At a rally in Las Vegas in September, the reggaeton star Nicky Jam came onstage in a Make America Great Again hat and endorsed Donald Trump. “We need you. We need you back, right? We need you to be the president,” he said. But after a comedian at Trump’s rally at Madison Square Garden last month called Puerto Rico “a floating island of garbage,” the singer—whose father is Puerto Rican and who was raised partly on the island—had second thoughts.

“Never in my life did I think that a month later, a comedian was going to come to criticize my country and speak badly of my country, and therefore, I renounce any support for Donald Trump,” Nicky Jam said.

He had no right to be surprised. Trump himself had previously gone after Puerto Rico—he punished its leaders for criticizing him after Hurricane Maria, and sought to swap it for Greenland—but even if Nicky Jam had missed or forgotten that, he had to know who Trump was.

Nicky Jam was ahead of the curve. Since the election, Trump has moved swiftly to do things he’d said he’d do, and yet many people—especially his own supporters—seem stunned and dismayed. This is absurd. Surprise was perhaps merited in late 2016 and early 2017, when Trump was still an unknown quantity. But after four years as president, culminating in an attempt to erase an election he lost, Trump has demonstrated who he is. Somehow, the delusion of Trump à la carte—take the lib-owning, take the electoral wins, but pass on all of the unsavory stuff—persists.

In an article about how Trump’s transition is “shocking the Washington establishment,” Peter Baker of The New York Times writes: “Nine years after Mr. Trump began upsetting political norms, it may be easy to underestimate just how extraordinary all of this is.” He’s right that the aberrant nature of the picks may be overlooked, as I have warned, yet it is also true that the actual unpredictability of them is overestimated.

[From the January/February 2024 issue: Trump isn’t bluffing]

On K Street, Politico reports, health-care-industry lobbyists can’t believe that Trump has nominated Robert F. Kennedy Jr. to lead the Department of Health and Human Services. They were “expecting a more conventional pick,” even though Trump emphasized Kennedy’s “Make America Healthy Again” agenda late in the campaign, and even though Kennedy said that Trump had promised him control of HHS. To be sure, Kennedy is a shocking and disturbing pick, as Benjamin Mazer and my colleague Yasmin Tayag have recently written for The Atlantic, but his nomination should not come as a surprise—especially for people whose entire business proposition is being highly paid to advise clients on how Washington actually works. (The influence peddlers reportedly hope that senators will block Kennedy. The fact that they’re still waiting for someone else to solve their problems is further evidence of how little they’ve learned, years into the Trump era.)

Meanwhile, the New York Post, a key pillar of Rupert Murdoch’s right-wing media juggernaut, is similarly jittery about the Kennedy choice. Back when Kennedy was a thorn in President Joe Biden’s side, threatening to run against him in the Democratic primary, the Post’s editorial board was all too happy to elevate him. Now the board condemns his nomination and tells us that it came out of a meeting with him last year “thinking he’s nuts on a lot of fronts.” The columnist Michael Godwin, who beamed on November 9 that Trump’s victory “offers the promise of progress on so many fronts that it already feels like Morning in America again,” was back a week later to complain that “it’s not a close call to say” that Kennedy and Matt Gaetz, Trump’s pick for attorney general, are “unfit” for the roles.

The lobbyists and editorialists are in good company, or at least in some sort of company. On Capitol Hill, Republican senators say they are shocked by many of Trump’s Cabinet picks. Senator Susan Collins of Maine, who notoriously professed surprise when Justices Neil Gorsuch and Brett Kavanaugh voted to overturn Roe v. Wade, is “shocked” at the Gaetz nomination. Gaetz’s House Republican colleagues are “stunned and disgusted.”

Reactions to Pete Hegseth’s nomination as secretary of defense are less vitriolic, if no less baffled. “Wow,” Senator Lisa Murkowski of Alaska told NBC. “I’m just surprised, because the names that I’ve heard for secretary of defense have not included him.” Senator Bill Cassidy of Louisiana was even blunter. “Who?” he said. “I just don’t know anything about him.”

[David A. Graham: The Trump believability gap]

If this is true, the senators could perhaps do with some better staff work. Hegseth was a real possibility to lead the Department of Veterans Affairs in the first Trump administration; more to the point, he was a prominent figure on Fox News, which is a dominant force in the Republican Party, from whose ranks Trump has repeatedly drawn appointees.

Staffers at the affected agencies have also expressed shock and horror at the prospect of an Attorney General Gaetz, a Defense Secretary Hegseth, or a Director of National Intelligence Tulsi Gabbard.

Ordinary Americans may also be taken aback. As I reported last month, Trump critics were concerned about a “believability gap,” in which voters opposed some of Trump’s big policy ideas, sometimes quite strongly, but just didn’t trust that he would really do those things. Although they perhaps deserve more grace than the Republican officials and power brokers who are astonished, they also had ample warning about who Trump is and how he’d govern.

Throughout his presidential campaign, Trump vowed to deport undocumented immigrants en masse. He’s appointing officials such as Stephen Miller and Tom Homan who are committed to that, and yesterday morning, Trump confirmed on Truth Social a report that he would declare a national emergency and use the military to conduct mass deportations. And yet, when the roundups start in January, many people are somehow going to be taken by surprise.

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Robert F. Kennedy Jr., the nominee to be the next secretary of Health and Human Services, is America’s most prominent vaccine skeptic. An advocacy organization that he founded and chaired has called the nation’s declining child-immunization rates “good news,” and referred to parents’ lingering doubts about routine shots as COVID-19’s “silver lining.” Now Kennedy may soon be overseeing the cluster of federal agencies that license and recommend vaccines, as well as the multibillion-dollar program that covers the immunization of almost half the nation’s children.

Which is to say that America’s most prominent vaccine skeptic could have the power to upend, derail, or otherwise louse up a cornerstone of public health. Raising U.S. vaccination rates to where they are today took decades of investment: In 1991, for example, just 82 percent of toddlers were getting measles shots; by 2019, that number had increased to 92 percent. The first Trump administration actually presided over the historic high point for the nation’s immunization services; now the second may be focused on promoting vaccines’ alleged hidden harms. Kennedy has said that he doesn’t want to take any shots away, but even if he were to emphasize “choice,” his leadership would be a daunting test of Americans’ commitment to vaccines.

In many ways, the situation is unprecedented: No one with Kennedy’s mix of inexperience and paranoid distrust has ever held the reins at HHS. He was trained as a lawyer and has no training in biostatistics or any other research bona fides—the sorts of qualifications you’d expect from someone credibly evaluating vaccine efficacy. But the post-pandemic era has already given rise to at least one smaller-scale experiment along these lines. In Florida, vaccine policies have been overseen since 2021 by another noted skeptic of the pharmaceutical industry, State Surgeon General Joseph Ladapo. (Kennedy has likened Ladapo to Galileo—yes, the astronomer who faced down the Roman Inquisition.) Under Ladapo’s direction, the state has aggressively resisted federal guidance on COVID-19 vaccination, and its department of health has twice advised Floridians not to get mRNA-based booster shots. “These vaccines are not appropriate for use in human beings,” Ladapo declared in January. His public-health contrarianism has also started spilling over into more routine immunization practices. Last winter, during an active measles outbreak at a Florida school, Ladapo abandoned standard practice and allowed unvaccinated children to attend class. He also seemed to make a point of not recommending measles shots for any kids who might have needed them.

Jeffrey Goldhagen, a pediatrics professor at the University of Florida and the former head of the Duval County health department, believes that this vaccine skepticism has had immense costs. “The deaths and suffering of thousands and thousands of Floridians” can be linked to Ladapo’s policies, he said, particularly regarding COVID shots. But in the years since Ladapo took office, Florida did not become an instant outlier in terms of COVID vaccination numbers, nor in terms of age-adjusted rates of death from COVID. And so far at least, the state’s performance on other immunization metrics is not far off from the rest of America’s. That doesn’t mean Florida’s numbers are good: Among the state’s kindergarteners, routine-vaccination rates have dropped from 93.3 percent for the kids who entered school in the fall of 2020 to 88.1 percent in 2023, and the rate at which kids are getting nonmedical exemptions from vaccine requirements went up from 2.7 to 4.5 percent over the same period. These changes elevate the risk of further outbreaks of measles, or of other infectious diseases that could end up killing children—but they’re not unique to Ladapo’s constituents. National statistics have been moving in the same direction. (To wit: The rate of nonmedical exemptions across the U.S. has gone up by about the same proportion as Florida’s.)

All of these disturbing trends may be tied to a growing suspicion of vaccines that was brought on during COVID and fanned by right-wing influencers. Or they could be a lingering effect of the widespread lapse in health care in 2020, during which time many young children were missing doses of vaccines. (Kids who entered public school in 2023 might still be catching up.)

In any case, other vaccination rates in Florida look pretty good. Under Ladapo, the state has actually been gaining on the nation as a whole in terms of flu shots for adults and holding its own on immunization for diphtheria, tetanus, and pertussis in toddlers. Even Ladapo’s outlandish choice last winter to allow unvaccinated kids back into a school with an active measles outbreak did not lead to any further cases of disease. In short, as I noted back in February, Ladapo’s anti-vaccine activism has had few, if any, clear effects. (Ladapo did not respond when I reached out to ask why his policies might have failed to sabotage the state’s vaccination rates.)

  

If Florida’s immunization rates have been resilient, then America’s may hold up even better in the years to come. That’s because the most important vaccine policies are made at the state and local levels, Rupali Limaye, a professor and scholar of health behavior at Johns Hopkins University, told me. Each state decides whether and how to mandate vaccines to school-age children, or during a pandemic. The states and localities are then responsible for giving out (or choosing not to give out) whichever vaccines are recommended, and sometimes paid for, by the federal government.  

But the existence of vaccine-skeptical leadership in Washington, and throughout the Republican Party, could still end up putting pressure on local decision makers, she continued, and could encourage policies that support parental choice at the expense of maximizing immunization rates. As a member of the Cabinet, Kennedy would also have a platform that he’s never had before, from which he can continue to spread untruths about vaccines. “If you start to give people more of a choice, and they are exposed to disinformation and misinformation, then there is that propensity of people to make decisions that are not based on evidence,” Limaye said. (According to The New York Times, many experts say they “worry most” about this aspect of Kennedy’s leadership.)

How much will this really matter, though? The mere prominence of Kennedy’s ideas may not do much to drive down vaccination rates on its own. Noel Brewer, a behavioral scientist and public-health professor at the UNC Gillings School of Global Public Health, told me that attempts to change people’s thoughts and feelings about vaccines are often futile; research shows that talking up the value of getting shots has little impact on behavior. By the same token, one might reasonably expect that talking down the value of vaccines (as Kennedy and Ladapo are wont to do) would be wasted effort too. “It may be that having a public figure talking about this has little effect,” Brewer said.

Indeed, much has been made of Kennedy’s apparent intervention during the 2019 measles crisis in Samoa. He arrived there for a visit in the middle of that year, not long after measles immunizations had been suspended, and children’s immunization rates had plummeted. (The crisis began when two babies died from a vaccine-related medical error in 2018.) Kennedy has been linked to the deadly measles outbreak in the months that followed, but if his presence really did give succor to the local anti-vaccine movement, that movement’s broader aims were frustrated: The government declared a state of emergency that fall, and soon the measles-vaccination rate had more than doubled.

As head of HHS, though, Kennedy would have direct control over the federal programs that do the sort of work that has been necessary in Samoa, and provide access to vaccines to those who need them most. For example, he’d oversee the agencies that pay for and administer Vaccines for Children, which distributes shots to children in every state. All the experts I spoke with warned that interference with this program could have serious consequences. Other potential actions, such as demanding further safety studies of vaccines and evidence reviews, could slow down decision making and delay the introduction of new vaccines.

Kennedy would also have a chance to influence the nation’s vaccine requirements for children, as well as its safety-and-monitoring system, at the highest levels. He’d be in charge of selecting members for the Advisory Committee on Immunization Practices, which makes recommendations on vaccines that are usually adopted by the states and result in standardized insurance coverage. He’d also oversee the head of the CDC, who in turn has the authority to overrule or amend individual ACIP recommendations.

Even if he’s not inclined to squelch any determinations outright, Kennedy’s goal of giving parents latitude might play out in other ways. Brewer, who is currently a voting member of ACIP (but emphasized that he was not speaking in that capacity), said that the committee can issue several different types of rulings, some of which roughly correspond to ACIP saying that Americans should rather than may get a certain vaccine. That distinction can be very consequential, Brewer said: Shots that are made “routine” by ACIP get prioritized in doctor’s offices, for instance, while those that are subject to “shared clinical decision-making” may be held for patients who ask for them specifically. Shifting the country’s vaccination program from a should to a may regime “would destroy uptake,” Brewer told me.

Those would seem to be the stakes. The case study of vaccine-skeptical governance that we have in Florida may not look so dire—at least in the specifics. But Kennedy’s ascendancy could be something more than that: He could steer the public-health establishment off the course that it’s been on for many years, and getting back to where we are today could take more years still.

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Donald Trump appears to experience the world through the glow of a television screen. He has long placed a premium on those who look the part in front of the camera. Paging Dr. Mehmet Oz.

Trump has picked Oz to lead the Centers for Medicare and Medicaid Services. CMS, as the agency is known, falls under the Department of Health and Human Services (HHS). Last week, Trump nominated Robert F. Kennedy Jr. to serve as HHS secretary. As you may have guessed, Kennedy and Oz are not only friends but kindred spirits. Oz is a global adviser at iHerb, a for-profit company that offers “Earth’s best-curated selection of health and wellness products at the best possible value.” He and Kennedy, two relative outsiders, are now positioned to enjoy a symbiotic relationship within Trump’s chaotic ecosystem.

Oz was last seen running for a Pennsylvania Senate seat in 2022. He lost to John Fetterman, who, despite dealing with the aftereffects of a stroke, carried the state by five points. Throughout that race, Oz struggled to combat the perception that he was a charlatan and carpetbagger who primarily lived in New Jersey. (Fetterman’s team repeatedly tagged Oz as an out-of-touch elitist, trolling him, for example, when he went grocery shopping for crudités and lamented high prices.) After that electoral defeat, Oz’s political dreams seemed all but dashed. But he wisely remained loyal to Trump—a person who has the ability to change trajectories on a whim.

In the pre-Trump era, it might have been a stretch to describe CMS administrator as an overtly political position. But Oz’s objective under Trump couldn’t be clearer. In a statement, Trump, using his reliably perplexing capitalization, telegraphed that Oz will bring a certain ethos to the job—a little MAGA, a little MAHA. Oz, Trump promised, will “cut waste and fraud within our Country’s most expensive Government Agency, which is a third of our Nation’s Healthcare spend, and a quarter of our entire National Budget.” And, because he’s Trump, he mentioned Oz’s nine daytime Emmy Awards.

Some 150 million Americans currently rely on the agency’s insurance programs, including Medicaid, Medicare, and Obamacare. Oz has been a proponent of Medicare Advantage for All. Though that sounds like the Medicare for All initiative championed by progressives such as Senator Bernie Sanders, the two programs are quite different. At its core, Medicare for All would set the U.S. on a path toward nationalizing health care. Trump would never go for that. But Medicare Advantage already exists within America’s patchwork private/public system, and Oz might push to strengthen it. He could also face budgetary pressure to weaken it. Oz’s own health-care views haven’t remained consistent. Though he once praised the mandatory universal models of Germany and Switzerland, as a Republican politician he threw his support behind privatized Medicare.

When asked about Oz’s nomination, Fetterman, his former opponent, told CNN: “As long as he’s willing to protect and preserve Medicaid and Medicare, I’m voting for the dude.” Some people were pissed. Victoria Perrone, who served as the director of operations on Fetterman’s Senate campaign, called out her old boss on social media: “Dr. Oz broke his pledge to ‘do no harm’ when he said red onions prevent ovarian cancer. My sis died of OC in 6/2022. This is a huge personal betrayal to me. We know he won’t protect the Medicaid that paid for her treatments,” Perrone posted on X. “I feel like I’ve been duped and 2 years of working on your campaign was a waste,” she added.

The above argument is illustrative of another reality Trump acknowledged in announcing his pick: “Make America Healthy Again” keeps growing. Oz, Trump declared, “will work closely with Robert F. Kennedy Jr. to take on the illness industrial complex, and all the horrible chronic diseases left in its wake.” He went a step further, promising that Oz will bring “a strong voice to the key pillars of the MAHA Movement.” Oz holds degrees from Harvard and Penn, and he worked as a professor of surgery at Columbia. In spite of that pedigree, Oz has spent years facing credible accusations of medical quackery for his endorsement of dietary supplements. In 2014, he received a dramatic dressing-down on Capitol Hill. Senator Claire McCaskill read three statements that Oz had made on his eponymous show:

“You may think magic is make-believe, but this little bean has scientists saying they’ve found the magic weight-loss cure for every body type: It’s green coffee extract.”

“I’ve got the No. 1 miracle in a bottle to burn your fat: It’s raspberry ketone.”

“Garcinia cambogia: It may be the simple solution you’ve been looking for to bust your body fat for good.”

Oz’s defense that day was that his job was to be a “cheerleader” for the Dr. Oz audience. “I actually do personally believe in the items I talk about in the show. I passionately study them. I recognize oftentimes they don’t have the scientific muster to present as fact, but nevertheless, I would give my audience the advice I give my family,” he testified.

He emerged from that hearing largely unscathed. Two years later, Oz would go on to read what he claimed were Trump’s medical records on that same show. He famously praised Trump’s testosterone levels and supposed all-around health. Four years after that, once Trump was president, Oz sent emails to White House officials, including Trump’s son-in-law Jared Kushner, pushing them to rush patient trials for hydroxychloroquine, an unproven treatment for COVID.

In the next Trump administration, those are the sorts of exchanges Oz could be having with Kennedy—or with Trump himself. How did we get here? Oz landed this gig because he’s good on TV, yes, but also because, when he entered the political arena, he fully aligned himself with Trump. The 47th president rewards loyalty. If there’s one thing that’s become clear from his administration nominations so far, it’s that.

Some of Trump’s appointments will be less consequential than others. Anything involving the health and well-being of tens of millions of Americans is inarguably serious. Oz’s confirmation is not guaranteed, but his selection has already confirmed that nothing about Trump 2.0 is mere bluster.

Related:

Trump is coming for Obamacare again. (From January) Why is Dr. Oz so bad at Twitter? (From 2022)

Here are three new stories from The Atlantic:

Another theory of the Trump movement What the men of the internet are trying to prove Arash Azizi: The problem with boycotting Israel

Today’s News

Republican members of the House Ethics Committee blocked the release of the investigation into the sexual-misconduct and drug-use allegations against former Representative Matt Gaetz. Jose Ibarra, who was found guilty of killing Laken Riley on the University of Georgia campus, was sentenced to life in prison without possibility of parole. Trump tapped former WWE CEO Linda McMahon, who previously led the U.S. Small Business Administration during Trump’s first term, to be the secretary of education.

Dispatches

The Weekly Planet: Drought is an immigration issue, and Trump’s climate policies are designed to ignore that, Zoë Schlanger writes.

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Evening Read

Video by Joanne Imperio / The Atlantic. Sources: Archive Films / Getty; Internet Archive; Prelinger Associates / Getty.

Put Down the Vacuum

By Annie Lowrey

The other night, a friend came over. A dear friend. A friend who has helped me out when I’ve been sick, and who brought over takeout when I had just given birth. Still, before he arrived, I vacuumed.

I thought about this while reading the Gender Equity Policy Institute’s recent report on gender and domestic labor. The study finds that mothers spend twice as much time as fathers “on the essential and unpaid work” of taking care of kids and the home, and that women spend more time on this than men, regardless of parental and relationship status. “Simply being a woman” is the instrumental variable, the study concludes.

Read the full article.

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Stephanie Bai contributed to this newsletter.

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