurers — representing more than two-thirds of the market — have submitted inflated bills, according to the federal audits. And four of the five largest players — UnitedHealth, Humana, Elevance and Kaiser — have faced federal lawsuits alleging that efforts to overdiagnose their customers crossed the line into fraud.

The government now spends nearly as much on Medicare Advantage’s 29 million beneficiaries as on the Army and Navy combined. It’s enough money that even a small increase in the average patient’s bill adds up: The additional diagnoses led to $12 billion in overpayments in 2020, according to an estimate from the group that advises Medicare on payment policies — enough to cover hearing and vision care for every American over 65.

Another estimate, from a former top government health official, suggested the overpayments in 2020 were double that, more than $25 billion.

The increased privatization has come as Medicare’s finances have been strained by the aging of baby boomers

Medicare Advantage plans can limit patients’ choice of doctors, and sometimes require jumping through more hoops before getting certain types of expensive care.

At conferences, companies pitched digital services to analyze insurers’ medical records and suggest additional codes. Such consultants were often paid on commission; the more money the analysis turned up, the more the companies kept.

they often have lower premiums or perks like dental benefits — extras that draw beneficiaries to the programs. The more the plans are overpaid by Medicare, the more generous to customers they can afford to be.

Many of the fraud lawsuits were initially brought by former employees under a federal whistle-blower law that allows them to get a percentage of any money repaid to the government if their suits prevail. But most have been joined by the Justice Department, a step the government takes only if it believes the fraud allegations have merit. Last year, the department’s civil division listed Medicare Advantage as one of its top areas of fraud recovery.

In contrast, regulators overseeing the plans at the Centers for Medicare and Medicaid Services, or C.M.S., have been less aggressive, even as the overpayments have been described in inspector general investigations, academic research, Government Accountability Office studies, MedPAC reports and numerous news articles,

Congress gave the agency the power to reduce the insurers’ rates in response to evidence of systematic overbilling, but C.M.S. has never chosen to do so. A regulation proposed in the Trump administration to force the plans to refund the government for more of the incorrect payments has not been finalized four years later. Several top officials have swapped jobs between the industry and the agency.

The popularity of Medicare Advantage plans has helped them avoid legislative reforms. The plans have become popular in urban areas, and have been increasingly embraced by Democrats as well as Republicans.

“You have a powerful insurance lobby, and their lobbyists have built strong support for this in Congress,”

Some critics say the lack of oversight has encouraged the industry to compete over who can most effectively game the system rather than who can provide the best care.

But for insurers that already dominate health care for workers, the program is strikingly lucrative: A study from the Kaiser Family Foundation, a research group unaffiliated with the insurer Kaiser, found the companies typically earn twice as much gross profit from their Medicare Advantage plans as from other types of insurance.

In theory, if the insurers could do better than traditional Medicare — by better managing patients’ care, or otherwise improving their health — their patients would cost less and the insurers would make more money.

But some insurers engaged in strategies — like locating their enrollment offices upstairs, or offering gym memberships — to entice only the healthiest seniors, who would require less care, to join. To deter such tactics, Congress decided to pay more for sicker patients.

Almost immediately, companies saw ways to exploit that system. The traditional Medicare program provided no financial incentive to doctors to document every diagnosis, so many records were incomplete

Under the new program, insurers began rigorously documenting all of a patient’s health conditions — say depression, or a long-ago stroke — even when they had nothing to do with the patient’s current medical care.

“Even when they’re playing the game legally, we are lining the pockets of very wealthy corporations that are not improving patient care,”

The insurers also began hiring agencies that sent doctors or nurses to patients’ homes, where they could diagnose them with more diseases.

Cigna hired firms to perform similar at-home assessments that generated billions in extra payments, according to a 2017 whistle-blower lawsuit, which was recently joined by the Justice Department. The firms told nurses to document new diagnoses without adjusting medications, treating patients or sending them to a specialist

Nurses were told to especially look for patients with a history of diabetes because it was not “curable,” even if the patient now had normal lab findings or had undergone surgery to treat the condition.

Adding the code for a single diagnosis could yield a substantial payoff. In a 2020 lawsuit, the government said Anthem instructed programmers to scour patient charts for “revenue-generating” codes. One patient was diagnosed with bipolar disorder, although no other doctor reported the condition, and Anthem received an additional $2,693.27, the lawsuit said. Another patient was said to have been coded for “active lung cancer,” despite no evidence of the disease in other records; Anthem was paid an additional $7,080.74. The case is continuing.

The most common allegation against the companies was that they did not correct potentially invalid diagnoses after becoming aware of them. At Anthem, for example, the Justice Department said “thousands” of inaccurate diagnoses were not deleted. According to the lawsuit, a finance executive calculated that eliminating the inaccurate diagnoses would reduce the company’s 2017 earnings from reviewing medical charts by $86 million, or 72 percent.

Some of the companies took steps to ensure the extra diagnoses didn’t lead to expensive care. In an October 2021 lawsuit, the Justice Department estimated that Kaiser earned $1 billion between 2009 and 2018 from additional diagnoses, including roughly 100,000 findings of aortic atherosclerosis, or hardening of the arteries. But the plan stopped automatically enrolling those patients in a heart attack prevention program because doctors would be forced to follow up on too many people, the lawsuit said.

Kaiser, which both runs a health plan and provides medical care, is often seen as a model system. But its control over providers gave it additional leverage to demand additional diagnoses from the doctors themselves, according to the lawsuit.

At meetings with supervisors, he was instructed to find additional conditions worth tens of millions of dollars. “It was an actual agenda item and how could we get this,” Dr. Taylor said.

few analysts expect major legislative or regulatory changes to the program.

Even before the first lawsuits were filed, regulators and government watchdogs could see the number of profitable diagnoses escalating. But Medicare has done little to tamp down overcharging.

Several experts, including Medicare’s advisory commission, have recommended reducing all the plans’ payments.

Congress has ordered several rounds of cuts and gave C.M.S. the power to make additional reductions if the plans continued to overbill. The agency has not exercised that power.

The agency does periodically audit insurers by looking at a few hundred of their customers’ cases. But insurers are fined for billing mistakes found only in those specific patients. A rule proposed during the Trump administration to extrapolate the fines to the rest of the plan’s customers has not been finalized.

Ted Doolittle, who served as a senior official for the agency’s Center for Program Integrity from 2011 to 2014, said officials at Medicare seemed uninterested in confronting the industry over these practices. “It was clear that there was some resistance coming from inside” the agency, he said. “There was foot dragging.”

Last year, the inspector general’s office noted that one company “stood out” for collecting 40 percent of all Medicare Advantage’s payments from chart reviews and home assessments despite serving only 22 percent of the program’s beneficiaries. It recommended Medicare pay extra attention to the company, which it did not name, but the enrollment figure matched UnitedHealth’s.

“Medicare Advantage overpayments are a political third rail,” said Dr. Richard Gilfillan, a former hospital and insurance executive and a former top regulator at Medicare, in an email. “The big health care plans know it’s wrong, and they know how to fix it, but they’re making too much money to stop. Their C.E.O.s should come to the table with Medicare as they did for the Affordable Care Act, end the coding frenzy, and let providers focus on better care, not more dollars for plans.”

Having convinced so many evangelicals that the next election could trigger the nation’s demise, Christian leaders effectively turned thousands of churches into unwitting cells in a loosely organized, hazily defined, existentially urgent movement—the types of places where paranoia and falsehoods flourish and people turn on one another.

“Hands down, the biggest challenge facing the Church right now is the misinformation and disinformation coming in from the outside,” Brown said.Because of this, the pastor told me, he can no longer justify a passive approach from the pulpit. The Church is becoming radicalized—and pastors who don’t address this fact head-on are only contributing to the problem

“The battle lines have been drawn,” Bolin told me, sitting in the back of his darkened sanctuary. “If you’re not taking a side, you’re on the wrong side.”

It’s the story of millions of American Christians who, after a lifetime spent considering their political affiliations in the context of their faith, are now considering their faith affiliations in the context of their politics.

“We fix our eyes not on what is seen, but on what is unseen,” Paul wrote. “Since what is seen is temporary, but what is unseen is eternal.”

The pastor said his concern was not simply for his congregation of 300, but for the millions of American evangelicals who had come to value power over integrity, the ephemeral over the eternal, moral relativism over bright lines of right and wrong.

For much of my lifetime, however, American Christians have done the opposite. Beginning in the 1980s, white evangelicals imposed themselves to an unprecedented degree on the government and the country’s core institutions

Once left to cry jeremiads about civilizational decline—having lost fights over sex and sexuality, drugs, abortion, pornography, standards in media and education, prayer in public schools—conservative Christians organized their churches, marshaled their resources, and leveraged their numbers,

Evangelical leaders set something in motion decades ago that pastors today can no longer control. Not only were Christians conditioned to understand their struggle as one against flesh and blood, fixated on earthly concerns, a fight for a kingdom of this world—all of which runs directly counter to the commands of scripture—they were indoctrinated with a belief that because the stakes were getting so high, any means was justified.

When Trump was elected thanks to a historic showing among white evangelicals—81 percent voted for him over Hillary Clinton—the victory was rightly viewed as the apex of the movement’s power. But this was, in many ways, also the beginning of its unraveling.

what’s notable about the realignment inside the white evangelical Church is its asymmetry. Pastors report losing an occasional liberal member because of their refusal to speak on Sunday mornings about bigotry or poverty or social injustice. But these same pastors report having lost—in the past few years alone—a significant portion of their congregation because of complaints that they and their staff did not advance right-wing political doctrines

Substantial numbers of evangelicals are fleeing their churches, and most of them are moving to ones further to the right.

Christianity has traditionally been seen as a stabilizing, even moderating, influence on American life. In 1975, more than two-thirds of Americans expressed “a great deal or quite a lot of confidence in the church,” according to Gallup, and as of 1985, “organized religion was the most revered institution” in American life

Today, Gallup reports, just 37 percent of Americans have confidence in the Church.

to Jeff and Deidre, Jenkinson’s stance amounted to cowardice. “I realize these are hard conversations, but the reason we left Milford is they were never willing to have the conversation,” Jeff said. “They were just trying to keep everybody happy. Paul is a conservative, but his conservatism has no teeth.”

a strictly apolitical approach can be counterproductive; their unwillingness to engage only invites more scrutiny. The whisper campaigns brand conservative pastors as moderate, and moderate pastors as Marxists. In this environment, a church leader’s stance on biblical inerrancy is less important than whether he is considered “woke.

“A pastor asked me the other day, ‘What percentage of churches would you say are grappling with these issues?’ And I said, ‘One hundred percent. All of them,’ ”

“It may sound like Chicken Little. But I’m telling you, there is a serious effort to turn this ‘two countries’ talk into something real. There are Christians taking all the populist passions and adding a transcendent authority to it.”

More than a few times, I’ve heard casual talk of civil war inside places that purport to worship the Prince of Peace. And, far from feeling misplaced, these conversations draw legitimacy from a sense of divine justice.

The Church is not a victim of America’s civic strife. Instead, it is one of the principal catalysts.

“Back when I believed there was an honorable alliance between Republicans and evangelicals, it was because I believed that our values would ultimately prevail, come what may on this Earth, whether we win or lose some election,” Brown said. “But over time, there was a shift. Losing was no longer an option. It became all about winning.”

And then,” Brown said, “came Barack Obama.”It felt silly at first—jokes about Obama’s birth certificate, comments about his faith. But over time, the discourse inside the church became more worrisome.

The cultural climate was getting chilly for evangelicals; the Great Recession was squeezing his blue-collar congregation. But much of the anxiety felt amorphous, cryptic—and manufactured. However effective Brown might be at soothing his congregants for 45 minutes on a Sunday morning, “Rush [Limbaugh] had them for three hours a day, five days a week, and Fox News had them every single night.”

Brown kept reminding his people that scripture’s most cited command is “Fear not.” But he couldn’t break through. Looking back, he understands why.

“Biblically, fear is primarily reverence and awe. We revere God; we hold him in awe,” Brown told me. “You can also have reverence and awe for other things—really, anything you put great value on. I think, in conservative-Christian circles, we place a lot of value on the life we’ve known. The earthly life we have known. The American life we’ve known …

If we see threats to something we value, we fear—that is, we revere, we hold in inappropriate awe—those who can take it away. That’s Barack Obama. That’s the left.”

For white evangelicals, the only thing more galvanizing than perceptions of their idealized nation slipping away was the conviction that their favored political party was unwilling to fight for the country’s survival.

“There was this sense that America is under siege, that the barbarians were at the gates,” Brown said. “Then along comes Donald Trump, who says he can make America great again. And for evangelicals, it was time to play for keeps.”

The Trump conversion experience—having once been certain of his darkness, suddenly awakening to see his light—is not to be underestimated, especially when it touches people whose lives revolve around notions of transformation.

Modern evangelicalism is defined by a certain fatalism about the nation’s character. The result is not merely a willingness to act with desperation and embrace what is wrong; it can be a belief, bordering on a certainty, that what is wrong is actually right.

This downward spiral owes principally to two phenomena: the constant stench of scandal, with megachurches and prominent leaders imploding on what seems like a weekly basis; and the growing perception that Christians are embracing extremist views.

Tony DeFelice is another new arrival at FloodGate—and another Christian who got tired of his pastor lacking teeth. At his previous church, in the Democratic-leaning Detroit suburb of Plymouth, “they did not speak a single word about politics. Not on a single issue,” he told me. “When we got to FloodGate, it confirmed for us what we’d been missing.”

“We didn’t leave the church. The church left us,” Tony told me. “COVID, the whole thing, is the biggest lie perpetrated on humanity that we’re ever going to see in our lifetime. And they fell for it.”

Tony and Linda say FloodGate’s style—and Bolin’s fiery messages on topics like vaccines and voter fraud—has changed the way they view their responsibilities as Christians. “This is about good against evil. That’s the world we live in. It’s a spiritual battle, and we are right at the precipice of it,” Tony said.

With the country on the brink of defeat at the hands of secularists and liberals, Tony no longer distinguishes between the political and the spiritual. An attack on Donald Trump is an attack on Christians. He believes the 2020 election was stolen as part of a “demonic” plot against Christian America. And he’s confident that righteousness will prevail: States are going to begin decertifying the results of the last election, he says, and Trump will be returned to office.

He is just as convinced that Trump won the 2020 election, he said, as he is that Jesus rose from the dead 2,000 years ago.

Most evangelicals don’t think of themselves as Locke’s target demographic. The pastor has suggested that autistic children are oppressed by demons. He organized a book-burning event to destroy occult-promoting Harry Potter novels and other books and games. He has called President Biden a “sex-trafficking, demon-possessed mongrel.”

Not long ago, Locke was a small-time Tennessee preacher. Then, in 2016, he went viral with a selfie video, shot outside his local Target, skewering the company’s policies on bathrooms and gender identity. The video has collected 18 million views, and it launched Locke as a distinct evangelical brand. He cast himself on social media as a lone voice of courage within Christendom. He aligned himself with figures like Dinesh D’Souza and Charlie Kirk to gain clout as one of the Christian right’s staunchest Trump supporters. All the while, his congregation swelled—moving from their old church building, which seated 250, into a large outdoor tent, then into an even bigger tent, and eventually into the current colossus. The tent holds 3,000 people and would be the envy of Barnum & Bailey.

“We are born for such a time as this. God is calling you to do something,” Schneider says. “We have a country to get back. And if that fails, we have a country—yes, I’ll say it—to take back.”

“I really don’t. No. Not too much. I don’t,” Bolin says, shaking his head. “Firebrand statements have been part of the pulpit, and part of politics, for as long as we’ve been a nation. And there is a long history of both sides exaggerating—like in a post like that.”

How many pastors at smaller right-wing churches—pastors like Bolin—would have felt uneasy sitting inside this tent? The answer, I suspect, is very few. Global Vision and FloodGate may be different in degree, but they are not different in kind.

his mission creep inside evangelicalism is why some churches have taken an absolutist approach: no preaching on elections, no sermons about current events.

“What’s coming is going to be brutal. There’s no way around that,” Bingham told me. “Churches are breaking apart everywhere. My only hope is that, when the time comes, our people can separate without shattering.”

At one point, I show Bolin a Facebook post he wrote months earlier: “I’m still wondering how 154,000,000 votes were counted in a country where there are only 133,000,000 registered voters.” This was written, I tell him, well after the Census Bureau had published data showing that more than 168 million Americans were registered to vote in 2020. A quick Google search would have given Bolin the accurate numbers.

“Yeah, that’s one I regret,” he tells me, explaining that he subsequently learned that the numbers he’d posted were incorrect. (The post was still active. Bolin texted me the following day saying he’d deleted it.)

Doesn’t he worry that if people see him getting the easy things wrong, they might suspect he’s also getting the hard things wrong? Things like sanctity and salvation?

Let’s be clear: Locke belongs to a category of his own. He recently accused multiple women at his church of being witches (his source: a demon he encountered during an exorcism). That makes it easy for evangelicals to dismiss Global Vision as an outlier, the same way they did Westboro Baptist. It’s much harder to scrutinize the extremism that has infiltrated their own church and ponder its logical end point. Ten years ago, Global Vision would have been dismissed as a blip on Christianity’s radar. These days, Locke preaches to 2.2 million Facebook followers and has posed for photos with Franklin Graham at the White House.

Bolin says FloodGate and churches like it have grown in direct proportion to how many Christians “felt betrayed by their pastors.” That trend looks to be holding steady. More people will leave churches that refuse to identify with a tribe and will find pastors who confirm their own partisan views. The erosion of confidence in the institution of American Christianity will accelerate. The caricature of evangelicals will get uglier. And the actual work of evangelizing will get much, much harder.

The Musk messages also reveal how some of the richest and most powerful men in the world treat actual billions of dollars with a level of care more appropriate for a 3-year-old tossing around Monopoly cash.

Oracle’s founder, Larry Ellison, essentially writes Musk a blank check over text, pledging, “A billion … or whatever you recommend.” The venture capitalist Marc Andreessen unsolicitedly offers Musk “$250M with no additional work required.” And Michael Grimes, a top investment banker at Morgan Stanley, proposes a meeting with Bankman-Fried as a way to “get us $5bn equity in an hour.”

The blitheness is the point. It is a total power move to talk about getting “$5bn in equity in an hour” the same way we mere mortals talk about Venmo-ing a friend $15 for lunch. The texts make it clear that these men are fundamentally alienated from the rest of the world by their wealth.

“These are absolutely not normal people with a normal understanding of the world.”

The men in Musk’s phone also appear wildly confident in their own abilities and those of their peers. Mathias Döpfner, the CEO of the media conglomerate Axel Springer, infamously texted Musk his bullet-pointed plan for Twitter, which began with the line item “1.),, Solve Free Speech.”

They teach us what happens when a small group of people with too much money come to view that money not just as a reward for success, but as its own form of merit—a specious achievement that totally alienates them from reality.

Ultimately, Exhibit H documents the loneliness and isolation of being the world’s richest man. As told via the texts, the seed of Musk’s Twitter purchase was planted by sycophants deferential to the billionaire who will never give him hard, truthful advice, because they wish to stay close to him.

the one time he receives actual, honest feedback from Agrawal, Musk behaves aggressively and impulsively, sealing his fate.

For researchers concerned with more immediate AI risks, such as bias, disinformation and job displacement, the voices of doom are a distraction. Professor Brent Mittelstadt, director of research at the Oxford Internet Institute, said the warnings of “the existential risks community” are overblown. “The problem is you can’t disprove the future scenarios . . . in the same way you can’t disprove science fiction.” Emily Bender, a professor of linguistics at the University of Washington, believes the doomsters are propagating “unhinged AI hype, helping those building this stuff sell it”.

Those urging us to stop, pause and think again have a useful card up our sleeves: the people building these models do not fully understand them. AI like ChatGPT is made up of huge neural networks that can defy their creators by coming up with “emergent properties”.

Google’s PaLM model started translating Bengali despite not being trained to do so

Let’s not forget the excitement, because that is also part of Moloch, driving us forward. The lure of AI’s promises for humanity has been hinted at by DeepMind’s AlphaFold breakthrough, which predicted the 3D structures of nearly all the proteins known to humanity.

Noam Shazeer, a former Google engineer credited with setting large language models such as ChatGPT on their present path, was asked by The Sunday Times how the models worked. He replied: “I don’t think anybody really understands how they work, just like nobody really understands how the brain works. It’s pretty much alchemy.”

The industry is turning itself to understanding what has been created, but some predict it will take years, decades even.

Alex Heath, deputy editor of The Verge, who recently attended an AI conference in San Francisco. “It’s clear the people working on generative AI are uneasy about the worst-case scenario of it destroying us all. These fears are much more pronounced in private than they are in public.” One figure building an AI product “said over lunch with a straight face that he is savoring the time before he is killed by AI”.

Greg Brockman, co-founder of OpenAI, told the TED2023 conference this week: “We hear from people who are excited, we hear from people who are concerned. We hear from people who feel both those emotions at once. And, honestly, that’s how we feel.”

A CBS interviewer challenged Sundar Pichai, Google’s chief executive, this week: “You don’t fully understand how it works, and yet you’ve turned it loose on society?

In 2020 there wasn’t a single drug in clinical trials developed using an AI-first approach. Today there are 18

Consider this from Bill Gates last month: “I think in the next five to ten years, AI-driven software will finally deliver on the promise of revolutionising the way people teach and learn.”

If the industry is aware of the risks, is it doing enough to mitigate them? Microsoft recently cut its ethics team, and researchers building AI outnumber those focused on safety by 30-to-1,

The concentration of AI power, which worries so many, also presents an opportunity to more easily develop some global rules. But there is little agreement on direction. Europe is proposing a centrally defined, top-down approach. Britain wants an innovation-friendly environment where rules are defined by each industry regulator. The US commerce department is consulting on whether risky AI models should be certified. China is proposing strict controls on generative AI that could upend social order.

Part of the drive to act now is to ensure we learn the lessons of social media. Twenty years after creating it, we are trying to put it back in a legal straitjacket after learning that its algorithms understand us only too well. “Social media was the first contact between AI and humanity, and humanity lost,” Yuval Harari, the Sapiens author,

Others point to bioethics, especially international agreements on human cloning. Tegmark said last week: “You could make so much money on human cloning. Why aren’t we doing it? Because biologists thought hard about this and felt this is way too risky. They got together in the Seventies and decided, let’s not do this because it’s too unpredictable. We could lose control over what happens to our species. So they paused.” Even China signed up.

One voice urging calm is Yann LeCun, Meta’s chief AI scientist. He has labelled ChatGPT a “flashy demo” and “not a particularly interesting scientific advance”. He tweeted: “A GPT-4-powered robot couldn’t clear up the dinner table and fill up the dishwasher, which any ten-year-old can do. And it couldn’t drive a car, which any 18-year-old can learn to do in 20 hours of practice. We’re still missing something big for human-level AI.” If this is sour grapes and he’s wrong, Moloch already has us in its thrall.

Dr. Monteiro and his colleagues developed a food classification system called Nova, named after the Portuguese and Latin words for “new.” It has since been adopted by researchers across the world.

Unprocessed or minimally processed foods, like fresh or frozen fruits and vegetables, beans, lentils, meat, poultry, fish, eggs, milk, plain yogurt, rice, pasta, corn meal, flour, coffee, tea and herbs and spices.

Processed culinary ingredients, such as cooking oils, butter, sugar, honey, vinegar and salt.

If you look at the ingredient list and you see things that you wouldn’t use in home cooking, then that’s probably an ultraprocessed food,”

his group includes freshly baked bread, most cheeses and canned vegetables, beans and fish. These foods may contain preservatives that extend shelf life.

Ultraprocessed foods made using industrial methods and ingredients you wouldn’t typically find in grocery stores — like high-fructose corn syrup, hydrogenated oils and concentrated proteins like soy isolate.

They often contain additives like flavorings, colorings or emulsifiers to make them appear more attractive and palatable.

Think sodas and energy drinks, chips, candies, flavored yogurts, margarine, chicken nuggets, hot dogs, sausages, lunch meats, boxed macaroni and cheese, infant formulas and most packaged breads, plant milks, meat substitutes and breakfast cereals.

Processed foods made by combining foods from Category 1 with the ingredients of Category 2 and preserving or modifying them with relatively simple methods like canning, bottling, fermentation and baking

That has led to debate among nutrition experts about whether it’s useful for describing the healthfulness of a food, partly since many UPFs — like whole grain breads, flavored yogurts and infant formulas — can provide valuable nutrients

Most research linking UPFs to poor health is based on observational studies, in which researchers ask people about their diets and then track their health over many years.

Why might UPFs be harmful?

In a large review of studies that was published in 2024, scientists reported that consuming UPFs was associated with 32 health problems, with the most convincing evidence for heart disease-related deaths, Type 2 diabetes and common mental health issues like anxiety and depression.

Such studies are valuable, because they can look at large groups of people — the 2024 review included results from nearly 10 million — over the many years it can take for chronic health conditions to develop

She added that the consistency of the link between UPFs and health issues increased her confidence that there was a real problem with the foods.

But the observational studies also have limitations,

It’s true that there is a correlation between these foods and chronic diseases, she said, but that doesn’t mean that UPFs directly cause poor health.

Dr. O’Connor questioned whether it’s helpful to group such “starkly different” foods — like Twinkies and breakfast cereals — into one category. Certain types of ultraprocessed foods, like sodas and processed meats, are more clearly harmful than others

UPFs like flavored yogurts and whole grain breads, on the other hand, have been associated with a reduced risk of developing Type 2 diabetes.

Clinical trials are needed to test if UPFs directly cause health problems, Dr. O’Connor said. Only one such study, which was small and had some limitations, has been done, s

In that study, published in 2019, 20 adults with a range of body sizes lived in a research hospital at the National Institutes of Health for four weeks. For two weeks, they ate mainly unprocessed or minimally processed foods, and for another two weeks, they ate mainly UPFs. The diets had similar amounts of calories and nutrients, and the participants could eat as much as they wanted at each meal.

During their two weeks on the ultraprocessed diet, participants gained an average of two pounds and consumed about 500 calories more per day than they did on the unprocessed diet

During their time on the unprocessed diet, they lost about two pounds.

That finding might help explain the link between UPFs, obesity and other metabolic conditions

The Nova system notably doesn’t classify foods based on nutrients like fat, fiber, vitamins or minerals. It’s “agnostic to nutrition,”

There are many “strong opinions” about why ultraprocessed foods are unhealthy, Dr. Hall said. “But there’s actually not a lot of rigorous science” on what those mechanisms are

Because UPFs are often cheap, convenient and accessible, they’re probably displacing healthier foods from our diets

the foods could be having more direct effects on health. They can be easy to overeat — maybe because they contain hard-to-resist combinations of carbohydrates, sugars, fats and salt, are high-calorie and easy to chew

It’s also possible that resulting blood sugar spikes may damage arteries or ramp up inflammation, or that certain food additives or chemicals may interfere with hormones, cause a “leaky” intestine or disrupt the gut microbiome.

Researchers, including Dr. Hall and Dr. Davy, are beginning to conduct small clinical trials that will test some of these theories.

most researchers think there are various ways the foods are causing harm. “Rarely in nutrition is there a single factor that fully explains the relationship between foods and some health outcome,”

In 2014, Dr. Monteiro helped write new dietary guidelines for Brazil that advised people to avoid ultraprocessed foods.

Other countries like Mexico, Israel and Canada have also explicitly recommended avoiding or limiting UPFs or “highly processed foods.”

The U.S. dietary guidelines contain no such advice, but an advisory committee is currently looking into the evidence on how UPFs may affect weight gain, which could influence the 2025 guidelines.

It’s difficult to know what to do about UPFs in the United States, where so much food is already ultraprocessed and people with lower incomes can be especially dependent on them,

“At the end of the day, they are an important source of food, and food is food,” Dr. Mattei added. “We really cannot vilify them,”

While research continues, expert opinions differ on how people should approach UPFs.

the safest course is to avoid them altogether

to swap flavored yogurt for plain yogurt with fruit, for example, or to buy a fresh loaf from a local bakery instead of packaged bread, if you can afford to do so

Dr. Vadiveloo suggested a more moderate strategy, focusing on limiting UPFs that don’t provide valuable nutrients, like soda and cookies

She also recommended eating more fruits, vegetables, whole grains (ultraprocessed or not), legumes, nuts and seeds.

Cook at home as much as you can, using minimally processed foods

As a young State Department policy planner in the 2000s, she was a lonely voice in Washington raising the alarm about the rise of China. She pushed for tariffs and against trade agreements before it was cool, and was an author of a book called “War by Other Means” about how blind faith in free markets put the United States at a geopolitical disadvantage. For years, she felt like an oddball in Washington, where both parties were still in thrall to neoliberalism.

The Hewlett Foundation hired her as the head of an initiative that has given away $140 million so far to people who are devising a new economic philosophy. Then she served a stint in the White House. Today, she’s an intellectual leader of a growing, bipartisan consensus

She fell in love with economics and studied it at Wake Forest. After she joined a student delegation to a NATO summit in Prague in 2002, a faculty adviser on that trip offered her a job in Washington working at the National Intelligence Council. In those early years, she believed what everyone else in Washington believed about the economy — that governments ought not meddle with it.

if Mr. Trump correctly identified a problem — “China is eating our lunch” — he did not solve it, beyond putting tariffs on Chinese products. His tax cut for the rich hurt rather than helped matters.

It’s the Biden administration that came in with a plan to build an economy that was good for workers, not just shareholders, using some strategies Ms. Harris had been talking about for years.

The thinking behind it goes like this: Unquestioning belief in the free market created a globalism that funneled money to the 1 percent, which has used its wealth to amass political power at the expense of everyone else. It produced free trade agreements that sent too many U.S. factories to China and rescue plans after the 2008 financial crisis that bailed out Wall Street instead of Main Street.

It was her job to track China’s use of subsidies, industrial espionage and currency manipulation to fuel its rise as a manufacturing powerhouse. Ms. Harris argued that tariffs on China were a necessary defense. Nobody agreed. “I was kind of just banging my head against this wall,” she told me. “The wall was a foreign policy establishment that saw markets as sacrosanct.”

Barack Obama campaigned on a pledge to renegotiate NAFTA, but he struck up a new trade deal instead — the Trans-Pacific Partnership. Ms. Harris argued against it. “We didn’t have the foggiest idea” of what it would do to our economy, she told me. Nobody listened.

it sent Democrats back to the intellectual drawing board. Larry Kramer, then the president of the Hewlett Foundation, recruited her in 2018 to promote alternatives to ideas that had guided U.S. policy for decades. He hoped she could do for free-market skepticism what Milton Friedman and his allies had done for free-market fundamentalism, which became policy under the Reagan administration and eventually was embraced by both parties as truth.

She has since rejoined the Hewlett Foundation, where she funds people who are proposing new solutions to economic problems. One grantee, the conservative think tank American Compass, promotes the idea of a domestic development bank to fund infrastructure — an idea with bipartisan appeal.

But the work that Ms. Harris and others in the Biden administration have done is unfinished, and poorly understood. The terms “Bidenomics” and “Build Back Better” don’t seem to resonate

Ms. Harris acknowledges that these ideas haven’t yet taken hold in the broader electorate, and that high interest rates overshadow the progress that’s been made. It’s too early for voters to feel it, she told me: “The investments Biden has pushed through aren’t going to be felt in a month, a year, two years.”

she celebrates the fact that leaders across the political spectrum are embracing the idea that Americans need to “get back to building things in this country.” This election has no candidates blindly promoting the free market. The last one didn’t either. In the battle of ideas, she has already won.