Coming to Terms with MAHA

The “Make America Healthy Again” (MAHA) movement has garnered polarized reactions, with praise among proponents for its core elements while also attracting its fair share of criticism. To be sure, there is much to be concerned about the movement, not the least of which is its disregard for scientific evidence that fails to align with its ideology about disease, wellness, and vaccination. Over the past year, Secretary of Health and Human Services Robert F. Kennedy Jr. and his associates have undermined trust in medicine and public health, particularly the science behind vaccines, by altering the childhood vaccine schedule, including dropping the universal newborn hepatitis B vaccine recommendation, and promoting false links between vaccines and autism. With great fanfare, the Department of Health and Human Services issued the “MAHA Report,” which played fast and loose with facts, using AI-generated citations (some of which were non-existent) and false information to support its claims. The movement also has advocated for dietary supplements without evidence of their safety and effectiveness, has promoted deregulation of federal agencies, most notably the Food and Drug Administration (FDA), and has supported the Environmental Protection Agency’s actions to dismantle regulations protecting air and water quality despite the clear threat of ever-present pollutants.

These are serious shortcomings, but it begs the question: Is MAHA all bad? The answer is not as dichotomous as some may think. Let’s consider MAHA’s positive attributes. Its focus on chronic disease, particularly childhood illnesses, appeals to many adherents, especially parents of young children. Its emphasis on removing ultra-processed foods¹, artificial dyes and ingredients, and chemical additives from the typical American diet is also quite popular, and the policy decision to eliminate such foods from the federal Supplemental Nutrition Assistance Program (SNAP) is well founded.² MAHA also has warned against the negative influence of corporate giants in the pharmaceutical and food industries on population health, and has called attention to environmental threats from pesticides, “forever” chemicals, and unhealthy food packaging. Yet, in a surprise move, Secretary Kennedy recently called for greater production of pesticides.

While many of these actions resonate with Americans, especially at a time when high prices threaten the affordability of prescription drugs and groceries, many public health professionals feel that MAHA doesn’t go far enough. And MAHA’s revision of the traditional dietary guidelines, which essentially inverts the food pyramid structure, goes against well-established recommendations for the Mediterranean diet and sows confusion and uncertainty. Thus, in view of these seemingly contradictory facts and the lack of trust in science-based evidence, is it reasonable to expect that MAHA will achieve its stated goal of making Americans healthier?

Secretary Kennedy apparently feels that surrounding himself with loyalists who share his MAHA worldview will lead to the desired end of a healthier nation. As this issue of the Quarterly goes to press, Dr. Casey Means stands on the threshold of Senate confirmation as the nation’s next surgeon general. Dr. Means lacks the time-honored qualifications of her predecessors, namely, an active medical license and a background in public health. But those attributes may be assets rather than liabilities in the eyes of Secretary Kennedy, who considers her unflinching advocacy for the MAHA movement to be her strong suit. As surgeon general, Dr. Means undoubtedly will play a central role in leading Mr. Kennedy’s MAHA policies. But her recent Senate confirmation hearing was quite contentious, with members of both parties raising serious questions about her views on vaccines for childhood diseases such as measles, which has emerged once again as a major threat to children’s health. Rather than providing clear answers, she dodged many questions, remaining noncommittal and leaving senators and observers to wonder where she actually stands on important health issues. While her appointment as surgeon general is bound to raise legitimate concerns among members of the medical and public health communities, for Mr. Kennedy at least, the end appears to justify the Means.

Whatever your point of view, the policy discourse over MAHA has been polarized and dysfunctional for far too long. As with any wellness movement, MAHA is imperfect. But instead of dismissing it entirely as a misguided ideological venture, we should recognize and accentuate its positive attributes that may be worthy of consideration and support. For example, its emphasis on eliminating unhealthy ultra-processed foods from our diet is both admirable and actionable, and there may be precedents in how we handled policies regarding other unhealthy products, such as tobacco, in the past (see the article in this issue by Ashley Gearhardt, Kelly Brownell, and Allan Brandt on how tobacco regulation policy may offer lessons for regulating ultra-processed foods).

In the end, when it comes to MAHA, we must be willing to accept “the good with the bad” in our policy discourse. After all, a healthier population is a goal shared by all. Though it is imperative that we continue to insist upon scientific evidence to inform policy decisions, it is equally important that we also be willing to engage in serious debate on controversial issues. In a recent Substack post, Sandro Galea insightfully redefined the parameters of such a policy debate. He outlined four steps that are key to success: (1) start the conversation by defining the core issue in terms that are understood by all sides; (2) outline the extreme positions, so that they may be avoided; (3) break the issue into sub-questions, tackling them one by one to identify trade-offs that are implicit in the policy choices that are faced; and (4) note where there is broad agreement and pinpoint exactly where opinions diverge. He argues that “by insisting on precision in our discussions, we can transform debates from shouting matches into problem-solving sessions.”

It is time to redirect our attention and energy toward broader engagement and more intensive interaction to seek practical solutions to our problems. And if such engagement leads to true bipartisan dialogue, it may yet produce reasonable compromise leading to resolution that transcends the partisan divide that has stymied policymaking for so long. This is a tall task, but it is vitally necessary in our journey toward realizing the shared goal of a healthier America.

In the March 2026 Issue of The Quarterly

In this issue of the Quarterly, readers will find three Perspectives on such topics as: direct-to-consumer advertising of prescription drugs; policy actions for engaging clinics and pharmacies to prevent Medicaid disenrollment; and strategies for building partnerships between health departments and community organizations. These Perspectives are followed by seven original scholarship articles on salient issues, including: the similarities between ultra-processed foods and tobacco products; the association between the 2021 Child Tax Credit and children’s health and well-being; new approaches for ranking state-level rurality; Latino community power as a structural determinant of health disparities; model legislation for establishing universal basic neighborhoods; the association between corruption and mortality; and a review of certified nurse-midwife and certified midwife care across six health care quality domains.

The United States is one of only two nations that allows direct-to-consumer (DTC) advertising of prescription drugs. Critics of this permissive regulatory policy argue that this form of drug promotion may mislead consumers with deceptive information about drug safety and effectiveness. While the First Amendment prevents a regulatory ban on DTC prescription drug promotion, it does not address false, deceptive or unfair advertising. In “Regulating Direct-to-Consumer Prescription Drug Advertising in the United States,” Jennifer Pomeranz, Erika Hanson, and Dariush Mozaffarian explore the regulatory landscape governing DTC advertising and how pharmaceutical manufacturers employ strategies involving influencer and social media promotion. The authors find that drug manufacturers are shielded from liability in most states by the learned intermediary doctrine when they engage in pervasive DTC advertising that leads to consumer misunderstanding. They conclude that state courts and legislatures should reconsider this doctrine to ensure that consumers are adequately protected. They also recommend that the FDA receive increased resources and additional authority over the promotion of compounded drugs.

The One Big Beautiful Bill Act (OBBBA) or HR 1, enacted July 4, 2025, established the first nationwide Medicaid work requirement. Historical evidence from welfare programs and Medicaid pilot programs, particularly in Arkansas, suggests that while work or community engagement requirements may have moderate public support, poorly designed reporting systems and administrative barriers can lead to substantial procedural disenrollment without measurable employment gains. In “Medicaid Work Requirements: Engaging Clinics and Pharmacies to Prevent Disenrollment,” T. Joseph (“Joey”) Mattingly II and Madeline O’Neal outline a framework for leveraging primary care clinics and community pharmacies to facilitate verification of work or community engagement hours. These sites have frequent contact with Medicaid beneficiaries, have established billing relationships with Medicaid, and can provide physical access points that mitigate digital access disparities. The authors offer options for provider compensation that include fee-for-service payments per verification or capitated per-member-per-month arrangements. They argue that integrating verification into trusted, accessible care settings will enable states to reduce administrative burden, preserve coverage for eligible beneficiaries, and align OBBBA’s implementation with program integrity goals.

Changing structures—such as laws, policies, regulations, practices, and norms—pose challenges for any organization that pursues health and racial equity. Most organizations, especially health departments, cannot succeed on their own. In “How Health Departments Can Use Inside-Outside Strategies to Build Partnerships With Community Power-Building Organizations to Achieve Structural Change,” Anthony B. Iton and colleagues propose that health departments advance health and racial equity by partnering with organized movements for fairer and more just social arrangements that often emanate from civil society through the work of community power-building organizations. The authors suggest that health departments adopt an inside-outside strategy that consists of internal practices needed to effectively participate in social movements and external practices needed to become allied with them.

Ultra-processed foods (UPFs) currently dominate the global food supply and are strongly associated with risks for heart disease, cancers, metabolic disease, diabetes, and obesity. They are designed to maximize compulsive consumption and undermine appetite regulation. Drawing on the history of tobacco regulation, Ashley Gearhardt, Kelly Brownell, and Allan Brandt examine how the design, marketing, and distribution of UPFs mirror those of industrial tobacco products in “From Tobacco to Ultra-Processed Food: How Industry Engineering Fuels the Epidemic of Preventable Disease.” The authors synthesize findings from addiction science, nutrition, and public health history to identify structural and sensory features that increase the reinforcing potential of both cigarettes and UPFs. They find that cigarettes and UPFs are not simply natural products but highly engineered delivery systems designed for maximal reinforcement and habitual overuse. Both industries have used similar strategies to increase product appeal, evade regulation, and shape public perception. The authors assert that UPFs should be evaluated not only through a nutritional lens but also as addictive, industrially engineered substances, and that public health efforts must shift focus from individual responsibility to food industry accountability.

In July 2021, Congress temporarily expanded the Child Tax Credit (CTC), one of the largest income transfer programs in the United States. Prior research has linked the expansion to improvements in material hardship, food insecurity, and parental mental health. In “The 2021 Child Tax Credit and Children’s Health and Well-Being: Evidence From a National Longitudinal Study,” Guangyi Wang and colleagues examine its association with child well-being by analyzing data from the 2020-2021 waves of the Child Development Supplement of the Panel Study of Income Dynamics. The investigators find that, compared with the pre-expansion period, advanced monthly payments were associated with short-term improvements in behavioral health. However, these gains did not persist after payments ended, likely reflecting stress and hardship tied to the policy’s temporary nature, especially among lower-income and Black children. They contend that policymakers may need to consider program design features, such as more frequent distribution of unconditional cash benefits, to better support child well-being.

Single indicators of state-level rurality, such as rural population percentage or population density, are often used in isolation and fail to capture the multidimensional nature of rural character. These shortcomings may obscure important differences among states, leading to flawed policy comparisons and resource allocation. In “Multidimensional Approaches to Ranking State-Level Rurality to Enhance Comparisons Across States,” Daniel Baslock and Nari Yoo introduce a multidimensional rurality index that combines population share, land area, and population density to create a more comprehensive ranking of US states. The index visually distinguishes between states with land-based rurality (e.g., vast, sparsely populated areas) and those with population-based rurality (e.g., high proportion of residents in rural towns). Using this holistic measure, the authors find that Mountain West states, including Alaska, Montana, and Wyoming, rank highest in multidimensional rurality. They believe that policymakers and researchers can use this index to better identify and compare states with similar rural profiles (e.g., Mountain West vs. Northeast), enabling more targeted and effective rural health policies and research.

Voting rights is the most common measure of power when studying the structural determinants of health (StrDOH). However, voting is a narrow conceptualization of community power and is irrelevant for populations who cannot exercise their right to vote, but who are vitally affected by health policymaking. In “Measuring Community Power as a Structural Determinant of Health for Latino Communities,” Julianna Pacheco and colleagues assess six factors related to Latino community power, including laws, policies, and practices/norms at the county level that act to either overcome or exacerbate historical power imbalances based on race and ethnicity. The six measures of Latino community power include the number of elected Latino officials, immigrant incorporation, and language protections under Section 203 of the Voting Rights Act (VRA) as well as measures of immigration enforcement such as removals and worksite raids. Although some associations are observed between increasing measures of Latino political power (Latino elected officials and language protections under the VRA) and poorer Latino health relative to non-Hispanic Whites, these associations do not hold when the analysis is stratified by counties with “established” versus “new” destinations. The authors conclude that power is a fundamental driver of the conditions that produce or mitigate health disparities, but that the processes may be difficult to measure. They maintain that future research should examine these processes at different temporal and geographic scales as well as partner with community organizations to better understand how to build and break community power.

Health disparities are a symptom of population-level problems, and many interventions for improving health equity often are aimed at population levels greater than local communities. In “Health and the Right to Universal Basic Neighborhoods,” Michael O. Emerson and colleagues assert that the most effective and pragmatic way to improve population health and health equity is through Universal Basic Neighborhoods (UBN) – defined as the minimally acceptable mix of neighborhood health assets for residents to flourish in quality and length of life. The authors present a Model Legislation Template that can help citizens and cities raise to legal status the right of neighborhoods to be designated as UBN, in order to transform neighborhoods into healthier, more equitable, vibrant communities. They apply this concept and its measurement to two neighborhoods in Louisville, Kentucky, assessing both health assets and liabilities. In doing so, they find that the Crescent Hill neighborhood can be considered a UBN, but that the Russell neighborhood’s extensive set of liabilities overwhelms its assets when health outcomes are considered. Nevertheless, the model legislation template should help guide policymakers in improving urban neighborhood health.

Public health research has examined the macro and structural determinants of health, but the link between corruption and population health has remained underexplored. In “How Corruption Influences Population Health,” Ilias Kyriopoulos and colleagues investigate the relationship between corruption and mortality, addressing key empirical challenges and exploring potential pathways underlying this association. The study draws upon country-level data from 102 countries spanning 2008 through 2018. The authors find a significant relationship between corruption and higher mortality rates. Corruption also is linked with weaker fiscal capacity, reduced government funding for health care, distorted resource allocation, and patterns consistent with misallocation of public funds. The association between corruption and mortality is more pronounced in countries with lower levels of public goods provision. The authors recommend that addressing corruption could be recognized as a public health priority.

The alarming rise in US maternal mortality and disparities in perinatal, sexual, and reproductive health outcomes underscores the urgent need for effective, equitable, and evidence-based models of care. Care provided by certified nurse-midwives (CNMs) and certified midwives (CMs) has played a vital role in addressing these disparities, but a comprehensive synthesis of its impact across health care quality domains has been lacking. In “A Scoping Review of Certified Nurse-Midwife and Certified Midwife Care in the United States: Assessing Outcomes Across Six Patient Care Domains,” Emma Virginia Clark and colleagues review 66 United States-based studies published since 2012 to assess the association of CNM/CM care and perinatal, sexual, and reproductive health outcomes through the lens of the Institute of Medicine’s six domains of health care quality: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Within the safety, effectiveness, and patient-centeredness domains, they find that CNM/CM care is associated with similar or improved health outcomes compared to physician care, including lower rates of cesarean birth, fewer interventions, improved neonatal outcomes, greater patient satisfaction, and reduced health care costs. CNM/CM care also demonstrates potential in mitigating racial and geographic maternal health disparities, though state scope of practice restrictions and institutional policies may limit CNM/CM integration. Despite this evidence, gaps remain in understanding the influence of CNM/CM care on health care quality as it relates to efficiency, timeliness, and equity.

We invite readers to visit the Quarterly’s website (https://www.milbank.org/quarterly/the-milbank-quarterly-opinions/) for insightful commentaries on an array of policy issues. Recent contributions include:

• Heidi L. Allen and Scarlett Wang on why health care affordability is worth fighting for
• Dave A. Chokshi and Judy Monroe on public health bonds as a way to fund a healthier future for America
• Sara Rosenbaum on Trump administration actions to eliminate aspects of Title VI of the 1964 Voting Rights Act
• Mark L. Rosenberg and Lawrence O. Gostin on the legacy of Dr. William H. Foege
• Madonna Harrington Meyer and Colleen M. Heflin on why the US must measure food insecurity in old age
• Pedram Fard and Hossein Estiri on the symbiosis between artificial intelligence and broadband to create a national neural network
• Harold Pollack on the importance of engaging the victim’s voice in public safety research

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