In the fall of 2021, Tammi Kromenaker started looking for a new home for her North Dakota abortion clinic. For more than 20 years, Red River Women’s Clinic had provided abortion care to the Fargo area, most of that time as the state’s only provider. But now Kromenaker, the practice’s owner and director, was moving it just across the state line to Minnesota. “We had seen the writing on the wall,” she told me. A few months earlier, the Supreme Court had announced that it would take up Dobbs v. Jackson Women’s Health Organization, and North Dakota had a trigger law that would almost completely ban abortion if the justices ruled in favor of Dobbs.

“We closed on a new building at 3 p.m. the day before they overturned Roe,” Kromenaker recalled. Over the next 47 days, with the help of $1 million raised through GoFundMe, she oversaw a frantic move and remodel, sneaking around in a hat and sunglasses to keep the new location a secret; another planned clinic had just been set on fire in Wyoming. Meanwhile, Kromenaker’s clinic sued the state of North Dakota to block the trigger ban.

Last month, a North Dakota judge struck down the state’s abortion ban in response to Red River’s suit. Kromenaker could now return to providing abortions in Fargo, but she told me she has no plans to. That leaves the state with no dedicated abortion providers.

In the aftermath of the Dobbs decision, abortion access has been all but obliterated in 14 states. Perhaps the most obvious consequence is what has happened to brick-and-mortar abortion providers: Clinics have closed, while physicians have fled restrictive states or left medicine altogether. In communities across the country, abortion pills have also been heavily restricted. A push to expand the rights of a fetus has coincided with a rise in pregnancy-related prosecutions, most of which have nothing to do with abortion—210 women were criminally charged in 12 states in the year after Dobbs, the highest number of such cases in a single year since 1973, according to one report.

The backlash has been forceful. Since Dobbs, citizens in six states have voted for ballot measures protecting abortion access. Next month, abortion rights will again be on the ballot, in 10 states. In the first presidential election since Roe was overturned, abortion has become a defining issue. Many Republican politicians, including the party’s presidential nominee, Donald Trump, have attempted to court female voters by wavering on their previous anti-abortion positions. (Trump’s wife, Melania, released a memoir this month, in which she underscored her support for abortion rights.) Meanwhile, Democrats, especially the presidential nominee, Kamala Harris, have campaigned heavily on restoring national reproductive rights. But a Democratic woman in the White House or new federal abortion protections won’t turn back the clock to 2021. Call it the Dobbs legacy, or the Dobbs hangover—the effects of America’s eroded abortion access will linger for years, if not decades.

[Read: Kamala Harris’s biggest advantage]

This summer, on the two-year anniversary of the Dobbs decision, a coalition of groups including Planned Parenthood and the American Civil Liberties Union announced that they were committing $100 million to Abortion Access Now, a campaign to pass federal legislation guaranteeing the right to abortion. Harris has floated one potential path: scrapping the filibuster to push reproductive protections through Congress. (That would probably require Democrats to control both chambers, which does not look likely.) If new federal protections were passed, “you would see overnight relief in a lot of places, depending on the nature of the legislation,” Kimberly Inez McGuire, a co-chair of Abortion Access Now and the executive director of Unite for Reproductive and Gender Equity, told me.

New federal protections, however, wouldn’t instantly undo the tangle of abortion restrictions that some states began enacting even before Dobbs was decided. Reproductive health in America is governed by a complex web of laws, regulations, and court decisions at the local, state, and federal levels. When the Supreme Court ended constitutional protections for abortion on June 24, 2022, trigger laws designed to ban abortion went into effect. By the end of the year, states had enacted 50 new abortion restrictions, many of them resulting in near-total bans. No federal law could immediately undo all of these restrictions at once. Around the country, clinics closed, moved, or quit providing abortions; as of March, the U.S. had 42 fewer clinics than in 2020, according to the Guttmacher Institute, a reproductive-health research and policy group.

With so many barriers in place, some medical providers have decided that living and working in states with restrictions isn’t worth the emotional and professional toll. In one recent study of ob-gyns in Texas, where abortion is banned with few exceptions, 13 percent of respondents said they plan to retire early, 21 percent said they either plan to or have thought about leaving to practice in another state, and 2 percent said they have already left. An analysis by the Association of American Medical Colleges found that applications for ob-gyn residency programs in Alabama, which has a total ban except in cases of “serious health risk” to a pregnant woman, dropped 21.2 percent in the first full cycle after the Dobbs decision.

[From the October 2024 issue: ‘That’s something that you won’t recover from as a doctor’]

None of these policies has reduced the number of abortions performed nationally since Dobbs—in fact, the number has increased—but their consequences have ricocheted far beyond abortion. As obstetricians have fled restrictive states, for example, access to other gynecological care has become strained, too. And this month, Louisiana reclassified the two drugs used in medication abortions as Schedule IV controlled substances, a category typically reserved for drugs with a potential for dependency, such as Xanax and Valium. Mifepristone and misoprostol, which can be prescribed by telehealth, have played a significant role in abortion access since Dobbs. In Louisiana’s bid to further restrict the drugs, the state has potentially limited their use in other routine applications, such as treating miscarriages, inducing labor, and stopping potentially fatal postpartum hemorrhaging.

Even if new federal abortion protections were passed into law tomorrow, restoring nationwide access would still likely take significant time. Clinics, for instance, need real estate and doctors and lots and lots of capital to open or move—that’s partly why, after a 2016 Supreme Court case struck down a Texas law designed to force clinics out of business, the number of providers in the state a year later remained a fraction of what it was before. After Alabama banned abortion in 2022, WAWC Healthcare, in Tuscaloosa, remained open to provide contraception and prenatal care but eventually lost its abortion provider, says Robin Marty, WAWC’s executive director. Such positions might be filled by recent graduates, but the pool of qualified providers in restrictive states will remain small for years thanks to plummeting residency enrollments—most doctors tend to stay in the state where they do their residency.

Recent legal fights in Ohio provide a glimpse of how even sweeping abortion protections don’t automatically undo the effects of restrictions, and could lead to new ones. Last year, Ohio voters approved a constitutional amendment enshrining the right to an abortion. But pro-abortion-rights advocates in the state are still fighting to throw out the state’s six-week ban and a law banning telemedicine in medication abortions, among other restrictions. Meanwhile, a state legislator has introduced a new bill that would withhold state funding from cities and counties that provide funding for local groups that provide abortion-support services such as gas money for patients. The immediate result of any national abortion protection would probably be a protracted legal battle. “Every state has a different assemblage of abortion restrictions,” Inez McGuire said. “A lot of that is going to be fought out through our judicial system. That is a daunting prospect.”

Roe’s downfall also opened up space for anti-abortion activists to renew their battle to recognize the rights of the fetus as a person. In February, when the Alabama Supreme Court found that IVF embryos are legally children, anti-abortion activists widely celebrated the decision as a sign that the country was ready to engage in this debate. As support for fetal rights has grown, pregnant people have found their bodily autonomy curtailed even when they’re not deciding whether to continue a pregnancy: According to the nonprofit group Pregnancy Justice, of the 210 cases of pregnant people who faced criminal charges, just five mentioned abortion. The majority alleged only substance abuse. In one, police charged an overdosing pregnant woman with child neglect after administering Narcan.

[Helen Lewis: The women killed by the Dobbs decision]

Abortion advocates, too, are adjusting to the new reality. Abortion access had been whittled away for decades before Dobbs was decided. But now the constitutional right to an abortion in America is no longer being infringed upon; it just doesn’t exist. Several clinic directors told me that it’s clear to them now that no new law will ever provide unassailable protection. When North Dakota’s ban was struck down by a district court last month, it wasn’t the first time; the same judge blocked a nearly identical abortion ban in 2022, eventually prompting the state legislature to repeal it and pass a new one with minor changes. Just this month, Georgia’s Supreme Court restored a six-week abortion ban that a lower court had overturned while it considers an appeal. “There is no finish line here,” says Katie Quinonez-Alonzo, the executive director of Women’s Health Center, which opened a branch of its West Virginia clinic three and a half hours away in Maryland after Dobbs. “This is work that needs to be done forever.” Kristi Hamrick, the vice president of media and policy for Students for Life of America, told me that the group already has a “Roe 2.0 Rollback plan” in place, ready to deploy at the state and federal levels after the election. “We are prepared legislatively and legally to address the human rights issue of the day, no matter which way the election turns out,” she told me.

Some clinics are tired of fighting. “If you had asked me a few weeks ago, I would have said we were completely ready to go should abortion somehow return to Alabama,” Robin Marty told me. Now she’s not so sure. “We worked in extraordinarily hostile conditions” before Dobbs, Marty said. Clinic staff faced daily protesters, in the parking lot and sometimes even at the back door. Anti-abortion activists filed malpractice complaints against them, reported them to the fire department for allegedly having too many people in the clinic, and alleged health-privacy violations after digging through the clinic’s dumpster and finding a piece of paper from a patient’s file. “Having abortion become illegal and then having it return would be even more dangerous right now. If it comes back, they’re going to be even angrier,” Marty said.

When Red River first opened, in 1998, the threat of extinction was already in the air. The previous director had chosen to name the clinic after a body of water that runs between North Dakota and Minnesota, so that the reference would still make sense on the other side of the state border. When Kromenaker finally made the move, her life became easier virtually overnight, because Minnesota was among the states that had passed abortion protections after Dobbs. “We ended up in a state where providing this care is more straightforward, more patient-centered and with less stigmatizing restrictions,” Kromenaker said. “We would never take a step back and re-inflict those restrictions on ourselves.”

[Read: Abortion pills have changed the post-Roe calculus]

The United States cannot easily go back to the pre-Dobbs status quo. In the past two years, too much has changed—more than 100 new legal provisions, dozens of clinics closed, and a cultural gulf that has grown ever wider. For both abortion-rights supporters and opponents, only one possibility remains: to inhabit the reality we all live in now.

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Election Day is in a few weeks, but for millions of Americans, early voting in the presidential and downballot races is already under way. Over the next 19 days, how people vote in dozens of swing districts will determine which party takes control of the House of Representatives.

The race for the House looks like “a true toss-up,” my colleague Russell Berman, who covers politics, told me. (He also noted that the Democrats he’s spoken with lately are “cautiously optimistic”—and some actually seem “a touch more confident about retaking the House than winning the presidency.”) To take back control, Democrats need to pick up four seats from Republicans.

Abortion is a key issue that could determine the balance of power in the House, Russell explained, in large part because many of the most important races are happening in suburban areas where significant numbers of college-educated women are expected to turn out. Still, it’s unclear whether that issue will actually mobilize blue-state voters who have perceived less of a threat to abortion access. Immigration policy could also come into play; some Democrats are striking a more hawkish tone on the border, Russell said, following a strategy that helped Representative Tom Suozzi win George Santos’s former seat in a special election on Long Island earlier this year.

Below are five competitive House races that we’re keeping an eye on.

***

New York’s Seventeenth District

New York is famously a Democratic stronghold. But in the 2022 midterms, Republicans’ sweep of the state’s most competitive House races was a key factor that contributed to the Democrats losing control of the House. Now, just north of New York City in a district where 80,000 more Democrats than Republicans are registered, Republican Mike Lawler is trying to defend his seat against former Representative Mondaire Jones in a close race that may help tip the House.

Lawler, who is framing himself as a moderate Republican, has worked to tie Jones to the embattled Democratic New York City Mayor Eric Adams, and he’s tried to haunt Jones with his old progressive stances from 2020, when he won a House seat in the Seventeenth District. Democrats have spotlighted Lawler’s abortion views—he opposes abortion except in cases of rape or incest, though he does not back a national ban—as a weakness in his campaign. Immigration has been another point of contention because of the recent influx of migrants in New York; both candidates have swiped at each other’s record on the border.

Pennsylvania’s Tenth District

In Pennsylvania, a must-win swing state for the presidential candidates, a race between a MAGA Republican and a former news anchor could affect the balance of power in the House. Republican Representative Scott Perry is fighting to hold onto his seat against a challenge from Janelle Stelson, who became a local celebrity thanks to her decades on air. In a recent dispatch from the district, Russell described Perry as “the most vulnerable Trump loyalist in the House,” in part because of his baggage related to January 6 (he reportedly tried to install an attorney general who would help Trump stay in power).

Stelson carries little political baggage as a longtime news anchor and first-time candidate. A former registered Republican and self-identified centrist, she has taken a stronger stance on immigration than many Democrats, and she declined to endorse Vice President Kamala Harris until recently. But she’s largely aligned with her party on abortion: Stelson has said that the overturning of Roe v. Wade fueled her decision to run as a Democrat, and Perry recently said that he wouldn’t rule out voting for a national abortion ban.

Washington’s Third District

A rematch will take place between Joe Kent, a MAGA loyalist who has denied the outcome of the 2020 presidential election, and Marie Gluesenkamp Perez, a vulnerable Democrat who won in an upset in 2022. That the Trump-backed Kent, rather than the district’s more moderate Republican incumbent, ran (and lost) in the district in 2022 was a “self-inflicted wound” that was “emblematic of how poor Republican choices and MAGA purity tests hurt the party in races up and down the ticket,” my colleague David Graham wrote at the time.

Washington’s Third District is a primarily rural area that voted for Trump in 2016 and 2020. In the House, Perez sometimes crosses the aisle to vote with Republicans on certain issues, including student-loan-debt relief, raising the ire of party loyalists. In July, she went where few Democrats did: Shortly after President Joe Biden withdrew from the race, she released a statement that appeared to cast doubt on his fitness to serve the rest of his term.

Arizona’s First District

Republican Representative David Schweikert, who is seeking his eighth term in the House, is running against Democrat Amish Shah, an ER physician turned state representative. Arizona’s First District, with its large share of college-educated suburban voters, is considered a bellwether district in a state that could determine the outcome of the presidential election.

Republicans have framed Shah as “an extreme liberal,” sympathetic to socialism and raising taxes in a race where taxes and border security are key issues. But abortion is also top of mind for many voters—a measure that would codify the right to abortion in Arizona will be on the state’s November ballot—and Schweikert repeatedly co-sponsored a bill that would have banned nearly all abortions nationwide.

California’s Forty-Seventh District

California, like New York, is sure to go to Harris in the presidential race. But across the state, a handful of House races remain highly competitive. In Orange County’s affluent Forty-Seventh District, Democratic State Senator Dave Min and the Republican attorney Scott Baugh are facing off in a tight race that both parties have identified as a key target to win in 2024. The two candidates are vying to take over the seat currently occupied by Democratic Representative Katie Porter, who opted to run instead for the late Senator Dianne Feinstein’s seat (a bid that failed in part because a tech-backed campaign spent $10 million attacking Porter for being insufficiently crypto-friendly).

The number of registered Democrats and Republicans in the district is nearly equal, and Orange County’s growing Asian American and Latino populations have helped shift left the area once known as a conservative bastion. Min and Baugh will likely need to court the vote of independents to win, with a focus on the local issues including the economy and crime.

Related:

Seven Senate races to watch The New York race that could tip the House

Here are four new stories from The Atlantic:

Israel has won the war, Franklin Foer writes. Can it win the peace? Ron Brownstein: Kamala Harris’s closing argument Donald Trump’s roomful of suspiciously friendly women Mike Pence is haunting this election.

Today’s News

Israeli forces killed Yahya Sinwar, Hamas’s top leader, in southern Gaza, officials confirmed today. A grand jury in Georgia indicted the 14-year-old Apalachee High School shooter and his father on murder charges for a mass shooting last month that left four people dead. The Roman Catholic Archdiocese of Los Angeles agreed yesterday to pay $880 million to 1,353 victims of clergy sexual abuse, the largest single child-sex-abuse settlement involving a single Catholic archdiocese.

Dispatches

Time-Travel Thursdays: Eleanor Roosevelt was ahead of her time, Helen Lewis writes. The beloved first lady was as visible as her husband in the White House. Work in Progress: On the whole, Democrats are pro-EV and Republicans are not, Matteo Wong writes. Partisanship only partly explains the difference.

Explore all of our newsletters here.

Evening Read

Illustration by The Atlantic

A Calculator’s Most Important Button Has Been Removed

By Ian Bogost

I worry that the calculator we’ve known and loved is not long for this Earth. This month, when I upgraded my iPhone to the latest operating system, iOS 18, it came with a refreshed Calculator app. The update offered some improvements! I appreciated the vertical orientation of its scientific mode, because turning your phone sideways is so 2009; the continuing display of each operation (e.g., 217 ÷ 4 + 8) on the screen until I asked for the result; the unit-conversion mode, because I will never know what a centimeter is. But there also was a startling omission: The calculator’s “C” button—the one that clears input—was gone. The “C” itself had been cleared.

Read the full article.

More From The Atlantic

The AI boom has an expiration date. What is this “post-birth abortion” Donald Trump keeps talking about? Arthur C. Brooks: Why humility is the key to well-being What does that dog bark mean?

Culture Break

Dr. Sherif Abdallah Ahmed, Tanta, Egypt

Check out. These are the stunning results of the 2024 Small World Photomicrography Competition—a contest that invites photographers and scientists to submit images of all things visible under a microscope.

Read. Richard Powers’s recent novels have traded complexity for preachiness, but his latest is an effective twist on AI panic, Randy Boyagoda writes.

Play our daily crossword.

P.S.

On the last Monday of each month, Lori Gottlieb answers a reader’s question about a problem, big or small, in the “Dear Therapist” newsletter. This month, she is inviting readers to submit questions related to Thanksgiving.

To be featured, email dear.therapist@theatlantic.com by Sunday, October 20.

By submitting a letter, you are agreeing to let The Atlantic use it—in part or in full—and we may edit it for length and/or clarity.

Stephanie Bai contributed to this newsletter.

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Scott Perry seemed to be in a good mood. When I found him on a recent Saturday, the Pennsylvania representative was visiting a local Republican office, joking with volunteers as he helped them prepare campaign materials for canvassers who would be knocking doors later that day. Perry was friendly with me too, until I asked whether he regretted any of his actions leading up to January 6.

That’s when I got a taste of Perry’s pugilistic side, which has both endeared him to conservative hard-liners and convinced Democrats that they can defeat him next month.

“And what were those actions, sir?” he replied, as if testing me.

Perry, a former chair of the far-right House Freedom Caucus who was first elected in 2012, had reportedly done plenty to aid former President Donald Trump’s efforts to overturn the 2020 election. The FBI seized Perry’s cellphone in 2022, which led to the revelation of text messages showing his extensive attempts to install an attorney general who would help keep Trump in office. Perry’s preferred candidate was Jeffrey Clark, a now-indicted Department of Justice official whose main qualification was spreading claims of election fraud.

I started by noting that Perry was the one who’d introduced Trump and Clark. He cut me off.

“An introduction?” he said, incredulously. “Is that illegal now?” Perry accused me of repeating “a narrative that has been promoted by the left” that the mainstream media have refused to verify. “Somebody said, Can you introduce me? I said sure,” he explained, saying it was no different than if he had introduced me to one of his aides standing nearby. “So no, I’m not embarrassed.”

[David A. Graham: The real weaponization of the Department of Justice]

Whether Perry agrees with it or not, the “narrative” about his role ahead of the January 6 assault on the Capitol is part of why he’s the most vulnerable Trump loyalist in the House. “For a lot of normie, older Republicans, all that January 6 stuff was really a line of demarcation,” Christopher Nicholas, a GOP strategist who lives in Perry’s district, told me. In their hunt for a House majority, Democrats are targeting Perry like never before, and they’re running a candidate, the former local-news anchor Janelle Stelson, who can match both his regional fame and his fundraising.

The race could help determine the House majority, and in the state that could decide the presidency, Perry is once again sharing a ballot with the ally he tried to keep in office four years ago. The issues that have defined Trump’s comeback attempt—immigration, abortion, trying to overturn the 2020 election—have also figured prominently in Perry’s race. Until this year, Perry had demonstrated even more political resilience than Trump; he outran him in 2020, winning his district while Trump narrowly lost Pennsylvania. That might not be the case in November. Both of their races are toss-ups, but at the moment, the bigger underdog might be Perry.

Perry’s district, which includes Harrisburg as well as nearby suburbs and small towns, became significantly bluer after Pennsylvania’s Supreme Court redrew the state’s congressional map in 2018. Trump won the new district by just four points in 2020, and two years later, the Democrat Josh Shapiro carried it by 12 points during his victorious campaign for governor.

Perry’s district may have shifted, but he has not. He’s a small-government conservative known for opposing bipartisan deals in Washington and prodding GOP leaders to dig in against Democrats, even if it results in a government shutdown or a debt default. Perry scoffs at “so-called Republicans” who say he should moderate his stances or his approach in order to accommodate the additional Democrats he now represents. “Doing the right thing is always doing the right thing,” he told me.

So far, his stubbornness has paid off. After winning a close race in 2018, he’s padded his margins in each of the past two elections. In 2022, he defeated the Democrat Shamaine Daniels, a member of the Harrisburg city council, by more than seven points, running well ahead of the Republican candidates for Senate and governor in Pennsylvania that year. “That is a mystery to a lot of us,” State Representative Patty Kim, a Democrat running for a state-senate seat in the area, told me. “He goes further right, and he gets away with it.”

For Perry, what’s changed this year is Stelson, whose decades on television in the Harrisburg market have made her a local celebrity and the most formidable challenger he has faced. “She’s a trusted voice in the community,” Shapiro, who has campaigned for Stelson, told me in a phone interview. “She’s been in people’s living rooms for so many years.” I followed her as she canvassed a mostly Republican neighborhood that has been shifting left. People greeted her with the slightly startled look of finding a TV star at their doorstep. “Oh my goodness, Janelle Stelson,” Jeff White, a 66-year-old retired welder, told her. “You look even prettier in person than you do in the news.” Another man didn’t even wait for a knock on the door. He called out to her on the street, “Janelle, I’m voting for you!”

Stelson relishes these encounters. She tends to deviate from the list of houses that her campaign prepares for her, in search of harder targets. “My favorite words in the English language are I’m a Republican, and I’m voting for you,” she told me with a laugh. Stelson used to be a registered Republican, although she told me she hasn’t voted for a GOP presidential candidate since Ronald Reagan. She made sure her viewers knew nothing about her politics. “That makes them not hate you,” she said.

Democrats have found sufficient GOP support for Stelson to make them optimistic about her chances. Stelson told me her internal polls show her slightly ahead, and a survey released last week by a Harrisburg-based polling firm found her leading Perry by nine points. She has raised more than $4.5 million and, as of July, had more cash than Perry, who’s had to spend a considerable amount of his campaign funds on legal fees related to the 2020 election. (In 2022, by contrast, Daniels raised less than $500,000.) In an indication that Republicans are worried about Perry, the House GOP’s main super PAC began airing ads in his district.

Stelson describes herself as centrist, and although she mostly sticks to her party’s line on issues such as abortion and voting rights, she is more hawkish on immigration than even the most conservative Democrats. During a debate with Perry last week, she largely backed Trump’s call for the mass deportation of undocumented immigrants (though she conceded that she doesn’t know how that might be accomplished). As part of her bid to win over Trump voters, Stelson declined for months to endorse Kamala Harris. When I asked her if she was voting for Harris, she replied that she would “absolutely support the Democratic ticket,” and then asked to go off the record. During the debate two days later, she confirmed that she would vote for Harris.

Stelson’s lack of a voting record—or really any history of expressing political views—has made her a difficult target for Republicans, who have tried criticizing her for living a few miles outside the district. “If you had to be nitpicky, that’s a big issue. But for me, it’s not,” Kim, the Democratic state representative, told me. Although Stelson has worked in the district for decades, Kim suggested that she may have taken a risk by not moving before the election: “I think there was an easy fix, but I respect her decision.”

Stelson says she decided to run after the Supreme Court struck down Roe v. Wade in 2022. She recalls being on air when the ruling came down, trying to keep her composure while describing the jubilant reactions of Republicans, particularly Perry. Abortion became a driving issue for Stelson’s campaign, and Perry has struggled to articulate a consistent position. He’s said the issue should be left to the states, and like Trump, he backs exceptions for rape, incest, and the life of the mother. But he has co-sponsored legislation called the Life at Conception Act, which guarantees “the right to life” for all people and says that a human life begins at “the moment of fertilization.” The bill doesn’t mention abortion, but Democrats say it would effectively ban the procedure. When I asked him whether he’d support a federal abortion ban with the exceptions he’s laid out, he said, “We don’t need to have that.” But he wouldn’t rule out voting for one if it came to the House floor: “I’m not going to get into hypotheticals.”

[Helen Lewis: Did Donald Trump notice J. D. Vance’s strangest answer?]

Perry is also elusive on a question that’s tripped up other Trump loyalists, most recently the vice-presidential nominee J. D. Vance: Did Joe Biden win the 2020 election? “Biden received the electoral votes necessary to win,” he told me. “I was right there at his inauguration. I saw him put his hand on the Bible,” Perry continued. “So there is no doubt that Joe Biden is the president.” I was surprised to hear this from the man who’d suggested to the Trump administration that people in Italy might have used military satellites to manipulate the vote count. So I tried a second time: Did Biden legitimately win the election? Again, Perry pointed to Biden’s Electoral College win. He bristled when I asked whether Trump should stop telling voters that the election was stolen. “Should Donald Trump give up his First Amendment rights because you don’t like what he says?” Perry replied. Is Trump wrong? “Why don’t you ask Donald Trump that.”

I saw a different side of Perry as I accompanied him across his district. Trailed by a few aides but no TV cameras, Perry evinced a childlike enthusiasm while doing things that many candidates treat as requisite indignities of political life. At a local fair, he seemed to genuinely enjoy feeding goats and playing carnival games. (Perry drew the line at the mechanical bull: “There’s the headline: ‘Candidate Breaks Back.’”) In the newer, bluer part of his district, he attended an event at a community garden where a mural was being unveiled. He gleefully stuck his hands in paint and planted them on the mural, along with neighborhood children. Unlike almost everyone else, he made his prints upside down.

When Perry was a child, he moved to Pennsylvania with his mother, the daughter of Colombian immigrants. They were escaping his abusive father and lived for a time in a house without electricity or running water. “We often ate food that was not only day-old but expired,” Perry said during his debate with Stelson. “But we got through it.” During his 2018 campaign, he said he’d been “embarrassed and humiliated to be on public assistance.”

Few people know Perry better than Lauren Muglia. The two met in the Army in the early 1990s, and when he went into politics, she became his chief of staff. “We fight like cats and dogs, and that’s how it’s been for 30 years,” she told me as we walked through the fair. When Perry loaded up on chocolate treats at a bake sale, Muglia joked about his addiction to chocolate. “I represent Hershey!” he replied. Muglia told me that Perry enjoys arguing with his staff, especially when they encourage him to take a more moderate stance. “He’s not a person who likes yes-men,” she told me. I got the sense that Muglia wishes more voters saw the Perry she knows—a demanding boss but also a loyal friend.

The deprivation Perry experienced in his childhood was worse than what he’s shared publicly, Muglia told me. He and his brother would sometimes scrounge for food in dumpsters. His mother would post ads in newspapers in search of people who could watch them for weeks at a time while she worked as a flight attendant. As a 4-year-old, Perry would cry for hours when his mother dropped him and his brother off. One couple who was taking care of them left him in a shed used for storing corn so they wouldn’t have to hear him scream. After Perry stayed there, he told Muglia, the couple made headlines when a child died in their care. Perry recounted this story to her a few years ago without any emotion, but she was brought to tears.

Learning about another child’s suffering helped prompt Perry to change his mind on marijuana policy—the one issue on which he will admit to moderating his views over the years. Perry had been opposed to any legalization of cannabis, but he began hearing from constituents who benefitted from medical CBD. The conversation that finally flipped him, Muglia told me, was when a father told Perry about his epileptic daughter, who had 400 seizures a week and had to travel to Colorado to receive medical-CBD treatment. “I became convinced that I was in the wrong place,” Perry told me.

[Read: Congress accidentally legalized weed six years ago]

Yet for the most part, he remains as unyielding as ever, and that, more than anything, might prove to be his undoing. He usually finds a reason to vote no, and not only on Democratic proposals. For much of the campaign, Stelson has criticized Perry for opposing abortion rights and for his role leading up to January 6, but in the closing weeks, she is focusing just as much on casting him as a cause of Washington’s dysfunction.

The House Republican majority, distracted by leadership battles, has been historically unproductive, and Perry is often in the middle of the party’s infighting. Even when Congress has managed to enact significant legislation, Stelson points out, Perry has usually tried to stop it. Indeed, Democrats have found that highlighting Perry’s opposition to popular bipartisan bills, such as the 2021 infrastructure package and legislation extending health benefits to military veterans exposed to toxic burn pits, is their most effective message.

Perry justifies his “no” votes by saying that the bills he opposed spent too much money on unnecessary things. And he’s tried to appeal to voters beyond his base by pointing out that some of the proposals that he fought came from Republicans. “When the stuff that is unaffordable, unnecessary, unwanted, outweighs the stuff that we need, I’m going to vote the way I need to,” he told me. For Perry, in other words, the bad parts of legislation too often outweigh the good. His trouble is that, come November, voters in his district might make the same judgment about him.

This is an edition of The Atlantic Daily, a newsletter that guides you through the biggest stories of the day, helps you discover new ideas, and recommends the best in culture. Sign up for it here.

Kamala Harris is in the midst of a media blitz this week, including an interview on CBS’s 60 Minutes yesterday evening and an appearance on The Late Show With Stephen Colbert tonight. But she is also dipping into the world of mega-popular, not straightforwardly journalistic podcasts—notably appearing on the show Call Her Daddy last weekend. I spoke with my colleague Helen Lewis, who covers the podcast-sphere, about why Donald Trump and Harris are both spending time on these sorts of shows, what these interviews avoid, and how independent podcasters became major players in political media.

The New Mainstream

Lora Kelley: How does the value to the viewer of a traditional press interview—one focused on the specific issues and policies of the race—differ from that of a lifestyle podcast?

Helen Lewis: Roughly speaking, there are two types of sit-down conversations in politics: the accountability interview and the talk-show appearance. One focuses on pinning down candidates on their past statements and their future promises; the other, which most podcasts fall into, tries to understand the candidate as a person. The latter aren’t necessarily soft options—being charismatic and engaging while making small talk or fielding deeply personal questions is a skill in itself. (And I found Donald Trump’s appearance on Theo Von’s podcast, where he talked about his elder brother’s struggle with alcoholism, very revealing indeed.)

But only with the accountability interviews do you get candidates pressed repeatedly on questions that they’re trying to dodge. On Logan Paul’s podcast, Impaulsive, Trump was asked about the transmission of fentanyl over the border, and he got away with rambling about how “unbelievable” the German shepherds Border Patrol officers use are. On Lex Fridman’s podcast, Trump asserted that he could easily sort out the crisis in Ukraine—and that was it. Who needs details? When Kamala Harris went on Call Her Daddy, the host, Alex Cooper, gave her a chance to lay out her message on reproductive rights but didn’t, for example, challenge her on whether she supports third-trimester abortions, which are deeply divisive.

Lora: From the perspective of a political campaign, are there any downsides to appearing on a podcast such as Call Her Daddy?

Helen: The obvious criticism of Harris appearing on Call Her Daddy, which has a young, female audience, is that she already has a big lead among young women aged 18–25. You can say the same about Trump appearing on podcasts that are popular with young men. But both groups contain many people who will be undecided about whether to vote at all.

Lora: Harris has done some traditional press interviews during this campaign cycle, including her 60 Minutes interview yesterday. But are we in a new era in which chats with friendly podcasters rival (or even overtake) traditional media interviews?

Helen: Well, quite. An article I think about a lot is John Herrman’s 2015 “Access Denied,” in which he asked why an A-lister—someone like Kim Kardashian—would give an interview to a celebrity magazine if she had something to sell, instead of simply putting a picture on Instagram. Why cooperate with the old guard of media when they are no longer the gatekeepers of attention? Herrman argued that the traditional media was suffering a “loss of power resulting in a loss of access resulting in further loss of power.”

That dynamic has now migrated to politics. The legacy brands no longer have a monopoly on people’s attention, and the online right, in particular, has been extremely successful in building an alternative, highly partisan media. Fox News is no longer the rightmost end of the spectrum—beyond that is Tucker Carlson’s podcast, or the Daily Wire network, or Newsmax, or Elon Musk’s X.

Now candidates tend to talk to the traditional media only when they want to reset the narrative about them, because other journalists still watch 60 Minutes or whatever it might be. There’s still a noisiness around a big legacy interview that you don’t get with, say, Call Her Daddy—even if more people end up consuming the latter.

Lora: Are these podcasts really doing anything new, or are they largely replicating traditional media interviews without the same standards and accountability?

Helen: The better ones strive for impartiality and don’t, for example, reveal their questions in advance—but many political podcasts are wrapped in an ecosystem where big-name guests mean more advertising revenue, and thus bigger profits for the hosts personally; plus, their only hope of getting a second interview is if the candidate feels the first one was sympathetic. Compare that with 60 Minutes, which interviewed Trump so robustly in 2020 that he has asked for an apology.

I’m as guilty as anyone, but we need to stop treating these podcasts as the “alternative” media when they are absolutely the mainstream these days. The top ones have audiences as big as, if not bigger than, most legacy outlets. If they don’t want to hire all the editorial infrastructure that traditional journalism has (such as fact-checkers, research assistants, etc.), or risk being unpopular by asking difficult questions, that’s on them. Joe Rogan renewed his Spotify contract for $250 million. Alex Cooper signed a deal with SiriusXM this year worth $125 million. We should stop treating the mega-podcasts like mom-and-pop outfits competing with chain stores. They’re behemoths.

Lora: You recently wrote about The Joe Rogan Experience, which is the top-listened-to podcast on Spotify and arguably the most influential behemoth of them all. Why haven’t the candidates gone on the show yet? Who from each ticket do you think would make the most sense as a guest?

Helen: As I understand it, Team Trump would love to get on The Joe Rogan Experience. The two politicians that Rogan adores are Tulsi Gabbard and Robert F. Kennedy Jr., who are now both working with the Republicans, and Team Trump would hope to encourage some of Rogan’s audience of crunchy, COVID-skeptic libertarians to follow them in moving from the independent/Democrat column to the GOP. But Rogan isn’t a full MAGA partisan like some of his friends, and Trump recently said that Rogan hasn’t asked him to appear.

In any case, I think Rogan would prefer to talk to J. D. Vance, who is very much part of the heterodox Silicon Valley–refugee tendency that he admires. For the Democrats, Harris might struggle to relax into the stoner-wonderment vibe of Rogan, given the tight-laced campaign she’s running. Rogan and Tim Walz could probably have a good chat about shooting deer and the best way to barbecue.

Related:

What going on Call Her Daddy did for Kamala Harris How Joe Rogan remade Austin

Here are three new stories from The Atlantic:

Milton is the hurricane that scientists were dreading. David Frum: Behind the curtain of Mexico’s progress Donald Trump flirts with race science.

Today’s News

Florida Governor Ron DeSantis announced that roughly 8,000 National Guard members will be mobilized by the time Hurricane Milton, a Category 5 storm, makes landfall this week. The Supreme Court appears likely to uphold the Biden administration’s regulation of “ghost gun” kits, which allow people to buy gun parts and build the weapons at home. Prime Minister Benjamin Netanyahu claimed that the Israeli military has killed the replacement successors of the Hezbollah leader Hassan Nasrallah, who was killed in an Israeli air strike last month.

Dispatches

Atlantic Intelligence: The list of Nobel laureates now contains two physicists whose 1980s research laid the foundations for modern artificial intelligence, Matteo Wong writes.

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Evening Read

Illustration by Ben Kothe / The Atlantic. Source: Getty.

They Were Made Without Eggs or Sperm. Are They Human?

By Kristen V. Brown

The little clump of cells looked almost like a human embryo. Created from stem cells, without eggs, sperm, or a womb, the embryo model had a yolk sac and a proto-placenta, resembling a state that real human embryos reach after approximately 14 days of development. It even secreted hormones that turned a drugstore pregnancy test positive.

To Jacob Hanna’s expert eye, the model wasn’t perfect—more like a rough sketch … But in 2022, when two students burst into his office and dragged him to a microscope to show him the cluster of cells, he knew his team had unlocked a door to understanding a crucial stage of human development. Hanna, a professor at the Weizmann Institute of Science in Israel, also knew that the model would raise some profound ethical questions.

Read the full article.

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Culture Break

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Read. Lauren Elkin’s latest novel, Scaffolding, suggests that total honesty can take a marriage only so far, Lily Meyer writes.

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Nigel Farage, the populist British politician and ally of Donald Trump, recently lit up outside a pub in London. This was not in itself unusual. He has regularly been photographed with a cigarette in hand, often also with a pint of beer—part of a “man of the people” shtick that he has honed over the years, belying his private education and previous career as a commodities trader. This time, though, Farage was staging a political protest of sorts. Smokers, he told reporters, could be considered the “heroes of the nation in terms of the amount of taxation they pay.”

Farage was speaking after The Sun, a popular right-wing tabloid, reported that the United Kingdom’s new Labour government is planning to expand a law that since 2007 has banned smoking in indoor public places in England to cover pub gardens and other outdoor settings as well. The policy’s details are still in flux, but Keir Starmer, the prime minister, has not denied the thrust of the plan, and his health minister has confirmed that he is considering the measure, pending a “national debate.” Farage, who has long advocated at least a partial reversal of the indoor-smoking ban and who is now seated in Parliament for the first time, was up in arms at the news. In addition to his pub protest, he threatened, in an op-ed, to never go to a pub again if the expanded ban becomes law.

From the outside, this can look like the latest installment in a long-running culture war: Since Brexit—which Farage did much to bring about—Britain has hardly been immune to the sort of populist grievance politics that has held policy progress hostage across the West. On smoking-related policy, the U.K. might appear to mirror the United States, where cigarettes and smoke-free nicotine products have become politicized. (Tucker Carlson said last year that “nicotine frees your mind.”)

Yet the U.K. has long been an international exemplar on the regulation of tobacco products—with surprisingly little domestic controversy. Mitch Zeller, a former director of the Center for Tobacco Products at the U.S. Food and Drug Administration, told me recently that many public-health professionals in his field “look at the U.K. as a thought leader” on tobacco control and harm-reduction measures, such as medical interventions to help smokers quit. The U.K. is now poised to go further than any of its peer countries in regulating who can legally buy tobacco products, and toughen restrictions on where they can be smoked. A majority of the British public appears to be on board with that.

The effort by Farage and his ilk to conjure controversy over anti-smoking laws channels modern grievance politics in its pure form: a revolt against expertise and authority in the name of the people—even if the people may not actually be asking for it. The U.K. first saw this dynamic in the run-up to the Brexit referendum, when Michael Gove, a Conservative politician, famously remarked that Britons “have had enough of experts from organizations with acronyms saying that they know what is best.” Farage and others later railed against COVID lockdowns as part of an imagined battle between tyrannical public-health edicts and freedom—despite broad public agreement that they were necessary.

Then again, elite political discourse in Britain has been captured by relatively fringe obsessions and talking points before, such as the debate over banning fox hunting. (Brexit itself arguably started out this way.) Farage and others on the right seem to be hoping that they can fracture Britain’s anti-smoking consensus as part of their broader populist project, or at least use the issue to inflict pain on Starmer’s struggling new government.

[Read: Contesting the science of smoking]

The U.K.’s history of regulating smoking dates back at least as far as the 1960s, the decade after British scientists established a strong link between smoking and lung cancer. As the academic Paul Cairney has written, tobacco companies had emerged from World War II with a “patriotic image” after “providing cigarettes to aid the war effort.” The U.K. government did ban cigarette advertising on television in 1965, but for years, Cairney writes, regulation was mostly voluntary, and “the dominant image of tobacco was as an economic good, providing export revenue, tax revenue, and jobs, with health as a secondary concern.”

Over time, though, this changed, and eventually, in 2007, Tony Blair’s Labour government prohibited smoking in indoor public places in England. At first, Labour considered exempting certain pubs and clubs, for fear, Cairney suggests, that the party would be seen as punishing its traditional working-class base. (The U.K.’s other constituent nations—Scotland, Wales, and Northern Ireland—all set their own smoking policy and had imposed similar bans even earlier.)

In the end, the ban was far-reaching. Critics said it would prove unenforceable, but “compliance was 98 percent in the first year, because there’d been a massive public debate,” Deborah Arnott, a former longtime advocate with a prominent anti-tobacco group and an honorary associate professor at University College London, told me. “Compliance has to be because that’s what people want.” And so, apparently, it was: A poll commissioned by Cancer Research UK a decade later found record low levels of smoking among the British public and only 12 percent support for reversing the ban.

In 2010, a coalition led by the Conservative Party ousted Labour and, among other things, imposed a sharp program of fiscal austerity that stripped back public-health budgets. But the Conservatives left the Labour ban in place and would later introduce tough measures of their own, including outlawing smoking in vehicles when children were present. Then, last year, the most recent Conservative prime minister, Rishi Sunak, laid out plans to ban anyone born in 2009 or later from ever buying tobacco products legally—an initiative hailed by Arnott and other advocates as a historic and world-leading move toward eradicating smoking altogether. Sunak framed the measure as one of fiscal responsibility, arguing that it would reduce pressure on the taxpayer-funded National Health Service and boost national productivity by reducing sickness and disability. He also spoke in paternalistic terms. “I want to build a better and brighter future for our children,” he said. “That’s why I want to stamp out smoking for good.”

And many in Sunak’s party supported his policy. When George Young—a Conservative lawmaker who has long advocated tough smoking restrictions and is now a member of the House of Lords—entered Parliament in the 1970s, his stance “was not wholly unusual, but it’s probably true to say that most of the people on the anti-smoking side were probably not of my persuasion.” Now, he says, “there are many, many more Conservative MPs and peers who feel strongly about smoking” and are campaigning for more restrictions.

But a vocal minority can sometimes be enough to bring about significant shifts in policy. Before Sunak proposed his age-related smoking ban, a center-left government in New Zealand passed a very similar measure, which had broad public support and did not seem an issue of contention in the country’s recent election. So it was a surprise when the incoming government reversed the policy, as part of a coalition agreement with a minority populist party. The revenue from tobacco sales, the new government said, would pay for tax cuts instead. Farage and his allies might favor a similar course of action—and they could one day have the leverage to force the issue.

[Helen Lewis: Goodbye to Tory Britain]

If anything, voters seem more enthusiastic about tobacco controls than Sunak’s government was. According to recent polling by YouGov, majorities of the British public support both the age-related ban and prohibiting smoking in various outdoor settings (though the former measure appears to enjoy much greater support than banning smoking specifically in beer gardens). Smoking policy is “one of the areas where politicians are most out of touch with the public,” Luke Tryl, the executive director of the research group More in Common UK, told me. Perhaps surprisingly, Britons are “really quite authoritarian” on such issues. “We have a joke in the polling world that if you put the word ban in a poll question, support for whatever you’re proposing jumps up by 20 points,” he said. “There’s this myth that there’s a big libertarian-right constituency in the U.K.”

And yet when Sunak put forward his ban, numerous prominent voices on the right attacked it. The Spectator, the magazine of the Conservative establishment, published an article in which its writers shared their favorite experiences of cigarettes; Boris Johnson, a former prime minister (and a former editor of The Spectator) argued that Sunak was ushering in a “smoking apartheid” and decried the fact that “the party of Winston Churchill” wants to ban cigars. Nor was the opposition to the policy confined to the right. Ian Dunt, a liberal journalist, dismissed the ban as authoritarian, unworkable, and unnecessary, as youth smoking rates are already at record lows. In the center-left New Statesman, Megan Nolan wrote that she opposed the ban out of a belief in bodily autonomy—even if that “sadly puts me in a Venn diagram with the likes of Nigel Farage.”

In the spring, Sunak called a general election earlier than many expected. His smoking ban did not become law before the U.K. voted in July, when Labour won a huge majority and swept the Conservatives from power. But Labour always supported Sunak’s ban, and is poised to implement it. The new prime minister has, like Sunak, justified his stance on smoking as motivated by a need to save spending on the National Health Service, which is an institution of quasi-religious importance to Labour and its voters. A report commissioned by the new government found that the NHS is in “critical condition.” Starmer is aiming to save it in part by preventing ailments that cost money to treat. To that end, his push on smoking is just one plank of a broader public-health agenda that will also include curbs on junk-food advertising, for example.

Anti-smoking advocates told me that they don’t anticipate trench warfare over the proposed tobacco measures; as Young put it, “I don’t really see smoking as becoming a huge cultural issue when most people who smoke want to give it up and nobody really wants their children to smoke.” But the case of New Zealand shows that even broad public backing can’t immunize health policy against the power of populist revolt. Starmer himself has acknowledged that “some prevention measures will be controversial,” but pledged that he’s “prepared to be bold, even in the face of loud opposition.”

How loud might that opposition be? Britons may not have any appetite for a big political fight over smoking. But Farage and his party, Reform, can use issues such as smoking bans to energize sections of their base. In July’s election, Reform picked up five seats in Parliament, including Farage’s own. This may seem a modest achievement, but Reform won nearly 15 percent of the popular vote and played spoiler to Conservative candidates in many places—and its popularity has continued to grow since then. (Labour, by contrast, won a huge majority of seats on only a third of the popular vote, because of the distorting effects of the electoral system.)

The Conservatives are currently in the process of picking a new leader, and seem likely to tilt toward the right with their choice. The pull that Farage and his allies might then exercise brings them closer to the heart of Britain’s political debate. Although many Tories, including even committed libertarians, supported Sunak’s smoking ban, two of the favorites in the party’s leadership contest—Robert Jenrick and Kemi Badenoch—voted against it.

Jenrick has already dismissed a pub-garden ban as “nonsense,” arguing that it would hammer the hospitality industry. The Conservatives’ official account on X attacked the proposal as a means of “social control” and “more evidence that Labour hates freedom”; one lawmaker even drew a tasteless analogy with the Nazis. And the tobacco industry, of course, has the deep pockets and lobbying power to foment a longer-lasting backlash.

One thing that could heat up the smoking issue is if the U.K.’s ferocious right-wing press persists in using it as a stick with which to beat Starmer, who is often caricatured as a joyless authoritarian. Already, the Labour leader has become embroiled in a scandal of apparent hypocrisy, over lavish gifts from donors when he has told the British people that they must make sacrifices; his approval ratings are sliding rapidly. Smoking could become a symbolic issue in a bigger fight about whether Starmer is defaulting on his promise to push back against noisy populists and deliver a “politics that treads a little lighter on all of our lives.” Farage seems to be hoping that even if smokers’ rights aren’t a universally popular cause, he can still exploit it to help mobilize a generalized disgust with the establishment. Either way, his broader appeal has proved hard to stub out.

In an otherwise confident debate performance on Tuesday, the Republican vice-presidential nominee, J. D. Vance, conspicuously dodged questions from the CBS moderators about his views on health care. For weeks, Vance has made clear his desire to dismantle one of the central pillars of the Affordable Care Act: the law’s provisions that require the sharing of risk between the healthy and the sick. On Tuesday, though, Vance refused to elaborate on his plans to reconfigure the ACA, instead pressing the implausible argument that Donald Trump—who sought to repeal the law, and presided over a decline in enrollment during his four years in office—should be viewed as the program’s savior.

Vance’s evasive response to the questions about health care, on a night when he took the offensive on most other subjects, exposed how fraught most Republicans still consider the issue, seven years after Trump’s attempt to repeal the ACA died in the Senate. But Vance’s equivocations should not obscure the magnitude of the changes in the program that he has signaled could be coming in a second Trump presidency, particularly in how the law treats people with significant health problems.

The ACA provisions that mandate risk-sharing between the healthy and sick underpin what polls show has become its most popular feature: the requirement that insurance companies offer coverage, at comparable prices, to people with preexisting conditions. In numerous appearances, Vance has indicated that he wants to change the law to restore to insurance companies the ability to segregate healthy people from those with greater health needs. This was a point that Tim Walz, the Democratic vice-presidential nominee, accurately stressed during the debate.

The political paradox of Vance’s policy is that the trade-off he envisions would primarily benefit younger and healthier people, at a time when most young people vote Democratic. Conversely, the biggest losers would be older adults in their last working years before they become eligible for Medicare. That would hit older working-class adults, who typically have the biggest health needs, especially hard. Those older working people are a predominantly white age cohort that reliably favors the Republican Party; in 2020, Trump won about three-fifths of white voters ages 45 to 64, exit polls found. The threat that the GOP’s ACA alternatives present to these core Republican voting groups represents what I called in 2017 “the Trumpcare conundrum.”

“Going back to the pre-ACA days of segregated risk pools would lower premiums for young and healthy people, but result in increased cost and potentially no coverage at all for those with preexisting conditions,” Larry Levitt, the executive vice president for health policy at the nonpartisan KFF (formerly known as the Kaiser Family Foundation), told me.

Vice President Kamala Harris’s campaign hopes to exploit that tension by launching a major advertising campaign across swing states this week to raise an alarm about the plans from Trump and Republicans to erode the ACA’s coverage. Support for the ACA—in particular, its provisions protecting people with preexisting conditions—may be one of Harris’s best assets to hold support from older and blue-collar white women, who may otherwise be drawn to Trump’s argument that only he can keep them safe from the threats of crime and undocumented immigration.

[Helen Lewis: Did Donald Trump notice J. D. Vance’s strangest answer?]

The efforts of Republicans like Vance to roll back the ACA this long after President Barack Obama signed it into law, in 2010, are without historical precedent: No other major social-insurance program has ever faced such a lengthy campaign to undo it. After Franklin D. Roosevelt signed Social Security into law in 1935, Alf Landon, the GOP presidential nominee in 1936, ran on repealing it. But when he won only two states, no other Republican presidential candidate ever again ran on repeal. And no GOP presidential candidate ever ran on repealing Medicare, the giant health-care program for the elderly, after President Lyndon B. Johnson signed it into law in 1966.

By contrast, this is the fourth consecutive election in which the GOP ticket has proposed repealing or restructuring the ACA—despite polling that shows the act’s broad popularity. During Trump’s first year in office, House Republicans passed a bill to rescind the law without support from a single Democrat. The repeal drive failed in the Senate, when three Republican senators opposed it; the final gasp came when the late Senator John McCain voted no, giving a dramatic thumbs-down on the Senate floor.

Most health-care analysts say that, compared with 2017, the ACA is working much better today. At that point, the ACA exchanges had begun selling insurance only three years earlier, following a disastrously glitchy rollout of the federal website that consumers could use to purchase coverage. When congressional Republicans voted on their repeal plans, about 12 million people were receiving coverage through the ACA, and the stability of the system was uncertain because insurers feared that too many of those buying insurance on the exchanges were sicker people with more expensive health needs.

“In 2017, not only did we have rising premiums because insurance companies were worried the market was getting smaller and sicker, but we also had insurance companies exiting markets and raising the risk that parts of the country would have nobody to provide coverage,” Sabrina Corlette, a professor at Georgetown University’s Center on Health Insurance Reforms, told me.

Today, however, “we are in a very, very different place,” she said. “I would argue that the ACA marketplaces are thriving and in a very stable” condition. The number of people purchasing insurance through the ACA exchanges has soared past 21 million, according to the latest federal figures. Premiums for plans sold on the ACA exchanges, Corlette said, are rising, but generally not faster than the increase faced by employer-provided insurance plans. And enough insurers are participating in the markets that more than 95 percent of consumers have access to plans from three or more firms, according to federal figures.

Despite Vance’s portrayal of Trump as the program’s savior, the number of people receiving coverage through the ACA exchanges actually declined during Trump’s term, to 11.4 million, after he shortened the enrollment period and cut the advertising promoting it. The big leap forward in ACA participation came when the Democratic-controlled Congress in 2021 passed a major increase in the subsidies available to people for purchasing insurance on the exchanges. That made a mid-range (“silver”) insurance plan available for people earning up to 150 percent of the poverty level at no cost, and ensured that people earning even four times that level would not have to pay more than 8.5 percent of their income on premiums.

“The biggest criticism of the ACA from the start, which in many ways was legitimate, was that the coverage was not truly affordable,” Levitt said. “The enhanced premium subsidies have made the coverage much more affordable to people, which has led to the record enrollment.”

Neera Tanden, the chief domestic-policy adviser for President Joe Biden, told me that the steady growth in the number of people buying insurance through the ACA exchanges was the best indication that the program is functioning as intended. “A way to determine whether a program works is whether people are using it,” Tanden said. “No one is mandated to be in the exchanges, and they have grown 75 percent in the past four years. This is a program where people are voting with their feet.”

Conservative critics of the law nonetheless see continuing problems with the system. Michael Cannon, the director of health-policy studies at the libertarian Cato Institute, points out that many insurers participating in the ACA exchanges limit their patients to very narrow networks of doctors and hospitals, a trend acknowledged even by supporters of the law. And Cannon argues that the continued rise in premiums for plans sold on the ACA show that it has failed in its initial ambition to “bend the curve” of health-care spending, as Obama often said at the time.

The ACA “has covered marginally more people but at an incredible expense,” Cannon told me. “Don’t tell me it’s a success when it is exacerbating what everyone acknowledges to be the main problem with the U.S. health sector”—the growth in total national health-care spending.

Other analysts see a more positive story in the ACA’s effect on coverage and costs. The insurance exchanges established by the ACA were one of the law’s two principal means of expanding coverage for the uninsured. The second prong was its provision providing states with generous grants to extend Medicaid eligibility to more working, low-income adults. Although 10 Republican-controlled states have still refused to extend eligibility, nearly 24 million people now receive health coverage through the ACA’s Medicaid expansion.

Combined with the roughly 21 million receiving coverage through the exchanges, that has reduced the share of Americans without insurance to about 8 percent of the population, the lowest ever recorded and roughly half the level it was before the ACA was passed.

Despite that huge increase in the number of people with insurance, health-care spending now is almost exactly equal to its level in 2009 when measured as a share of the total economy, at slightly more than 17 percent, according to KFF figures. (Economists usually consider that metric more revealing than the absolute increase in spending.) That share is still higher than the equivalent figure for other industrialized countries, but Levitt argues that it counts as an overlooked success that “we added tens of millions of people to the health-insurance rolls and did not measurably increase health-care spending as a result.”

[David Frum: The Vance warning]

The ACA’s record of success underscores the extent to which the continuing Republican opposition to the law is based on ideological, rather than operational, considerations. The GOP objections are clustered around two poles.

One is the increase in federal spending on health care that the ACA has driven, through both the generous premium subsidies and the costs of expanding Medicaid eligibility. The repeal bill that the House passed in 2017 cut federal health-care spending on both fronts by a total of about $1 trillion over a decade. This spring, the conservative House Republican Study Committee released a budget that proposed to cut that spending over the same period by $4.5 trillion; it also advocated converting Medicaid from an entitlement program into a block grant. Every serious analysis conducted of such proposals has concluded that they would dramatically reduce the number of Americans with health insurance.

Even if Republicans win unified control of Congress and the White House in November, they may not be able to muster the votes for such a sweeping retrenchment of federal health-care spending. (Among other things, hospitals in reliably red rural areas heavily depend on Medicaid.) At a minimum, however, Trump and congressional Republicans would be highly unlikely to extend the enhanced ACA subsidies that expire at the end of 2025, a move that could substantially reduce enrollment on the exchanges.

The other main Republican objection is the issue that Vance has highlighted: the many elements of the ACA that require risk-sharing between the healthy and the sick. The ACA advanced that goal with an array of interlocking features, including its core protection for people with preexisting conditions.

In varying ways, the GOP alternatives in 2017 unraveled all of the law’s provisions that encouraged risk-sharing—by, for instance, allowing states to override them. That triggered the principal public backlash against the repeal effort, as Americans voiced their opposition to rescinding the ACA’s protections for people with preexisting conditions. But Vance has made very clear that a second Trump administration would resume the effort to resurrect a pre-ACA world, in which insurers sorted the healthy from the sick.

“A young American doesn’t have the same health-care needs as a 65-year-old American,” Vance argued recently on Meet the Press. “A 65-year-old American in good health has much different health-care needs than a 65-year-old American with a chronic condition.” Although “we want to make sure everybody is covered,” Vance claimed, “the best way to do that is to actually promote some more choice in our health-care system and not have a one-size-fits-all approach.”

Supporters of this vision, such as Cato’s Cannon, argue that it would allow younger and healthier people to buy less comprehensive plans than the ACA now requires, at much lower cost. As those more affordable options become available, Cannon says, cutting Medicaid spending to the degree Republicans envision would be more feasible, because people currently covered under that program could instead purchase these skimpier but less expensive private-insurance policies. Government-subsidized high-risk pools, the argument goes, could provide affordable coverage for the people with greater health needs whom insurers would weed out from their new, slimmed-down plans.

“If you want to make health care universal, you need to give insurers and consumers the freedom to agree on the prices and terms of health-insurance contracts themselves,” Cannon told me. “You need to let market competition drive the premiums down for healthy people as low as possible so they can afford coverage.”

Supporters of the ACA generally agree with the first point: that a deregulated system would allow insurers to create less expensive plans for young, healthy people. But they believe that all the arguments that follow are mistaken. Initial premiums might be lower, but in a deregulated system, even young and healthy families might find comprehensive policies, including such coverage as maternity benefits, unaffordable or unavailable, Georgetown’s Corlette told me. And when, before the ACA, states sought to establish high-risk pools for people with greater health needs, those efforts almost uniformly failed to provide affordable or adequate coverage, she pointed out.

Even if a reelected Trump lacks the votes in Congress to repeal the ACA’s risk-sharing requirements, he could weaken them through executive-branch action. In his first term, Trump increased the availability of short-term insurance plans that were free from the ACA’s risk-sharing requirements and its protections for people with preexisting conditions. Biden has shut down such plans, but if Trump won a second term and reauthorized them, while ending the enhanced subsidies, that could encourage many healthy people to leave the exchanges for those lower-cost options. Such actions would further the goal of Vance and other ACA critics of separating the healthy and sick into separate insurance pools.

Vance’s most revealing comment about this alternative vision may have come during a recent campaign stop in North Carolina, when he said that his proposed changes to the ACA would “allow people with similar health situations to be in the same risk pools.” But—as many health-policy experts noted to me, and Walz himself observed last night—that notion rejects the central purpose of any kind of insurance, which is to spread risk among as many people as possible—which, in fact, may be the point for Vance and other conservative critics of the ACA.

“The far right,” Tanden told me, “has always believed people should pay their own way, and they don’t like the fact that Social Security, Medicare, the ACA are giant social-insurance programs, where you have a giant pooling of risk, which means every individual person pays a little bit so they don’t become the person who is bankrupted by being sick or old.”

To date in the presidential race, health care has been eclipsed by two other major issues, each foregrounded by one of the nominees: immigration for Trump, and abortion for Harris. Under the glare of the CBS studio lights on Tuesday night, Vance was tactical in saying very little about his real health-care ideas. But the arguments he has advanced aggressively against crucial provisions of the Affordable Care Act have made clear that its future is still on the ballot in 2024.