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The End Of Civilization As We Knew it, Part Twenty-Nine

Today, July 1 2025, may go down as the worst and most pivotal day in history.

A big statement, backed up by an abyss of darkness, which will be pursued in ongoing depth in the future, as the lead up to today has been thoroughly in the past.

Today, USAID, which hundreds of millions of the most vulnerable people in the world, mostly children, depend on to not starve to death, be killed by disease, and be maimed in countless ways, rather than be fed, nurtured, medically cared for, helped in conflicts, and have the leading edge of disease prevention provided for–which is the key to providing this for all people on the planet, as well as providing global stability instead of chaos and conflict that willl take the planet down in blood and flames–was officially disbanded by the Trump administration. It’s gutting had already happened in the first weeks after his inauguration, led by the richest person in the world, Elon Musk, and his so called DOGE team who Trump had tasked to do this.

On the same day, the US Senate passed Trump’s budget, the most radical transfer of wealth ever from the poorest to the richest in America. The decimation by lack of funding for or destruction of the programs that from the poorest to the lower middle class, the bulk of the working class, that have been supported with basic services is incomparable, a reversal unlike any before of the basic needs and services that impact virtually all Americans, again disproportionally hurting children, except the wealthy.

Although Musk also fashioned the essence of the above as part of his previous mandate from Trump, after he and Trump infamously turned on each other a short time ago, Musk attacked the bill as the worst thing in history based on the enormous increase in the already out of control national debt. His attacks on Trump and the Bill escalated again today, with Trump responding that he might have Musk deported.

The wreckage both of them, and all those who supported the above in Congress (the bill was so charged politically that it took Vice-President Vance to break a tie in the voting in the senate), is impossible to overstate.

Hundreds of millions of lives have been saved and improved by USAID over its lifetime since President John F Kennnedy founded it in 1961.

Hundreds of millions will now die or be hurt for life in many ways. This is what the American flag will now stand for in the eyes of the people of the world.

Millions will also go hungry, suffer from disease, and lack basic services and support in America.

All the above programs and agencies and their critical work worldwide and in America have been widely supported by both parties for decades. Until now.

The infrastructure of the world since the Great Depression and the end of World War Two is now being decimated in radically unimaginable ways. This could never have happened in the America that existed before 2024, not even in the America of 2016 and the many internal cultural and external horrific events that had culminated in it. The movement in this direction, a complete breakdown in sanity and morality in the culture at large and the political results have been moving in this direction more and more for many years, as we have written extensively about. But even so, where we are now has never been possible, or imagined as possible before.

President Bush, President Obama, and musicial and global activist Bono, all came out today critiquing what has happened in the strongest terms.

These programs and policies have been at the center of our work from the outset and we have had a substantial impact on supporting and improving them. Seeing this happen is heartbreaking beyond description.

As written in the last installment of The End Of Civilization As We Knew It:

Everything has changed.

The full meaning of this will continue to be flushed out by us.

For now, an extensive group of articles on these events, follows, including the front page article in the Sunday New York Times the day after the US bombed Iran on how Trump had dismantled USAID in weeks, demonstrating the momentous nature of the issue:

. . .

Shuttering of USAID Will Lead to Millions of Deaths Around the World: Studies

JUL 1, 2025

by Chad de Guzman, Time Magazine

President John F. Kennedy said in 1961 that “there is no escaping” what he described as America’s “moral obligations as a wise leader and good neighbor in the interdependent community of free nations; our economic obligations as the wealthiest people in a world of largely poor people, as a nation no longer dependent upon the loans from abroad that once helped us develop our own economy; and our political obligations as the single largest counter to the adversaries of freedom.”

He was speaking to Congress about foreign aid and later that year would establish through executive order what has since been known as the U.S. Agency for International Development (USAID), which helped make the U.S. the world’s largest foreign aid provider. 

For more than six decades, USAID has helped dozens of low- and middle-income countries, including conflict-stricken ones, to improve access to food, water, health care, and education. It’s helped stop disease outbreaks, revolutionize agricultural practices, and in some cases, promote democracy.

But on Tuesday, USAID shutters its doors for good.

The agency’s dismantling began just days after President Donald Trump returned to the White House at the start of this year. Tech billionaire and one-time Trump ally Elon Musk, who was spearheading the Department of Government Efficiency, singled out the agency as a locus of “corruption and waste,”despite the fact that it constituted just about 0.5% of government spending.

Secretary of State Marco Rubio, who took the reins of the agency in February, said in March that more than four-fifths of USAID programs were cancelled, and the approximately 1,000 that remained would be absorbed by the State Department by July 1, even amid court battles about the constitutionality of USAID’s closure.

On the eve of USAID’s final day, former Presidents George W. Bush and Barack Obama gathered with former staffers as well as U2 singer and humanitarian Bono on a video call. Obama described USAID’s gutting as a “travesty” and a “tragedy,” according to the Associated Press.

“You’ve showed the great strength of America through your work,” Bush told the USAID staffers. “Is it in our national interests that 25 million people who would have died now live? I think it is, and so do you.”

Trump, evidently, does not.

Just how many lives won’t be saved as a result of the closure of USAID has been the subject of several studies and projections. 

On Monday, medical research journal The Lancet estimated that USAID prevented the deaths of more than 90 million people between 2001 to 2021. The study, conducted by researchers from Brazil, Mozambique, and Spain, forecasted that the defunding of the agency could lead to some 14 million deaths by 2030, including 4.5 million deaths of children and babies under the age of 5.

Here are some of the biggest estimated impacts of the U.S. shirking Kennedy’s “obligations.”

Hundreds of thousands of HIV-AIDS deaths

To fight against HIV globally, President Bush launched PEPFAR, or the U.S. President’s Emergency Plan for AIDS Relief, in 2003. The program supports some 20.6 million people with HIV worldwide, including 566,000 children, through providing anti-retroviral therapy (ART) to control the infection. The program also provided HIV testing services to 83.8 million people in 2024.

USAID was PEPFAR’s main implementing agency, and while the State Department is seeking $2.9 billion in funding to continue HIV-AIDS programs, it’s far lower than the at least $4.7 billion budget PEPFAR had. 

A study published in the Retrovirology journal in March said that the suspension of USAID funding could hamper access to ART and cause a potential resurgence of up to 630,000 HIV-AIDS-related deaths annually, with sub-Saharan Africa most affected.

Millions of malaria cases

USAID has invested $9 billion to help tackle malaria, the mosquito-borne illness that is preventable and curable but causes millions of deaths in Africa every year, since the inception of the President’s Malaria Initiative (PMI) in 2005.

An impact tracker by Boston University infectious disease mathematical modeller and health economist Dr. Brooke Nichols and Amsterdam-based product manager Eric Moakley forecast almost 10 million additional cases of malaria globally—of which an estimated 7 million would affect children—in just one year due to USAID funding cuts.

The tracker also only considered African countries that were part of PMI and did not include countries in Asia that have also been supported by USAID. “Thus we may be underestimating the effect of PMI’s cessation,” it said.

. . .

OPINION

GUEST ESSAY

I Worked at U.S.A.I.D. for Over 8 Years. This Is Our Biggest Failure.

June 29, 2025

Listen to this article · 6:40 min Learn more

By William Herkewitz, The New York Times

Mr. Herkewitz is a former head of communications for U.S.A.I.D. missions in Rwanda, Ethiopia and Kenya.

On July 1, the Trump administration will effectively dissolve the United States Agency for International Development and shunt the agency’s few remaining contracts to the State Department. Over the next two months, remaining employees will be terminated — including the entirety of the government’s global humanitarian aid work force. Quietly, America will abandon the fight against global famine.

Most Americans won’t notice.

For many, it may take months or years to connect reports of mass death abroad back to these decisions made at home. That’s because after six decades, U.S.A.I.D. became so efficient at quietly stopping millions of deaths worldwide that most Americans didn’t even know many of the humanitarian disasters were occurring. Because they never heard about the lives regularly saved by their tax dollars, Americans don’t realize the generosity that has been stolen from them.

I worked for U.S.A.I.D. in East Africa over the past eight and a half years, selling the story of American foreign aid to people in Rwanda, Ethiopia and Kenya. Our inability to tell this same story to Americans is our great failure. It is what put the agency into the Department of Government Efficiency’s wood chipper first. It’s what allows Secretary of State Marco Rubio to get away with insisting that lifesaving humanitarian aid would continue while the administration drastically slashed its funding. And it’s what I fear will let this presidency cast the deaths from the next preventable catastrophe as unstoppable or inevitable.

In East Africa I saw our development projects during times of peace and our humanitarian aid during crises and conflicts. Yes, our agency was often tangled in a slow, maddening bureaucracy. But I believe most Americans would be horrified to learn what they’re forfeiting.

One example is enough.

In April 2022, I flew eight Ethiopian journalists to Gode, a dusty city in southeastern Ethiopia, where the temperature that week neared 100 degrees Fahrenheit. We were there to see communities ravaged by the 2020-23 Horn of Africa drought, the longest ever recorded in the three countries it spanned — Ethiopia, Kenya and Somalia. We took the journalists to a temporary tented camp for 2,500 families that was built in part with American funding. We saw a hospital saving children from malnutrition death with American-bought nutritional medicines. Soaked in sweat, we visited a cavernous warehouse stocked with just a fraction of the more than 150,000 tons of food that included American-grown grain, dried peas and cooking oil that our nation was rushing into the region each year.

During the drought, more than 40 million people were helped by humanitarian aid, of which over 70 percent was paid for by the United States. Dr. Oliver Watson, a lecturer at Imperial College London who has modeled drought deaths, estimates that without American aid, between 2.1 million and 3.9 million more excess deaths would have occurred. That’s an especially grave figure, given that half of those who died from the region’s last famine were newborns or young children.

It was not a complicated story to tell — Americans were paying to stop a famine and keep fleeing families alive. Yet it barely registered in American public life.

We’ve been told of late that programs like these were undue, wasteful expenses of American taxpayer money. That raises the question: How much did this humanitarian aid really cost?

For the most expensive fiscal year, 2022, the American government spent over $2 billion for the entirety of the drought response. That means it cost the average American household roughly $6 a year in taxes to prevent about half as many deaths as occurred in the Holocaust.

It sounds absurd to justify something so self-evidently humane. And in the end, I don’t believe individual Americans would believe it even needs justification. For any of our faults, we are not so small a people as to refuse such a financial and moral bargain.

When the drought ended in 2023, U.S.A.I.D. stood down the emergency response. Though America had just completed one of the most successful humanitarian responses in modern history, we didn’t even attempt a victory lap. There was no presidential address. No plaque in Washington. Not even a full public report. We merely shared some ineffective social media posts and moved on to the next disaster. It is baffling in hindsight.

This failure is partly because after decades of routine silence, the agency could only see the banality in the extraordinary and partly because of a broader incompetency by the federal government to communicate directly to the public it serves. But the biggest reason we never got the story out is that the American public was never U.S.A.I.D.’s primary audience.

Instead, a majority of our communication efforts were aimed entirely at Congress and other government insiders. This was our choice. Our flawed logic was that if lawmakers understood the agency’s impact, they’d protect its work.

They did, at least, understand. Members of Congress and their staffs regularly joined delegations overseas. They met U.S.A.I.D. staff members, received private briefings and toured lifesaving projects. And they came often, often praising the work in private. In Kenya we hosted over 35 such high-level delegations in 2024 alone.

That’s what makes this moment so bitter: The people who know exactly what we’re losing are the ones letting it happen. They know that when the next drought happens, America won’t be able to replicate our former successes. Not after cutting America’s humanitarian contributions or the contracts with warehouses to store food aid, or after crippling our support for the world’s only famine early-warning apparatus, FEWS NET. And certainly not after purging the very humanitarian professionals whose work embodies some of America’s highest values.

What I described here is just one example of U.S.A.I.D.’s work. It doesn’t account for the lives saved worldwide from H.I.V., tuberculosis and childbirth complications. It says nothing of the children who got their first book, classroom or shot at something better.

With no other nation stepping in to fill the void America is leaving, we must not forget the lesson of this moment. If we ever return to serious global aid, we cannot rebuild on the same broken foundation that treated public awareness as optional.

It’s too late to save U.S.A.I.D. The question now is whether we can still save America’s willingness to show up when people are dying.

. . .

Missteps, Confusion and ‘Viral Waste’: The 14 Days That Doomed U.S.A.I.D.

The rapid dismantling of the global aid agency remains one of the most consequential outcomes of President Trump’s efforts to overhaul the federal government, showing his willingness to tear down institutions in defiance of the courts.

By Christopher FlavelleNicholas Nehamas and Julie Tate, Front Page Story, Sunday New York Times

Reporting from Washington

June 22, 2025

It was the day of President Trump’s inauguration, and the U.S. Agency for International Development’s new director looked like he might pass out, as the color drained from his face.

Jason Gray, U.S.A.I.D.’s chief information officer, who had been at the agency for only two years, had just learned he would be in charge, effective immediately. Mr. Gray wasn’t supposed to be the boss. The outgoing Biden administration had selected somebody with more foreign aid experience to manage U.S.A.I.D. until the new president chose, and Congress approved, a permanent administrator. But Mr. Trump’s team, apparently eager to reverse any decisions by the former president, told Mr. Gray to take the helm instead.

Listen to our reporter’s commentary

Christopher Flavelle spent three months reporting on what led to the dismantling of U.S.A.I.D. Here, he details his main takeaways.

Inside the agency’s offices, Mr. Gray’s colleagues gathered around, trying to buck him up.

Yes, the job would be challenging under Mr. Trump, whose “America First” politics weren’t exactly sympathetic to sending U.S. taxpayer money around the world. But U.S.A.I.D. had come through the first Trump administration largely unscathed, and Marco Rubio, the incoming secretary of state, was a longtime supporter.

A little after 4 p.m., Mr. Gray issued an upbeat memo to the agency’s more than 10,000 employees, telling them to expect a focus on innovation and new partnerships.

“The next four years offer a great opportunity for our agency,” he wrote.

Two weeks later, U.S.A.I.D. was on the cusp of oblivion — its programs around the world stopped, its staff in Washington told to stay home.

Today, the rapid-fire dismantling of the country’s sprawling global aid agency remains one of the most consequential outcomes of the Trump administration’s efforts to overhaul the federal government. Not only did it transform U.S. foreign policy, but it also provided a vivid opening display of Mr. Trump’s willingness to tear down institutions as he saw fit, in defiance of Congress and the courts, with a speed that was hard for his opponents to comprehend, much less resist.

This is the story of those two weeks.

A New York Times examination found that Trump administration officials came to U.S.A.I.D. with no plan to dismantle the agency, at least not so quickly. Instead, that decision emerged day by day, marked by rash demands, shock and confusion. It culminated with a tense showdown 10 days after Mr. Trump’s inauguration, in which agency employees defied orders from Elon Musk, who was then at the height of his influence in Washington, and personally intervened to drive the agency’s elimination.

Mr. Musk demanded that Mr. Gray shut off email and cellphone access for U.S.A.I.D. workers around the world, including in conflict zones. Mr. Gray refused, saying that doing so would put their lives at risk, according to people familiar with the exchange. By the next day, he had been removed from his post.

This account, the most definitive to date of the sprawling agency’s rapid demise, is based on interviews with more than 50 current and former U.S.A.I.D. and State Department officials, and a review of internal emails and other documents. Most of those interviewed for this article spoke on the condition of anonymity out of fear of retribution.

The Times investigation found that Mr. Musk’s Department of Government Efficiency first approached U.S.A.I.D. as a source of useful anecdotes of what it called “viral waste” — government spending that seemed foolish, and could be exploited to support the case for cuts.

When employees raised concerns about demands that they viewed as dangerous or unlawful, the administration branded their actions as “insubordination” — then used that charge to justify dismantling the agency.

The result was a real-time decision to take down an institution created almost 65 years ago as a linchpin of U.S. foreign policy, intended to advance the country’s national security interests by establishing new markets for American goods, reducing conflicts that risked entangling U.S. troops, and countering efforts by communist and autocratic regimes to expand their power.

What Remains of U.S.A.I.D.?

The few hundred programs that survived DOGE’s purge reveal the future of foreign aid.

Few Republicans had been as vocal in their support for U.S.A.I.D. as Mr. Rubio, who, as a senator, once said that “in every region of the world, we should always search for ways to use U.S.A.I.D. and humanitarian assistance to strengthen our influence.” But as the agency collapsed, its remnants placed under his control as secretary of state, Mr. Rubio was largely a bystander while Mr. Musk and others shaped decisions on foreign aid.

A spokeswoman for Mr. Musk did not respond to requests for comment. 

The State Department did not address detailed questions outlining the findings of The Times’s investigation. In a statement, Jeremy Lewin, the department’s director of foreign assistance, said Mr. Rubio has “refocused foreign assistance to be more efficient, strategic and calibrated to advance American interests.”

“Folding U.S.A.I.D. under State has been an idea many have talked about for decades,” Mr. Lewin said. “President Trump and Secretary Rubio have actually gotten it done.”

Shuttering U.S.A.I.D. so quickly “likely violated the United States Constitution in multiple ways,” a federal judge ruled less than two months into the new administration. (That ruling is on hold while an appeals court completes a review.)

By that point, it didn’t matter. The agency was effectively gone.

Immediate Confusion

The decision to end U.S.A.I.D. brought deadly consequences. But the events leading to that moment can be traced in part to a particularly banal cause: a confusingly worded directive from Mr. Trump.

On the day he was sworn in — Monday, Jan. 20 — Mr. Trump signed 26 executive orders, far more than his predecessors. Among them was Executive Order 14169, directing officials to “immediately pause new obligations and disbursements of development assistance funds” for a 90-day review.

Even the agency’s supporters acknowledged it could use reform. Much of the more than $35 billion it managed last year went to Washington-based contractors, not directly to communities in need overseas. The success of its programs, especially those focused on economic and political development, was often hard to measure. And U.S.A.I.D.’s goals sometimes clashed with those of the State Department.

U.S.A.I.D. had its share of fraud, waste and abuse, according to Paul Martin, whose job as inspector general at U.S.A.I.D. gave him responsibility for investigating such cases.

But Mr. Martin, who like other inspectors general was fired by the Trump administration, said he had found no evidence that U.S.A.I.D. was subject to more fraud, waste or abuse than other agencies.

Whether U.S.A.I.D. was wasteful often depended on how the term was defined. Under President Joseph R. Biden Jr., U.S.A.I.D. emphasized priorities that many Republicans disagreed with, including promoting gay and transgender rights.

But Mr. Trump’s executive order created a more immediate problem: U.S.A.I.D.’s leadership, including the president’s own appointees, wasn’t sure what his directive meant.

The document blocked U.S.A.I.D. from signing contracts for new projects. But, staff members wondered, did it also stop U.S.A.I.D. from making payments for contracts that were already agreed to? And did the directive block payments for work that had already been performed? Such a step, some worried, might be illegal.

The following evening — Tuesday, Jan. 21 — Mr. Gray seemed to acknowledge the confusion. In a memo about the president’s instructions, Mr. Gray said that the order’s effect on payments “will be subject to further guidance.”

That guidance arrived two days later, but not in a way that Mr. Gray could have expected.

The Return of Pete Marocco

On the Trump administration’s third full day — Thursday, Jan. 23 — a U.S.A.I.D. official got a late-night call that marked the first sign of trouble for the agency.

On the phone was Pete Marocco, the State Department’s newly appointed director of foreign assistance, giving him a degree of authority over U.S.A.I.D. Mr. Marocco said he had reason to believe employees were trying to subvert the president’s executive order, according to people with direct knowledge of the call. He was upset.

Mr. Marocco’s forceful approach was no surprise. In 2020, near the end of the first Trump administration, Mr. Marocco had been appointed to run a division inside U.S.A.I.D., the Bureau for Conflict Prevention and Stabilization, where he tried to stop spending that he believed failed to support the president’s agenda.

A former Marine Corps platoon sergeant and an Oxford University graduate, Mr. Marocco followed a particular pattern at U.S.A.I.D. in the first Trump administration, according to people familiar with his time there. He would try to cancel contracts or freeze payments, then accuse U.S.A.I.D. employees of insubordination when they would complain. 

The political appointees above Mr. Marocco in 2020 soon encouraged him to take personal leave. They were frustrated that Mr. Marocco wouldn’t follow their guidance on how to run the bureau, according to people familiar with those events. U.S.A.I.D. employees viewed the episode as a public rebuke.

Now, back in power in a second Trump administration, Mr. Marocco was demanding that the employees he saw as subverting the president’s directives be identified, then pushed out.

The next morning — Friday, Jan. 24 — senior staff members met in the Ronald Reagan Building, U.S.A.I.D.’s glass and limestone headquarters three blocks from the White House, to decide how to respond to Mr. Marocco’s accusations.

Staff members said Mr. Marocco’s concerns appeared to reflect a misunderstanding of U.S.A.I.D.’s convoluted payment systems, according to people familiar with what happened during the meeting.

Even if the president’s order prohibited the flow of funding for existing contracts — and U.S.A.I.D.’s leaders believed it did not — there was still the question of timing. Employees explained that the agency’s payments moved slowly: After U.S.A.I.D. signed off on a payment, that money was transferred to other agencies, such as the Treasury Department, where it often sat for days or weeks before leaving the federal government.

In other words, the payments in question had likely been approved by U.S.A.I.D. before Mr. Trump’s directive. The administration appointees at the meeting seemed satisfied. Once that system could be explained to Mr. Marocco, the thinking went, he would realize his concerns were unfounded.

The meeting ended with U.S.A.I.D.’s leaders believing the problem was resolved. Instead, it was about to get worse.

Shock Waves to Global Aid

A few hours later, on Friday afternoon, the State Department issued a memo written by Mr. Marocco and signed by Mr. Rubio, putting a halt to all foreign assistance payments from the agency.

But that new directive also went a step further. It told U.S.A.I.D. to issue “stop-work orders” on its more than 6,200 grants and contracts.

Mr. Rubio’s instructions reverberated around the world.

U.S.A.I.D.’s programs included preventing and treating diseases like H.I.V. and malaria; providing emergency food assistance; supporting emerging democracies by funding election monitors and civil rights groups; and helping communities cope with climate shocks like storms or drought.

Sometimes the agency’s programs had even simpler goals, like reuniting families.

Gabriel Walder, the head of a faith-based nonprofit called Alliance for Children Everywhere, was in London, meeting with prospective funders, when he got an email telling him to halt projects, including one helping destitute families in Africa whose children had been placed in orphanages. The group provided parents with the resources to feed and care for their children at home.

The group had signed a contract to reunite families in Malawi, with a focus on children who were younger than 5 — those at the greatest risk living in institutions. It had already identified the families whose children would be returned; after U.S.A.I.D.’s stop-work order, the families had to be told their children would not be coming home after all.

Sophia, a mother of six in Malawi, was separated from her year-old son, who had been placed in an orphanage because she couldn’t afford to care for him. An American faith-based group, Alliance for Children Everywhere, was preparing to reunite Sophia with her child and support his care. Then U.S.A.I.D. cut off funding.Credit…Brian Otieno for The New York Times

On Saturday, Jan. 25, Dayne Curry, who was then the Afghanistan country director for Mercy Corps, a large nonprofit, awoke to an email carrying the same message to stop all programs.

The agency added that exceptions were available for “lifesaving” programs. But what counted as lifesaving? It was hard to know, because U.S.A.I.D.’s political appointees had also restricted employees from communicating with anyone outside the agency, including Congress, the State Department or even the aid groups affected by the freeze.

A U.S.A.I.D. employee who worked on projects in Afghanistan, and who held weekly meetings with aid groups, recalled suddenly being prohibited from attending those meetings, or canceling them. So when aid workers in Afghanistan signed into Google Meet for their weekly checkup, the space on the screen usually occupied by U.S.A.I.D. staff was blank.

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U.S.A.I.D. had been trying to prevent a humanitarian catastrophe in Afghanistan since 2021, when the Biden administration’s disastrous withdrawal of U.S. forces left the country without a functioning government.

“It felt like a betrayal,” the employee said of the stop-work order. “We owed people in Afghanistan just a little bit of something, and then we failed again.”

Enter DOGE

Back in Washington, U.S.A.I.D.’s problems were compounding.

One week into the Trump administration — Monday, Jan. 27 — Mr. Marocco arrived at the Reagan building. He said he still believed U.S.A.I.D. employees had deliberately violated the president’s order, and said he was expanding his investigation.

To do that, Mr. Marocco was accompanied by members of the Department of Government Efficiency — the effort set up by Mr. Musk, who had promised to cut $2 trillion in federal spending, though he would ultimately fall far short of that goal. U.S.A.I.D. was one of the first agencies visited by DOGE.

But the people who arrived at U.S.A.I.D. were neither experts in foreign assistance contracts nor trained auditors. Luke Farritor was a 23-year-old computer programmer who had dropped out of college. Edward Coristine was a 19-year-old high school graduate who goes by “Big Balls.” Clayton Cromer was a lawyer and former executive assistant to Ed Martin, Mr. Trump’s then-acting U.S. attorney in Washington, who had sought to investigate the president’s perceived enemies.

KEY PLAYERS

Pete Marocco

Trump appointee at the State Department who oversaw the dismantling of U.S.A.I.D.

Jason Gray

Acting U.S.A.I.D. administrator for the first two weeks of the Trump administration.

Marco Rubio

Mr. Trump’s secretary of state, and one-time U.S.A.I.D. advocate. Replaced Mr. Gray as acting administrator.

Clayton Cromer

Member of the DOGE team at U.S.A.I.D.

Elon Musk

Head of DOGE. Personally intervened on multiple occasions to tell U.S.A.I.D. employees what to do.

Luke Farritor

Member of the DOGE team at U.S.A.I.D., a 23-year-old computer scientist.

Jeremy Lewin

First came to U.S.A.I.D. as a DOGE member. Later replaced Mr. Marocco as director of foreign assistance.

The political appointees brought in to run U.S.A.I.D., by contrast, tended to have more and broader experience. They included an oil and gas executive, a naval intelligence officer, a former Heritage Foundation fellow, a retired Army lieutenant colonel, a reporter for a right-wing media outlet and the manager of a Christian elementary school. Several had served in the first Trump administration.

But despite their relative lack of experience, the DOGE members moved quickly to force changes.

After a few hours interviewing agency officials, DOGE staff presented Mr. Gray with a list of 57 U.S.A.I.D. employees they said were involved in the payments Mr. Marocco had complained about, according to people familiar with the events of that day. DOGE demanded those employees be put on administrative leave — removed from the building, cut off from their computer systems, email accounts and work phones.

The list made little sense, according to people with direct knowledge of the meeting: It included most of the senior career officials across the agency. Even if the payments had somehow violated the president’s order, most of the people DOGE had identified would have had nothing to do with them.

DOGE insisted, promising to compile the evidence and present it to U.S.A.I.D.’s leaders a few days later. Mr. Gray relented.

The 57 employees were put on leave that afternoon. Mr. Gray later issued a memo to the entire agency, saying the employees seemed to have taken steps to “circumvent the president’s executive orders,” according to a copy of the email reviewed by The Times.

‘Viral Waste’

There soon turned out to be another reason DOGE had come to U.S.A.I.D. It was looking for something — and not just savings. Its goal was finding “viral waste,” as one person familiar with the strategy put it, meaning examples of government spending that could be easily mocked.

On Tuesday, Jan. 28, Karoline Leavitt took the podium at the White House for her first media briefing as Mr. Trump’s press secretary. Ms. Leavitt listed examples of spending that the administration had frozen. One stood out.

“There was about to be 50 million taxpayer dollars that went out the door to fund condoms in Gaza,” Ms. Leavitt said. “That is a preposterous waste of taxpayer money.”

After Ms. Leavitt’s briefing, U.S.A.I.D. staff went to Laken Rapier, the agency’s political appointee for public affairs, and told her that the money in question wasn’t for condoms, but for family planning more broadly, such as birth-control pills, according to people familiar with the exchange. 

More important, the Gaza in question was Gaza province, a part of Mozambique, in southern Africa — almost 4,000 miles away from the Gaza Strip. They urged Ms. Rapier to alert the White House, so it could at least avoid repeating the statement.

The warnings from staff went unheeded. The following day, Mr. Trump expanded on the claim during a White House event. “We identified and stopped $50 million being sent to Gaza to buy condoms for Hamas,” he said, generating laughter. Mr. Trump added that Hamas used condoms “as a method of making bombs,” without explaining what that meant.

“These were the types of payments, and many others,” Mr. Trump said. “I could stand here all day and tell you the things that we found.”

Asked if Mr. Trump knew at the time that his statement about Gaza was false, a White House spokeswoman, Anna Kelly, did not address the question. 

“Over decades of mismanagement, USAID strayed from its original mission and became a bloated, taxpayer-funded nonprofit,” Ms. Kelly said in a statement. “President Trump was elected by the American people to put America First.”

The Big Day

The next day — Thursday, Jan. 30 — marked a turning point. Instead of redirecting U.S.A.I.D., the Trump administration and DOGE began moving to shut it down.

That morning, DOGE members approached top U.S.A.I.D. officials, seeking to back up their assertion that some of the people sent home were involved in improper payments.

That evidence turned out to be thin: It revolved around an email that Luke Farritor sent to his teammates in which he shared the results of his review of U.S.A.I.D. payments since the executive order was signed.

It was, in the eyes of DOGE and the White House, the ultimate act of resistance — a clear-cut case of insubordination by a career official.

And it was, by many accounts, the moment that sealed U.S.A.I.D.’s fate.

Mr. Cromer, one of the DOGE members, immediately began running around looking for Mr. Gottlieb’s office, according to one person with direct knowledge of the events. Moments later, Mr. Cromer knocked on Mr. Gottlieb’s door, accompanied by a group of people, including other DOGE staff members — and security personnel, who walked Mr. Gottlieb out of the building.

That evening, members of DOGE — including Mr. Lewin, who was then part of the DOGE operation — accused Mr. Gray of losing control of the agency, according to three people familiar with the conversations that followed Mr. Gottlieb’s actions. 

DOGE made a striking demand, ordering Mr. Gray to consent to locking every U.S.A.I.D. employee worldwide out of the agency’s systems, including phones and emails. Mr. Marocco, who joined some of those conversations by phone, echoed that demand, the people said.

Mr. Gray refused. Mr. Lewin then called Mr. Musk, and handed the phone to Mr. Gray. Mr. Musk repeated the demand, according to the people familiar with what happened.

Again, Mr. Gray refused. He said that U.S.A.I.D. staff members were in the midst of being evacuated from the Democratic Republic of Congo because of civil unrest. They were fighting Ebola in Uganda. They were helping move food into Gaza. 

Suddenly cutting off access to U.S.A.I.D. systems could get people killed, Mr. Gray said.

U.S.A.I.D. canceled a project with Mercy Corps to provide clean water in Afghan villages. Rahmatullah, a local farmer, said the 400 families in his village don’t have the money to dig a new well. “Your country is rich,” he said. “I am asking you to have mercy.”Credit…Joao Silva/The New York Times

By the next day, the White House had removed Mr. Gray from his position as acting U.S.A.I.D. administrator.

Mr. Rubio became the new administrator, in addition to his responsibilities as secretary of state. He named Mr. Marocco the acting deputy administrator. Now Mr. Marocco had the reins — and freedom to impose what many saw as revenge for having been pushed out of the agency five years earlier.

‘Rank Insubordination’

That same night, a parallel struggle was underway for control of U.S.A.I.D.’s computer systems and access to the agency’s headquarters.

Members of DOGE demanded that U.S.A.I.D.’s security team provide them with full control of the agency’s networks, including the power to lock anyone out of the system.

Employees at first declined to give that kind of access to DOGE, most of whom lacked security clearances, according to people familiar with what happened. Members of DOGE got Mr. Musk on the phone, who told U.S.A.I.D. employees to cooperate.

Days later, when Mr. Rubio was asked if U.S.A.I.D. had to be abolished, he responded: “Well, that was always the goal, was to reform it. But now we have rank insubordination.”

“Their basic attitude is: ‘We don’t work for anyone. We work for ourselves. No agency of government can tell us what to do,’” Mr. Rubio told a reporter for Fox News.

In the days that followed, DOGE began to tear the agency down.

On Saturday, Feb. 1, DOGE demanded that U.S.A.I.D. staff members provide total access to the website, which was then shut down. One U.S.A.I.D. employee described the move as wiping away the public face of the agency.

That day also brought fresh turmoil inside the building. Some DOGE members wanted to work in the administrator’s suite, according to people familiar with what happened. But their badges were not properly coded to open that door.

DOGE members believed the agency’s employees were deliberately keeping them out. The episode cemented DOGE’s view that U.S.A.I.D. employees could not be trusted.

On Sunday, Feb. 2, thousands of U.S.A.I.D. staff members lost access to their email accounts and computer systems, according to a lawsuit filed by employees. At 12:20 p.m. that afternoon, Mr. Musk wrote on X: “U.S.A.I.D. is a criminal organization. Time for it to die.”

That evening, Mr. Trump weighed in publicly on U.S.A.I.D. “It’s been run by a bunch of radical lunatics, and we’re getting them out,” he told reporters a little after 7 p.m. “And then we’ll make a decision.”

Within a few hours, that decision was announced — not by the president or his secretary of state, but by Mr. Musk.

The Wood Chipper

That night around midnight, Mr. Musk said on X that he had obtained Mr. Trump’s approval to shut down the agency.

“As we dug into U.S.A.I.D.,” Mr. Musk said, “it became apparent that what we have here is not an apple with a worm in it, but we have actually just a ball of worms.”

Around 12:45 a.m. that morning — Monday, Feb. 3 — a DOGE member emailed U.S.A.I.D. employees, telling them not to come into the office that day. At 1:54 a.m., Mr. Musk posted his now-infamous message on X: “We spent the weekend feeding U.S.A.I.D. into the wood chipper. Could gone to some great parties. Did that instead.”

At the agency’s Washington offices that morning, staff members who got in fielded requests from colleagues to collect their personal items. One person recounted going desk to desk with a tote bag, gathering up family photos to return to their owners.

Not far away, at the State Department, Mr. Marocco told a meeting of senior diplomats and other officials that U.S.A.I.D. was getting shut down. “We’re going to be doing this,” Mr. Marocco said, according to a person who was in the meeting. Career officials in the room were too shocked to respond.

(Mr. Marocco would abruptly leave his role as director of foreign assistance at the State Department two months later, replaced by Mr. Lewin.)

Two thousand miles from Washington, Mr. Rubio walked onto the patio behind the American ambassador’s residence in El Salvador. Mr. Rubio had come to the country to meet with its president, Nayib Bukele; now he was scheduled to address embassy employees, many of whom worked for U.S.A.I.D.

That Mr. Rubio was in El Salvador on the day of U.S.A.I.D.’s demise carried a particular resonance. The agency spent more than $50 million on human rights and other pro-democracy programs in El Salvador last year, according to federal data. Now, Mr. Rubio was meeting with Mr. Bukele, who has called himself the world’s “coolest dictator,” to discuss sending undocumented migrants from the United States to a notorious Salvadoran prison.

One of the groups that U.S.A.I.D. funded in El Salvador, Cristosal, is a human rights group that investigates corruption by the country’s government.

When Cristosal’s director, Noah Bullock, heard Mr. Rubio would visit the country, he asked the embassy if the secretary would make time to meet with representatives from civil society groups like his, as had often been the case for such visits around the world. The embassy never responded. Cristosal’s U.S.A.I.D. funding has since been canceled; the head of its anticorruption unit, Ruth López, was arrested last month, and is still in prison.

The day before Mr. Rubio’s visit, as U.S.A.I.D. was being dismantled, Mr. Bukele posted on X that 90 percent of U.S.A.I.D.’s funding “is used to fuel dissent, finance protests, and undermine administrations that refuse to align with the globalist agenda.”

One of the U.S.A.I.D. employees at the ambassador’s residence asked Mr. Rubio what would happen to the agency’s programs in El Salvador, according to two people in attendance. The employee cited some of those programs and their importance to the United States — including work aimed at helping migrants find jobs in Central America, so that fewer people would journey north to the American border.

Mr. Rubio did not repeat Mr. Musk’s message from earlier in the day that U.S.A.I.D. was being torn apart, according to the people in attendance. And he said that U.S. foreign assistance programs would largely continue.

The same day, the State Department sent Congress a letter with Mr. Rubio’s signature, which seemed to better capture the scale of change underway.

“U.S.A.I.D. may move, reorganize, and integrate certain missions, bureaus, and offices into the Department of State,” the letter read. “The remainder of the agency may be abolished.”

A few days later, workers removed the agency’s name from above the entrance to the Ronald Reagan Building.

Mr. Trump seemed delighted. He posted on social media: “CLOSE IT DOWN!”

Reporting was contributed by Michael Crowley, Zach Montague, Stephanie Nolen, Amy Schoenfeld Walker, Mattathias Schwartz, Jonathan Swan, Edward Wong and Ryan Mac. Sheelagh McNeill and Emily Powell contributed research.

Christopher Flavelle is a Times reporter covering how President Trump is transforming the federal government.

Nicholas Nehamas is a Washington correspondent for The Times, focusing on the Trump administration and its efforts to transform the federal government.

A version of this article appears in print on June 22, 2025, Section A, Page 1 of the New York edition with the headline: 14 Stormy Days That Wiped Out An Aid Agency. 

. . .

What Remains of U.S.A.I.D.?

The few hundred programs that survived DOGE’s purge reveal the future of foreign aid.

By Amy Schoenfeld Walker, Malika Khurana and Christine Zhang June 22, 2025, Sunday New York Times

As the United States Agency for International Development was being dismantled in early February, aid workers and officials in Washington and around the world set out to salvage what they could.

In the months since, there has been a widespread and under-the-radar effort to retain and restore some of the agency’s most critical work — including some projects favored by those who had the administration’s ear, a New York Times investigation shows.

Former President George W. Bush, who created the H.I.V./AIDS prevention program known as PEPFAR, called Secretary of State Marco Rubio. Leadership at the World Food Program called senators and ambassadors, and they said that millions of hungry people would die. Aid workers and foreign officials found programs that could be said to align with Mr. Trump’s America First agenda and flagged them for Republicans to pass on to the White House with a request to reinstate them.

The shell of U.S.A.I.D that is left today is the result of this chorus of pleas and negotiations, and of hasty decisions made by political leaders, many of whom had little experience in foreign aid.

Remaining U.S.A.I.D programs by sector

SECTOR	REMAINING PROGRAMS	SHARE REMAINING	VALUE, IN MILLIONS
All programs	891	14%	$69,115
Crisis relief	528	63%	$9,457
Malaria	16	32%	$2,901
H.I.V./AIDS	99	31%	$23,954
Tuberculosis	16	28%	$400
Emerging health threats	10	23%	$948
Disaster readiness	52	21%	$868
Water supply and sanitation	11	12%	$133
Maternal and child health	9	11%	$579
Social protections	5	10%	$56

+ SHOW MORE

Note: Sector data was unavailable for 15 awards, worth $3 billion. Value is measured as obligations to date. 

By The New York Times

The overhaul was a far cry from the comprehensive review to evaluate aid programs and realign them with U.S. foreign policy that Mr. Trump promised on his first day in office.

Aid workers said different departments frantically drafted their own lists of awards to keep or restore, but no one seemed to be looking at the big picture. Sometimes Mr. Rubio would sign off on a decision, only for staffers from Mr. Musk’s Department of Government Efficiency or other political appointees to determine the opposite. The piecemeal approach, aid workers said, ignored the reality that some programs relied on others to function.

Read more: Vendettas, Missteps & ‘Viral Waste’: The 14 Days That Doomed U.S.A.I.D.

U.S.A.I.D. employees and officials — including members of Congress who are supposed to provide oversight of the agency’s work — have said they are still struggling to decipher the administration’s goals for foreign aid.

This account is based on 70 interviews and dozens of internal documents and correspondence, and an analysis of both public and internal award databases.

Where U.S.A.I.D. funding remains

As a share of each country’s funding before cuts

0

5

20

50

100%

No dataUkraineUkraine91%91%VenezuelaVenezuela70%70%CubaCuba73%73%ChinaChina30%30%AfghanistanAfghanistan3%3%GuatemalaGuatemala38%38%MexicoMexico0%0%MyanmarMyanmar31%31%South AfricaSouth Africa4%4%South SudanSouth Sudan57%57%United StatesUnited States9%9%

Notes: Most funding to the United States is for administrative costs or for crops for food aid. Only awards operating primarily in a single country are included. 

By The New York Times

The remaining awards are designed to address acute disease, hunger and other emergencies, and not areas like education, governance or jobs that are supposed to help countries avoid crises in the first place. Aid workers and experts said this is a short-sighted way to handle foreign aid that reflects a deep misunderstanding of the agency’s work and will have long-term consequences for Americans.

“You know what is not efficient? Putting out fires,” said Laura Meissner, a former U.S.A.I.D. contractor, whose work to manage humanitarian aid in multiple countries was terminated. “It’s way cheaper to stabilize people so they can weather the storm than to wait until they are destitute and their kids are malnourished.”

No rhyme or reason

In February, Elon Musk appeared in an X Spaces event in part to discuss DOGE’s work at U.S.A.I.D. “You have just got to get rid of the whole thing,” he said.

Vivek Ramaswamy, who helped create DOGE, was also on the call and offered a solution: “Let’s say something is cut that the people of this country just demand needs to exist again. It can always be voted back into existence.”

Mr. Musk agreed. “Well said, Vivek.”

Demands to return funding to certain U.S.A.I.D. programs were already underway.

The day after Mr. Musk’s talk, Senator Jerry Moran, Republican of Kansas, publicly urged Mr. Rubio to move American-grown food aid that was stuck in U.S. ports with no funding for shipment. In the weeks to follow, U.S. shippers and farmers met with members of Congress to explain the value of their lifesaving programs.

Many U.S.A.I.D.-supported organizations, including Catholic Relief Services and Mercy Corps, spoke with members of Congress. Several award recipients, including faith-based groups, had private meetings with Pete Marocco, who was managing the agency for Mr. Rubio. Other aid organizations sued the administration.

These efforts were far more frantic than standard lobbying on Capitol Hill. At the same time, U.S.A.I.D. staff members were pushing Trump-appointed officials inside the agency to restore dozens of terminated awards that provided lifesaving food or medicine or kept employees safe overseas.

Political leaders, who had told employees that they knew little about the agency’s programs, acknowledged in late February that some of these awards might have been cut in error, according to internal emails reviewed by The Times.

Then on March 2, a former U.S.A.I.D. official who oversaw global health programs leaked memos that estimated millions would suffer or die from disease if programs did not resume. Over the next day, more than 300 awards were restored, according to internal documents reviewed by The Times. More than 100 more would be “unterminated” in the days to follow.

The newly restored awards included U.S.-grown emergency food aid, disaster preparedness, programs to combat H.I.V./AIDS and malaria, and several awards in Jordan and Cuba.

A senior State Department official who was not authorized to speak publicly said that agency leaders had conducted a faster review than originally planned, after a federal judge ordered officials to reverse the president’s freeze on foreign aid programs.

The official added that recalibrations should be an expected part of any major overhaul and noted that a vast majority of the termination decisions remained in place. The agency declined to make officials available for an on-the-record interview.

U.S.A.I.D. staff members said they felt there was no rhyme or reason to any of it.

The idea was to destroy everything, said a global health security expert at U.S.A.I.D., who spoke on the condition of anonymity for fear of retaliation, as did most aid workers and other officials interviewed for this article. If someone complained, they would bring it back.

Smaller, local organizations were largely absent from the restorations. Without people in Washington to speak up for them, many were left behind.

“Many were wholly dependent on U.S.A.I.D.,” said Tom Hart, the president of InterAction, an alliance of global nongovernmental organizations. “Suddenly pulling the rug from beneath them hurts the idea of helping countries reach self-reliance, a goal the first Trump administration rightly sought.”

Not about fraud, inefficiency or cost

Despite its claims that “waste and abuse run deep” at U.S.A.I.D., the administration did not prioritize keeping programs that work to reduce fraud.

Instead, officials canceled contracts designed to prevent abuse, including awards for inspectors to watch over aid delivery in high-risk locations in more than a dozen countries.

Cost savings was not a significant factor in the administration’s decision making, either. In March, Mr. Rubio announced that officials had cut about 83 percent of the programs at U.S.A.I.D., but, in dollar terms, they cut programs that were worth less than half of the agency’s obligations.

Officials kept some of U.S.A.I.D.’s largest commitments and cut thousands of less expensive ones, an analysis of multiyear grants and contracts shows. The median kept award was worth $6 million, and 40 percent of these awards were worth $10 million or more.

Some were worth billions. For example, the Washington-based private development firm Chemonics retained two awards for global health supply chains focused on H.I.V. and malaria, worth over $6 billion and $2 billion, respectively.

The median cut award, by contrast, was worth just over $1 million. About a third of the cut awards were worth $100,000 or less.

In March, Mr. Marocco told officials privately that he planned to save $125 billion by cutting programs at both U.S.A.I.D. and the State Department. All together, the canceled awards at U.S.A.I.D. were worth an estimated $76 billion over several years, and $47 billion had already been committed to them.

It remains unclear what will happen to that money. An analysis of spending data shows the canceled awards had about $17 billion left unspent when DOGE took its ax to the agency.

If the overhaul wasn’t focused on fraud, efficiency or costs, there was one north star: a post on X from Mr. Rubio on March 10, which explained the government was keeping “approximately 1,000” U.S.A.I.D. programs. Agency staff members said they were told that they could recommend programs to restore — or even seek new funds for existing awards — but that they could never let the total count surpass 1,000.

Aid workers saw the post as Mr. Rubio retaking some control of the U.S.A.I.D. overhaul after DOGE had taken it too far.

Divisions between the secretary and Mr. Musk’s team became clear in April, when Jeremy Lewin, a DOGE staff member who became a top U.S.A.I.D. official, canceled dozens of the most critical emergency food awards that officials had already promised to keep. Mr. Rubio had just signed off on more funds for at least one of the awards, a rare step and a clear sign of its priority.

Within days of the cuts, Mr. Lewin asked agency employees to restore at least six of the awards, according to an email reviewed by The Times. He apologized for the back and forth, saying it was his fault.

“You have Secretary Rubio getting kind of made a fool of by DOGE because he has repeatedly said that they are going to protect these kinds of lifesaving programs. And then you have DOGE go out and basically countermand him,” said Jeremy Konyndyk, president of Refugees International and a former U.S.A.I.D. adviser to the Biden and Obama administrations. “It’s really unclear who is steering the bus.”

The senior State Department official said that all decisions had been made by U.S.A.I.D. and State Department officials in close consultation with Mr. Rubio, and that they made adjustments as priorities evolved.

Picking up after DOGE

Conservatives have long wanted to reform foreign aid and the layers of bureaucracy that stand between Washington and the people who benefit. But the enormous scope of the U.S.A.I.D. reduction, and the rushed and opaque way it was done, has privately concerned many Republicans.

Andrew Natsios, a former U.S.A.I.D. administrator under President George W. Bush, said that DOGE made a mess that has left gaps for China and Russia to fill.

“Our economy, our security and our way of life is dependent on our connection to the developing world and not just the rich world,” he said “And we have just lost our influence in the developing world.”

As Mr. Musk has stepped back from the spotlight, the remaining steps of the overhaul have been relatively calm and more strategic, according to internal correspondence reviewed by The Times and interviews with people familiar with the decision making. Officials are bringing the remaining U.S.A.I.D. awards under the umbrella of the State Department this summer, where plans for these programs could change again.

The bureaus that will absorb the awards are facing significant cuts too, and employees have expressed concern that they simply do not have the staff, resources or expertise to run them. They plan to terminate more awards and to let others expire.

After months of uncertainty, even the chosen projects are struggling to plan for the future.

One is a World Food Program contract in Kenya that helps feed 700,000 refugees from nearby conflicts. The program is nearly out of food, and while it remains on the list of active U.S.A.I.D. awards, it has not received any funding this year.

As a result, the program’s organizers have had to reduce the rations they provide.

“Do I feed more people for a shorter period of time, or do I feed fewer people who are more critical?” said Lauren Landis, the program’s country director in Kenya. “We haven’t made that decision yet.”

Methodology

A complete list of U.S.A.I.D. awards operating after the president’s decision to review the agency’s work has not been made public. To assess which programs were kept or cut, The Times obtained internal data on individual award status from U.S.A.I.D. and the State Department in April and May and compared that data to similar information on award status that was shared with Congress in March and obtained by The Times. A small number of awards were missing from each of these data sets.

Reporters drew on data from ForeignAssistance.gov and USASpending.gov to determine information about the sectors, recipients and spending for each award.

Award status data is as of May 7; a few dozen awards have been cut since then, internal data shows.

Except where noted, the dollar value of awards is based on the amount that had been obligated over the lifetime of the award, as of May 7 for active awards and as of March 25 for terminated awards.

Spending, sector, and recipient data was not available for 45 terminated awards. Spending data was not available for 18 active awards.

Reporting was contributed by Christopher Flavelle, Apoorva Mandavilli, Nicholas Nehamas and Stephanie Nolen. Sarah Cahalan contributed research. Additional production by Nico Chilla and Jon Huang.

. . .

Promise of Victory Over H.I.V. Fades as U.S. Withdraws Support

A new drug that gives almost complete protection against the virus was to be administered across Africa this year. Now, much of the funding for that effort is gone.

Listen to this article · 12:08 min Learn more

By Stephanie Nolen

Stephanie Nolen has covered H.I.V. for 25 years. She reported this story from South Africa and Eswatini.

June 25, 2025, The New York Times

This was supposed to be a breakthrough year in the 44-year-long struggle against H.I.V.

Decades of research and investment produced new approaches to vaccines that were going into their first significant clinical trials.

The hunt for a cure was homing in on key mechanisms to block the virus, which can lurk dormant and near-untraceable in the body for years.

Most critically, a breakthrough preventive drug, lenacapavir, a twice-yearly injection that offers total protection from H.I.V., was to be rapidly rolled out across eastern and southern Africa. The main target: young women. About 300,000 of them were newly infected with the virus last year — half of all new infections worldwide.

Every one of these plans has been derailed by the Trump administration’s slashing of foreign assistance.

There is more potential than ever before to end the H.I.V. epidemic, scientists and public health experts say. But now, H.I.V. programs across Africa are scrambling to procure drugs that the United States once supplied, replace lost nurses and lab technicians, and restart shuttered programs to prevent new infections.

“We imagined we would be in a different world right now,” said Dr. Leila Mansoor, a senior research scientist at the Centre for the AIDS Program of Research in Durban, South Africa. She had planned to spend 2025 analyzing data from one H.I.V. prevention trial, preparing for another and tracking how lenacapavir was transforming the epidemic — alongside colleagues testing new vaccines and cure strategies.

“And instead we’re moving backwards at warp speed,” she said.

Already, there are fears that H.I.V. infection rates are rising in the hardest-hit countries, but there is no clear way to measure the damage because data collection was mostly reliant on the terminated U.S. funding. Stocks of prevention drugs once supplied by the U.S. are running out across Africa.

In South Africa, which has led much of the H.I.V. work in close partnership with the United States, clinical trials of vaccines that had participants ready for their first shot have been canceled, the immunizations left in the back of lab refrigerators. Scientists leading cure studies have laid off their staffs and turned out the lights in their departments.

The Trump administration says that too much foreign aid is wasted by corrupt governments and bloated programs. The president and his allies have repeatedly said that the United States has shouldered an unfair share of responsibility for global health support and that other countries must do more.

The United States has historically contributed about three-quarters of the global spending on H.I.V., about $6 billion annually in recent years. This is a legacy of a commitment made by President George W. Bush more than two decades ago. Mr. Bush made ending the AIDS pandemic a U.S. priority, saying this was a wealthy nation’s humanitarian obligation, and that it would also benefit American health and security, to bring the deadly virus in check.

Now, even as the Trump administration has dismantled numerous H.I.V. research and prevention programs, Secretary of State Marco Rubio has insisted that the United States will preserve its support for treatment programs.

Among the prevention programs cut is U.S. support for an ambitious plan to distribute lenacapavir, which the U.S. Food and Drug Administration approved this week. Rapid rollout of the new injection is seen by many public health experts as the best opportunity the world has yet had to stop the spread of H.I.V. in the United States and abroad. 

Historically, it has taken years for H.I.V. treatments and prevention methods to reach Africa, where three-quarters of people with the virus live, even when those drugs and interventions were first tested on Africans.

Lenacapavir was supposed to be the product that showed that the world was finally doing things differently, said Dr. Linda-Gail Bekker, director of the Desmond Tutu H.I.V. Centre at the University of Cape Town, who was a principal investigator in the trial that proved the drug’s extraordinary effectiveness.

To bridge the gap until that time, Gilead committed to producing enough of the drug to protect two million people over three years, to be sold at “a no-profit price.”However, about half of those doses from Gilead were supposed to be purchased by the President’s Emergency Fund for AIDS Relief, known as PEPFAR. But the Trump administration has decided that PEPFAR should no longer support H.I.V. prevention for anyone except pregnant and breastfeeding women, and will most likely fund only a sliver of the planned Gilead purchase.

The other half of the doses were meant to be bought by the Global Fund to Fight AIDS, Tuberculosis and Malaria, a multilateral donor agency to which the United States has historically been the largest funder. But the Trump administration is also cutting deeply into its support to the Global Fund.

The third potential buyer for lenacapavir is the countries themselves. But many are already straining health budgets to patch gaping holes created by the reduced PEPFAR support and loss of other U.S. assistance.

“The promise of lenacapavir for prevention was — everybody thought this is the last stage to bring the H.I.V. epidemic down to its knees, and there was such enthusiasm for what we would see,” said Dr. Ntobeko Ntusi, the chief executive of the South African Medical Research Council. “That’s now all up in the air.”

Executives at Gilead Sciences say the company is producing the bridge doses now, and publicly say they are confident that the planned two million people will receive the drug.

“Gilead has not stopped or slowed down in our ambition to make sure we get lenacapavir to as many people as possible,” said Janet Dorling, senior vice president for global patient solutions at Gilead. “The changing landscape means we might have to do that differently. I would not tell you that everything is as we expected. But everyone’s working very hard to find a way to make this happen.”

Privately, however, the company is somewhere between anxious and panicked about who will pay for the product, according to people who have been part of negotiations.

Gilead would not disclose what price it would charge for these initial doses for Africa, but H.I.V. program managers in several countries said they had been told the target price was about $100 per patient per year.

That is roughly double what African countries pay for daily H.I.V. prevention pills, but ultimately cost-effective for public health services because it offers much greater protection, said Hasina Subedar, who oversees the design of H.I.V. prevention programs for South Africa’s health ministry. Women who tested the injection said it worked better for them than pills because they didn’t have to remember to do something every day, and they didn’t have to worry about stigma associated with H.I.V.-related tablets that a parent or partner might see.

There is widespread hope in African countries that the Gates Foundation may step in to cover the lost U.S. government funding for the purchase — Bill Gates has often expressed enthusiasm about the potential of lenacapavir to accelerate the end of AIDS — but the foundation is resistant to buying the product from Gilead, the people familiar with the negotiations said, because its executives are reluctant to make a large payment to a major pharmaceutical company.

“We’ve been working on how quickly we can get the generic version activated,” said Trevor Mundel, president of global health at the Gates Foundation. The foundation will guarantee large-volume purchases to encourage the generics makers to ramp up production, he said, in the hope that the low-cost version of lenacapavir is available by early 2027.

But prevention experts are concerned that generic drug makers will be reluctant to scale up production of lenacapavir if demand hasn’t already been proven — potentially keeping supply limited for years. Mitchell Warren, executive director of the H.I.V. prevention organization AVAC, said a potential buyer like the foundation was best placed to negotiate the price down further in this complicated moment for Gilead. (The foundation is a major backer of the Global Fund and would contribute to a lenacapavir purchase in that way.)

Peter Sands, executive director of the Global Fund, has been lobbying politicians in Washington to support lenacapavir, hoping that some part of the U.S. funding pledge for the rollout might be restored.

“If you want countries to take on the responsibility for their H.I.V. responses, in terms of both leadership and funding, it’s a very different thing to take on a problem that is still growing than a problem where you have made a significant dent in the numbers of new infections,” he said. “And lenacapavir gives us that opportunity to dramatically reduce new infections.”

The Children’s Investment Fund Foundation, a British charity, has pledged $150 million to the Global Fund to support the rollout of lenacapavir, and the fund is urgently seeking new philanthropic and private sector donors, Mr. Sands said, as well as urging recipient countries to rejigger their budgets where possible to help fast-track the introduction of lenacapavir.

The South African government, which now pays for the daily oral prevention drug, was counting on PEPFAR assistance to introduce the twice-yearly injection of lenacapavir as an additional, most likely more popular option. Ms. Subedar said South Africa hoped to use it fast and widely, interrupting viral transmission and swiftly pushing infection rates down.

She had envisioned getting lenacapavir to 800,000 young women in 2026, blitzing college dorms and minibus stops. Now, she said, South Africans are once again stuck, knowing a revolutionary technology exists but unsure if and when they will have access to it.

In Eswatini, the country which once had the world’s highest rate of H.I.V. infection, Sindy Matse, program manager of the Swazi National AIDS Program, said the rates of H.I.V. testing in the country had fallen precipitously since January. And from January to April, nearly 5,000 people who take H.I.V. treatment failed to pick up their medication, most likely because their clinics were closed or their outreach workers were fired, she said.

Ms. Matse worries that infected people aren’t starting on treatment and that pregnant women may give birth to infected babies — but she doesn’t know for sure what’s happening because much of her program’s data was collected and processed by clerks whose salaries were paid by PEPFAR and whom the government has yet to replace.

“We never got time to transition,” Ms. Matse said. “Now we are expecting to see new infections, and drug resistance from people whose treatment is interrupted.”

South Africa has also seen a sharp drop in the number of people taking pills to prevent infection. In Cape Town, Dr. Bekker fears that South Africa’s hospitals will soon start to see a surge of people with tuberculosis — people whose H.I.V. treatment has been interrupted, or who have not been diagnosed. Clinicians will need a crash course in what AIDS-related infections look like, she said; young doctors will not have seen them because South Africa’s H.I.V. program has been so effective over the past 15 years. Soon they will be back.

“The stars were aligning, with these new innovations, to really bring this thing to its knees,” she said. “But this money was critical to get there. And now it’s gone.”

Stephanie Nolen is a global health reporter for The Times.

A version of this article appears in print on June 26, 2025, Section A, Page 10 of the New York edition with the headline: Decades-Long Dream Of Victory Over H.I.V. Is Victim of U.S. Cuts. Order Reprints | Today’s Paper | Subscribe

See more on: U.S. Politics, Gilead Sciences Inc, Bill and Melinda Gates Foundation, President’s Emergency Plan for AIDS Relief, Global Fund to Fight AIDS, Tuberculosis and Malaria

. . .

OPINION

THE EZRA KLEIN SHOW

The Disaster That Just Passed the Senate

July 1, 2025, The New York Times

By Ezra Klein

The Disaster That Just Passed the Senate

Trump’s “big beautiful bill” would gut Medicaid, nutrition assistance and clean energy credits. All for what?

This is an edited transcript of an episode of “The Ezra Klein Show.” You can listen to the conversation by following or subscribing to the show on the NYT Audio App, Apple, Spotify, Amazon Music, YouTube, iHeartRadio or wherever you get your podcasts.

I’m taping this introduction on Tuesday, July 1. The Senate passed Donald Trump’s “big beautiful bill” just moments ago in a 50-50 vote, with Vice President JD Vance as the tiebreaker.

This bill is a bad piece of legislation — trillions of dollars in tax cuts, very much tilted toward the rich, with savage cuts to Medicaid, nutrition assistance and green energy. Even with those cuts, we can expect more than $3 trillion to be added to the national debt over 10 years.

And befitting a policy like that, the bill is hugely unpopular: A poll from late June found nearly two-to-one opposition to the bill. Vulnerable Republicans do not seem excited to run on the wreckage it’s going to create. Thom Tillis, the Republican senator from North Carolina — a state Trump has won over and over again — just announced he’s stepping down at the end of this term, in part over the Medicaid cuts.

But bad policy only matters if people know about it, and a lot of people don’t. Those of us hearing about this bill — even those of us covering it — can’t keep the whole package in mind. The Times has a great list of nearly all the provisions, and a lot of them would be major policy fights on their own.

But in part because of that — and because the Trump administration is flooding the zone with so many other major policy fights — it has been hard to focus attention on what is passing and what can actually be done about it.

So I asked Matt Yglesias back on the show to go through what is in this bill, and why it has been so hard to generate the kind of political force on it that we saw in Trump’s first term, when the Obamacare repeal went down to defeat.

Matt, of course, is the author of the Slow Boring Newsletter. We spoke on Thursday, June 26.

Ezra Klein: Matt Yglesias, welcome back to the show.

Matthew Yglesias: Really glad to be here.

So the “big beautiful bill” — Chuck Schumer calls it the “big ugly bill.” What is your high-level description of how this thing fits together?

You have two different versions. They both contain about $5 trillion worth of tax cuts — of which they’re trying to disguise the cost and say it’s more like $4 trillion. But it’s trillions of tax cuts, mostly tilted toward wealthier people, although some for middle-class, working-class people. And then it’s offset by cuts to nutrition assistance, clean-energy programs and Medicaid.

There’s a lot of disagreement between the House and the Senate about exactly how to do the Medicaid cuts. And that’s a lot of what the wrangling is about. But the broad shape of the bill, which has been the locked-in framework for months, continues to be the parameters they’re dealing with.

So has Donald Trump just always been Paul Ryan in orange makeup?

I don’t know that he’s exactly Paul Ryan in orange makeup, but he has always been in favor of big tax cuts, and there is some pressure to offset the cost of those tax cuts with spending cuts.

The big change is that Trump made Republicans much more cautious about cutting Medicare and Social Security. So that means that the Trump-era Republican cut proposals fall much more heavily on poor people, specifically, rather than on the elderly, which was the Paul Ryan version of this.

And I think it’s a really underplayed aspect because Trump has actually gained a lot more support from low-income voters than Republicans have in the past. He has really changed the image of the party with regard to how it relates to lower-income people. But the policy is incredibly unfavorable to them.

This is a bill where some of the most brutal cuts fall on Medicaid users. How do they cut Medicaid?

This is part of what they’re disagreeing about. One of the big ways is that they’re changing what’s called Medicaid provider taxes. States raise money for Medicaid in part by taxing the hospitals and others who provide Medicaid services. The House and the Senate have different ways of putting even stricter, tighter rules on the use of these provider cuts.

The other thing they do is big work-requirement rules. So you’re going to have to certify that you are working or participating in some kind of work-related activity. And a lot of people are expected to fall through the cracks of that kind of system.

Really reduced spending. They’re also putting higher enrollment barriers for Affordable Care Act subsidies. And different rules around immigration status.

But the biggest ones are those provider cuts and the work requirements.

The way Republicans defend this out on the trail is: Look, all we’re saying is, if you’re on Medicaid, you should either be working, or if you’re an able-bodied adult, you should be trying to find work.

And you said people fall through the cracks. But when I talk to people who do Medicaid work, who know about how these work requirements work, they say they’re not going to fall through the cracks — that this is a very onerous paperwork and reporting requirement.

People often just fail to be able to do it. They check in with the government but then forget to one month — or don’t realize they have to. And they argue that the work requirement is a way of using administrative burden, like all this paperwork, to kick people off the program.

I think you could see there’s a mismatch in the way Mike Johnson characterizes this. He talks about: We’ve got all these able-bodied young men who are sitting on the couch all day playing video games, collecting Medicaid benefits.

But you don’t collect Medicaid benefits. Able-bodied young men are not racking up incredible medical bills, almost by definition. So for the bill to save money, it has to be cutting off care to people who are in fact sick and in need of medical care. That’s how the savings work.

It’s also easy to neglect how hard it is to fulfill certain kinds of requirements. But people who are poor, who are dealing with medical problems, who have a lot of stuff going on in their lives, aren’t always able to get all this check-box stuff done, which is why millions of people are going to lose coverage — and why it’s going to save a meaningful amount of money.

The only way to offset the cost of tax cuts is to deny medical care to people who need treatments.

I really want to underscore this thing you just said because I think you stated it very clearly: You could save money on Social Security by not having Social Security send people checks every month, but you cannot save money on Medicaid that way.

The way Medicaid has to save money is that somebody who would have gotten treatment for cancer, for C.O.P.D., for an aching back — whatever it might be — will now either not go get that treatment or somehow this person who was on Medicaid and was poor enough to qualify for Medicaid is going to pay for it some other way.

The federal government is implementing an onerous set of paperwork and reporting requirements where, if people who are already poor, sick or otherwise disorganized cannot or do not abide by them, when they get sick, they will not be able to get chemotherapy — or they will have to go into medical debt to get chemotherapy.

Like — why? So I can get a tax cut?

There’s a profound ideological disagreement. One of the things Gallup asked people: Should it be the federal government’s responsibility to make sure that everybody gets health care? And about 60 percent of the public said yes.

At the highest level of abstraction, the public has a progressive view about this, and Republicans don’t. They were not for the Affordable Care Act. The most conservative states don’t accept Medicaid expansion funds. They have tried to impose work requirements in Arkansas, for example.

So we ran the experiment: Does putting work requirements on Medicaid increase employment? And the answer was no. When they did it, employment didn’t go up. People did lose coverage, but employment didn’t go up.

And Republicans didn’t reverse course after that. They didn’t say to themselves: Oh, our goal here was to get more people working, but we didn’t succeed at that. They said: You know what? This cut the rolls. It cut spending. We’re happy with that.

That’s a free market view: If you want a television, you’ve got to pay for it yourself. If you want chemotherapy, you’ve got to pay for it yourself.

And I think that’s a morally questionable worldview. But I think it’s something that Republicans believe in pretty sincerely. But they also don’t want to articulate it in those terms because it sounds terrible.

In the 2012 election, Mitt Romney famously got caught on tape saying: Look, there’s 47 percent of this country who are just takers. They’re not paying income taxes, they’re just getting things from the federal government.

I’m paraphrasing him here, but he basically says: Look, our job is going to be harder because that’s always going to be a popular politics, and those are not our voters.

But Donald Trump won voters making less than $50,000. It is very plausible that a majority of people on Medicaid now vote for Republicans.

So I think the politics of this used to be that Republicans want to make these cuts for the ideological reasons that you’re describing. But they were cuts to the Democratic Party’s voters.

Now they are very substantially cuts to the Republican Party’s voters. They’re cuts to Republican states. They’re cuts to Republican hospitals — rural hospitals in areas that vote for Republicans and are very dependent on the care that gets financed by Medicaid in order to stay open.

This is the Republicans’ old ideology coming into conflict with their new coalition.

Absolutely. If you look at the share of people who are on Medicaid by state, there are seven states where more than a quarter of the population is on Medicaid.

One of them is New York, and one of them is California. But the other five are New Mexico, Louisiana, Arkansas, Kentucky and West Virginia.

And then you look at states like Mississippi and Alabama: If they would accept Medicaid expansion funding, there’s a huge, potentially eligible population share in those states.

It’s a big conflict inside the heart of Republican politics. Mitch McConnell is from Kentucky. His political swan song is really just saying what he thinks about everything. He said about this: I know my colleagues are hearing from people who are worried about Medicaid, but we have got to get this done. His literal words were: “They’ll get over it.” — which I think is not something a person running for re-election would say. But it’s very emblematic of what you’re talking about.

There’s just a conflict between the Republican Party electorate and their ideology, which has shifted in some ways but really remains focused on low taxes, on investment income, low corporate taxes and wanting to cut spending on programs for the poor.

Let’s talk about the tax side of this bill. You can cut taxes in a lot of different ways. There’s not just a giant, individual income tax cut.

What are the major things this bill does? And I don’t just mean here how the bill is tilted toward the rich or the poor. But how does it change the incentives for people to do, or not do, things in the economy?

The centerpiece of this bill is taking the temporary provisions from the 2017 Tax Cuts and Jobs Act and making them permanent.

A lot of that is just small reductions in the income tax rate at every particular bracket. Some of that is an expansion of the child tax credit. And a lot of it is corporate tax breaks — different ways to lower the taxes of businesses that have large investments.

Trump then also piled on the campaign these new ideas: No tax on tips, no tax on Social Security, no tax on overtime. Those weren’t really fleshed out in the campaign in a real way, but Congress has felt the need to put some version of them in here — which is part of why Republicans are having trouble with this. Making the T.C.J.A. permanent is nonnegotiable for them, but delivering on Trump’s promises is also nonnegotiable. And so that has turned this into this very, very expensive sort of thing.

The no tax on Social Security didn’t really make it in, though, right? Because of various budget rules?

The “Byrd Rule” — yes.

I’m just going to give a very quick budget explainer before I go on.

In order to not have this be subject to the filibuster, in which case it would not pass, Republicans are using a legislative vehicle called budget reconciliation. This is now used for almost everything that’s very big. Build Back Better, the Inflation Reduction Act used it.

And it has weird rules, according to something called the “Byrd Rule.” One of those rules is it can’t really do all that much to Social Security. Other rules are that everything has to be explicitly budgetary in nature.

So then the parliamentarian goes through it, and things get challenged, and the parliamentarian decides: Is doing this really a budget thing? Or are you trying to sneak in another change and calling it a spending and tax change?

So one thing about this bill that’s a little strange, I guess, is that if you talk to conservative tax wonks, the thing that they are most excited about is the business provisions — a 100 percent bonus depreciation for equipment and domestic R&E expensing.

So these are corporate tax breaks that conservatives believe will encourage more investment and make the economy more prosperous. That totals to about $700 billion to $800 billion worth of costs. I don’t want to say that’s not a lot of money, but it’s a relatively minor share of a $5 trillion tax bill.

So the bulk of the dollar cost of the bill is repealing the alternative minimum tax, expanding the standard deduction and rate cuts in individual income taxes, and this 1099 pass-through deduction thing. Which is basically: If you own certain kinds of closely held businesses, you get to claim a huge tax cut. So for example, if you are a real estate developer or you own golf clubs, you just arbitrarily pay a lower tax rate. And then there’s a $200 billion estate tax cut.

Again, on the merits, the conservative view is that these kinds of tax cuts encourage higher levels of savings than investment in the economy. Because the people who save and invest are disproportionately very rich, it has a very skewed distributional tilt.

So they’ve also thrown in all kinds of other stuff that doesn’t have that same kind of impact. There’s a bonus standard deduction for senior citizens that’s supposed to be something that you can go to a town hall and say to, you know, grandma: This is what I did for you.

But the cost of that is $90 billion versus $212 billion from the estate tax cut.

It’s amazing the way a bill this big begins to warp one’s ability to talk about big numbers. Like: That’s only $90 billion. That’s pocket change.

Those of us who have to read a lot of Congressional Budget Office reports know there is a long-running fight over whether they’ll use something called dynamic scoring or static scoring when a bill like this has its cost estimated by the Joint Committee on Taxation and — sort of but not exactly by the C.B.O.

Static scoring just totals up how much things cost. And then dynamic scoring, in theory, runs a model saying: Will this help grow the economy or not? And if it does help grow the economy, then in theory that should offset some of its cost — because a faster-growing economy creates more tax revenues that then can be put in.

The Republican argument is always that these things are overestimated in their cost because they’re using static scoring, not dynamic scoring. And we need to use dynamic scoring.

So they got, in this case, dynamic scoring.

But what happened when they got the dynamic scoring, Matt?

So the dynamic score actually raised the cost of the bill by about $400 billion.

Why did it do that?

Because it expands the deficit by trillions of dollars — which they think, in the current climate, will raise interest rates.

Importantly, this would raise interest rates throughout the economy. But it means that the federal government’s interest rate costs will go up, and that swamps the growth impact that this bill is supposed to have.

One reason for that also is that the dynamic modelers see a very muted growth impact because the big pro-growth measures are temporary. Bonus depreciation, interest rate limits, domestic research expensing — those are all extended through 2029.

So if you’re talking about changing the long-term trajectory of business investment, a temporary extension doesn’t necessarily move the needle that much. If you’re adding trillions of dollars to the debt in what’s already a somewhat inflationary environment with some upward pressure on interest rates, you create bigger costs for the federal government — but also bigger costs for if you want to get a mortgage, if you want to get a car loan, if you want to build a house, any kind of project like that.

And that’s a big difference from 2017. When Trump was president before, interest rates were superlow. So the professional deficit hawks were saying: Oh, this is bad. But the modeling was like: It’s probably fine.

But now it’s not fine. The deficit is a serious issue. And this makes it much worse.

I have genuinely not seen a big tax cut bill fail a dynamic score like this.

I know this question has a sort of naive, begging quality to it, but: There is some world in which you would have expected the cost estimate to get Republicans who are running the policy process here to stop for a minute and wonder if this bill is well designed for the moment in which they are trying to drive it. In theory, they care about the debt. In theory, they’re trying to grow the economy.

The fact that this gave them so little pause — aside from listening to Donald Trump and paying off big donors, what they’re even trying to achieve here becomes a little bit opaque. They’re not going to get more people working.

What is all this for?

Donald Trump, I think even his fans would acknowledge, is not a super-detail-oriented policy wonk. He is a person with a certain kind of feel for the vibes in the electorate.

The idea that there should be no taxes on car loan interest rate payments — I think that’s a terrible idea on the merits, but I also acknowledge that it probably sounds good to most people. So he kind of hit on some of this stuff over the course of the campaign trail, and they’re putting it in the bill. And it really raises the cost, even though it doesn’t relate to the core objectives of Republican Party tax policy designers.

And one of the things I have often lamented about the Democratic Party in recent years is that it has lacked the kind of strong leadership that can make choices and put its stamp on things.

Republicans have very strong leadership in the form of Donald Trump, and that means that nobody wants to tell him: This overtime thing, we can’t do it. It’s undermining our goals here. It’s going to backfire, even though it sounds good to people.

They don’t really want to pick and choose between these provisions. So they’ve come up with something that’s just too big to pull off unless you want to make the spending cuts even bigger and even harsher. So already they’re facing a lot of pushback and some dissension inside the caucus about what they are going to do.

If you took trillions of dollars more out of spending, you could make this work. Once upon a time, Elon Musk was claiming that he was going to find $2 trillion worth of fraud in the federal government. That didn’t happen.

The difference between the state of the world in which you can save hundreds of billions of dollars in fraudulent Social Security payments and one in which you can’t should alter your policies. But we’re not in that mode.

This is really a lot of money to put on the credit card at a time of high interest rates.

Because there is such a tendency for the out-of-power coalition to emphasize the deficit and the consequences of unpaid-for spending or tax cuts, I’m always trying to catch myself: Am I just doing motivated reasoning here?

But the Biden administration really did pay for the Inflation Reduction Act. That really did have pay-fors in it. Barack Obama paid for the Affordable Care Act.

How are you thinking about the debt and deficits right now? What is actually the problem? And why is it actually different than maybe it was 10 years ago? And how much does this actually then matter layered on top of that?

I remember four years ago we were talking about the American Rescue Plan, which was not paid for — deliberately. It was a stimulus measure. And some people were saying: This costs way too much money. It’s too big.

And my thought at the time was: Interest rates have been superlow forever. For basically my whole career.

So A, I sort of just don’t believe that inflation and high interest rates can happen. And B, if it does happen, the politics is just going to shift. We’re going to be back to where we were in 2011, when everybody was fanatically focused on deficit reduction — and that might be good.

And I was just completely wrong about that. Inflation did go up. Interest rates went up to get inflation contained. It became a serious concern. And then we got the Inflation Reduction Act, which, sure, it was paid for. But it wasn’t a deficit reduction bill.

And then there was nothing. There was no big speech about how we have to get everybody around the table and talk about things.

And Trump came back with just incredibly fiscally irresponsible proposals. And it’s weird, right? If you ask anyone in politics, they’ll be like: Voters are really upset about the cost of living.

And I get that it is a little bit complicated to explain to somebody why a giant deficit-increasing tax bill will raise your cost of living, but it will. Factually.

How?

Because it’s going to raise interest rates. It’s going to raise the cost of money.

Why will it raise interest rates? Explain it to me like I’m 5.

All right, here we go: So when the budget deficit goes up, the federal government needs to sell more debt. And the federal government is the safest entity you could lend money to in the universe — certainly in the United States of America.

So however much money is sort of loaned to the federal government drains the pool of potential savings that could be lent to everybody else. That’s one way to think about it: Loanable money will become scarcer because the federal government is borrowing all of it.

Another way is to look at it through the inflation mechanism. The gap between what the federal government spends and what it taxes is like extra money into the economy. That has an inflationary impact, which the Federal Reserve then has to offset by keeping interest rates higher.

So you have JD Vance and Trump and others who are on Twitter screaming: Powell has got to get the interest rates down.

And I think reasonable people can disagree: Should there be a quarter-point rate cut next meeting? Or should there be no rate cut?

But if you borrow trillions of additional dollars, that’s going to make it harder to make the case for those kinds of rate cuts. It’s also going to make it harder for these short-term rates to pass through to the longer term rates.

So if you’re talking about young people who want to buy a house, the sticker price of a house matters, but the price of a mortgage also matters. It’s a huge influence on what you can afford to do in practice: small business loans, car loans, large equipment. I don’t really think people should be financing consumer purchases with credit card debt, but a lot of people do.

So it’s going to raise costs across the board for middle-class people, take away health care from lower income people, put a big strain on rural hospital systems. We haven’t talked about the energy provisions — which are going to make electricity probably more expensive in the face of rising demand.

Let’s go back to the energy revisions in a moment.

The other thing I want to emphasize that you said there: When we talk about the cost of living in a bill like this, we tend to be talking about interest rates and inflation, just as you did.

But I do want to state the obvious, which is: If you are poor and you had Medicaid and now you don’t, your cost of living just went up. Health care becomes more expensive for you if you don’t have another form of equivalently subsidized and comprehensive health insurance sitting in your back pocket. If you were on food stamps, on SNAP, and you got thrown off the program because of these proposed cuts, food just became much more expensive for you.

Republicans sometimes try to pretend that government transfers are not real, that the role they play in people’s budgets is not real. But it is a real role.

For a president who ran promising to bring down the cost of living and also promising to balance the budget, the scale of the dishonesty and the cruelty is so staggering.

There’s a robust debate happening about the health impact of Medicaid cuts.

The lottery-style evidence tends to show a fairly muted health impact but has a small sample size. If you look at different research designs that offer more statistical power — but raise more questions about causation — the data tends to show that many lives will be endangered by these Medicaid cuts.

The skeptical analysis shows that the financial benefit of Medicaid is large. I think it’s important for affluent people not to lose sight of that. For instance, my son has been to see the doctor a lot of times over the course of his life, but he’s never actually had a serious medical problem. If we had been unable to get him medical treatment all those times, I think in the grand scheme of things, he would have been fine. But the anxiety, for parents, of not being able to take your kid to the doctor when he’s sick is extreme. If you had any ability to pay for medical care for your sick child, you would do it.

What we see is that Medicaid expansion states reduce medical debt by about $1,400 to $2,300 per person because people are more likely to seek health care when they feel that they need it.

Per person on Medicaid or just per person in the state?

Per person on Medicaid.

The other thing is that you get uncompensated care in hospitals, because we don’t actually have a system in the United States where we’re going to leave you on the street corner if you’re having a stroke or something like that.

So you are shifting costs onto foregone care by poor people, medical debt and uncompensated care for hospitals. This cost is then paid for by the insured population.

There’s this threat that hospitals will go out of business. I’m in Maine right now in a very rural area, and hospitals don’t have a ton of customers here. If they lose let’s say 10 percent or 15 percent of their customer base and have higher uncompensated care burdens — some of the facilities will just close.

Senate Republicans have discussed creating a hospital bailout fund to prevent this, but it seems crazy to me to address hospitals’ business model problems by giving them direct payments to stay in business even though they’re not treating patients, rather than just letting people get the treatment they need.

I do want to talk about the energy credits. Tell me about that side of the bill.

The Inflation Reduction Act created a lot of tax credits for different kinds of zero-carbon energy. They took what were existing investments in production tax credits for wind and solar as well as somewhat different ones for geothermal and nuclear. They folded it all together into a technology-neutral tax credit program that was made permanent.

Republicans in the House have proposed basically scrapping all of this. That would leave us with less financial support for clean energy than we had in the previous Trump administration.

The context for this is that electricity demand is going up a lot, primarily because of data-center construction. The pipeline for building new natural gas turbines has been bottlenecked — the turbines are not available. Most of the new electricity that is coming onto the grid in the United States is utility-scale solar or onshore wind. There’s going to be less of that built.

If the House version were to pass, you would also be cutting off promising speculative research in clean firm technology. So we’re going to have less but dirtier electricity and higher bills.

These were promising sources of investment.

I was just reading a story the other day about how this is throwing battery investment into turmoil. That was a pretty bright part of the U.S. economy.

We’ve done a lot to begin building the supply chains, and we consider them important. We also consider the solar panel supply chains important.

One way we were inducing those supply chains to grow in the U.S. and in other friendly countries was through tax credits. There was always a lot being done by this part of the I.R.A. It had these intense “Buy American” provisions because we were trying to onshore this technology as well as deploy it.

If you rip this up, you have the increasing climate change risk and consequence. You also risk greater electricity volatility and possibly higher electricity bills. And you’re ceding yet more to China, which is investing massively in solar and battery technology. If you look at the charts of Chinese utility-scale solar installations, it is astonishing.

This has this quality of destroying a useful part of the economy — just because they ideologically don’t like renewables and didn’t like the I.R.A.

The battery stuff, especially. Batteries have improved significantly over the course of the past five, 10, 15 and 20 years. Most batteries are manufactured in China through supply chains dominated by China. This has been a Republican critique of electric car promotion — that it will only increase the United States’ dependence on the Chinese supply chain.

Democrats tried to address this concern by investing in creating an American supply chain for batteries. Republicans, however, are not assuaged by that and now want to eliminate the supply chain altogether.

Setting aside the electric cars, if you look at the war in Ukraine or the fighting between Israel and Iran, battery-powered drones clearly represent the future of warfare. It’s genuinely dangerous for the United States to cede the battery technology entirely to the People’s Republic of China. It’s probably not viable to have a military-only battery industry, because the batteries used in military drones aren’t special. So if you have a good civilian industry, you can also have a strong military industry.

Also the amount of money at stake there is not very big. A lot of it seems like cultural identity politics.

Trump claimed in his first campaign that he was going to bring back the American coal industry. That just completely didn’t happen during his first term — but he’s making another run at it.

They’re going to classify coal as a critical mineral. And they seem to be trying to cut off all other potential forms of energy other than coal.

And wind in particular is really big in red states. Iowa, Kansas — these are places with big, empty open space that are good for building wind.

So I don’t know that there’s any logic to it — other than just an affective disdain for batteries and renewables.

They also seemed — though you can tell me if this is still true in the current versions of the bill — to be causing havoc in nuclear loan guarantees and subsidies, which are the kinds of things that might support technologies like advanced geothermal.

In environmental politics, there’s this weird divide where a few clean energy technologies fall on the other side of the left-right culture divide. Nuclear and advanced geothermal were both in that group, but now it seems like they’re slashing into that, too.

The sort of center-right or right-wing innovation types I know have seemed very unhappy about what this bill is doing to the kinds of energy they support and get excited about.

The House bill in particular does. The Senate bill reflects more input from those kinds of people, such as Lisa Murkowski and others.

In the House bill, they were going to eliminate the Energy Department’s Loan Programs Office — which has been supporting most nuclear development — and cut tax credits for geothermal. Republicans tend to like these technologies more than renewables, at least in principle, but they are very speculative.

The provision of subsidies to keep investment flowing into those industries is very important. Right now, you can’t actually make money right now by investing in advanced geothermal. The hope is that, in the future, as they adapt drilling technologies to the case of hot rocks — that this will unleash incredible amounts of clean energy. But someone still needs to drill the money-losing wells today.

You know what’s interesting? We say that Republicans like nuclear and geothermal a lot more than they like renewables. I think that’s true of D.C. Republicans and Republican Party theoreticians.

But the Republican Party is closely attuned with the fossil fuel industry as such. The natural gas industry, I would argue, is more fearful of nuclear and geothermal than it is of wind and solar.

Gas sort of complements renewables. When the sun doesn’t shine, you can just turn on the natural gas plants. The whole virtue of clean firm technology is that you don’t need to turn it off when the sun isn’t shining, and that could put fossil fuels out of business.

On an interest-group level, there’s as much or more hostility to those kinds of clean firm technologies. Even though, theoretically, Republicans are more open to it.

If you go back to the inauguration, you’ll see all the tech C.E.O.s arrayed at the inauguration. And if you’ve been listening to JD Vance interviews, you’ll notice that he’s very pro-nuclear.

This influence comes from figures like Peter Thiel and Elon Musk, both of whom have been strong advocates for technology and innovation. Musk is known for his work with rocket ships, electric cars and batteries.

And that kind of promise is reminiscent of the futuristic vision associated with the Trump administration — what I would call “reactionary futurism.” People like Marc Andreessen and Joe Lonsdale embody this idea. The folk understanding of where their ideology has gone is that we need an authoritarian leader to drive us past the weak, risk-averse interest groups and fractured mess of politics in order to get to this technofuturistic technocracy we’ve all imagined.

But that just has always seemed really weak. Elon Musk went around cutting organizations like U.S.A.I.D. and the Consumer Financial Protection Bureau — which was horrible — but didn’t build a government capable of innovating in a new way or getting us to space any faster. All this stuff where you could have imagined a technofuturistic right or dark abundance right — it’s just not happening. You’re not seeing it.

I think some of that is the slipshod nature of DOGE, which was put together by people who didn’t really know very much about the federal government and didn’t seem inclined to read any books.

I think the hyperpartisan nature of Trump’s politics makes it impossible to implement these kinds of effective government reforms or futurism.

One thing both parties have found is that when you try to push things along party lines during an era of high polarization, you’re working with very thin margins. That means you can’t alienate any of the people within your coalition.

Everything ends up being a series of buy-offs, which makes it really difficult to advance a futuristic vision. You can’t drive big change —

I want to push on this. Because that’s true up until Donald Trump gives a damn himself. And then it’s like: R.F.K. Jr., a Democrat until 45 minutes ago, can be the head of H.H.S. Tulsi Gabbard is now the director of national intelligence.

If Donald Trump wanted big subsidies for nuclear energy in this bill, they would be there. What you’re saying about the dynamic is partly true, but I think it also reflects a kind of a drift.

Those people were there, but in the end, they didn’t maintain power. You don’t hear that much about Marc Andreessen at Mar-a-Lago anymore. Elon Musk, very famously, is no longer on the inside of the Trump administration. And Trump himself was never truly ideologically bought in. As for JD Vance, I guess he either doesn’t care enough to engage or doesn’t want to talk to Donald Trump about it.

The entire political economy of Trumpism is built on the fact that you don’t have a strong policy process. But if a random person can get Donald Trump to like something, he can make the Republican Party do anything he wants — including supporting things like crazy tariffs that they would have never touched at other times.

You’ve mentioned tariffs. That’s actually the one economic policy topic where Trump has persistently fought with conventional Republican Party thinking over the course of 10 years now.

That’s antithetical to this idea of a more dynamic American economy. AndtThe fact that there was a sect of futurists who were so annoyed with Joe Biden that they decided that Trump would be their champion — it never really made sense, especially in light of his profound commitment to trade protectionism.

Not just because trade is important on its own terms, but because the debate over trade protection is a question of: Are the costs of economic change worth paying for the benefits of growth and dynamism — or not?

Trump has been very clear that as long as the people paying the costs meet a certain Trumpy vision of the kind of person he likes, he doesn’t want change.

He supported the longshoremen’s union in opposing port automation because he has a longstanding personal relationship with the head of the East Coast dockworkers. And because it’s the kind of people he likes — burly white guys.

He also likes the coal mining industry. It’s very obsolete, but he doesn’t want it to be put out of business by change and dynamics. I think one should have known that on some level.

But the other thing I would say is that everything with Trump ends up being closer to base line Republican Party politics than it kind of seems at first glance. So Tulsi Gabbard is his director of national intelligence, but we bombed Iran. R.F.K. Jr. is the H.H.S. secretary, but we’re still not regulating the fast food industry.

No, we’re cutting Medicaid.

There are aspects of MAHA that kind of remind me of an Ezra Klein column from 15 years ago. But none of that is actually happening. There’s no actual taking on agribusiness concerns or any drive to transform the food system to make people healthier.

There’s no aspect of Trumpism that’s like: I’m going to take on the stakeholders in conservative politics in a really meaningful way. There’s a lot of personalism. He can push the “No tax on tips” idea onto the political agenda, but he’s not going to say we’re doing that instead of a business tax cut.

We’re not doing choice-making populism where the Chamber of Commerce says: No, Donald, you can’t do that because we need our business tax cuts. It’s more of a “yes, and” approach. Trump feels that it all worked out in the first term, and people liked that first Trump economy —

Here’s the thing about Donald Trump: Everybody knows that he has an incredible intuition for public opinion — what’s popular and what’s not. Granted, this bill has a lot of bad ideas, but at least it’s really popular in polling, right?

[Laughs.] No.

No? [Laughs.]

The polling is terrible. People really don’t like Medicaid cuts. This is a big political transformation of the past decade, that Medicaid has become dramatically more popular. A lot of people have had Medicaid themselves, or they have a friend or family member who’s on Medicaid. And they basically like it.

This has become a popular program as there has been class realignment. But as rich people become Democrats, they still feel sentimental about the poor. And as poor people become Republicans, they still like having health insurance.

This has become really toxically unpopular in a striking way — but it hasn’t received much attention. I wouldn’t say the dominant story of Trump’s first six months in government has been the one “big beautiful bill.”

It is extremely unpopular. And I’m actually surprised at how unpopular it is, given how little attention it has gotten.

You and I have talked a lot over the years about what gets called popularism. The argument is that the big problem for the Democrats is they don’t take enough popular positions or abandon enough unpopular positions.

One of Donald Trump’s strengths is that he’s done a bunch of that — moderating on Medicare and Social Security.

But there’s always been this other question: Even if you are taking a popular or unpopular position, how much attention is that position actually getting? What is politics really about? Is it about your good issues or your bad issues?

One of the arguments you’ve been making about Democrats in the past month or so is that they’re not doing enough. Or not succeeding in doing enough to make politics about this bill. Which should not be a crazy thing for politics to be about. This is a $5 trillion bill — depending on how you count it — that’s actually going to be the signature legislation of Donald Trump’s term.

Walk me through that critique. Is that a problem with the Democrats — or with the media or voters who aren’t paying attention? How do you understand the sort of failure of this bill to become the thing we are talking about?

It’s a mixed bag. On some level, it’s just harder to get people engaged in discussions about J.C.T. dynamic scoring and Medicaid eligibility rules — compared to something like our deploying Marines to the streets of Los Angeles.

That said, eight years ago, the Affordable Care Act repeal was a really big deal. There were big protests around it, largely because Democrats had built up a health care advocacy infrastructure during the A.C.A. years.

But much of that advocacy has withered over the past few years. Partly because Democrats are more focused on climate change, and partly because the “Medicare for all” wars have become an ugly pain point for people. If you go stand up and say you really want to talk about health care, you’re going to get a bunch of people saying we should do Medicare for all.

And now you’re fighting with people to your left instead of making a point about Republicans. That said, party leaders like Chuck Schumer and Hakeem Jeffries are talking about this a lot. They’re constantly pushing to get more people discussing it and encouraging their colleagues in Congress to engage more on the issue.

I think a big problem is that the Democratic Party is leaderless at the moment. The leadership they have is held in low regard by their own voters. And there’s a lot of interest in factional infighting. For instance, we can have debates about abundance or about Zohran Mamdani.

My Twitter feed is national, and there’s more debate right now about the New York City mayoral primary than about the actually national “big beautiful bill.”

Yes, and it’s because in a genuine way, Democrats are interested in stories that have implications for factional infighting. I think one of the ironies of this bill is that all Democrats agree on it: Jared Golden, Marie Gluesenkamp Perez and Adam Gray — the most moderate members in the House think it’s terrible and are all voting no.

The most liberal members also don’t like it, so there’s nothing to fight about. And Republicans or conservative people are pretty disengaged from it, too. They’re not making a lot of noise about it, which I think is tactically savvy on their part.

You could call it a failure of the media. I wish the mainstream media would only run articles about the things I think are important. But the reality is we’re doing business here. My articles on this subject do not perform as well as my articles on other things that have more juice.

Let me ask you about that.

When we were at Vox, we both covered the Trump administration in its first term in their effort to repeal Obamacare.

Maybe I’m mistaken, but I remember that being a dominant news story for an extended period. I’m not sure if that’s because there was less that happened in the middle of it — like us bombing Iran.

I don’t know if it was because it was a clearer narrative. I have this view that these massive omnibus bills have become harder for people to talk about because there’s just too much going on in them. I think this is actually a problem for Build Back Better, which Democrats had trouble messaging and getting people to think about because it just did 80 different things. I think it was a little bit true with the Inflation Reduction Act.

There really does feel like there’s a difference between how central the Obamacare repeal effort was in Trump 1.0 and the way attention feels like it slides off this in Trump 2.0.

I think the analogy to the Biden-era megabills is a good one.

At the time, Democrats were claiming to believe that if people were paying a lot of attention to the contents of Build Back Better, they would love it and that there would be this outpouring of public enthusiasm. They were struggling to get attention for a bill that was a very miscellaneous hodgepodge of things.

I would say that’s probably working in Trump’s favor right now. People are having trouble getting their minds around an initiative that’s not very popular.

There’s always this idea that Trump is trying to distract our attention from things. Probably they didn’t have a war with Iran for the purposes of distracting our attention from this legislative fight. But that is what happens when you do big, dramatic things on other issues and just kind of say: You know what? I’m going to trust that congressional leaders can get this done without me spending a lot of time driving attention to it. I think that might be a good strategy.

During the A.C.A. repeal fight, Trump really pivoted his messaging — talking a lot about the need to get it done and staging big, splashy events with House Republicans. He believed, as presidents tend to — and you’ve written about this many times over the years — that if a president talks a lot about something, it will make people want to do what the president is saying. But all the evidence shows that’s not true.

I think Trump is wisely not talking about this and saying it’s party politics. He can convey his opinions to senators without making it a dominant story in the news.

At the same time, I’ve been thinking about how unbelievably uninspired the Democratic messaging is on this. When I was preparing for this conversation, I was watching Chuck Schumer — or Hakeem Jeffries on the House floor, holding up an Elmo puppet.

Whether or not the C-SPAN messaging is good or bad, it’s just not the kind of thing that breaks through. Democrats have a lot of money in their campaign accounts.

You could imagine really slick videos where you’re doing the man-on-the-street thing with people who use Medicaid in very Trumpy districts: talking about what Medicaid means to them, what it’s done for them and how they would feel if it were slashed to the bone or at these rural hospitals.

I’m not saying everything would break through. But it doesn’t seem impossible to me that, if you had millions of dollars to message things, you could come up with something that would dramatize what is happening here in ways that might get some attention.

Democrats and Republicans seem to have allowed this to become an inside game in Congress, and inside games are not that attractive for people to cover. That hasn’t been true, say, on immigration stuff — where Democrats are getting arrested by ICE because they’re trying to create mass mobilization events.

I feel like the news media is always thinking about whether this thing will pass. And if it seems they have the votes, the coverage kind of turns down because we mostly cover uncertainty and conflict. But there needs to be something. And it doesn’t feel impossible to me to create interesting content about this.

It just feels like if everybody is playing by real congressional rules, then the attention goes to the things that do not work that way and have more compelling visuals and mass participation in them.

I think that the younger, especially more media savvy and safe district members are not serving their caucus goals very well. They are putting a lot of time into thinking of ways to be creative about the immigration issue and be seen as fighting Trump on the level of tyranny.

We had these nationwide “No Kings” protests that were very successful and well organized. It got attention, and there were good visuals. Those could have been “No Medicaid Cuts” protests, but they weren’t.

We know that the democracy message has fallen flat in the Trump districts. Whereas the health care stuff is shocking to Trump voters. It’s new information.

And then if you ask the frontline members what they’re most comfortable talking about, it’s Medicaid, and it’s O.B.B.B.A. But when it comes to immigration, it’s more like “eh” on this immigration stuff.

I think there is blame to be leveled at Schumer and Jeffries for the lack of creativity in their own messaging, a lack of skill, things like that. But also there are many dimensions of political efficacy. I don’t think either of those guys was ever known as viral-video guys. The members who are gaining clout inside the coalition are finding that the way to do it is through advocacy on more postmaterial issues — the kinds of things that are more engaging to Democratic donors. I don’t think it’s serving the country well or the party all that well, either.

When Cory Booker did his talking filibuster, his key message point was about Medicaid and Medicare. Obviously he talked about a lot of things because he was going for 24 hours —

Twenty-five.

Twenty-five. But that was the focus.

A lot of this goes back to this factional argument. In 2017, Democrats felt more self-confident about the party. They’re like: What brings us together is health care, and we’re going to talk about that.

And now there’s a lot of uncertainty, depression and infighting: What brings us together is health care — and that’s boring. Let us fight with each other instead.

Something I’m taking out of what you’re saying or that feels true to me: A lot of what is engaging Democrats and liberals — and, certainly, abundance has been part of this — is a working backward from 2028.

I feel Democrats’ minds are not even in 2026, in the midterms. It’s in 2028. They’re sort of disassociating, in many ways, from this moment.

Zohran Mamdani might be the exception. But people are interested in him not necessarily because they care that much about the New York City mayoralty, but because maybe he represents the future — where the kinds of Democrats that democratic socialists actually want are the ones running the party. People are doing a lot of projecting forward.

Mamdani holds forth the possibility that, in the future, Democrats will break with the longstanding bipartisan pro-Israel consensus. And that’s interesting.

You look at something like the New Jersey gubernatorial primary — it was just a bunch of Democrats running. Mikie Sherrill won. Good for her. I like her. She’s against Medicaid cuts. But so is everybody, right? It’s just about New Jersey, and therefore people are appropriately not interested unless they happen to live there.

But what happens between now and 2028 is important for millions of people. It would be good to get some more focus and some more attention on it, even though it doesn’t connect to “blue sky” questions or questions about what the future of Democrats will be.

Everyone agrees that the future of Democrats is that they’re going to support progressive taxation and a social safety net. I actually think that’s important and the actual foundation.

Yes, it’s funny — one of the critiques I got over the past couple months that I wasn’t expecting was people being like: “Abundance” doesn’t talk about things like Medicaid or universal health care. And that supposedly shows you don’t care.

But it’s like: No — I just thought that was settled. I didn’t think I needed to edit my support for Medicaid or universal health care.

It’s a great example. If you had put a chapter in the book where you talked about how Medicaid is good and we should have incremental expansions of health care access, people would have read it and thought: That’s a boring chapter. Why is it in the book? It’s not good content to reiterate Democratic Party conventional wisdom.

But there are millions of people with health care on the line, and it’s important to find ways to talk about and get people engaged.

But there’s so much investment in: What does this mean for 2028? What are the prospects for generational change in the Democratic Party? That’s interesting to people.

I’ve honestly heard more about the David Hogg infighting around the Democratic Party and primarying older Democrats.

I’ve been thinking a lot about the dynamics that sustain attention. You get attention on one thing. There have been plenty of tweets on this or a video or floor speech. But the question of: How do you sustain attention? It requires people arguing about a thing.

And the other thing that I think is real here is the dynamics of social media algorithms, which means that people are mainly talking to others within their coalition. And so arguments happening within the coalition are very salient. And then arguments between the coalitions are much less so — there’s less engagement between the two sides.

The things that they debate become a big deal during an election. But in off times it actually creates this sort of weird dynamic where it’s like all the Democrats are against this.

You’re an attentional merchant. What do you think would make this more salient?

What do you think the actual hooks of it are?

I do think, obviously, Medicaid cuts and hospital closures are good.

Good for getting attention — not that you’re super pro Medicaid cuts, right? [Laughs.]

Yes, it’s the attention-grabbing part.

Republicans and conservatives writ large have been pretty disciplined about not debating this kind of issue in a way that’s a little bit challenging to deal with. I do think that it would be helpful to have more of an affirmative agenda on health care, something people could actually talk about and argue over.

If you could get people together on the same issue — how we want to make health care more affordable for the American people — because they want to make it less affordable — then you can have a somewhat more focused and structured argument that hopefully gets some people on the right to articulate their opinions about this. Otherwise, it’s too easy to sort of let things slide.

You raised the point that political media is a very interested in process and in wins and losses. The Republican Senate margin is just big enough that I don’t think anybody thinks: This is not going to pass.

The question is: What will this be? The House majority is thin, but House moderates have never blocked a bill, as far as I can remember. I’m sure it happened in the 1870s or something, but it has always been Senate moderates who have more independent stature, or are sort of known in their home states. But we’re no longer in a mode where Susan Collins, Lisa Murkowski and one other person can block this thing.

Josh Hawley wrote a piece in The New York Times saying that the Medicaid cuts were bad.

There’s a weirder dynamic here and a more exploitable dynamic than just: Democrats like Medicaid, and Republicans don’t.

A bunch of the rising populist generation of Republicans think they shouldn’t be doing this, and have clearly just been cowed into submission.

I think that’s right, and it should be a good opportunity for things.

I saw, for the first time this week, Medicaid protesters at the Capitol. People in wheelchairs were getting arrested and zip-tied to chairs — to keep the Capitol safe, I guess, from people who can’t walk.

You know how seriously Donald Trump and the Republicans take the safety of the U.S. Capitol.

The integrity of the U.S. Capitol has always been his top thing. So maybe it’s just about to begin now, this mobilization.

I think a great thing for Zohran Mamdani to do would be to spend some time talking about a big consensus issue.

One thing I’ve been thinking about is: In whose interest is it to facilitate a lack of factional infighting? And it’s the guy who just won the contentious primary. He already won. Now he needs is to remind people who didn’t vote for him of all the stuff they agree with him about.

It’s just an amazing revealed insight into how weird the dynamics of political attention are. Because I’m not saying you’re wrong — you’re right. But it’s obvious to both of us that it would be more meaningful for the 33-year-old assembly member who won a New York mayoral primary to really engage on this Medicaid bill than for all of the Democratic politicians who actually hold office and might have a vote. [Laughs.]

There’s something about the way attention does not accrue to power that’s really interesting. Hakeem Jefferies can’t get people to pay attention to this, and he’s the minority leader in the House.

I agree with you: Zohran Mamdani could. A.O.C. has obviously been messaging about it, but I think she could focus on it more. Attention is just such an unevenly distributed capacity.

Yes, and you know this old saw: Dog bites man and man bites dog. Of course the Democratic leaders are saying this is bad.

Jimmy Kimmel played an important role in the A.C.A. repeal fight —

With his story about pre-existing conditions.

Yes. In part because he’s not a very political person. So when he decided to talk about something, it was like: Oh, my God, Jimmy Kimmel! I agreed with the point he was making, but it’s not like nobody else had ever thought of that in the preceding 10 years of talking about this. [Laughs.]

It was just: You heard from somebody fresh and somebody famous making a really sort of banal point about the importance of those pre-existing conditions regulations.

Everybody likes to talk about who is and isn’t going on “Joe Rogan.” Where’s he at on Medicaid cuts? I don’t know, and that’s interesting.

Obviously I hope everybody listens to “The Ezra Klein Show” and talks about this with their friends. Because one of the things about attention in a social media era is we’re not passive, helpless victims of the attention economy.

We decide to an extent what to pay attention to. What to give hearts on, what to argue about, what to retweet or what to discuss with our friends. Part of the message here is the metamessage.

You, the listener, ought to try to increase your personal level of engagement with this topic and with content related to it — rather than being monomaniacally focused only on factional positioning for the future.

It’s good to talk about abundance — I think it’s important. It’s good to talk about the housing legislation that’s pending in California — that’s a big one. But we also need to talk about aspects of consensus.

I think that’s a good place to end. Always our final question: What are three books you’d recommend to the audience?

Laura Spinney’s book “Proto: How One Ancient Language Went Global.” It’s about the rise of the Proto-Indo-European language. That’s a really good one.

“Wuthering Heights,” a classic novel that I just finished.

I also revisited Paul Starr’s classic “The Social Transformation of American Medicine” because I’ve been trying to get my attention back on the health care issue.

Did you really? Or are you just saying you did?

No — I picked it up, and I was reading through it. I wanted to read about the origins of our path-dependent health care system.

I will tell you: I did not do a cover-to-cover reread.

That book is great.

And just while we’re discussing old health care books: If anyone wants to read a book about how differently health care and policy processes work — something you and I talk about sometimes when we get together is that it feels like there’s no policy process anymore. But David Broder wrote a book about the 1994 health care fight, the Bill Clinton health care fight, called “The System.”

If you read that book and about how much energy went into the crafting, debating, recrafting and redebating and committee members and everything of the Clinton health care bill — and then you think about the insanely slapdash way a giant bill has been put together now: barely debated, with things traded in and out and no serious analysis.

I don’t want to say it’s unserious — because the consequences here are deadly serious. But there’s been a real deterioration of the procedural scaffolding and deliberative structure of politics and how we make bills, particularly on the Republican side — although not only.

I think people would be more shocked by it than they realize.

Yes, because if you read Jonathan Cohn’s book “The Ten Year War,” about Obamacare, it’s not the same committee-driven process from Broder’s book. It has become more leadership-driven, but they were still very focused on the actual policy stakes.

At critical points, people in the White House say you have to do it this way for boring wonk reasons. And lots of members of Congress really don’t want to — they’re pushing them on the policy merits really hard. That kind of thing seems completely out the window these days.

Matt Yglesias, thank you very much.

Thank you.

You can listen to this conversation by following “The Ezra Klein Show” on NYT Audio App, Apple, Spotify, Amazon Music, YouTube, iHeartRadio or wherever you get your podcasts. View a list of book recommendations from our guests here

Opinion | Ezra Klein

This episode of “The Ezra Klein Show” was produced by Jack McCordick and Rollin Hu. Fact-checking by Kelsey Kudak. Our senior engineer is Jeff Geld, with additional mixing by Aman Sahota. Our executive producer is Claire Gordon. The show’s production team also includes Marie Cascione, Annie Galvin, Michelle Harris, Elias Isquith, Marina King, Jan Kobal, and Kristin Lin. Original music by Pat McCusker. Audience strategy by Kristina Samulewski and Shannon Busta. The director of New York Times Opinion Audio is Annie-Rose Strasser.

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Ezra Klein joined Opinion in 2021. Previously, he was the founder, editor in chief and then editor at large of Vox; the host of the podcast “The Ezra Klein Show”; and the author of “Why We’re Polarized.” Before that, he was a columnist and editor at The Washington Post, where he founded and led the Wonkblog vertical. He is on Threads.  

. . .

To be continued.