The Ongoing Assault on Science and Truth

The Trump administration’s efforts to eliminate all manner of diversity, equity, and inclusion (DEI) practices from government agencies, universities, and private sector workplaces has been coupled with steep funding cuts to key health agencies and the cancellation or freezing of medical research grants and contracts. It’s not just the careers of promising scientists and medical researchers that are at stake, but also the nation’s preeminent standing in the scientific community. Science unfortunately has become the latest victim in the culture wars taking place in the United States.

Some of the harm, though, may have been self-inflicted, as Aaron Carroll, the president and CEO of AcademyHealth, posits in a recent Washington Post opinion. He argues that the well-worn phrase of “follow the science” has backfired in public health policy circles. Rather than instilling confidence in science as a key contributor to evidence-based policymaking, the phrase instead has been used to stifle dialogue and sow doubt, confusion, and distrust. The net effect of the public backlash against science has been to undermine critical advice and policy directives issued by previously trusted government institutions such as the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the National Institutes of Health (NIH), the Environmental Protection Agency, and the Bureau of Labor Statistics.

Carroll writes that science provides facts – some of which are irrefutable, while others may be nuanced and open to different interpretations. That’s why dialogue and scientific discourse are necessary precursors to the use of evidence to support policymaking. Sound public policy, he asserts, involves choices and tradeoffs, not all of which can be reasonably predicted or assured. To restore faith in science, he recommends the acknowledgement and acceptance of “the limits, uncertainty, and complexity of scientific evidence,” as well as active engagement in open dialogue about the desired outcomes.

This is a noble sentiment, but it also is a truly challenging task. While the loss of trust in science is clearly palpable, the ultimate victim here is truth. Numerous politicians, government bureaucrats, and self-styled influencers have exploited the public’s discontent¹ with science to spread misinformation, falsehoods, and “alternative facts” when confronted with inconvenient truths that conflict with their political or personal aims. Without the unvarnished truth about vaccines, health risks, and clinical trials, there can be no public trust in science, medicine, government or health care providers.

In recent weeks, we have witnessed an unprecedented, relentless assault on science and truth by the Trump administration involving various policy sectors. In the health sector, policy statements and decisions made by Secretary of Health and Human Services Robert F. Kennedy Jr. have played a major role in the administration’s campaign against science and truth. Mr. Kennedy is responsible for engineering the dismantling of the nation’s public health infrastructure at the CDC.² He dismissed all 17 scientific members of the Advisory Committee on Immunization Practices (ACIP), which had advised the CDC for decades regarding the recommended vaccines for Americans, and he replaced them with 8 new members, many of whom are vaccine skeptics. He also has appointed vaccine skeptics to key posts in the Department of Health and Human Services, including a disgraced researcher charged with mounting a study to find the causes of autism. He abruptly cancelled research contracts for mRNA vaccine development, thereby posing risks for both public health and national security according to experts and, when asked to explain the reasons for such action, he cited scientifically questionable studies as justification for cancelling the contracts. Mr. Kennedy also publicly stated that healthy children do not need Covid vaccines, an assertion disputed by experts and unsupported by facts, and he revived the defunct Task Force on Safer Childhood Vaccines at the urging of anti-vaccine activists. In addition, he offered an intellectually dishonest excuse for defunding Gavi, the international vaccine alliance whose role in assuring equitable access to vaccines for all nations is urgently needed. He also cancelled the July 10, 2025 meeting of the United States Preventive Services Task Force and appears poised to change its membership despite its vital role in recommending screening tests for Americans as well as preventive services that should be covered by health insurance. Presently, he is overseeing the dissolution of the Agency for Healthcare Research and Quality, a key funder of health services research to improve quality of care, through severe staff reductions and budget cuts. Moreover, he has discontinued valuable studies and programs at NIH that focus on the disparities among racial and socioeconomic groups.

Perhaps the most damaging (and arguably wrong-headed) decision in the long run will be the cancellation of research contracts for mRNA vaccine development. The core mRNA technology proved safe and effective during the COVID pandemic and saved millions of lives. Future development of mRNA treatments for cancers, cystic fibrosis, and rare diseases is now jeopardized. If actions speak louder than words, this action alone makes it abundantly clear that the Secretary is pursuing his avowed MAHA anti-vaccine agenda despite his assurances to the contrary during his Senate confirmation hearings last December. His deliberate avoidance of well-established scientific norms runs counter to the best interests of the nation. Broken promises aside, his policy actions pose serious threats to the health and wellbeing of the American people. 

However, the greatest tragedy is the absence of truth in the Secretary’s statements to the public as well as to members of Congress. If we cannot take him at his word, how can we possibly trust his judgment?

IN THE SEPTEMBER 2025 ISSUE OF THE QUARTERLY

The September 2025 issue of the Quarterly opens with five Perspectives on such topics as: the ascendancy of Medicare Advantage over traditional Medicare; the implementation of state drug price transparency laws; using narrative power to tell the story of health and racial equity; the challenges of quantifying Latinx individuals eligible for, but not enrolled in, public health insurance programs; and a framework for assessing academic leaders’ outside activities. Six original scholarship articles then follow on salient issues, including: the performance and stability of federally qualified health centers; definitions of community benefits in nonprofit hospitals; state public coverage of pregnant undocumented immigrants; a comparative international analysis of government lobbyist registers; incarceration and psychiatric emergency department visits among Black Americans; and Lean leader practices for advancing equity.

Medicare Advantage (MA) enrollment grew from 13% of all Medicare beneficiaries in 2004 to 53% in 2024, with continued growth predicted in the future. Drawing on an extensive review and synthesis of the literature, oral history interviews, Congressional committee hearings, data from the Centers for Medicare and Medicaid Services, and reports from the Medicare Payment Advisory Committee, Rick Mayes and Micah Johnson analyze the evolution of Medicare and managed care in “From Disappointment to Predominance: Medicare Advantage’s Ascendancy and Transformation of Medicare.” Tracing the early efforts to build an integrated managed care option to the traditional, fragmented fee-for-service Medicare program, the authors identify four key changes in federal policy that set the stage for the significant expansion of MA after the passage of the Affordable Care Ac  in 2010. They also contrast the current structure of MA with that of Traditional Medicare (TM), finding that the massive growth of MA now annually costs an estimated 29% (or approximately $100 billion) more than Medicare would have spent if beneficiaries were in TM. They contend that this differential in payments has overwhelmingly advantaged MA relative to TM and has transformed the Medicare program by privatizing and corporatizing it for tens of millions of beneficiaries.

The high price of prescription drugs has induced 21 states to pass drug price transparency laws with the goals of creating greater accountability around drug pricing and facilitating the development of policy solutions to address high prices. These laws vary in design but often require manufacturers to report the wholesale acquisition cost of drugs above a certain threshold for a new drug or cost increases above a certain margin, along with other data such as the manufacturer’s costs. In “National Analysis of the Requirements and Implementation of State Drug Price Transparency Laws,” Hannah Rahim and Aaron Kesselheim explore the key features of state drug price transparency laws, including the reporting triggers, the data to be reported, the entity to which manufacturers must report, enforcement penalties, and whether data are publicly shared. Their initial findings suggest that these laws may have contributed toward informing policymaking based on newly available public information, but they do not appear to have affected drug prices.

The importance of addressing differences in power as a fundamental determinant of health inequities has been well understood in the field of public health. To pursue health equity, public health practitioners must move beyond identifying differences in health outcomes between populations (disparities) to articulating why those differences are unfair or unjust (inequities) and then identifying laws, policies, practices, and norms, that advantage some while disadvantaging others. In “Changing the Story on Health and Racial Equity: Why Public Health Needs an Infrastructure for Building Narrative Power,” Sarah E. Gollust and colleagues assert that one form of power required for advancing health and racial equity is narrative power, the ability to shift the stories used to make sense of the world. They argue that building this form of power requires the field of public health to work strategically to connect institutions and organizations to align in complementary ways to create, construct, and sustain new narratives, what they refer to as “narrative infrastructure.” The authors illustrate their ideas using real-world examples drawn from work in tobacco control and emerging work in addressing systemic racism.

Latinx communities in the United States experience disproportionately high uninsurance rates owing to systemic barriers that include language, misinformation, and immigration-related fears. There is a lack of data on individuals eligible for, but not enrolled in, Medicaid and Affordable Care Act insurance marketplaces, which prevents the identification of barriers, the population impacted, and tailored approaches to meet specific needs of vulnerable communities. In “No Data, No Problem – Quantifying Latinx Individuals Eligible, But Not Enrolled in Medicaid or ACA Marketplace-based Insurance in North Carolina,” Gabriela Plasencia and colleagues recount the history of misinformation and scams during the COVID pandemic and more recently during the unwinding of Medicaid Expansion that may have prevented many Latinx individuals in North Carolina from enrolling in public insurance programs despite the efforts of the state Medicaid program to use innovative and exhaustive methods for reaching potentially eligible individuals during the unwinding. The authors propose several community-informed policy strategies, including culturally-tailored outreach, involvement of trusted community health workers, and improved health equity data collection, to reach these individuals in the future. They believe that framing data in terms of “eligible but not enrolled” individuals shifts the focus to existing coverage gaps and the potential for improvement, thus encouraging states to take more proactive enrollment actions.

In recent years, there has been renewed public scrutiny of the practice of academic leaders, such as medical school deans and health system executives, serving on the boards of for-profit health care companies and earning hundreds of thousands of dollars a year as directors of drug and device companies. Critics have urged academic institutions to rethink conflict of interest policies governing leaders’ outside activities, which are understood to pose individual conflicts for leaders as well as institutional conflicts for their academic employers. Although the Association of American Medical Colleges and the Association of American Universities provide guidance on managing such conflicts, neither offers a structured approach for determining when and under what conditions it is appropriate for a leader to engage in specific outside activities.  In “A Framework for Assessing the Permissibility of Academic Leaders’ Outside Activities,” Matthew McCoy and colleagues propose a decision-making framework to address this gap.  The authors recommend that institutional oversight bodies use the framework to assess the permissibility of academic leaders’ proposed outside activities.

Federally Qualified Health Centers (FQHCs) are a critical part of the health care safety net, providing essential health care to more than 31 million patients in traditionally underserved communities  However, FQHCs increasingly have opened care delivery locations in communities already served by another FQHC, potentially creating competitive markets with unknown implications for how this safety net operates. In “Turfs Wars: How Growth and Competitive Shocks Have Impacted the Performance and Stability of Federally Qualified Health Centers,” Justin Markowski conducted a retrospective cohort study in 810 FQHCs that operated between 2009 and 2023. Using a difference-in-differences design with staggered implementation to examine the impacts of competitive shocks on clinic performance and, consequently, whether such shocks changed the types of patients served and how clinics operate, he found that when a rival FQHC’s growth resulted in a competitive shock, 95% of new sites were located no more than 10 miles away from their existing service area. After a competitive shock, incumbent FQHCs on average experienced significant decreases in financial stability and shifts in their patient mix toward those with more generous insurance coverage and fewer chronic conditions. Clinics also reallocated 11% of their resources closer to the encroaching rival, recentering and concentrating their organizations. Multiple competitive shocks also increased the annual probability of a closure, acquisition, or loss of FQHC status. He concludes that, despite explicit policy guardrails, this pattern of rapid, localized growth distorts incentives for individual clinics, weakening the safety net and inducing clinics to engage in a turf war by reallocating and concentrating resources closer toward the encroaching rival at the expense of their social mission and financial solvency. He calls upon state and federal policymakers to incentivize clinics to disperse into communities without established clinics and protections against underservice by stabilizing clinic budgets.

In 2022, it was estimated that nonprofit hospitals in the United States spent $129 billion on community benefits, a sum that dwarfed the entire budget for the US Public Health Service. However, estimates of community benefit spending likely depend on the definition of community benefit being used. In “The Significance of Definitions in Determining the Level of Community Benefits for Nonprofit Hospitals,” Hossein Zare and Gerard Anderson used Internal Revenue Service data between 2019 and 2022 to determine the value of 17 components of community benefit and bad debt in nonprofit organizations. They found that, in 2022, nonprofit hospitals spent $94 billion on all 17 categories of community benefit, plus $26 billion on bad debt. Community benefit spending included $21 billion in services that directly benefited patients, $33 billion on services that benefited the community, and $41 billion on shortfalls in Medicaid payments. From their analysis, the authors conclude that the value of community benefits varies significantly based on the definition used, even when the same data set is analyzed. They recommend that greater agreement on the meaning of community benefit is necessary to ensure compliance with regulations regarding community benefit spending.

Although health insurance coverage increases access to recommended pregnancy care, undocumented immigrants are not eligible for pregnancy Medicaid coverage without state uptake of alternative policy options. At present, 24 states and the District of Columbia offer public insurance to undocumented immigrants who are income-eligible for pregnancy Medicaid benefits through the Children’s Health Insurance Program From-Conception-to-End-of-Pregnancy (CHIP FCEP) option or through state funds. In “State Public Coverage of Pregnant Undocumented Immigrants and Prenatal Insurance Uptake,” Meghan Bellerose and colleagues used data from the 2016 to 2021 Pregnancy Risk Assessment Monitoring System (PRAMS) linked to maternal nativity based on birth certificate records from 19 states and the District of Columbia to compare the prevalence of any insurance, Medicaid insurance, and private or other insurance coverage of prenatal care between Medicaid income-eligible immigrants and non-immigrants. In the 10 included states with public coverage of pregnant undocumented immigrants, the authors found that the proportion of immigrants with any insurance for prenatal care was 16.9 percentage points higher than the proportion of immigrants in states without such coverage. In policy-adopting states, the proportion of immigrants with Medicaid for prenatal care was also 16.9 percentage points higher compared to immigrants in non-policy-adopting states.  Providing state public insurance coverage to undocumented immigrants during pregnancy may increase overall prenatal insurance coverage by expanding access to Medicaid, but the study did not find evidence that extending public coverage to this population crowds out other insurance options.

Information about lobbying is crucial to alert the public about undue influence in government decision-making. However, government disclosures of lobbying activities vary considerably across nations in their completeness and accessibility. In “Lobbying in the Shadows: A Comparative Analysis of Government Lobbyist Registers,” Jennifer Lacy-Nichols and colleagues reviewed 4 international surveys that assessed lobbying transparency in 128 countries. To highlight the importance of transparency for public health, they compared the visibility of tobacco industry lobbying across all registers by documenting the information provided about two prominent tobacco companies: Philip Morris International and British American Tobacco. Their analysis identified 27 countries with online lobbyist registers, all in upper or upper-middle income countries. They found evidence of lobbying by Philip Morris International, British American Tobacco or one of their subsidiaries in 14 of the 27 countries with online lobbyist registers. The authors claim that their study empirically demonstrates the hidden nature of lobbying internationally. In the case of industries whose interests conflict with public health, poor lobbying transparency presents a risk that vested interests may undermine public health policymaking without anyone knowing. To ensure that health-harming industry interests cannot escape scrutiny, they recommend that public health advocates support efforts to strengthen political transparency measures.

The justice system in the United States incarcerates nearly 2.3 million individuals, with Black Americans comprising 40% of those incarcerated despite representing less than 15% of the population. Prior research suggests that greater incarceration may influence population-level health, specifically in communities of color. However, little is known whether incarceration, as well as the racial disparity in incarceration, corresponds with psychiatric help seeking in the Black community. In “Incarceration and Psychiatric Emergency Department Visits Among Black Americans,” Abhery Das and colleagues examined annual psychiatric Emergency Department (ED) visits (per 100,000 population) among Black Americans in 404 counties from 10 US states between 2006 and 2015. Their findings revealed that one additional individual incarcerated (per 100,000 population) corresponds to a 1.4% increase in psychiatric ED visits in Black communities, and that an increase in racial inequity in incarceration (Black Americans vs. non-Hispanic Whites) also coincides with a 2.2% increase in psychiatric emergencies among Black Americans. They recommend that policy makers consider measures, such as drug reform or other social policies, to reduce the influence of mass incarceration on acute and adverse mental health in the Black community.

Lean management is an approach to quality improvement that aims for consistency in work processes and outcomes. It can be used to reduce inequities by ensuring consistent delivery of high-quality care to meet the needs of diverse patients. Despite its adoption in practice, there is limited study of how managers implement health equity and diversity goals as key organizational priorities. In “Advancing Equity: Lean Leader Practices and A Path Forward,” Dorothy Y. Hung and colleagues conducted in-depth interviews with 67 leaders ranging from C-suite executives to frontline managers in 5 hospital-health systems in the United States. The authors identified cross-cutting themes on how leaders use lean methods to advance equity in health care settings, including facilitators, barriers, and recommendations for continuous improvement.  They found that leaders employed the lean daily management system (DMS) as a robust platform to introduce and sustain equity initiatives.  Leaders strongly recommended integrating equity into other strategic goals (e.g., quality, affordability, patient/employee experience) and stratifying data to inform key performance indicators.  The authors conclude that health care leaders can use lean management practices to advance equity by reducing variation in care processes and enhancing measurement of outcomes for diverse populations.

For insightful commentaries on a variety of policy issues, we invite readers to visit the Quarterly’s website (https://www.milbank.org/quarterly/the-milbank-quarterly-opinions/). Recent contributions include:

• Sara Rosenbaum on what the Medicaid work requirements really are all about
• John McDonough on how Chief Justice Roberts’ 2012 ruling on Medicaid may actually undermine work requirements
• Jamila Michener and Sarah Gollust on public opinion regarding Medicaid cuts
• Tiffany Joseph on how the “One Big Beautiful Bill Act” (H.R. 1) decimates health care access for all but a privileged few
• Beth McGinty and Magdalena Cerdá on how Medicaid cuts will heighten the mental health and substance use crisis in the United States
• Jerel Ezell and Sugy Choi on opioid settlements, Big Pharma, and racial disparities
• Dalton Conley on the paradox of personalized medicine
• Thom Walsh on rethinking the affordability of health insurance
• Kushal Kadakia, Rebecca Giglio, and Dave Chokshi on how community health workers can help rebuild trust in public health
• Harold Pollack, Kenton Johnston, and Brian Chicoine on the 90% lifetime dementia risk faced by persons with Down Syndrome

References

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