The institute founded by President George W. Bush issued an urgent call on Wednesday for Congress to renew the global AIDS program known as PEPFAR, a centerpiece of Mr. Bush’s foreign policy legacy that has become a victim of abortion politics on Capitol Hill.PEPFAR — the President’s Emergency Plan for AIDS Relief — has saved an estimated 25 million lives since Mr. Bush founded it 20 years ago. The $6.9 billion program, which must be reauthorized by Congress every five years, has long had bipartisan support and is often cited as a powerful example of America’s moral leadership in the world.But it faces an uncertain future. The legislation authorizing the program lapsed on Sept. 30 after some House Republicans claimed, without evidence, that the Biden administration was using it to promote abortion overseas. Those Republicans want to attach abortion-related restrictions to PEPFAR that would doom its reauthorization in the Democratic-controlled Senate.The Bush Institute, which is nonpartisan, has thus far been reluctant to step into the debate.But in a bipartisan letter signed by more than 30 retired ambassadors, foreign policy luminaries and organizations — including the Carter Center, founded by former President Jimmy Carter — the institute pleaded with Congress to reauthorize the program. It argued that in addition to saving lives, PEPFAR was countering the rising influence of Russia and China and burnishing America’s reputation as a global leader.“PEPFAR is a model of United States leadership and a source of great national pride,”the letter said. “It is one of the most successful international development programs since World War II. Abandoning it abruptly now would send a bleak message, suggesting we are no longer able to set aside our politics for the betterment of democracies and the world.”For now, at least, PEPFAR is continuing to operate. But advocates fear that, without the underlying authorization, the program will be subject to budget cuts or even elimination in the future. And they say the program is weaker without the bipartisan imprimatur of Congress.“The classic conservative talking point is that we don’t want to fund programs that aren’t authorized,” said Keifer Buckingham, the advocacy director at the Open Society Foundations and a longtime PEPFAR supporter. “It’s also fair to say that in global health and global health politics, optics matter,” she added.Mr. Bush himself did not sign the institute’s letter; people close to him have said he is trying to use his voice judiciously. The lead individual signer is Dr. Deborah L. Birx, a senior fellow at the Bush Institute who ran PEPFAR under Presidents Barack Obama and Donald J. Trump, and also served as Mr. Trump’s coronavirus response coordinator. But Mr. Bush has made no secret that he wants the program reauthorized. Over the summer, he discussed its future with Representative Michael McCaul, a Texas Republican and the chairman of the House Foreign Affairs Committee, over lunch at the Bush family compound in Maine. In mid-September, he published an opinion piece in The Washington Post urging Congress to save it.At that time, PEPFAR’s supporters on Capitol Hill thought they were making progress toward breaking the logjam. Representative Barbara Lee, a California Democrat who is a leading proponent of the program, said in an interview then that she was working with a freshman Republican, Representative John James of Michigan, on a bipartisan reauthorization bill.But the effort was put on hold last month in the face of a threatened government shutdown, and it remains stalled because the House is in a state of dysfunction with Republicans unable to choose a speaker.

The Biden administration is restarting a program to provide free rapid tests through the mail.The Biden administration, looking ahead to a possible winter surge of Covid-19, announced on Wednesday that it was reviving its program of offering Americans free coronavirus tests through the mail and would spend more than $600 million to buy tests from a dozen domestic manufacturers.The website for the program, covidtests.gov, will begin accepting orders on Monday, and households will be able to receive four tests. Dawn O’Connell, the assistant secretary for preparedness and response at the Health and Human Services Department, said the money would fund the purchase of 200 million tests to replenish the nation’s stockpile as tests are sent out.But a byproduct of the program, Ms. O’Connell said, is that it will shore up domestic manufacturing capacity in the event of another serious coronavirus surge. Coronavirus hospitalizations have been on the rise in the United States, though they remain low compared with earlier stretches of the pandemic, and free tests are now harder to come by for many Americans. While private insurers had previously been required to cover up to eight at-home tests per month, that requirement ended when the Biden administration allowed the public health emergency for the coronavirus to expire in May.

One by one, doctors who handle high-risk pregnancies are disappearing from Idaho — part of a wave of obstetricians fleeing restrictive abortion laws and a hostile state legislature. Dr. Caitlin Gustafson, a family doctor who also delivers babies in the tiny mountain town of McCall, is among those left behind, facing a lonely and uncertain future.When caring for patients with pregnancy complications, Dr. Gustafson seeks counsel from maternal-fetal medicine specialists in Boise, the state capital two hours away. But two of the experts she relied on as backup have packed up their young families and moved away, one to Minnesota and the other to Colorado.All told, more than a dozen labor and delivery doctors — including five of Idaho’s nine longtime maternal-fetal experts — will have either left or retired by the end of this year. Dr. Gustafson says the departures have made a bad situation worse, depriving both patients and doctors of moral support and medical advice.“I wanted to work in a small family town and deliver babies,” she said. “I was living my dream — until all of this.”Idaho’s obstetrics exodus is not happening in isolation. Across the country, in red states like Texas, Oklahoma and Tennessee, obstetricians — including highly skilled doctors who specialize in handling complex and risky pregnancies — are leaving their practices. Some newly minted doctors are avoiding states like Idaho.The departures may result in new maternity care deserts, or areas that lack any maternity care, and they are placing strains on physicians like Dr. Gustafson who are left behind. The effects are particularly pronounced in rural areas, where many hospitals are shuttering obstetrics units for economic reasons. Restrictive abortion laws, experts say, are making that problem much worse.“This isn’t an issue about abortion,” said Dr. Stella Dantas, the president-elect of the American College of Obstetricians and Gynecologists. “This is an issue about access to comprehensive obstetric and gynecologic care. When you restrict access to care that is based in science, that everybody should have access to — that has a ripple effect.”Idaho doctors operate under a web of abortion laws, including a 2020 “trigger law” that went into effect after the Supreme Court eliminated the constitutional right to abortion by overturning Roe v. Wade last year. Together, they create one of the strictest abortion bans in the nation. Doctors who primarily provide abortion care are not the only medical professionals affected; the laws are also impinging on doctors whose primary work is to care for expectant mothers and babies, and who may be called upon to terminate a pregnancy for complications or other reasons.Idaho bars abortion at any point in a pregnancy with just two exceptions: when it is necessary to save the life of the mother and in certain cases of rape or incest, though the victim must provide a police report. A temporary order issued by a federal judge also permits abortion in some circumstances when a woman’s health is at risk. Doctors convicted of violating the ban face two to five years in prison.Dr. Gustafson, 51, has so far decided to stick it out in Idaho. She has been practicing in the state for 20 years, 17 of them in McCall, a stunning lakeside town of about 3,700 people.Dr. Gustafson, a family doctor who also delivers babies, has been practicing in Idaho for 20 years. Angie Smith for The New York TimesShe sees patients at the Payette Lakes Medical Clinic, a low-slung building that evokes the feeling of a mountain lodge, tucked into a grove of tall spruces and pines. It is affiliated with St. Luke’s Health System, the largest health system in the state.On a recent morning, she was awakened at 5 a.m. by a call from a hospital nurse. A pregnant woman, two months shy of her due date, had a ruptured membrane. In common parlance, the patient’s water had broken, putting the mother and baby at risk for preterm delivery and other complications.Dr. Gustafson threw on her light blue scrubs and her pink Crocs and rushed to the hospital to arrange for a helicopter to take the woman to Boise. She called the maternal-fetal specialty practice at St. Luke’s Boise Medical Center, the group she has worked with for years. She did not know the doctor who was to receive the patient. He had been in Idaho for only one week.“Welcome to Idaho,” she told him.In rural states, strong medical networks are critical to patients’ well-being. Doctors are not interchangeable widgets; they build up experience and a comfort level in working with one another and within their health care systems. Ordinarily, Dr. Gustafson might have found herself talking to Dr. Kylie Cooper or Dr. Lauren Miller on that day.But Dr. Cooper left St. Luke’s in April for Minnesota. After “many agonizing months of discussion,” she said, she concluded that “the risk was too big for me and my family.”Dr. Miller, who had founded the Idaho Coalition for Safe Reproductive Health Care, an advocacy group, moved to Colorado. It is one thing to pay for medical malpractice insurance, she said, but quite another to worry about criminal prosecution.“I was always one of those people who had been super calm in emergencies,” Dr. Miller said. “But I was finding that I felt very anxious being on the labor unit, just not knowing if somebody else was going to second-guess my decision. That’s not how you want to go to work every day.”The vacancies have been tough to fill. Dr. James Souza, the chief physician executive for St. Luke’s Health System, said the state’s laws had “had a profound chilling effect on recruitment and retention.” He is relying in part on temporary, roving doctors known as locums — short for the Latin phrase locum tenens, which means to stand in place of.He likens labor and delivery care to a pyramid, supported by nurses, midwives and doctors, with maternal-fetal specialists at its apex. He worries the system will collapse.In rural states like Idaho, strong medical networks are critical to patients’ well-being. Angie Smith for The New York Times“The loss of the top of a clinical pyramid means the pyramid falls apart,” Dr. Souza said.Some smaller hospitals in Idaho have been unable to withstand the strain. Two closed their labor and delivery units this year; one of them, Bonner General Health, a 25-bed hospital in Sandpoint, in northern Idaho, cited the state’s “legal and political climate” and the departure of “highly respected, talented physicians” as factors that contributed to its decision.Other states are also seeing obstetricians leave. In Oklahoma, where more than half of the state’s counties are considered maternity care deserts, three-quarters of obstetrician-gynecologists who responded to a recent survey said they were either planning to leave, considering leaving or would leave if they could, said Dr. Angela Hawkins, the chair of the Oklahoma section of the American College of Obstetricians and Gynecologists.The previous chair, Dr. Kate Arnold, and her wife, also an obstetrician, moved to Washington, D.C., after the Supreme Court overturned Roe in Dobbs v. Jackson Women’s Health Organization. “Before the change in political climate, we had no plans on leaving,” Dr. Arnold said.In Tennessee, where one-third of counties are considered maternity care deserts, Dr. Leilah Zahedi-Spung, a maternal-fetal specialist, decided to move to Colorado not long after the Dobbs ruling. She grew up in the South and felt guilty about leaving, she said.Tennessee’s abortion ban, which was softened slightly this year, initially required an “affirmative defense,” meaning that doctors faced the burden of proving that an abortion they had performed was medically necessary — akin to the way a defendant in a homicide case might have to prove he or she acted in self-defense. Dr. Zahedi-Spung felt as if she had “quite the target on my back,” she said — so much so that she hired her own criminal defense lawyer.“The majority of patients who came to me had highly wanted, highly desired pregnancies,” she said. “They had names, they had baby showers, they had nurseries. And I told them something awful about their pregnancy that made sure they were never going to take home that child — or that they would be sacrificing their lives to do that. I sent everybody out of state. I was unwilling to put myself at risk.”Dr. Leilah Zahedi-Spung, a maternal-fetal specialist, decided to move from Tennessee to Colorado not long after the Supreme Court overturned Roe v. Wade.Joanna Kulesza for The New York TimesPerhaps nowhere has the departure of obstetricians been as pronounced as in Idaho, where Dr. Gustafson has been helping to lead an organized — but only minimally successful — effort to change the state’s abortion laws, which have convinced her that state legislators do not care what doctors think. “Many of us feel like our opinion is being discounted,” she said.Dr. Gustafson worked one day a month at a Planned Parenthood clinic in a Boise suburb until Idaho imposed its near-total abortion ban; she now has a similar arrangement with Planned Parenthood in Oregon, where some Idahoans travel for abortion care. She has been a plaintiff in several lawsuits challenging Idaho’s abortion policies. Earlier this year, she spoke at an abortion rights rally in front of the State Capitol.In interviews, two Republican state lawmakers — Representatives Megan Blanksma, the House majority leader, and John Vander Woude, the chair of the House Health and Welfare Committee — said they were trying to address doctors’ concerns. Mr. Vander Woude acknowledged that Idaho’s trigger law, written before Roe fell, had affected everyday medical practice in a way that lawmakers had not anticipated.“We never looked that close, and what exactly that bill said and how it was written and language that was in it,” he said. “We did that thinking Roe v. Wade was never going to get overturned. And then when it got overturned, we said, ‘OK, now we have to take a really close look at the definitions.’”Mr. Vander Woude also dismissed doctors’ fears that they would be prosecuted, and he expressed doubt that obstetricians were really leaving the state. “I don’t see any doctor ever getting prosecuted,” he said, adding, “Show me the doctors that have left.”During its 2023 session, the Legislature clarified that terminating an ectopic pregnancy or a molar pregnancy, a rare complication, would not be defined as abortion — a move that codified an Idaho Supreme Court ruling. Lawmakers also eliminated an affirmative defense provision.But lawmakers refused to extend the tenure of the state’s Maternal Mortality Review Committee, an expert panel on which Dr. Gustafson served that investigated pregnancy-related deaths. The Idaho Freedom Foundation, a conservative group, testified against it and later called it an “unnecessary waste of tax dollars” — even though the annual cost, about $15,000, was picked up by the federal government.That was a bridge too far for Dr. Amelia Huntsberger, the Idaho obstetrician who helped lead a push to create the panel in 2019. She recently moved to Oregon. “Idaho calls itself a quote ‘pro-life state,’ but the Idaho Legislature doesn’t care about the death of moms,” she said.Most significantly, the Legislature rejected a top priority of Dr. Gustafson and others in her field: amending state law so that doctors would be able to perform abortions when the health — not just the life — of the mother is at risk. It was almost too much for Dr. Gustafson. She loves living in Idaho, she said. But when asked if she had thought about leaving, her answer was quick: “Every day.”

A decades-old program created by President George W. Bush to combat AIDS around the world is at risk of being sucked into a partisan dispute over abortion, with some Republicans threatening to block its renewal.Nancy Pelosi, the Democratic former House speaker, and George W. Bush, the Republican former president, do not agree on much. But earlier this year, they joined a high-powered gathering in Washington — with the Irish rock star Bono on video from Dublin — to mark the 20th anniversary of America’s biggest and, arguably, most successful foreign aid program.Mr. Bush created that program, the President’s Emergency Program for AIDS Relief, in 2003. In the two decades since, PEPFAR, as it is known, has saved 25 million lives and served as a powerful tool for soft diplomacy, a symbol of America’s moral leadership in the world. It has had extraordinary support from a bipartisan coalition of liberals and Christian conservatives.But now PEPFAR is in danger of becoming a victim of abortion politics — just as the State Department is reorganizing to make the program permanent.The program is set to expire at the end of September. But House Republicans are not moving forward with a bill to reauthorize it for another five years, because abortion opponents — led by a G.O.P. congressman who has long been a supporter of PEPFAR — are insisting on adding abortion-related restrictions.The stalemate is the latest example of how Republicans are using their majority in the House of Representatives to impose their conservative views on social policy throughout the federal government. They have focused in particular on abortion, a year after the Supreme Court overturned Roe v. Wade and, with it, the right to legal abortion. Earlier this summer, House Republicans loaded up the annual military policy bill that has long been bipartisan with provisions to limit abortion access and transgender care.The fight over PEPFAR, a $7 billion-a-year program that operates in more than 50 countries, is similar, because it is a broadly bipartisan program that now appears at risk of being sucked into a partisan fight over cultural and social issues.PEPFAR continues to have wide support, including from Representative Michael McCaul of Texas, the Republican chairman of the Foreign Affairs Committee, which oversees the program and approve the reauthorization legislation. But so far, Mr. McCaul has not advanced it because of the objections of abortion foes, including his Republican colleague, Representative Christopher H. Smith of New Jersey, one of the leading anti-abortion voices in Congress who also helped draft the legislation creating PEPFAR.Representative Christopher H. Smith of New Jersey wants PEPFAR funding to include restrictions barring the program from partnering with organizations that provide abortion services.Pool photo by Ken CedenoMr. Smith now says he will not agree to renew the program unless it is subject to the so-called Mexico City policy — enacted by Republican presidents but lifted by Democrats, including President Biden — that would bar the program from partnering with any organization that provides abortion services, no matter the source of the funding.That is a non-starter for Democrats, who are demanding a “clean” five-year reauthorization — one with no added policy restrictions.“We’ve done clean reauthorizations for 20 years,” said Representative Barbara Lee, Democratic of California and a chief sponsor of PEPFAR.But there is a substantial stumbling block: Three influential outside groups that oppose abortion — the Family Research Council, the Heritage Foundation’s political action arm and Susan B. Anthony Pro-Life America — have sided with Mr. Smith and intend to “score” the vote when they compile their annual ratings of members of Congress. A vote for renewing PEPFAR without the anti-abortion language would be counted as a demerit, making it politically toxic for most Republicans.The situation has alarmed champions of the program. In an email, Bono called the impasse “madness,” and called on Congress to “protect the bipartisan commitment to keeping politics out of PEPFAR.”Mr. McCaul said he is “talking to supporters both inside and outside the government, and working with my colleagues on both sides of the aisle in the House and the Senate” to resolve the dispute. He has also been texting with Bono, who in turn has been in touch with congressional leaders on the matter.A senior White House official, speaking on the condition of anonymity to describe the negotiations, said on Thursday that the White House was “engaging closely with Congress at senior levels” in pursuit of a straight five-year reauthorization.The program is an important legacy for Mr. Bush and other Republicans of his era, including Bill Frist, the former Senate majority leader, and Rick Santorum, a former senator from Pennsylvania.President George W. Bush at the White House in 2003 with a choir from Uganda made up of children who had been orphaned by H.I.V., AIDS or conflict.Doug Mills/The New York Times“I look back on the things I did as a member of Congress, and feel like I was able, as the pro-life warrior in the United States Senate, to forge a compromise to get conservatives to support this,” Mr. Santorum said in an interview. “It’s been a great thing for our country, and it’s been a great thing for humanity.”Last week, Mr. Santorum publicly pleaded for a “five-year, clean extension” in an opinion essay in the conservative outlet Newsmax. He said he intended to use Congress’s upcoming August recess to try to forge a compromise.But in recent months, Mr. Smith, the New Jersey Republican, and right-wing groups have begun accusing the Biden administration of injecting progressive politics into the program.In late May, a Heritage Foundation scholar published an essay in The Hill arguing that PEPFAR had become “increasingly politicized” and needed an overhaul. Mr. Smith followed in early June with “Dear Colleague” letter asserting that Mr. Biden had “hijacked PEPFAR.”In an interview, he pointed to new language in a PEPFAR country and regional operational plan calling for the program to partner with organizations that advocate for “institutional reforms in law and policy regarding sexual, reproductive and economic rights of women.” He argued that was code for a plan to “integrate abortion with H.I.V./AIDS work.”The document also says PEPFAR programs should “advance human rights and decriminalization for lesbian, gay, bisexual, transgender, queer, and intersex (L.G.B.T.Q.I.+) communities.” That did not sit well with the Family Research Council, whose chief lobbyist, Travis Weber, recently called PEPFAR “a massive slush fund for abortion and L.G.B.T. advocacy.” In an interview, he said he stood by those words.The senior White House official said that the “intentional focus on health equity is new” and that it came in response to requests from local communities for PEPFAR to “address barriers to health for children, adolescent girls and young women, and key populations.” The mention of women’s rights refers to ensuring that adolescent girls have access to schools, the official said.The Biden administration has added a footnote to the document clarifying that PEPFAR does not fund abortions, an assertion that Mr. Smith called “meaningless.”There is no evidence that PEPFAR or its foreign partners have used federal tax dollars to promote or perform abortions; U.S. law does not allow it. But some PEPFAR grantees, such as Population Services International, a global health nonprofit based in Washington, do provide abortion-related services with money from other sources.“The assertion is made by critics is that organizations like P.S.I. are working with U.S. money and involved in abortion — and shouldn’t that be illegal?” said Karl Hofmann, the group’s president and chief executive. “I guess my answer is, those two facts are true, and it’s not illegal.”Ms. Lee, the California Democrat, said she is working to “clarify this misrepresentation” being made by Mr. Smith.But the prospects for a five-year extension seem bleak.“We are in a very precarious place,” said Shepherd Smith, an evangelical Christian and a co-founder of Childrens AIDS Fund International, a nonprofit. He has organized other faith-based groups to issue a letter in support of reauthorization.Christopher H. Smith, the New Jersey congressman, has proposed an alternative: He persuaded fellow Republicans to insert language into a State Department spending bill that would allow PEPFAR to keep operating for a year without a new authorization, but subject to the anti-abortion restrictions. But even if that were to pass, certain programs — including one devoted to orphans and vulnerable children — would lapse after Sept. 30.And the symbolism of such a move would be devastating, PEPFAR’s backers say — a signal to other nations that the United States is abandoning its bipartisan commitment to end the AIDS epidemic by 2030, and that Washington is truly broken. It would also be a setback for global health; PEPFAR has created an infrastructure of clinics in poor nations that provide other services, including Covid-19 testing and vaccines.“This is not an issue that at all involves abortion — it’s about having health care facilities in countries to deal with pandemic type of challenges,” said Senator Benjamin L. Cardin, Democrat of Maryland. He called PEPFAR’s creation “one of the great moments in American foreign policy.”A man receives a Covid-19 vaccine in Kathantha, Sierra Leone. PEPFAR has created an infrastructure of clinics in poor nations that provide other services, including Covid-19 testing and vaccines.Finbarr O’Reilly for The New York TimesAs the debate plays out on Capitol Hill, the State Department official who oversees PEPFAR, Dr. John N. Nkengasong, is about to get a big promotion. On Tuesday, Secretary of State Antony J. Blinken is expected to announce the establishment of a new Bureau of Global Health Security and Diplomacy, to be led by Dr. Nkengasong. The idea is to integrate PEPFAR into the department’s broader global health work and to transition it out of emergency status.Since its inception, the program has invested more than $100 billion in fighting the global AIDS crisis. Independent analyses by K.F.F., formerly the Kaiser Family Foundation, have found that PEPFAR has helped improve maternal and child health and is “associated with large, significant declines in mortality” in countries where it has operated.Backers of the program are hoping that Mr. Bush will weigh in. Earlier this year, Emily Bass, an author and activist, sent the former president a signed copy of her book, “To End a Plague: America’s Fight to Defeat AIDS in Africa,” which chronicles the PEPFAR story.A few weeks ago, Ms. Bass said, Mr. Bush sent a letter thanking her.“Laura and I will remain invested in this mission for the rest of our lives,” he wrote.

The NewsPresident Biden has picked Dr. Paul Friedrichs, a military combat surgeon and retired Air Force major general who helped lead the Covid-19 response at the Pentagon, to head a new White House office created by Congress to prepare for and manage future biological threats.The White House said that it would announce the appointment on Friday and that it would take effect on Aug. 7. It will then be up to Dr. Friedrichs to set up the new office, the Office of Pandemic Preparedness and Response Policy, although the administration has christened it with a shorter Washington acronym: O.P.P.R.The appointment comes after a lengthy search for a director that ended where it began — at the White House, where Dr. Friedrichs recently joined the staff of the National Security Council as the senior director for global health security and biodefense. Before that, he served as the Joint Staff surgeon at the Pentagon, providing medical advice to the chairman of the Joint Chiefs of Staff. His planned selection was reported last week by The Washington Post.Dr. Paul Friedrichs at the Pentagon in 2021. He retired from the Air Force as a major general and recently joined the staff of the National Security Council.Alex Brandon/Associated PressWhy It Matters: Future health threats loom.The coronavirus pandemic has often been described as the worst public health crisis in a century. But experts agree that given current migration patterns and the way humans intersect with animal life, it will not be a century — and it might not even be a decade — before the next pandemic arrives.The era of Covid “czars” is over. Mr. Biden’s first White House coronavirus response coordinator, Jeffrey D. Zients, is now the White House chief of staff. The second coordinator, Dr. Ashish K. Jha, has gone back to his position as dean of the Brown University School of Public Health. Mr. Zients praised Dr. Friedrichs for his work on the pandemic, saying he would “lead the charge to ensure that never happens again.”Covid-19 made clear that a biological health threat does not respect boundaries — including the boundaries that divide federal agencies. The appointment of Dr. Friedrichs signals a more permanent and coordinated effort to prepare for and respond to pandemics — one that will last beyond the Biden administration and will be centralized within the White House.Background: Dr. Friedrichs served decades in the Air Force.In a February speech, Dr. Friedrichs reflected on his 37-year career in the Air Force and shared a bit about himself. His father served in the Navy at the end of World War II, and his mother was a Hungarian freedom fighter whose parents were killed by the Russians. His wife was an Army doctor when they met.He also reflected on the role of the military in fighting Covid-19, an effort that included helping to develop and distribute vaccines and providing medical support to struggling hospitals. “The military health system became the pinch-hitter that stepped in to help our civilian partners as we collectively struggled to work through that pandemic,” he said.What’s Next: The job will focus on preparedness.Dr. Friedrich’s new position gives him authority to oversee domestic biosecurity preparedness. He will need to work on the development of next-generation vaccines, ensure adequate supplies in the Strategic National Stockpile and ramp up surveillance to monitor for new biological threats. He will also have to work with Congress to secure funding for preparedness efforts.

After Justice Clarence Thomas cast doubt on the Supreme Court decision that established a right to contraception, reproductive rights advocates are pressing for new protections at the state level.One year after Justice Clarence Thomas said the Supreme Court should reconsider whether the Constitution affords Americans a right to birth control, Democrats and reproductive rights advocates are laying the groundwork for state-by-state battles over access to contraception — an issue they hope to turn against Republicans in 2024.The justice’s argument in Dobbs v. Jackson Women’s Health Organization, the case that overturned Roe v. Wade and the right to abortion, galvanized the reproductive rights movement. House Democrats, joined by eight Republicans, promptly passed legislation that would have created a national right to contraception. Republicans blocked a companion bill in the Senate.Now, reproductive rights advocates are pressing their case in the states. Even before Dobbs, some states had taken steps to protect the right to contraception, by either statute or constitutional amendment; 13 states and the District of Columbia currently have such protections, according to KFF, a health policy research organization.This month, the movement scored an important but little-noticed victory in Nevada, where the Democratic-controlled Legislature passed a bill, inspired by the defeated federal measure, that would guarantee a right to contraception. Gov. Joe Lombardo, a Republican, has not said whether he will sign it, and a spokeswoman said she could not speak to his views. Proponents of codifying such a right see Nevada as a test case.“It’s going to be up to Republicans to choose whether they want to protect the right to contraception,” Senator Edward J. Markey, Democrat of Massachusetts and the sponsor of the failed Senate bill, said in an interview. He called the Dobbs decision “a preview of coming atrocities.”On Wednesday, Mr. Markey and Representative Kathy Manning, Democrat of North Carolina, reintroduced legislation to create a national right to contraception. With the House now controlled by Republicans and Senate Democrats well short of the 60 votes needed to break a filibuster, the legislation is most likely dead on arrival in Washington.Polls have consistently shown broad bipartisan support for access to contraception, and while Republicans may not be eager to enshrine a right to it in federal law, neither do they generally want to ban it. Still, some opposition to birth control does exist.The Roman Catholic Church opposes any form of artificial birth control, arguing that some contraceptives “can cause early abortions.” Some abortion foes claim that two common methods of preventing pregnancy — intrauterine devices and emergency contraception, also known as the morning-after pill and marketed as Plan B — are “abortifacients” that prevent a fertilized egg from implanting in a woman’s uterus.But the American College of Obstetricians and Gynecologists says intrauterine devices work “mainly by preventing fertilization of an egg by sperm.” And the Food and Drug Administration said last year that Plan B does not prevent a fertilized egg from implanting in the womb and cannot be considered an abortion pill.Critics of codifying a right to contraception say such legislation amounts to a solution without a problem — or is purely a political gesture meant to put Republicans in a difficult spot and spur voters into rejecting them at the ballot box.“Most Republicans saw that as a political vote, not really a serious vote,” John Feehery, a Republican strategist, said of the vote on the House bill last year. “In the Republican coalition, there is a small but vocal element that is anti-contraception, but the vast majority of Republicans don’t have any interest in making contraception illegal.”Since the Dobbs decision, debates over birth control have also become increasingly tied up with abortion. Some Republicans who voted against the House bill complained that it would have sent more money to Planned Parenthood, an organization that is a target for many in the party because it is a major provider of abortions. Representative Cathy McMorris Rodgers, Republican of Washington, described the bill as a “Trojan horse for more abortions.”Writing for the majority in the Dobbs case, Justice Samuel A. Alito Jr. stressed that the ruling “concerns the constitutional right to abortion and no other right.” But in a concurring opinion, Justice Thomas said the Supreme Court should reconsider other rulings, including Griswold v. Connecticut, a 1965 decision that established the right of married couples to use contraception. He said the logic of the majority opinion in Dobbs undermined Griswold.Justice Clarence Thomas said the Supreme Court should reconsider Griswold v. Connecticut, a 1965 decision that established the right of married couples to use contraception.Allison V. Smith for The New York Times“For years, we asked elected officials around the country to pay more attention to the conflation of abortion and contraception,” said Clare Coleman, the president and chief executive of the National Family Planning & Reproductive Health Association, which represents health providers. “We shouldn’t have to answer the ‘Why are we worried?’ question anymore.”Ms. Coleman and her allies in the movement say that complacency is what cost American women the right to abortion. They also see what they regard as worrisome efforts to restrict access to birth control.In 2021, Republicans in Missouri tried to ban taxpayer funding for intrauterine devices and emergency contraception. Missouri is one of four states — the others are Arkansas, Mississippi and Texas — that have ejected Planned Parenthood, a major provider of birth control, from their Medicaid programs.At the same time, the federal family planning program known as Title X is being challenged in Texas, where a federal judge ruled late last year that it violated parents’ constitutional rights by permitting clinics to provide birth control to teenagers without parental consent. If the ruling is upheld, it could threaten access to contraceptives for minors nationwide.So far, though, the Dobbs case has not spawned the kind of widespread attacks on birth control that advocates feared. In fact, access to contraception has been expanded in a handful of red states, according to the Guttmacher Institute, which tracks reproductive health measures.In Indiana, Gov. Eric Holcomb signed legislation allowing pharmacists to prescribe birth control. In West Virginia, Gov. Jim Justice signed a bill requiring insurance plans to cover 12-month supplies of contraceptives from pharmacies. In Arkansas, Gov. Sarah Huckabee Sanders signed legislation requiring Medicaid to cover intrauterine devices and other long-acting reversible contraceptives for women who have just given birth. All are Republicans.The push for laws declaring a right to contraception comes as the F.D.A. is considering allowing birth control pills to be sold over the counter for the first time. A panel of advisers to the agency said last month that the benefits of over-the-counter contraception outweighed the risks. In anticipation of possible action by the F.D.A., Senate Democrats recently reintroduced legislation that would require insurers to cover over-the-counter contraception.But Senator Catherine Cortez-Masto, Democrat of Nevada and one of the bill’s chief sponsors, said she did not know if the measure’s backers could get any Republican support in the current post-Dobbs climate. “We think that we should,” she said, “but, you know, it’s a different and challenging time right now.”In North Carolina, the Dobbs case and abortion politics doomed a bill to affirm a right to contraception, said State Senator Lisa Grafstein, a Democrat who introduced the measure. Ms. Grafstein said in an interview that she had spoken to at least one Republican who was interested in becoming a co-sponsor.But that was before lawmakers in the state moved to ban most abortions after 12 weeks.State Senator Lisa Grafstein, a Democrat in North Carolina, introduced a contraception bill that was doomed by abortion politics.Kate Medley for The New York Times“Once the abortion debate took off, there wasn’t any more discussion of these kinds of issues,” Ms. Grafstein said. “The tenor of things has really changed a lot in terms of whether a conversation like that would even be possible at this point.”Even in Nevada — a state where voters codified a right to abortion through a referendum more than three decades ago, in 1990 — it was tough for the bill’s backers to get Republican support. Ultimately, a handful of Republicans voted for the measure. Its chief sponsor, Assemblywoman Selena Torres, a Democrat, said she was hopeful that the governor would sign it.“This was a very separate topic from abortion,” Ms. Torres said. “But I do think that the Dobbs decision is ultimately what drives this conversation.”Supporters of codifying a right to contraception are hoping Nevada will serve as a model for other states and will also put pressure on Republicans in Congress. Americans for Contraception, an advocacy group that has orchestrated the state-by-state strategy, ran attack ads last year against Republicans who voted against the House bill.The group says it has lined up Democratic state legislators in five more states — Arizona, Mississippi, Tennessee, Virginia and Wisconsin — to introduce bills next year to guarantee a right to contraception.“Last year, 195 House Republicans tried to get away with opposing the right to contraception by voting against a straightforward bill,” said Dana Singiser, a senior adviser to the group. “Nevada demonstrates that some of their colleagues at the state level recognize that supporting the right to contraception is a policy and a political no-brainer.”In Washington, there is a ready explanation for why so many Republicans voted against the House bill: Susan B. Anthony Pro-Life America, an anti-abortion group, decided to include the vote in its scorecard for lawmakers.The organization derided the measure as the “Payouts for Planned Parenthood Act” and said it would “trample conscience rights” in states that allow health providers or pharmacists to refuse to provide birth control. The group asserted that the bill’s definition of contraceptives — “any drug, device or biological product intended for use in the prevention of pregnancy” — was overly broad and could be construed to include abortion pills.“If you’re a Republican, you want to be seen as pro-life, and the Susan B. Anthony group, they help define who’s pro-life,” said Mr. Feehery, the Republican strategist, adding, “I think most Republicans would much rather be on the side of Susan B. Anthony than on the side of Planned Parenthood.”

President Biden said on Monday that he had selected Dr. Monica M. Bertagnolli, who has led the National Cancer Institute since October, to be the next director of the National Institutes of Health.WASHINGTON — President Biden will announce on Monday that he will nominate Dr. Monica M. Bertagnolli, a cancer surgeon who became the director of the National Cancer Institute in October, to be the next director of the National Institutes of Health, filling a position that has been vacant for more than a year.Dr. Bertagnolli is also a cancer patient. She announced late last year that she had she received a diagnosis of early breast cancer.In a statement shared by the White House, Mr. Biden called her a “world-class physician-scientist” who had “spent her career pioneering scientific discovery and pushing the boundaries of what is possible to improve cancer prevention and treatment for patients, and ensuring that patients in every community have access to quality care.”Dr. Bertagnolli will need to be confirmed by the Senate. She is the first female director of the National Cancer Institute, which is part of the National Institutes of Health. She would be only the second woman to lead the N.I.H. on a permanent basis.For Mr. Biden, cancer research is deeply personal. His elder son, Beau Biden, died of brain cancer in 2015 at age 46. Last year, the president set a goal of reducing the death rate from cancer by at least 50 percent over the next 25 years — part of an effort, he said then, to “supercharge” the cancer “moonshot” program he initiated and presided over when he was vice president.On Monday, Mr. Biden praised Dr. Bertagnolli for advancing that initiative and for her efforts to promote research on childhood cancers and programs to expand access to cancer clinical trials.The announcement of her nomination was not a surprise; a number of news organizations, including The New York Times, reported last month that the president planned to nominate Dr. Bertagnolli. It is not clear why there was a delay.Fighting cancer is also personal for Dr. Bertagnolli. In mid-December, she announced her diagnosis and said she was “thankful to be receiving excellent care” at Brigham and Women’s Hospital and Dana-Farber Cancer Institute, where she had worked as a surgical oncologist before taking the helm of the National Cancer Institute.She said then that her prognosis was good and that she had enrolled in a clinical trial. In an interview with NPR in February, she said she was still in treatment.“I went in for my regular mammogram expecting it to be negative like all the others and got a nasty surprise,” she said. “And so now I know what it feels like.” She added: “First thing I asked my doctors was, is there anything available for me? And there was a study available for me, and I signed on.”Only one woman, Dr. Bernadine P. Healy, an appointee of President George H.W. Bush, has led the National Institutes of Health on a permanent basis. Dr. Ruth Kirschstein, a longtime federal scientist and N.I.H. administrator, did two stints as the agency’s acting director.If confirmed, Dr. Bertagnolli would replace Dr. Lawrence A. Tabak, who has led the agency in an acting capacity since its last permanent director, Dr. Francis S. Collins, left his post in December 2021. Dr. Collins, an appointee of President Barack Obama, served in that job for more than 12 years.As N.I.H. director, Dr. Bertagnolli would lead one of the world’s premier research agencies, a collection of 27 institutes and centers focusing on cancer, infectious disease, heart and lung ailments, mental health and drug abuse, among other medical matters. With an annual budget of more than $47 billion, the N.I.H. funds research around the world.A daughter of Italian and French Basque immigrants, Dr. Bertagnolli grew up on a ranch in southwestern Wyoming, studied engineering as an undergraduate at Princeton University and attended medical school at the University of Utah. Before joining the federal government, she was a professor of surgery specializing in surgical oncology at Harvard Medical School.

The president is expected to pick Dr. Monica M. Bertagnolli, who last year became the director of the National Cancer Institute.WASHINGTON — President Biden plans to nominate Dr. Monica M. Bertagnolli, an oncologist who has run the National Cancer Institute for the past six months — and a cancer patient herself — to be the next director of the National Institutes of Health, an administration official said.If confirmed by the Senate, Dr. Bertagnolli would be only the second woman to serve as the medical research agency’s director on a permanent basis since its origins in the late 1800s. She is the first female director of the National Cancer Institute, which is part of the National Institutes of Health.The White House is expected to announced her selection in the coming days, the administration official said. A White House spokeswoman declined to comment, saying a decision on the new director was not yet final. The Wall Street Journal earlier reported on her emergence as Mr. Biden’s pick.Dr. Bertagnolli became the director of the National Cancer Institute, or N.C.I., in October. Two months later, she announced that she had received a diagnosis of early breast cancer and would begin treatment at Brigham and Women’s Hospital and Dana-Farber Cancer Institute in Boston, where she had worked as a surgical oncologist before joining the federal government. She said her prognosis was good.“I’m in a waiting period right now, and there are things we don’t know,” she said then. “But thanks to research funded by N.C.I., answers about the treatment that’s best for me will come in time.”If confirmed, Dr. Bertagnolli would lead one of the world’s premier medical research agencies, a collection of 27 separate institutes and centers focusing on a wide array of medical matters, including cancer, infectious disease, heart and lung ailments, mental health and drug abuse. A branch of the federal Health and Human Services Department, the National Institutes of Health has an annual budget of more than $47 billion, much of it dispersed around the world to finance basic medical research.Dr. Bertagnolli would replace Dr. Lawrence A. Tabak, who has served in an acting capacity since Dr. Francis S. Collins stepped down at the end of 2021 after more than 12 years as director.Only one woman — Dr. Bernadine P. Healy, who was appointed by President George H.W. Bush — has served as the agency’s director, although Dr. Ruth Kirschstein, a longtime federal scientist and N.I.H. administrator, served as acting director.Before joining the National Cancer Institute, Dr. Bertagnolli was a professor of surgery specializing in surgical oncology at Harvard Medical School. Her past research has focused on the gene mutation that spurs the development of gastrointestinal cancer and on the role that inflammation plays in the growth of cancer.Ellen V. Sigal, the founder and chairwoman of Friends of Cancer Research, a research and advocacy group, said she would be thrilled if the president selected Dr. Bertagnolli.“She has every perspective that one would want in an N.I.H. leader,” Ms. Sigal said. “She has basic science. She has clinical experience. She has proven leadership capacity — and now is a patient.”

Mr. Kennedy, a Democrat who plans to kick off his campaign this week, says he wants to make vaccines safer, but he is spreading misinformation by twisting facts out of context.WASHINGTON — Robert F. Kennedy Jr. stood before the Lincoln Memorial in January 2022 and condemned the federal government’s coronavirus response by railing against totalitarianism. Jews in Nazi Germany, he suggested, had more freedom than Americans facing vaccination mandates and school, church and business closures in the era of Covid-19.“Even in Hitler’s Germany, you could cross the Alps to Switzerland,” he told a crowd of flag-waving anti-vaccine enthusiasts at a “Defeat the Mandates” rally. “You could hide in an attic like Anne Frank did.”Mr. Kennedy later apologized, though it was not the first time he had invoked the Holocaust. Over the past two decades, as he has pursued what he calls “safe vaccine activism,” Mr. Kennedy has evolved from an environmental lawyer concerned about mercury poisoning into a crusader for individual liberty — a path that has landed him, a scion of a storied Democratic clan, in the unlikely embrace of the American political right.On Wednesday, Mr. Kennedy, plans to formally announce that he is challenging President Biden for the Democratic nomination for president. His vaccine skepticism gives him something in common with another candidate: former President Donald J. Trump, who like Mr. Kennedy has blamed childhood vaccines for autism — a discredited theory that has been repudiated by more than a dozen peer-reviewed scientific studies in multiple countries.“Robert F. Kennedy could jump into the Republican primary for president and only DeSantis and Trump, I think, would do better,” Stephen K. Bannon, Mr. Trump’s former chief strategist, said recently on his podcast, referring to Gov. Ron DeSantis of Florida. Mr. Bannon said Mr. Kennedy had a “massive following” with his audience. “People love this guy,” he said.Vaccination is a singular public health success that has saved untold millions of lives. Vaccines have eradicated smallpox, averted millions of deaths from measles and sent naturally occurring polio cases plummeting, from an estimated 350,000 in 1988 to six reported cases worldwide in 2021, according to the World Health Organization.Mr. Kennedy condemned the federal government’s coronavirus response in front of the Lincoln Memorial in January 2022.Kenny Holston for The New York TimesMr. Kennedy has insisted that he is not opposed to vaccines and that his sole interest is in making them safer. “I’m not anti-vaccine, although I’m kind of the poster child for the anti-vax movement,” he said during a recent speech at Hillsdale College, a conservative Christian college in Michigan.But through his nonprofit, Children’s Health Defense, and his movies, speeches and books — including one that portrays Dr. Anthony S. Fauci as in the pocket of the pharmaceutical industry — Mr. Kennedy has used his platform and his family’s star power to sow doubts about vaccine safety, spreading misinformation by twisting facts out of context.In 2021, the Center for Countering Digital Hate named him one of its “Disinformation Dozen” — the 12 people whom the organization found to have been responsible for roughly three-quarters of anti-vaccine content on Facebook.Facebook and Instagram have removed the accounts of Children’s Health Defense, and Mr. Kennedy has accused them of censorship. He is also suing the Biden administration and Dr. Fauci, who for decades led the National Institute of Allergy and Infectious Diseases, accusing them of pressuring social media companies to censor free speech.Mr. Kennedy declined to be interviewed. In an email message, he said Children’s Health Defense had “an extremely robust fact-checking operation.” He also pointed to a response by Meta, Facebook’s parent company, disputing the “Disinformation Dozen” report. Meta critiqued the study’s design, saying that focusing on just 12 people “misses the forest for the trees.”Family BacklashMr. Kennedy, 69, is the third-eldest child of Robert and Ethel Kennedy and a nephew of former President John F. Kennedy, who urged Americans to take the Salk polio vaccine and signed the Vaccination Assistance Act of 1962 to help states and cities carry out childhood immunization programs.His activism, and now his political aspirations, have been wrenching for his family. Some of his family members have publicly rebuked him. His sister Rory Kennedy told CNN she was backing Mr. Biden, while his sister Kerry Kennedy said in a statement, “I love my brother Bobby, but I do not share or endorse his opinions on many issues.”Mr. Kennedy’s name and family reputation have opened doors for him. Dr. Fauci said he had met with Mr. Kennedy several times and had told him “that I believe that his intentions are not evil, but his information is incorrect, and he’s misguided and can inadvertently cause significant harm.” Dr. Fauci said that when Mr. Kennedy’s book about him, titled “The Real Anthony Fauci,” came out in 2021, he was “really shocked.”“The entire book is such a complete lie,” Dr. Fauci said.Mr. Kennedy, top left, is the third-eldest child of Robert and Ethel Kennedy, and a nephew of former President John F. Kennedy.Associated PressMr. Kennedy’s messages often have a grain of truth. The Children’s Health Defense website, for instance, says “vaccines contain many ingredients, some of which are known to be neurotoxic, carcinogenic and cause autoimmunity.” Vaccines do contain preservatives and additives, such as aluminum salts, which have been in use in vaccines for decades. Studies show adverse reactions are rare and typically involve skin allergies.The Children’s Health Defense website also states that certain vaccines are not tested against placebos in clinical trials, citing polio, hepatitis and meningitis vaccines as examples. That is misleading. Brand-new vaccines — from polio to measles to Covid-19 — are tested in large clinical trials that include placebo groups. But scientists agree it would be unethical to withhold lifesaving vaccines from study participants. For that reason, when older vaccines are reformulated or updated, studies do not include a placebo group.“Vaccine injuries can and do happen,” the website declares. That is true as well, but the federal government has an aggressive system to track and detect side effects so they can be addressed.The measles vaccine, for instance, lowers the platelet count in about one in every 25,000 to 30,000 people. That can cause red spots from bleeding under the skin — a problem that is usually “short-lived and self-resolving,” said Dr. Paul A. Offit, the director of the Vaccine Education Center at Children’s Hospital of Philadelphia. But measles causes that problem in one in 3,000 children — roughly 10 times as many as the vaccine, he said.“There are no risk-free choices, just choices to take different risks,” said Dr. Offit, who has been a vocal critic of Mr. Kennedy. “You could argue the greatest risk of vaccines is driving to the office to get them.”A Movement GrowsBy his own account, Mr. Kennedy was at first a reluctant critic of vaccination. He got involved in 2005, when he was an environmental lawyer suing coal-fired power plants to force them to reduce emissions of mercury and other toxic chemicals.The anti-vaccine movement in the United States had been growing amid debate over a rise in cases of autism. In 1998, a British doctor named Andrew Wakefield published a study of 12 children in The Lancet, a prestigious medical journal, that suggested a link between the measles, mumps and rubella vaccine and autism.The article was retracted in 2010, and Mr. Wakefield was later barred from practicing medicine. But in the years after its publication, another theory began to take hold: that thimerosal, a mercury-based preservative that had been used for decades to prevent bacteria from growing in multiple-dose vials of vaccines, caused autism.Mr. Kennedy examining a canal that supplied water from a natural spring to a Palestinian village in 2019. He got involved in the anti-vaccine movement when he was an environmental lawyer.Daniel Rolider for The New York TimesThe measles, mumps and rubella vaccine never contained thimerosal, but other vaccines given to infants did. The Centers for Disease Control and Prevention says there is “no evidence” that the low doses of thimerosal in vaccines cause harm, “except for minor reactions like redness and swelling at the injection site.”But in 1999, after Congress directed the Food and Drug Administration to look at mercury in all products, the American Academy of Pediatrics, federal health agencies and vaccine manufacturers agreed that thimerosal should be removed from childhood vaccines. The decision was made “out of an abundance of caution,” said Daniel Salmon, the director of the Institute for Vaccine Safety at the Johns Hopkins Bloomberg School of Public Health.But the move alarmed parents. As Mr. Kennedy traveled the country giving speeches, he has said, mothers of intellectually disabled children began buttonholing him, pressing him to investigate vaccines.“They would say to me in a very respectful but also kind of vaguely scolding way, ‘If you’re really interested in mercury exposures to children, you need to look at vaccines,’” he told the Hillsdale College audience.In 2005, Rolling Stone and Salon copublished an article by Mr. Kennedy, headlined “Deadly Immunity,” that blamed thimerosal in vaccines for fueling the rise in autism. Salon later retracted the article. Mr. Kennedy insisted Salon caved to pressure from government regulators and the pharmaceutical industry.Thimerosal is still used in flu vaccines. In 2015, shortly after Mr. Kennedy published a book about the preservative, he met Eric Gladen, an engineer who believes he was sickened by thimerosal in a tetanus vaccine and who made a film about his experience. The two joined forces. Mr. Gladen’s advocacy group, World Mercury Project, was later rebranded as Children’s Health Defense.“We had two huge tools to raise funds; we had my film, which is about 10 years of research put into 90 minutes, and his book,” Mr. Gladen said in an interview, adding, “Between him being a Kennedy, the film and his book, it compelled a lot of people to get involved.”The anti-vaccine movement was, at the time, largely the province of the political left. Mr. Kennedy found allies in Hollywood celebrities like Jim Carrey and Jenny McCarthy. In California, he waged an unsuccessful fight against a bill to eliminate the “personal belief” exemption that allowed parents to opt out of vaccinating their children.Mr. Kennedy speaking to an anti-vaccine rally at the New York State Capitol in Albany in 2020.Hans Pennink/Associated PressMr. Kennedy has been a vocal opponent of the Vaccine Injury Compensation Act, a 1986 federal law intended to promote the development of vaccines by shielding manufacturers from lawsuits. In 2003, at the height of the thimerosal controversy, a bipartisan measure to update the law by offering immunity to vaccine additive manufacturers collapsed in Congress.Mr. Kennedy points to such efforts as evidence that lawmakers and federal regulators are conspiring to protect drug companies, which he says lack incentives to focus on safety. During the fight over the California legislation, he invoked those arguments, said Dr. Richard Pan, a former state senator who was an author of the bill and met with Mr. Kennedy at the time.“He mainly focused on the F.D.A. being corrupt and in cahoots with the pharmaceutical companies to hide the danger of vaccines,” Dr. Pan said.Meeting With TrumpShortly before Mr. Trump was inaugurated in January 2017, Mr. Kennedy met with him at Trump Tower in Manhattan. Mr. Kennedy said afterward that the president-elect wanted him to lead a “vaccine safety and scientific integrity” commission. He told Science magazine that Mr. Trump had told him he had five friends whose healthy children “developed a suite of deficits” after being vaccinated.The commission never came to pass, but the coronavirus pandemic gave Mr. Kennedy an even bigger platform. As the country grew ever more polarized, with many of Mr. Trump’s followers shunning the vaccines and Dr. Fauci becoming a lightning rod, Mr. Kennedy’s book about Dr. Fauci became a best seller.Another book by Mr. Kennedy is due out in June, this time focusing on the controversy over the origins of the coronavirus. Titled “The Wuhan Cover-Up,” it claims that federal health officials “conspired with the Chinese military” to hide the pandemic’s origins — an assertion that appears to conflate experiments by the Chinese military at the Wuhan Institute of Virology with other work there funded by the U.S. government.How much Mr. Kennedy will talk about vaccine safety during his presidential campaign remains unclear. As he did during the rally at the Lincoln Memorial, he used his talk at Hillsdale College to cloak his activism in a broader point — that the government, the press and social media companies are trying to silence him, pushing the United States toward tyranny.“The founders, specifically Hamilton, Madison, Adams, said, ‘We put freedom of expression in the First Amendment because all the other amendments are dependent on it,’” Mr. Kennedy said. “Because if you give a government the right to silence their opponents, they now have a license for any atrocity.”

Intense patient advocacy, shifting politics, a determined Democratic governor and a handful of maverick Republicans led the state to join 39 others that have expanded Medicaid.RALEIGH, N.C. — People who watch politics in North Carolina say that Phil Berger, a Republican who calls himself a fiscal conservative and a “social traditionalist,” is the most powerful man in the state. For years, as the top Republican in the State Senate, he blocked North Carolina from expanding Medicaid under the Affordable Care Act.But in a sunny outdoor ceremony at the governor’s mansion late last month, with the dogwoods blooming in a sign of spring, Mr. Berger looked on with pride as Gov. Roy Cooper, a Democrat, signed Medicaid expansion into law. State officials estimate that the expansion will cover more than 600,000 North Carolinians.Thirteen years after the adoption of the Affordable Care Act under President Barack Obama, Republicans are abandoning their opposition to Medicaid expansion. Lingering reservations about the welfare state and the cost of expansion are giving way to arguments about Medicaid as an engine for economic growth and a lifeline for struggling hospitals.Mr. Berger cites a string of reasons for his change of heart: North Carolina, where the legislature is controlled by Republicans, revamped its Medicaid program into one that relies on managed care, which made it financially stable. New federal incentives made expansion difficult to resist. Hospitals, which stand to benefit from Medicaid reimbursement, will pick up 10 percent of the cost of the new program — ordinarily paid by states — and the federal government will pay the rest. Most North Carolinians who will benefit have jobs.“I felt that I had a certain responsibility — that if the reasons that I had articulated for 10 years no longer exist, then I had a responsibility to be honest with myself and be honest with other people about that,” Mr. Berger said in an interview. “And so I talked to my members, and I told them where I was — and why.”Ten states remain where Republicans have refused to expand Medicaid, most of them in the South, leaving an estimated 1.9 million uninsured adults in the so-called coverage gap. Too poor to qualify for subsidized private insurance through the Affordable Care Act but ineligible for traditional Medicaid, they are forced to get by with patchwork charity care or skip care altogether. They are disproportionately people of color.Nationally, the coverage gap is expected to grow in the coming months because of the end of a pandemic-era policy that provided states with additional funding in exchange for guaranteeing that recipients of Medicaid would not lose their coverage.Since 2017, voters in seven states — most recently South Dakota — have approved ballot measures to expand Medicaid, despite longstanding Republican objections. Now the question is whether North Carolina will be a turning point.State Representative Donny Lambeth, a North Carolina Republican who pushed for Medicaid expansion, said Republican lawmakers in Tennessee had reached out to him, “curious as to how we did this.” Backers of expansion are looking toward Alabama, whose governor, Kay Ivey, a Republican, can act without legislative approval.“This is the beginning of the end of the Medicaid expansion story,” said Lawrence O. Gostin, an expert in public health law at Georgetown University. Noting North Carolina’s place as a traditionally conservative state in the South, he added, “The recognition that even the state’s Republican legislature would sign onto Medicaid expansion will begin to chip away at the reluctance by conservative states.”Penelope Wingard, a breast cancer survivor, was among those who advocated Medicaid expansion. “I never thought this would happen in North Carolina,” she said.Eamon Queeney for The New York TimesFor Penelope Wingard, 59, who worked with children who have behavioral disabilities until she became sick with breast cancer in 2013, the Republicans’ turnabout is life changing. Ms. Wingard lost Medicaid when she finished radiation treatment and is now uninsured; she stitched together charity care when she needed eye surgery, racking up $50,000 in medical debt. She turned to advocacy, sharing her experience, but it was painful, she said.“I’m proud that I didn’t give up,” said Ms. Wingard, who lives in Charlotte. “I wanted to give up. I didn’t want to talk about it anymore. I was just so angry. But today I can say I’ve been crying all day, tears of happiness, because I never thought this would happen in North Carolina.”Years of AdvocacyNorth Carolina Republicans did not change their views on Medicaid overnight. The story of how they got from no to yes is one of intense patient advocacy, smart messaging, shifting politics, a determined Democratic governor and a handful of maverick Republicans. Support from local officials and sheriffs, as well as eager hospital executives, also played a role, as did Mr. Obama’s fading presence.“If they had some kind of A.C.A. hangover, my guess is it has probably worn off,” Steve Lawler, the president and chief executive of the North Carolina Healthcare Association, a trade group for hospitals, said of Republican lawmakers.Progressives set the table for expansion, partly by helping to elect Mr. Cooper, said the Rev. Dr. William J. Barber II, a prominent civil rights leader and longtime pastor in North Carolina. He described Mr. Berger as “a very regressive force” in state politics.“They didn’t just change,” Dr. Barber said of Republican lawmakers. “They were forced to change.”Phil Berger, the top Republican in North Carolina’s State Senate, blocked Medicaid expansion for years before throwing his support behind it.Eamon Queeney for The New York TimesIn addition to its creation of marketplaces for buying private insurance, the Affordable Care Act also required states to expand Medicaid to cover people earning up to 138 percent of the federal poverty level — currently about $41,000 for a family of four. The program was drawn up to be a good deal for states, with the federal government picking up all of the costs at first and then eventually paying for 90 percent of them, a higher share than for traditional Medicaid.But conservative state officials balked, saying they did not trust the federal government to live up to its end of the bargain and did not want to contribute to what they saw as the welfare state. A group of states sued, claiming in part that forcing states to expand Medicaid was unconstitutional. In 2012, the Supreme Court upheld the Affordable Care Act but ruled that states could not be required to adopt expansion.The following year, Dr. Barber began leading demonstrations every Monday at the North Carolina General Assembly to protest cuts to unemployment benefits, education and Medicaid. “Moral Mondays” made national news; as the weeks and months went on, thousands turned out and hundreds were arrested.Mr. Berger, who had ridden a Tea Party wave to help deliver his party control of the State Senate for the first time in more than 100 years, had little inclination to bend. Republicans had a supermajority — enough votes to override a governor’s veto. Mr. Berger said unpredictable Medicaid costs had driven the state into the red.“The thought of signing on to Obamacare, when the memory of that budget debacle was so fresh in our minds, was not something that was very appealing to us,” he said.Hospitals, especially rural ones, were struggling and desperate for Medicaid reimbursement dollars. In the summer of 2014, the Republican mayor of tiny Belhaven, N.C., made a two-week trek to Washington to try to save a hospital that had closed. Dr. Barber walked part of the way with him.Mr. Lambeth, the Republican state representative, who had recently retired after a long career as a hospital executive, was eager to put his own expertise to use. He led an effort to transform Medicaid in North Carolina from a fee-for-service program, in which doctors are reimbursed for each service they provide, into a managed care system with a fixed budget and metrics to monitor health outcomes.Mr. Berger and Mr. Lambeth say their work fixing what they called “a broken system” cleared the way for expansion. Their critics blame Republicans for breaking Medicaid by starving it of cash so they could claim they had fixed it.But Mr. Cooper, in an interview, said, “I don’t think there is any question that we made Medicaid more efficient.”A Republican ReversalThe early push for Medicaid expansion in North Carolina came from the political left, led by the North Carolina Justice Center, a progressive research and advocacy group, which enlisted Ms. Wingard and others to tell their stories. But Peg O’Connell, a longtime health policy consultant, said backers needed a less liberal look. She helped found a new group, Care4Carolina, to take the lead.“The most important thing we did,” she said, was to ditch the phrase “Medicaid expansion” and replace it with “closing the coverage gap” — a message that conservatives could embrace. She knew it had worked when a Republican lawmaker told her, without a trace of irony, “I will never vote for Medicaid expansion, but I will vote to close the coverage gap.”Mr. Cooper, who is more than halfway through his second term, called for Medicaid expansion in his 2016 campaign for governor.Eamon Queeney for The New York TimesMr. Cooper called for expanding Medicaid when he ran for governor in 2016, and upon taking office the next year, he tried to fulfill that goal by working with the outgoing Obama administration. That did not sit well with Mr. Berger and the speaker of North Carolina’s House of Representatives, Tim Moore, a Republican.“They sued me in federal court to stop it,” Mr. Cooper said, “and we kind of set it aside.”But in the House, Mr. Lambeth and a small group of colleagues were at work on legislation. They looked at Indiana, which had expanded when Mike Pence, the former vice president, was governor. They examined Ohio and later invited John Kasich, a Republican who oversaw that state’s expansion when he was governor, to speak.Mr. Lambeth took “a lot of grief” from his fellow Republicans, he said. But he found an ally in a Republican state senator, Kevin Corbin, who was in the insurance industry and tired of being unable to help working people.“We’d see it all the time,” Mr. Corbin said. “A 27-year-old single mother comes in. She has two children and she makes $15 an hour. Her kids are already on Medicaid; she doesn’t have insurance. So I give her a quote and it’s $600 a month, and she’s not going to do that because she has to pay rent.”By 2020, research was confirming what backers of Medicaid expansion had been saying; health outcomes were better in expansion states. Mr. Cooper tried to build bipartisan support by partnering with Republican county commissioners and sheriffs who backed expansion. After President Biden took office in 2021, Congress passed a coronavirus relief package that offered states additional financial incentives to expand.But the most important thing that happened, people in the state agree, is that Mr. Berger changed his mind. That opened the door for other Republicans to fall in line.“It’s like Nixon going to China,” Ms. O’Connell said.Adam Searing, a health policy expert in Chapel Hill, N.C., who is affiliated with Georgetown University, sees politics at work. Polls show Medicaid expansion is popular. Mr. Cooper is more than halfway through his second term and cannot run again because of term limits, and Mr. Searing said Republicans seeking to reclaim the governorship wanted to “get Medicaid expansion off the table.”The expansion does not go into effect immediately. It is tied to passage of the state budget. But in the days after last month’s signing ceremony, the mood in the North Carolina General Assembly was upbeat. Ms. O’Connell beamed as lawmakers and lobbyists congratulated her. Mr. Lambeth said Mr. Kasich, the former Ohio governor, had called to congratulate him.The expansion bill contains a priority of Mr. Berger’s: a provision aimed at encouraging competition in health care by making it easier for companies to open new surgical centers and M.R.I. clinics.Even so, Mr. Berger still has concerns. He worries that a shortage of health care providers has already restricted access to care. What good is having coverage, he asks, if you cannot find a doctor? Medicaid is not the system he would have crafted, he said, if he had “a blank slate.”But he said he was able to reconcile his support for expansion with his philosophical opposition to big government programs: “We do not live in a perfect world.”