A Preface from Camp Kotok
At our gathering in Maine, we asked attendees about RFK Jr’s leadership in healthcare. Six people wanted him to stay. They cited his effort to improve nutrition and his objective to move the society away from food made in a factory. Twenty-three wanted him replaced. They enumerated many reasons, some of which are reflected in the report that follows. Two people pointed to the deaths of unvaccinated children who died from measles. They placed responsibility for those deaths squarely in RFK Jr’s lap. Other detractors issued warnings about the future. We had one cyclospora victim among us. She made the healthcare discussion personal. All conversations were conducted under Chatham House Rule, so participants can report the takeaways from the group but not quote anyone without permission. Many in the group faulted Congress, including the Republican Chair of the US Senate Health Committee. Others who leaned politically to the center-right said that the only way to reverse the damage to America’s healthcare system is to throw incumbent Republicans out of office. This came from Republicans in the group, not from Democrats. My takeaway is that healthcare system failures hit a household one person at a time, but the folks in many affected households are beginning to connect the dots in a political way. We will find out in the midterms.
This morning we offer a report on the healthcare system in America.
Healthcare in the US: Pillars & Sledgehammers
by David Kotok and Elizabeth Sweet
A number of stout pillars are required to support an effective national healthcare system that shelters populations from preventable worst-case health outcomes. Poor outcomes constitute personal tragedies; but, at scale, they also weaken nations and their economies. It’s an interesting back-of-the-napkin exercise to list those pillars that are essential to safeguarding human health. Today we briefly consider just three — prevention, medical expertise, and access — and we look at the policy sledgehammers that are now landing blows against those pillars, with chips flying and cracks compromising the structural integrity of the healthcare system for everyone.
Pillar 1. Prevention
It is not possible to stop a hurricane, but it is possible to contain or mitigate some kinds of infectious disease outbreaks or prevent them, given timely information and the right tools. While it is true that cultivating our overall good health through diet and exercise puts us in a better position to withstand illness than we would be in otherwise, these alone do not constitute a stout pillar of infectious disease prevention or mitigation. Just ask previously healthy, athletic people whose lives have been upended by Long Covid. There are other dimensions of the prevention pillar that cannot be neglected, and those include thoroughgoing surveillance and widespread use of vaccines that have minimal risks relative to the risks of remaining unprotected from disease.
Surveillance — An Early Warning System That Enables Timely Response
Infectious disease surveillance has been significantly impaired since January of 2025. Key points follow, though our list is not exhaustive:
- Clawing back pandemic-era grants in 2025 meant losing 439 lab positions across 25 states. National STD and viral hepatitis reference laboratories were eliminated.
- The parasitic diseases lab saw its staff slashed from 11 to 3. Interviewed by WIRED in an article about the cyclospora outbreak, molecular parasitologist Joel Barrett, who headed the team before he opted to leave in September 2025, noted the damage:
“Based on simple math, these outbreak responses—which require rapid, timely responses—are going to be greatly diminished…. Cyclospora is just one piece. It’s making the news right now, but there are other, more dangerous pathogens than cyclospora.”
- Funding cuts impacted not only the national lab but also state and local health departments on the front lines of response, diminishing staffing in those settings, too. The CDC’s latest numbers put confirmed cyclospora cases at 13,895, with 10,455 additional suspected cases under investigation.
- Since July 2025, the CDC’s FoodNet surveillance program has been required to track only two foodborne pathogens—Salmonella and E. Coli. It is no longer required to track cases of Campylobacteriosis, Cyclosporiasis, Listeriosis, Shigellosis, Vibriosis, or Yersiniosis. Gail Hansen, DVM, MPH, speaking to CIDRAP last year, explained the significance of the change:
“The beauty of FoodNet was that it collected and coordinated information from all the states about germs that make us sick and quickly communicated it to everyone…. Despite what the current HHS administration believes, ignoring a problem doesn’t make it go away. States do not have the ability to coordinate information and data across states, and this cut will bring us back to a time before FoodNet.”
Cyclosporiasis has provided an object lesson to support Hansen’s point.
- Of 82 CDC databases previously updated monthly, only 38 remained in February of 2026. In an opinion piece published at STAT, titled “America’s disease surveillance system is going dark,” Robert B. Shpiner, a clinical professor of medicine at UCLA, explained how important the missing data had been to doctors:
“Physicians have relied on that data for 40 years. Every morning before walking into the ICU, my colleagues and I checked flu activity levels, RSV hospitalizations, drug-resistant organism patterns. This wasn’t academic curiosity — it was how we kept patients alive. When influenza surged, we had antivirals ready. When adult RSV spiked, we warned colleagues in pediatrics. When resistant pathogens emerged, we adjusted our antibiotic choices before culture results returned.”
- US withdrawal from the World Health Organization curtailed international collaboration in surveillance efforts. (Notably, the State of California stepped up independently to join the WHO network early in 2026.) The ebola crisis in the DRC and surrounding region reminds us of how critical US involvement has been in the past to global disease surveillance and outbreak response.
- The CDC’s National Wastewater Monitoring Program, established in 2021 during the COVID-19 pandemic, currently includes 1225 actively reporting wastewater testing sites that serve 142 million Americans (just 42% of the population). (There used to be hundreds more testing sites.) There are gaping holes in the data we have now about the incidence of diseases tracked through wastewater testing today. Those include influenza A, COVID-19, RSV, measles, avian influenza A(H5), and monkeypox. More concerning still, the Trump administration has proposed to slash the program’s FY 2027 budget from $125 million to $25 million, which might be expected to cripple the nation’s ability to track disease outbreaks. Most state-level testing programs are, in fact, funded by the federal government. An already tattered early warning system for those diseases would be largely gone, and timely response to limit the damage that infectious outbreaks, including pandemics, can do would become virtually impossible.
Vaccinations
Where doubt and confusion are sown or recommendations weakened, vaccination rates drop, with a predictable and inevitable consequence: a resurgence of vaccine-preventable diseases.
In a quick note earlier this week, we referenced President Trump’s executive order attempting to revive the changes to the childhood vaccination schedule that RFK Jr. made back at the beginning of the year, which were blocked by a judge in March. Incoming CDC Director Erica Schwartz, who vowed at her confirmation hearing that she would “never betray the science,” will now have to decide whether to sign off on the changes or defend the old schedule, as her predecessor Susan Monarez did. Monarez was, of course, fired for refusing to endorse policy directives that were not based on sound medical science. Though the president’s executive order does not prevent parents from vaccinating their children against 18 diseases recommended by the CDC, it does encourage vaccine hesitancy. The effect of falling vaccination rates has been most evident in a resurgence of measles — 2566 cases so far in 2026 as of August 13. The administration has resorted to asking for a delay of the international meeting at which the US is likely to lose its measles elimination status, from April to November.
In another move, Robert F. Kennedy Jr.’s HHS has altered the charter of the National Vaccine Advisory Committee, which advises on vaccine policy issues. The committee, as reenvisioned, will consider “non-immunization strategies for individuals who are unable to be vaccinated, or who choose not to be vaccinated due to medical contraindications or strongly held personal, conscientious or religious beliefs” which “should include healthy lifestyle and disease prevention initiatives, off label repurposed use of existing FDA approved drugs and the use of dietary supplements known to support healthy immune function.” In a nutshell, the altered committee will be commissioned to enshrine vaccine alternatives that fall short of affording adequate protection against infectious diseases, alongside vaccines that do protect. Results of this move are predictable: fewer vaccinations and continued resurgence of preventable diseases, with associated costs counted in dollars, illnesses, disability rates, and in some instances lives. The sledgehammer swings, and cracks finger their way deep into the prevention pillar.
Pillar 2. Medical Expertise
Personnel
Most of us do not go to a politician, a real estate developer, or an environmental lawyer when we need healthcare guidance. Neither do we go to a podiatrist for a heart problem. We seek out genuine medical expertise applicable to the condition we confront. We strive to sort evidence-based information from misinformation or as-yet-unproven notions. At the level of national governance, we might expect the same reliance on expertise. We are not getting that.
Under Trump 2.0 and the leadership of Robert F. Kennedy Jr. as HHS secretary, HHS has lost some 20,000 positions. The CDC now functions with a reduced staff, lacking almost a third of its leadership, though it will now have a new Senate-approved director in Erica Schwartz. The once highly qualified Advisory Committee on Immunization Practices (ACIP), replaced with individuals hand-picked by RFK Jr, is perilously short of vaccine experts. Voting members of ACIP now include an ER doc, a transplant specialist, a couple of ob-gyns, a psychiatrist and neuroscientist, pediatricians, and a professor of operations management. Committee member Vicky Pebsworth brings a focus on vaccines, but from her work with the National Vaccine Information Center, which was founded in 1982 under a different name (Dissatisfied Parents Together) by three parents who believed that their children were harmed by the DPT vaccine. Cody Meissner, on the other hand, is both a professor of pediatrics at Dartmouth and senior vaccine and biologics development analyst at BARDA. On this committee he is a highly qualified army of one who has been outvoted by less qualified peers on matters such as weakening the recommendation that newborns be vaccinated against hepatitis B.
The process of replacing genuine scientific and medical expertise with loyalists to the preferences of RFK Jr. and Trump himself has continued with the Preventive Services Task Force. Top leaders were dismissed in June, after Kennedy cancelled a series of meetings and left vacancies unfilled. This committee determines the evidence-based preventive care that insurers must cover in full under the Affordable Care Act, and Kennedy has indicated that he intends to replace its 16 members, to the consternation of the medical community. Upheaval in this committee raises the question of what impacts new appointments will have on treatment or preventive screening recommendations and insurance coverage for about 50 services, from cancer screenings to heart disease prevention to HIV prevention.
Research
Sound medical research is likewise essential to the pillar of US medical expertise. In early 2026, Nature detailed Trump administration cuts to medical research — more than 5,800 NIH grants were cancelled or suspended, 800 of those grants focused on infectious disease research, which was hardest hit, along with those focused on misinformation, vaccine hesitancy, or minorities. Clinical trials took a hit, with 3.5% of active clinical trials involving more than 74,000 participants halted when the grants that funded them (totaling $1.81 billion) were terminated.
When Congress rejected the Trump administration’s request to cut NIH funding by $18 billion, the administration responded this year by slow walking the money Congress had approved: As of July, the NIH under RFK Jr had awarded 10,000 fewer grants (that’s 8% fewer) than had been awarded by July in 2024. The US biomedical science brain drain continues, threatening the US leadership in research and discovery — its “ability to generate evidence, innovation, and new treatments,” as Lucinda Hiam, UK Harkness fellow in healthcare policy and practice, noted in a BMJ opinion piece.
Mark Krass and Ames Grawert, writing for the Brennan Center for Justice, have pointed to the flight of research scientists, biomedical and otherwise:
According to one study, American scientists submitted 32 percent more applications to jobs abroad this year compared with the same period last year. Eighty-five rising and established U.S. scientists, including an NIH neurobiologist and a Princeton nuclear physicist, moved to China in the past year. And in May 2025, the European Union launched a €500 million package to attract scientists to Europe.
The choice to sacrifice that global leadership in medical science comes with an economic price, though that price is difficult to quantify. The Brennan Center estimates that the administration’s proposed budget cuts to the sciences last year, rejected by Congress, would have translated to a half trillion dollar decrease in future economic activity. Slow walking grants will impose a future cost of some significant magnitude, but it is difficult to quantify yet what that will be.
Looking ahead, the White House’s proposed budget for FY 2027 calls for a NIH budget cut of more than $7 billion compared to inflation-adjusted amounts budgeted for fiscal years 2020–2024. SCIMaP, the Science and Community Impacts Mapping Project, projects that such a cut, if passed, would whittle US economic activity in 2027 by more than $18 billion, and it maps the economic impacts of those proposed cuts by congressional district.
Pillar 3. Funded Access to Healthcare
Healthcare services adequately funded by a mix of sources (patients, insurance companies, federal programs such as Medicaid or Medicare) have the means they need to continue to provide services, such that the healthcare access pillar remains sturdy. But when funded access is chipped away for enough people, services available to everyone else are chipped away, too. That’s a piece that architects of current policy are missing as Medicaid is cut. Those who lose access often forego preventative or maintenance care altogether, driving higher costs to the system when a medical emergency lands them in an ER.
In “Cutting Medicaid for Children—A Bet Against the Future,” a viewpoint published at JAMA, Andrew D. Racine, MD, PhD, a professor of clinical pediatrics at the Albert Einstein College of Medicine and Jonathan H. Gruber, an economics professor at MIT, teamed up to examine the impact of Medicaid cuts included in the One Big Beautiful Bill Act (OBBBA), looking specifically at their impact on coverage for kids. Fully 40 million of the 85 million people currently covered by Medicaid are children. The authors note that as adults lose access to Medicaid, their children tend to become uninsured as well. That might not be the plan policy makers had in mind, but it is a documented impact, with broader implications for children’s futures in less financially stable households even if children themselves remain covered. Given that half of our nation’s children are enrolled in Medicaid, Medicaid is a vital source of funding for pediatric care. It’s a vital part of that funding pillar. The authors note:
There is not a neonatal intensive care unit, not a pediatric intensive care unit, nor a pediatric inpatient service in the US that can function in the absence of support from Medicaid. Therefore, the integrity of the program has implications beyond the immediate recipients of this insurance because the entire infrastructure of pediatrics depends on access to this source of revenue.
Lower Medicaid reimbursements along with other issues have already resulted in a reduction of pediatric services in hospitals around the country, including for appendectomies, pneumonia, and asthma. Parents seeking care for a seriously ill child may find that the services their child needs are available only in a hospital in a city a couple of hours away. A family with limited means struggles to manage with one parent in the city staying with the sick child, one parent at home handling the others. There’s yet another GoFundMe posted to help them handle costs. And in a medical emergency, time can be of the essence.
Pointing to the costs of providing Medicaid benefits is easy — it’s a line item in the budget, and politicians are happy to do that. But tallying the societal level benefits the program provides is the obligatory second step. Racine and Gruber point out that Medicaid for children results in “greater participation in the labor force, less reliance on government transfer payments, higher tax payments, and better health.” Those positive impacts, measured in dollars over time, actually outweigh the costs of providing Medicaid coverage for kids, the authors conclude.
To defund access to healthcare for millions shrinks the healthcare system’s capacity to serve everyone, not just those whom current policy makers envision denying benefits.
Conclusion
The metaphor of the pillars and policy sledgehammers is key to grasping the import of the various forms of damage to American biomedical science and healthcare under RFK Jr and Trump 2.0. The damage done by ill-conceived policy is not damage done merely here or there to this or that program or to some people and not to others. It is structural damage to a system essential to quality of life for all, to a strong economy, and ultimately to national security. Decisions about American healthcare are shifting away from evidence-based best practices to reflect the will of politicians possessed of misbegotten notions. They prefer to circumvent and sideline medical and scientific expertise rather than to rely on it. They minimize and fail to prepare for real risks. They do all this at our peril.
Further Reading
“The CDC Has a Cyclospora Lab. DOGE Downsized It Last Year” | WIRED
“Trump’s deep public health cuts hinder response to record US cyclosporiasis outbreak” | Guardian
“Explosive foodborne outbreak” | Your Local Epidimiologist
“CDC cuts back foodborne illness surveillance program” | CIDRAP
“America’s disease surveillance system is going dark. Here’s what we can build to replace it” | STAT
“‘Failures of ‘America First Global Health’: US Global Health Cuts and DRC Conflict Fuel Ebola Crisis” | PHR
“CDC studies show value of nationwide wastewater disease surveillance, as potential funding cut looms” | AP via WAVY.com
“What Trump’s Executive Order Means for Childhood Vaccinations” | Council on Foreign Relations
“New CDC director faces first major test before she even begins work” | CIDRAP
“How Trump’s order on vaccines is sowing confusion, doubt and fear” | Guardian
“After revising charter, HHS seeks nominees for its National Vaccine Advisory Committee” | CIDRAP
“RFK Jr. Reportedly Planning to Fire All USPSTF Members” | MedPage Today
“The Cost of the Trump Administration’s Attacks on Research Funding” | Brennan Center
“Cutting Medicaid for Children—A Bet Against the Future” | JAMA
“As Pediatric Capabilities Shrink, Family Strain Grows” | AAP Journals Blog
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