The state’s Democratic governor signed a bill expanding the health insurance program for low-income people days after the measure cleared the Republican-controlled legislature.RALEIGH, N.C. — North Carolina on Monday became the 40th state to expand Medicaid under the Affordable Care Act, the latest sign of how Republican opposition to the health measure has weakened more than a decade after President Barack Obama signed it into law.Gov. Roy Cooper, a Democrat, signed legislation expanding the state’s Medicaid program during a sunny afternoon ceremony on the lawn of the Executive Mansion, days after the Republican-controlled legislature gave final approval to the measure. He was surrounded by patients, advocates and some of the same Republican leaders who had previously blocked expansion in the state.The bill will expand Medicaid to adults who make less than 138 percent of the federal poverty level, or about $41,000 for a family of four. State officials say the expansion will cover an estimated 600,000 people. It will take effect when the state adopts a budget, likely by June, Mr. Cooper said in an interview before the signing ceremony.“Today is a historic step toward a healthier North Carolina,” the governor declared before signing the measure. When a reporter pressed him on when the expansion would take effect, he said, “It’s only a question of when, not if.”It has been nearly 11 years since the Supreme Court ruled that states did not have to expand Medicaid — the government health insurance program for low-income people — under the Affordable Care Act. Nearly half the states opted out. More recently, progressives have helped to expand Medicaid in seven states — all of them with either Republican-controlled or divided governments — by putting the question directly to voters; in November, South Dakota adopted Medicaid expansion via the ballot box.But getting Republican elected officials to abandon their opposition to expanding the program has not been easy. The last state where a Republican-controlled legislature voted to expand Medicaid was Virginia, in 2018. The governor at the time was a Democrat, Ralph Northam.The battle over Medicaid has been particularly intense in North Carolina. Supporters of expansion conducted hundreds of “Moral Mondays” protests at the State Capitol. In 2014, the Republican mayor of a town that lost its hospital walked all the way to Washington to build support for expansion.Monday’s bill signing leaves just 10 states — all with divided or Republican leadership, and most of them in the South — that have yet to expand Medicaid. Advocates say they now have their sights set on Alabama, where Gov. Kay Ivey, a Republican, can expand her state’s program with her own authority.In North Carolina, there are various reasons for Republicans’ recent change of heart. Much of the opposition in the state and elsewhere has been both ideological and partisan — a reflection of Republicans’ deep distaste for Mr. Obama. But it is now clear that the Affordable Care Act, known as Obamacare, is here to stay. Republicans in Washington have been unable to repeal the law and appear to have largely given up fighting it, helping to pave the way for expansion in North Carolina.“The argument that this is somehow an endorsement of Obamacare is losing a lot of political currency, even among conservatives,” said Frederick Isasi, the executive director of Families USA, a health care advocacy group based in Washington.Hospitals, especially struggling rural ones, are eager for the extra income that Medicaid reimbursement will bring. The federal government picks up 90 percent of the costs of reimbursement under the expansion, and in North Carolina, hospitals will pay the other 10 percent. The state has revamped its Medicaid program, moving it from a fee-for-service program to one that relies on managed care — a long-sought goal of Republicans.“This has been a long day coming, but it’s been as a result of a lot of reforms,” Tim Moore, the speaker of the state’s House of Representatives and a Republican, said during the signing ceremony. The changes, he said, “allowed us to be in the position that we’re in today to be able to expand this coverage.”For Mr. Cooper, who is in his second term and has been mentioned as a possible future Democratic candidate for Senate or even president, the bill signing was a significant victory. He sought to expand Medicaid when he first took office in 2017, and Republicans sued in federal court to stop him from doing it.The push for expansion picked up steam last year, when the state’s House and Senate approved separate measures. But the two chambers were unable to reconcile differences.The signing ceremony on Monday was at turns poignant and celebratory. Cassandra Brooks, who operates Little Believer’s Academy, a day care center in the Raleigh area, choked back tears as she recalled two of her teachers who had died, she said, because they could not afford health care.“They were excellent early childhood teachers who didn’t have health insurance and passed away due to preventable health conditions,” she said. She cast the expansion measure as a boon to small businesses that operate on thin margins and cannot afford to offer their employees coverage.“Here’s to Medicaid expansion in North Carolina,” she said. “Here’s to supporting small business in North Carolina. Here’s to continued growth in North Carolina. I believe in North Carolina.”

The Biden administration announced a plan to modernize how patients are matched to available organs to shorten wait times and reduce the number of people who die while waiting.WASHINGTON — The Biden administration announced on Wednesday that it seeks to break up the network that has long run the nation’s organ transplant system, as part of a broader modernization effort intended to shorten wait times and reduce the number of patients who die while waiting.More than 100,000 people in the United States are awaiting organ transplants in a system that has long been defined by an imbalance between supply and demand. Patients sometimes wait years for donated organs, and people die each day. This is not the first reform effort; 25 years ago, the Clinton administration tried its own modernization initiative.For nearly four decades, the system has been run by the United Network for Organ Sharing, a national nonprofit known as UNOS that, under contract with the federal government, coordinates the work of transplant hospitals and organ procurement organizations to match transplant candidates with donated organs.Critics have long said the system is ineffective and disadvantages poor patients who do not have the means to travel. Federal officials say the computer system that does the matching is outdated.The Biden administration is now putting the network out to bid, hoping to foster competition in a system that has effectively operated as a monopoly. Federal officials say they are open to having multiple networks operating across the country.Officials also want to end a current practice in which members of the UNOS board sit on the Organ Procurement and Transplantation Network’s board, a panel of industry experts established by Congress to determine policies regarding organ transplantation. Officials view that as a conflict of interest.The administration is also rolling out a website that will, for the first time, provide detailed, de-identified data on transplant wait lists, donors and recipients. The site will also include outcomes for individual hospitals to help patients and their families make decisions about where to seek care. The moves were reported earlier by The Washington Post.“Every day, patients and families across the United States rely on the Organ Procurement and Transplantation Network to save the lives of their loved ones who experience organ failure,” Carole Johnson, the administrator of the Health Resources and Services Administration, the branch of the Department of Health and Human Services that oversees the transplant system, said in a statement.She said the overhaul was intended to “bring greater transparency to the system and to reform and modernize” the network, adding, “The individuals and families that depend on this lifesaving work deserve no less.”

WASHINGTON — In two unsuccessful bids for the White House, Senator Bernie Sanders made no secret of his disdain for billionaires. Now, in what could be his final act in Washington, he has the power to summon them to testify before Congress — and he has a few corporate executives in his sights.One is Stéphane Bancel, the chief executive of Moderna, who Mr. Sanders complains “has become a multibillionaire” by developing a coronavirus vaccine with government money. “I think Mr. Bancel should be talking to his advisers about what he might say to the United States Senate,” Mr. Sanders warned in an interview.Jeff Bezos, the founder of Amazon, and Howard Schultz, the on-and-off chief executive of Starbucks, are also on his list. He views them as union busters whose companies have resorted to “really vicious and illegal” tactics to keep workers from organizing. He has already demanded that Mr. Schultz testify at a hearing in March.Mr. Sanders, independent of Vermont, can put these men on the spot because he is the new chairman of the Senate Committee on Health, Education, Labor and Pensions. The job gives him sweeping jurisdiction over issues that have animated his rise in politics, such as access to health care, the high cost of prescription drugs and workers’ rights.Mr. Sanders, 81, who identifies as a democratic socialist, has said he will not seek the Democratic nomination for president again if President Biden runs for re-election — a position he reiterated in a recent interview in his Senate office. He is himself up for re-election in 2024 and would not say whether he would run again, which raises the prospect that the next two years in Congress could be his last.Mr. Sanders is clearly operating on two tracks. Last week, in a move that might surprise critics who view him as unbending, he partnered with a Republican, Senator Mike Braun of Indiana, to call on rail companies to offer seven days of paid sick leave to their workers — a provision that the Senate defeated last year when it passed legislation to avert a rail strike.But he also sent a curt letter to Mr. Schultz, giving him until Tuesday to respond confirming his attendance at the hearing. That followed an earlier, angry letter in which Mr. Sanders urged the Starbucks chief to “immediately halt your aggressive and illegal union busting campaign.” A Starbucks spokesman said the company was considering the request for Mr. Schultz to testify and was working to “offer clarifying information” about its labor practices.Former Senator Tom Daschle of South Dakota, a Democrat who served as majority leader, said that Mr. Sanders could “bring a balance between the progressive and the pragmatic.”“He will be progressive, he will be aspirational, he will continue to fight the fight,” Mr. Daschle said. “But at the same time, I believe Bernie Sanders wants to get things done.”The chairmanship is the latest turn in Mr. Sanders’s long career in politics, a coda to his rise from a left-wing socialist curiosity to a national figure with respect, power and a devoted fan base. After three decades in Washington, he still manages to cast himself as an outsider. And while he may never ascend to the presidency, there is no question that he has left his mark on national politics, reviving and strengthening the American left.Health Care in the United StatesThe Cost of Miracle Drugs: A wave of innovative medicines promise to cure devastating diseases. But when prices are too high, patients have to hunt for other ways to pay.Medicare: The Biden administration announced a rule targeting Medicare private plans that overcharge the federal government. The change strengthens the ability to audit plans and recover overpayments.‘Hospital at Home’ Movement: In a time of strained capacity, some medical institutions are figuring out how to create an inpatient level of care outside of hospitals.Omnibus Bill: The giant spending bill passed by Congress kept the government open. But it also quietly rewrote huge areas of health policy.But Mr. Sanders’s national following cuts both ways. He is both a darling of the progressive movement and fodder for conservatives, who are already gleefully caricaturing him.“Medicare for all, baby!” crowed Whit Ayres, a Republican strategist, referring to Mr. Sanders’s signature legislative initiative, a government-run health care program for all Americans. “I guarantee you Bernie Sanders will provide a wonderful target for Republicans to shoot at.”He already has. Mr. Sanders’s rise has put him in the ranks of the very wealthy Americans he criticizes, in part thanks to a book he wrote, “Our Revolution,” in the wake of his first bid for the presidency. (“If you write a best-selling book, you can be a millionaire, too,” he said in 2019.)He is about to go on tour to hawk a new book, “It’s OK to Be Angry About Capitalism,” due out later this month and billed by its publisher as “a progressive takedown of the über-capitalist status quo.” Tickets for an upcoming book event at a concert venue in Washington are selling for up to $95 on Ticketmaster — a company that last month was accused of anti-competitive behavior by some of Mr. Sanders’s Senate colleagues. His Republican critics are having a field day with that.“Anyone else see the ‘irony’ in Bernie Sanders selling tickets for his ‘It’s Okay to Be Angry About Capitalism’ book tour on Ticketmaster?” Representative Bill Huizenga, Republican of Michigan, wrote on Twitter. A spokesman for Mr. Sanders declined to comment on the book event.With Republicans running the House and 60 votes needed to pass most bills in the Senate, Mr. Sanders has little hope of pushing major legislation through Congress. He intends to introduce a Medicare for all bill, as he has done in past Congresses, because he feels “it’s important to keep that issue out there,” as he put it. But he is well aware that it is going nowhere on Capitol Hill.“We don’t have the votes,” he said matter-of-factly. “We have no Republican support for it. And I would guess, you know, we have maybe half of Democrats who might support it.”That is Mr. Sanders the realist speaking, in a tone far more practical than the one he has used during his campaign rallies and familiar rants against millionaires and billionaires. But those who watch Mr. Sanders closely know that, while he has never been a master legislator in the mold of former Senator Edward M. Kennedy of Massachusetts, a predecessor of his as the health committee chairman, he is able to work across the aisle.President Barack Obama signing legislation overhauling the veterans’ health care system in 2014. Mr. Sanders worked with Senator John McCain, Republican of Arizona, on the measure.Doug Mills/The New York TimesIn 2014, as the chairman of the Senate Veterans’ Affairs Committee, Mr. Sanders partnered with Senator John McCain, Republican of Arizona, on a major overhaul of the veterans’ health care system — a measure that the Vermont senator described then as “not the bill that I would have written,” but nonetheless “a significant step forward.”A copy of the bill hangs on the wall of his office, alongside a photograph of President Barack Obama signing it, with Mr. Sanders looking over his shoulder and doing something he is not often seen doing in the Capitol: smiling.Mr. Sanders’s activist roots run deep, but after arriving in Washington in 1991 as Vermont’s lone member of the House, he quickly learned that being an outsider would only get him so far; he would have to deal with Democrats if he wanted any power. In the Senate, which he joined in 2007, he has worked his way up the ranks. In addition to leading the Veterans’ Affairs Committee, he has also served as chairman of the Budget Committee.No one — perhaps not even Mr. Sanders himself — could have predicted then that he would wage two credible runs for the Democratic nomination for president. In the interview, Mr. Sanders brushed aside questions of politics. He wanted to talk policy.“We spend twice as much per capita on health care as the people of other industrialized nations, and yet we have 85 million who are uninsured or underinsured,” he said, adding, “So you have a system that is not working.”“It’s propped up by the power of the insurance companies, some drug companies,” he continued, “and I will do my best to change it.”Mr. Sanders wants to hear from Moderna, he said, about the company’s plan to sharply hike the price of its coronavirus vaccine. In a recent letter to Mr. Bancel, he assailed the vaccine maker for “unacceptable corporate greed” and urged the company to reconsider.A spokesman for Moderna said the company had always “been willing to engage in conversation with government stakeholders” and would continue to do so.At the hearing in March, Mr. Sanders wants Mr. Schultz to explain why Starbucks has drawn scrutiny from the National Labor Relations Board. The board has been investigating Starbucks for various allegations of misconduct, including that it had illegally denied raises to union employees and had fired seven workers at a store in Memphis for their union-organizing activity. A court later ordered Starbucks to reinstate those workers.Mr. Sanders at a campaign rally in Salt Lake City in 2016. He developed a national following in his two bids for the Democratic presidential nomination.Kim Raff for The New York TimesThe health committee also has some must-pass legislation on its agenda, including the reauthorization of the Pandemic and All-Hazards Preparedness Act, a 2006 law intended to improve public health and medical preparedness for emergencies, including acts of bioterrorism. The law was reauthorized in 2013 and must again be reauthorized this year.Joel White, a Republican strategist who specializes in health policy, said Mr. Sanders might be more bipartisan than some of his critics expect, adding, “I think Bernie probably wouldn’t have become chair of the health committee just to throw bombs.”Two Republicans on the panel, Mr. Braun and Senator Roger Marshall of Kansas, both said in interviews that they thought they might find common ground with Mr. Sanders on matters like lowering the cost of prescription drugs and supporting community health centers.And Mr. Daschle said Mr. Sanders had a counterpart he could probably work with: Senator Bill Cassidy of Louisiana, the top Republican on the committee. A physician who helped found a community health clinic to treat the uninsured, Mr. Cassidy was one of seven Republicans who voted to convict former President Donald J. Trump at his second impeachment trial.As committee chairman, Mr. Sanders said he intended to “take the show on the road” by having hearings in places other than Washington so he could hear from ordinary Americans, such as older people who have a hard time paying for prescription drugs, working families struggling to pay for child care and students who cannot afford to pay for college.With the recent retirement of Senator Patrick J. Leahy, a Democrat who served for 48 years, Mr. Sanders is finally the senior senator from Vermont. Asked how he felt, he said, “Pretty good.” Then, ever combative, he shot back, “How do you feel?”He said people who wonder about whether he will run again — and by people, he meant reporters — should “keep wondering.”Why? “Because I’ve just told you, and this is very serious,” he said, wearing his trademark scowl. “If you think about my record, I take this job seriously. The purpose of elections is to elect people to do work, not to keep talking about elections.”

Now in the majority, House Republicans are eager to scrutinize the Biden administration’s Covid policies and the origins of the virus, as a hearing on Wednesday demonstrated.WASHINGTON — The acting director of the National Institutes of Health pushed back on Wednesday against Republicans’ assertions that a lab leak stemming from taxpayer-funded research may have caused the coronavirus pandemic, telling lawmakers that viruses being studied at a laboratory in Wuhan, China, bore no resemblance to the one that set off the worst public health crisis in a century.Those viruses “bear no relationship to SARS-CoV-2; they are genetically distinct,” the N.I.H. official, Dr. Lawrence A. Tabak, told a House panel, using the formal name for the virus. He added that to suggest otherwise would be akin to “saying that a human is equivalent to a cow.”Dr. Tabak’s comments came at a hearing before members of the House Energy and Commerce Committee, with the House newly under Republican control. For two years, Republicans in Washington seethed as Democrats investigated the Trump administration’s coronavirus response. On Wednesday, they flipped the script.During a public grilling that lasted nearly four hours, Republicans accused Dr. Tabak and two other top Biden administration officials — Dr. Robert M. Califf, the commissioner of the Food and Drug Administration, and Dr. Rochelle P. Walensky, the director of the Centers for Disease Control and Prevention — of stonewalling their requests for information, imposing unnecessary vaccine mandates and eroding Americans’ faith in public health institutions.“President Biden’s public health leaders are here today because they have broken the American people’s trust,” Representative Cathy McMorris Rodgers, Republican of Washington and the committee’s chairwoman, declared at the outset of the session.A Divided CongressThe 118th Congress is underway, with Republicans controlling the House and Democrats holding the Senate.Performative Patriotism: A 43-minute recitation of the Constitution by House Republicans was the latest in a series of acts of public patriotism, ranging from the sincere to the performative.Reviving an Old Debate: The House Republican majority is pursuing limits on how long members of Congress can serve. Similar proposals in the 1990s went nowhere; will the result be the same this time?Avoiding a Train Wreck: For the first time, the leaders of the House and Senate Appropriations Committees and the White House budget official are all women. Can they avert a fiscal disaster?Ilhan Omar: House Republicans voted to oust the Minnesota Democrat from the Foreign Affairs Committee over past comments about Israel, delivering retribution for the removal of G.O.P. members when Democrats held the majority.It was only a hint of things to come. Republicans have made clear that they intend to tap into Americans’ frustration with masking, mandates and other coronavirus restrictions to wage a broad assault on Mr. Biden and his administration. The House’s Select Subcommittee on the Coronavirus Pandemic expects to hold its own hearings beginning in March.Beyond hearings, Republicans are passing mostly symbolic measures to signal their discontent with Mr. Biden’s Covid policies. On Wednesday, the House passed, by a vote of 227 to 201, a bill that would end the C.D.C.’s requirement that most foreign air travelers entering the United States show proof of vaccination against Covid-19.Last week, Republicans pushed through legislation that would repeal the vaccine mandate for health care workers and end the public health emergency for Covid; shortly before those votes, the White House said it planned to allow the emergency to expire in May.Wednesday’s hearing laid bare the vast gulf in the way Democrats and Republicans perceive the risk posed by the virus, and the federal response. That gulf is particularly pronounced in the debate over the so-called “lab leak theory,” which is deeply intertwined with Republican suspicions that N.I.H.-funded research in Wuhan may have led to a laboratory leak that caused the pandemic. There is no direct evidence linking the Wuhan laboratory to the start of the pandemic.The suspicions revolve around $8 million in grants to EcoHealth Alliance, a nonprofit that was collaborating on coronavirus research with scientists at the Wuhan Institute of Virology, in the city where the pandemic began.Late last month, an internal federal watchdog agency found that the N.I.H. had made significant errors in its oversight of those grants. In a 64-page report, the Office of Inspector General at the federal Department of Health and Human Services outlined missed deadlines, confusing protocols and misspent funds — raising and reinforcing concerns about the government’s system for monitoring research on potentially risky pathogens.The Wuhan studies looked at how animal coronaviruses, especially bat coronaviruses, evolve naturally in the environment and have the potential to become transmissible to the human population. N.I.H. officials have long maintained that the viruses studied in Wuhan “could not have possibly been the source of SARS-CoV-2 or the Covid-19 pandemic,” as an agency website puts it — the sentiment Dr. Tabak reiterated on Wednesday.But Representative Morgan Griffith, Republican of Virginia, who leads one of the two subcommittees that convened Wednesday’s hearing, was not persuaded by Dr. Tabak.While he conceded that he did not have absolute proof that a lab leak caused the pandemic, Mr. Griffith said that, as a lawyer, he did not feel the need to eliminate “all doubts.” Rather, he said, he is convinced beyond “a reasonable doubt,” in part because China has withheld information from the United States and in part because of the irregularities uncovered by the inspector general.“What he has is a lack of evidence,” Mr. Griffith said of Dr. Tabak. “He does not have evidence that they didn’t study the coronavirus that became Covid-19.”Representative Diana DeGette, Democrat of Colorado and a longtime member of the committee, has come to the opposite conclusion with the same set of facts. After reviewing reports and attending a classified briefing, she said, she agrees with scientists who say the pandemic was most likely caused by “viral spillover” — the virus jumping from animals to humans — at a wet market in Wuhan.“I have looked at all the evidence, all of the reports,” she said. “And I haven’t seen definitive evidence that the virus came from a Wuhan lab.”Several Republicans on the committee who are medical professionals — both doctors and pharmacists — expressed deep frustration with federal officials, including the C.D.C., over vaccine mandates and messages about masking and vaccines to the public.“As a public health director, what I conveyed to my staff was that our credibility was the most important thing that we have in public health,” said Representative Mariannette Miller-Meeks, an ophthalmologist and former director of the Iowa Department of Public Health. She added, “It’s demoralizing, and it is depressing that agencies that were once held in such high esteem cannot translate and transfer research and evidence and respond to real-world evidence when they come up with strategies and policies.”The hearing brought a moment of satisfaction to one Republican in particular: Representative Greg Pence of Indiana, the brother of former Vice President Mike Pence, who oversaw the Trump administration’s Covid-19 response. The congressman took what he called a “shameless point of personal privilege” to thank his brother for his “humble leadership,” his wisdom and his “clear and transparent communications to the American public.”

Dr. David A. Kessler took over Operation Warp Speed when President Biden entered office, and his departure signals the end of the program.WASHINGTON — Dr. David A. Kessler, who for the past two years has been the behind-the-scenes force driving a vast federal effort to develop and distribute coronavirus vaccines and treatments, said on Friday that he was leaving the Biden administration to return to teaching at the University of California, San Francisco.Dr. Kessler may be best remembered in Washington for a far more public role, as commissioner of the Food and Drug Administration in the 1990s, when he took on the tobacco companies. As chief science officer for the Biden administration’s Covid-19 response, he has operated largely unseen by the public, but his work has affected the lives of millions of Americans.“Six hundred sixty-five million vaccines, 13 million antivirals,” Dr. Kessler said in a brief interview on Friday, referring to the number of doses that Americans have taken since December 2020, shortly before President Biden took office. “We did what we set out to do.”Still, millions of Americans remain unvaccinated. In an interview over the summer, Dr. Kessler talked about the mass vaccination sites he had helped set up, his efforts to distribute the shots to pharmacies and nursing homes and his work to make them available to children.“Our job was getting safe and effective vaccines to be accessible,” he said, “and to make sure that everyone could have it, and that it was easy.”Dr. Kessler’s departure signals the end of Operation Warp Speed, which was started by the Trump administration to develop and distribute coronavirus vaccines. Now the Biden administration is working to shift Covid vaccination from a government-run effort to one that will be handled by the private sector.In his role, Dr. Kessler was responsible for negotiating with drug companies to make certain that vaccines were available to anyone who wanted one — at a price for taxpayers that is far lower than the one companies want to charge on the commercial market.When Mr. Biden was running for office, at the height of the coronavirus pandemic, Dr. Kessler was one half of a two-person team — the other half was Dr. Vivek H. Murthy, now the surgeon general — that briefed the candidate almost daily on matters related to the pandemic. When Mr. Biden became president, Dr. Kessler took over Operation Warp Speed and ran it alongside Gen. Gustave F. Perna, who had worked under President Donald J. Trump.“For decades, Dr. Kessler has worked tirelessly to address our nation’s most challenging public health issues, and his work during the Covid-19 pandemic has been no different,” Xavier Becerra, the secretary of health and human services, said in a statement.

The nation’s top infectious disease expert, whose last day as a federal employee is Saturday, plans to write a memoir and wants to encourage people to go into public service.WASHINGTON — The walls in Dr. Anthony S. Fauci’s home office are adorned with portraits of him, drawn and painted by some of his many fans. The most striking one is by the singer Joan Baez. The two of them, he said, “have become pretty good friends over the years.”Dr. Fauci seemed a little uncomfortable with people knowing about the pictures. He said that previously, when they were captured on camera, the “far right” attacked him as an “egomaniac.” If someone goes to the trouble of sending him a portrait of himself, he said, he would “feel like I’m disrespecting them” if he discarded it.It was a revealing glimpse into the psyche of America’s most loved and hated doctor as he wraps up more than half a century of government service at the National Institutes of Health. After Saturday, Dr. Fauci, President Biden’s chief medical adviser and for the past 38 years the director of the N.I.H.’s National Institute of Allergy and Infectious Diseases, will no longer be a federal employee.Dr. Fauci, who turned 82 on Christmas Eve, said he may be retiring, but he is not going away. He hopes to do some public speaking, become affiliated with a university and treat patients if it has a medical center. He intends to write a memoir, he said, and he wants to encourage people to pursue careers in science, medicine and public service.Republicans, who will take control of the House early next month, will see to it that he does not slip out of the public eye. They have promised to investigate his handling of the coronavirus pandemic and to call him to Capitol Hill to testify. He says he has every intention of showing up and has nothing to hide.From the AIDS epidemic to Covid-19, Dr. Fauci has been the public face of American science for decades, advising seven presidents along the way. In late November, The New York Times spoke to him at his home office in Washington about his career and his plans for the future. This interview has been edited and condensed.You have said that you’re retiring from government service but that you’re going to prepare for a “next chapter.” So what’s the next chapter?That’s a good question. Since I can’t negotiate any details of my post-government life for ethical reasons and conflicts of interest, I’m doing something that is unusual for me, which is not knowing exactly what the details of the next step are going to be. But I decided that I wanted to have a few years outside of government to pursue things that are commensurate with my stage in life.Namely, I’m going to be 82 years old in a month. And what do I have to offer? Is it more important for me to do yet again another experiment or do yet again another clinical trial, or would it be more important to utilize the benefit of my experience by writing, by lecturing, by getting involved in advisory issues — and importantly, which I really feel strongly about, is to maybe inspire younger people to either go into medicine and science, or, for the people who are already in medicine and science, to maybe consider a career in public service.When you think about a memoir, how do you envision it? Is there a separate book about Covid?What I would like to do is make it a real memoir, which is a life story of which Covid is a part. Because if you look at what Tony Fauci was and is, Tony Fauci is not defined by Covid. I would much rather give a story of the whole me, from the time I grew up in the streets of Brooklyn to where I am right now. But I don’t know. I’ve never written a book before.Read More on the Coronavirus PandemicBoosters: Americans who received updated shots for Covid-19 saw their risk of hospitalization reduced by roughly 50 percent this fall compared with certain groups inoculated with the original vaccines, the Centers for Disease Control and Prevention reported.Seniors Forgo Boosters: Nearly all Americans over 65 got their initial Covid vaccines. But only 36 percent have received the bivalent booster, according to C.D.C. data.Free at-Home Tests: With cases on the rise, the Biden administration restarted a program that has provided hundreds of millions of tests through the Postal Service.Contagion: Like a zombie in a horror film, the coronavirus can persist in the bodies of infected patients well after death, even spreading to others, according to two startling studies.Beyond looking forward for you, I also want to look forward for the country. What do you think are the biggest health challenges we face?Unfortunately, I have lived through, and the country and the world has lived through, a series of emerging and re-emerging infections, some of which had profound global impact and some of which have been curiosities and some of which have been regionally impactful. I don’t think it’s going to stop.A drawing of Dr. Fauci in his home office. He says he feels obligated to display the portraits that his fans create and send to him. Kenny Holston for The New York TimesAre there other threats that you think about beyond infectious disease threats?What really, really concerns me is the politicization of public health principles. How you can have red states undervaccinated and blue states well vaccinated and having deaths much more prevalent among people in red states because they’re undervaccinated — that’s tragic for the population.You’ve worked for seven presidents. Do you have any favorites?No, I would not discuss favorites. That would not be appropriate.But certainly Donald Trump must have been the most challenging president.It was obviously challenging because I have said — and I’ll say it to you — I have a great deal of respect for the office of the presidency of the United States. And I have had the opportunity to tell presidents things that sometimes they may not want to hear, but they took what I said seriously and respected me for giving them the straight scoop.I did not like nor seek out a position of having to publicly contradict a president of the United States. The far right seems to think I did that deliberately and took pleasure in it. I did not. I felt very, very pained at having to get up in a public press conference and contradict what he says about hydroxychloroquine, contradict what he says about the virus is going to disappear like magic. But I had to do that for my own personal and professional integrity and for fulfilling my responsibility.My primary responsibility is to the American public. I serve the public; I don’t serve a political party. I’m completely nonpolitical.Are you registered as an independent?Yes, I am.House Republicans will bring you in to testify. Are you prepared for that?I have no problem testifying before the Congress. I have nothing to hide. I could easily explain and justify everything I’ve done. So they’re making a big to-do about it, but I respect the concept of oversight.Are there lessons that you think we’ve learned from Covid that, going forward, we should act on?I look at preparedness and response to the outbreak in two major buckets. One is the scientific bucket, and one is the public health bucket.If you look at what the major overriding success story of the pandemic has been, it’s the scientific response, the years of investment in basic and clinical research that led to the absolutely unprecedented feat of going from the recognition of a brand-new virus in January of 2020 to doing massive clinical trials to getting the vaccine proven to be safe and effective and in the arms of people within 11 months. That was a major success.What was not so successful was the public health response. We had antiquated systems. Things were not online or computerized. People were using fax machines. You can’t do that when you’re going to have a response to a pandemic.So the lesson is continue to support the basic and clinical science, because we’re going to need it, and try and strengthen our domestic and global public health infrastructure.Bobbleheads of Dr. Fauci sit next to family photos in his home office. After leaving government, he plans to write a memoir and become affiliated with a university.Kenny Holston for The New York TimesReading between the lines there, it might be said, “Tony Fauci did a great job, but the C.D.C. didn’t do such a good job.”No, that’s not me. I don’t criticize them. But we did — the scientific community did a great job on this. We did.If you had, let’s say, another 10 years in your job, what are the things that you would focus on? Would it be an AIDS vaccine? Are there some big unrealized goals?It would certainly be optimization of AIDS therapy, perhaps with a cure. I would love over the next 10 years to apply the new technologies that proved so successful with Covid to get a vaccine for malaria and for tuberculosis.What about you do people not know? You’re such a public person.They don’t know hardly anything about the physician aspect of me and how sensitive I am and empathetic towards illness and suffering.Will you continue to treat patients?Well, it depends on what institution I hook up with.You’re retiring from government service. Your ties are being cut with N.I.H. and you’re packing up your office there. How is that for you?It’s sort of a strange feeling, because I’m so busy. I was just on this Zoom with the White House about a press conference that I’m going to be on. I’m so busy I can’t think about stepping down, and the thing that’s sort of intimidating is that I’ve got to get all that stuff out of my office pretty quickly.Do you think you’ll donate your papers?All of my papers are going to go to the Library of Congress and to the National Archives.I’m sure there are television networks that would like you to be a commentator or work with them. Is that in your future? Will we still see you on TV?You’ll still see me on TV if they want me on, but I’m not going to make TV a professional aspiration.I want to ask a little bit more about the politicization of science. How do you think we could come back from this deep hole that we seem to be in?I don’t know what the mechanism is, but hopefully people will realize that this is detrimental to what we all care about. We love our country. We care about family and values. Maybe it’s naïve. I don’t think it is. I’m not a naïve person. I’m an optimist, but I’m a cautious optimist. I just hope that the better angels in people will prevail.

The Biden administration said those coming from China, Hong Kong and Macau must show negative coronavirus tests before entering the United States.The Biden administration announced on Wednesday that travelers from China, Hong Kong and Macau must present negative Covid-19 tests before entering the United States, a move that it says is intended to slow the spread of the coronavirus. The requirement will take effect on Jan. 5.The announcement, by the Centers for Disease Control and Prevention, came amid growing concern over a surge of cases in China and the country’s lack of transparency about the outbreak there.C.D.C. officials said the requirement for testing will apply to air passengers regardless of their nationality and vaccination status. It will also apply to travelers from China who enter the United States through a third country, and to those who connect through the United States to other destinations.China’s Covid outbreak has been worsening in recent days, with local governments reporting hundreds of thousands of infections a day. Videos obtained by The New York Times show sick patients crowding hospital hallways. But the situation is difficult to track in real time because China does not release reliable Covid data.This is a developing story. Check back for updates.

The 9/11 Commission prompted a national reckoning over the Sept. 11 terrorist attacks. A bipartisan bill would create an independent panel to investigate the pandemic response, but the measure is in limbo.WASHINGTON — The nation was reeling from an unfathomable number of deaths. Politicians were pointing fingers, asking why the United States had been so ill-prepared for a lethal threat. Congress, defying the White House, ordered an independent investigation.That was 20 years ago, and what came of it was a national reckoning. A bipartisan panel investigating the Sept. 11, 2001, terrorist attacks held televised hearings, developed 41 recommendations for how to improve national security and produced a best-selling book — a gripping historical narrative about what had gone wrong.Now the United States is climbing out of a different crisis, the coronavirus pandemic, which has killed vastly more people than the Sept. 11 attacks and set off a global economic crisis. But some experts in biodefense and public health fear that the opportunity for a national reckoning with Covid-19 is slipping away — and with it, a chance to build on lessons learned during the pandemic.Bipartisan legislation to create a Sept. 11-style independent panel to investigate the government’s pandemic response appears stalled on Capitol Hill, despite a 20-to-2 vote in favor of the measure by the Senate health committee. Backers say their last hope for passage is to tack it onto an upcoming spending bill, the final major must-pass piece of legislation of the current Congress.The commission would be created as part of a sprawling bill called the PREVENT Pandemics Act. The measure would also make the director of the Centers for Disease Control and Prevention a Senate-confirmed position and take other steps to improve pandemic preparedness, including increasing coordination among public health agencies and addressing supply chain deficiencies.There has been no vocal opposition to the bill, but it has been in limbo since it passed the health committee in March — a victim of inertia and other legislative priorities.There is no companion measure in the House, where Republicans are planning their own pandemic-related investigations once they take control of the chamber next month. Perhaps more significantly, President Biden has not taken a position on the bill. Senator Chuck Schumer of New York, the majority leader, who has focused his efforts on judicial nominations and the president’s agenda, has not brought it up for a floor vote. Mr. Schumer’s office and the White House declined to comment.A medical assistant gathered information at a testing site in Sacramento in 2020.Max Whittaker for The New York TimesPresident Donald J. Trump held coronavirus news briefings early in the pandemic. A commission would be charged with examining the response by the Trump and Biden administrations.Doug Mills/The New York TimesOne of the bill’s two chief sponsors, Senator Patty Murray, Democrat of Washington and the chairwoman of the health committee, made an impassioned appeal for it on the Senate floor last week. In an interview, she said the White House was “well aware” of her efforts.“This is a bill that we needed both Republicans and Democrats on,” she said. “They understand that.”A New U.S. Congress Takes ShapeFollowing the 2022 midterm elections, Democrats maintained control of the Senate while Republicans flipped the House.Divided Government: What does a split Congress mean for the next two years? Most likely a return to gridlock that could lead to government shutdowns and economic turmoil.Kyrsten Sinema: The Arizona senator said that she would leave the Democratic Party and register as an independent, just days after the Democrats secured an expanded majority in the Senate.A Looming Clash: Congressional leaders have all but abandoned the idea of acting to raise the debt ceiling before Democrats lose control of the House, punting the issue to a new Congress.First Gen Z Congressman: In the weeks after his election, Representative-elect Maxwell Frost of Florida, a Democrat, has learned just how different his perspective is from that of his older colleagues.More than a million Americans have died of Covid-19 — over 300 times the number that perished on Sept. 11. With cases and hospitalizations once again rising, more than 450 Americans are still dying of Covid each day. Over 200,000 children have lost a parent or a caregiver, and the C.D.C. estimates that millions of adults have long Covid, a constellation of lasting symptoms.The idea for a commission has been percolating for nearly two years, backed by members of Congress, advocacy groups representing the bereaved and the former executive director of the 9/11 Commission. Experts say that beyond charting a blueprint for confronting future pandemics, an independent panel — with the power to issue subpoenas and convene public hearings — would serve as a form of catharsis for the country and a way to comfort those who lost loved ones.It might also answer a pressing question: Why does the United States have a higher death rate from Covid-19 than other wealthy nations?“Although much of the country is acting like the pandemic is over, the hurt and the anger and the pain and the way lives have changed is still with people every day,” said Dr. Nicole Lurie, a top official with the Coalition for Epidemic Preparedness Innovations, a global nonprofit. “If a commission can really start to grapple with questions about how does our country heal, and what do leaders do to get on a path to that healing, that would be an important contribution.”Waiting to get tested in New York in 2020. Cases and hospitalizations are once again rising in the United States.Hiroko Masuike/The New York TimesAny investigation of the pandemic would necessarily be vast and complex, encompassing topics such as better detection of new pathogens, improvements to the public health system’s antiquated data collection apparatus, supply chain vulnerabilities, the harmful effect of lockdowns on many schoolchildren, the spread of misinformation and a lack of public trust in agencies like the C.D.C.Members of Congress have tried to examine the crisis. On Friday, the House subcommittee on the coronavirus crisis released its final report, which was sharply critical of the Trump administration. On Thursday, Democrats on the Senate homeland security committee issued a study of the pandemic’s early months. In October, Republicans on the Senate health committee released an examination of the pandemic’s origins that suggested it was the result of a lab leak — a view most scientists disagree with.But those inquiries are partisan. The bill to create the independent commission would establish a 12-member expert panel of “highly qualified citizens” appointed by congressional leaders from both parties. Like the Sept. 11 panel, it would have subpoena power and hold public hearings. It would be charged with examining the origins of the pandemic as well as the response by the Trump and Biden administrations.“There’s no substitute for showing the vision that we showed in the early 2000s at creating an architecture that fixes things that we got wrong then, that addresses things that we didn’t think of then that we’ve learned, having gone through it,” said Senator Richard M. Burr of North Carolina, the health committee’s top Republican, who is sponsoring the measure with Ms. Murray.Some experts see a broad-based examination of the pandemic as too daunting. And even if a commission were established, it might have difficulty overcoming the intense partisanship surrounding Covid-19. The nation was so deeply divided after Sept. 11 that “partisan pressures almost tore apart our commission,” said Philip D. Zelikow, a University of Virginia historian and former government official who was the executive director of the Sept. 11 panel. The problem is even worse today, he said.Mr. Zelikow now leads the Covid Commission Planning Group, a privately funded effort involving about three dozen independent experts who have spent the better part of the past two years conducting research to lay the groundwork for a national inquiry. The group, which has held several hundred interviews, grew tired of waiting for Congress and plans to publish its findings in a book this spring, Mr. Zelikow said. He declined to discuss details.Infectious disease experts predict that pandemics will occur with increasing frequency, fueled by global travel, climate change and humans moving into closer proximity with animals. Biodefense experts say that pandemics are every bit as big a threat to national security as terrorist attacks. But the public may not see it that way.“Nine-eleven was a national convulsion that was shared with varying intensity across the country, and everybody basically agreed it was shocking and terrible,” said Tara O’Toole, a former official in the Homeland Security Department who is a senior fellow at In-Q-Tel, a venture fund backed by the C.I.A. “Epidemics are not lights-and-sirens events.”Covid-19 has killed vastly more people than the Sept. 11, 2001, terrorist attacks.Adria Malcolm for The New York TimesShortages of personal protective equipment posed major problems at the outset of the pandemic, forcing health workers to scramble.Alex Welsh for The New York TimesAdvocacy groups like Marked by Covid and Covid Survivors for Change have been lobbying Congress to create an investigative commission, just as the Sept. 11 families did in the aftermath of the attacks. To some people grieving losses from Covid-19, the notion that Congress may fail to act feels like a slap in the face.“I am not looking for a commission to blame people,” said Pamela Addison, who has been raising two young children alone since her husband, a health care worker, died early in the pandemic. “I just want a commission to look into what went wrong so this can be prevented, and I feel it would give me some closure knowing what happened and why.”Various organizations, including the Commonwealth Fund and the Center for Strategic and International Studies, have also tried to issue blueprints for pandemic prevention. The Biden White House recently published an updated national biodefense strategy and is asking Congress for $88 billion over five years to fund pandemic prevention, but there has been no movement on that request.But those efforts are not the same as a high-profile panel that has “the imprimatur of Congress and the White House,” said Joseph I. Lieberman, the former Connecticut senator who sponsored the bill that created the Sept. 11 panel, which passed in November 2002. Mr. Lieberman, who is now a chairman of a nonprofit devoted to biodefense, called on Mr. Biden to back the effort.Some lessons from the pandemic are already clear. Scientists figured out how to fast-track the development of tests and vaccines. The C.D.C. established a new program to detect the coronavirus in wastewater. Public health officials learned how to use masks and better air quality systems to control the spread of respiratory viruses.Experts are trying to build on those lessons. The Coalition for Epidemic Preparedness Innovations is seeking to raise $3.5 billion for a plan to create and scale up manufacturing of a vaccine within 100 days of the emergence of a new pathogen, a goal shared by the Biden administration. The C.D.C. is reorganizing in response to what its director, Dr. Rochelle Walensky, has described as “some pretty dramatic, pretty public mistakes” in its pandemic response.But no one is putting it all together, and Mr. Zelikow says time is growing short. The pandemic is already three years old. Important facts may be lost with the passage of time — in part, he surmises, because politicians and the public mistakenly believe that nothing can be done to avert a future crisis.“People in both parties, and Americans in general, have no idea what to do about pandemic danger, and therefore they become naturally resigned to thinking about it fatalistically, as a condition they have to bear,” he said. “This is the giant hole, the gaping crater in our discourse about the pandemic.”Among the lessons of the coronavirus pandemic: Scientists figured out how to fast-track the development of tests and vaccines.Emily Elconin for The New York TimesEmily Cochrane

An examination by the Democratic staff of the Senate homeland security committee portrayed a government wholly unprepared for the arrival of the coronavirus.WASHINGTON — A new examination by Senate Democrats of how the federal government bungled its early response to the coronavirus pandemic faults President Donald J. Trump and his administration for numerous missteps while also laying blame on “multiple systemic problems” that long predated his time in office.The 241-page report was produced by the Democratic staff of the Senate Homeland Security and Governmental Affairs Committee. The report relied on documents and interviews with key Trump administration officials, including Dr. Deborah L. Birx, the White House coronavirus response coordinator, and Dr. Robert R. Redfield, who served as director of the Centers for Disease Control and Prevention.Many issues covered in the report, such as serious problems with data collection and insufficient testing capacity, had already been explored by news organizations, but the study painted a sweeping portrait of a government that was wholly unprepared for the arrival of a deadly new pathogen.The report cited inadequate funding, supply chain vulnerabilities, overlapping government roles and other problems that it said “have been flagged by experts and oversight agencies for years, yet have been largely overlooked by all branches of the federal government.”It found, for example, that a public health emergency fund created to support state and local health systems had received no new appropriations since 1999 and had been “virtually empty” since 2012.While the federal preparedness apparatus had been in place for decades, the report noted that planning from 2005 through 2019 had been “narrowly focused on influenza and failed to adequately incorporate other potential infectious disease threats.”The report is not the first analysis of the coronavirus outbreak to come out of Congress.The top Republican on the Senate health committee, Senator Richard M. Burr of North Carolina, recently released a report asserting that the pandemic was likely the result of a laboratory accident in China — a theory that is popular with his party but not with scientists. The House subcommittee on the coronavirus crisis, controlled by Democrats, has produced a series of scathing reports about the Trump administration’s response.The Senate homeland security committee’s analysis was narrow in scope. It focused on the chaotic first few months of the pandemic, after the coronavirus was first identified in China in December 2019. At the beginning of the outbreak, the United States “failed to heed critical public warnings that foreshadowed the severity and transmissibility of the virus,” the report said.As the crisis unfolded, the report said, the White House barred the C.D.C. from holding news briefings. Though experts repeatedly recommended the use of face masks, the administration did not formally do so until April 3, 2020 — and even then, Mr. Trump declined to wear one. He also insisted the virus would disappear.“There’s no question that political decisions were being made and that those decisions were unfortunately considered more important than what was being put out by public health officials,” Senator Gary Peters, Democrat of Michigan and the chairman of the homeland security committee, told reporters on Wednesday.He added, “And so that got politicized in a way that it should have never been politicized — and lives would have likely been saved.”But at the same time, Mr. Peters said, there was “no question that there were systemic problems that were unaddressed for decades.”

Ten years after the Supreme Court ruled that states did not have to expand Medicaid, the politics are changing in states like South Dakota, where rural hospitals and nursing homes are struggling.CONDE, S.D. — Progressives have helped bring health coverage to tens of thousands of uninsured Americans with an exercise in direct democracy: They have persuaded voters to pass ballot measures expanding Medicaid in six states where Republican elected officials had long been standing in the way.Now comes the latest test of this ballot box strategy: South Dakota.An unlikely coalition of farmers, business leaders, hospital executives and clergy members have coalesced around Amendment D, a ballot measure that would enshrine Medicaid expansion in the South Dakota Constitution, over the objections of Gov. Kristi Noem, a Republican. It is widely expected to pass next week on Election Day.It has been 10 years since the Supreme Court ruled that states did not have to expand Medicaid — the government health insurance program for low-income people — under the Affordable Care Act, and the politics around the issue have shifted. Philosophical objections to large government programs are giving way to economic considerations, particularly in rural states like South Dakota, where struggling hospitals and nursing homes are eager for federal reimbursement dollars that come from Medicaid.If Medicaid expansion is adopted in South Dakota — a state where Donald J. Trump won more than 60 percent of the vote both times he ran — advocates say it will send a strong signal to other Medicaid expansion holdouts, like Texas and Florida. South Dakota is one of 12 remaining states that have not expanded, down from 19 in 2016.“It is harder and harder for conservative politicians to stand behind the idea that the A.C.A. is just one lawsuit away from being repealed or overturned,” said Kelly Hall, the executive director of the Fairness Project, a national nonprofit that is behind the “Yes on D” campaign.“Our work,” she said, “is about how do we build odd-bedfellows coalitions delivering the message that Medicaid expansion is good for the economy, brings back tax dollars to the states, is helpful for small businesses and is not just ‘Do you support Obamacare?’”In the tiny farming town of Conde, where a road sign puts the population at 140, that is exactly the argument that Doug Sombke, the president of the South Dakota Farmers Union, is making.Doug Sombke, the president of the South Dakota Farmers Union, is among the ballot measure’s supporters.Tim Gruber for The New York Times“Farmers and ranchers,” Mr. Sombke said, “are small-business men, and they just can’t afford insurance.”Tim Gruber for The New York TimesNationally, an estimated 2.2 million uninsured American adults fall into the Medicaid “coverage gap” because they live in one of the 12 states that refuse to expand the program. Too poor to qualify for subsidized private insurance through the Obamacare exchanges yet not poor enough for Medicaid, they rely on charity care — or skip care altogether.South Dakota officials estimate that 42,500 people would be newly eligible for Medicaid under an expanded program. Some of them are people Mr. Sombke represents. “Farmers and ranchers,” he said, “are small-business men, and they just can’t afford insurance.”The State of the 2022 Midterm ElectionsElection Day is Tuesday, Nov. 8.Biden’s Speech: In a prime-time address, President Biden denounced Republicans who deny the legitimacy of elections, warning that the country’s democratic traditions are on the line.State Supreme Court Races: The traditionally overlooked contests have emerged this year as crucial battlefields in the struggle over the course of American democracy.Democrats’ Mounting Anxiety: Top Democratic officials are openly second-guessing their party’s pitch and tactics, saying Democrats have failed to unite around one central message.Social Security and Medicare: Republicans, eyeing a midterms victory, are floating changes to the safety net programs. Democrats have seized on the proposals to galvanize voters.Four rural nursing homes have already closed this year in South Dakota, and a fifth is set to close by the end of this month. Additional federal reimbursement dollars, Mr. Sombke said, might help forestall future closures and prevent people in rural areas from having to drive 60 miles or more for care.He cited a state legislative analysis showing that South Dakota would save $162 million over five years by expanding Medicaid. Using numbers contained in that analysis, proponents of Amendment D have calculated that during the first year of the program, $328 million would flow back into the state from the federal government.“We’re talking about money that we’re sending to Washington — our own money that we pay, tax money that we’re letting other states use,” Mr. Sombke said. “I’m sorry, but that’s not conservatism. That’s just stupid.”Medicaid, created in 1965 under President Lyndon B. Johnson to provide health coverage to the poor, is jointly financed by states and the federal government. The Affordable Care Act, passed in 2010, initially required states to expand Medicaid to cover nearly all adults with incomes up to 138 percent of the poverty level, currently around $19,000 for an individual and $38,000 for a family of four. But the Supreme Court struck down the requirement in 2012.Congress intentionally made expansion a good deal for states, as the Affordable Care Act requires the federal government to pick up 90 percent of the cost for patients enrolled in the expansion program. When Congress passed the $1.9 trillion coronavirus relief package last year, it increased the incentives for states by offering an additional federal match for two years.Those new incentives have “reignited some of the discussion around expansion,” said Robin Rudowitz, an expert on Medicaid at the nonpartisan Kaiser Family Foundation. “Republicans who had not supported expansion for a long time are starting to think about it.”Among them is Greg Jamison, a South Dakota state representative and self-described fiscally conservative Republican who had previously opposed expanding Medicaid. Mr. Jamison represents part of Sioux Falls, which is home to two of the state’s largest health care organizations, Sanford Health and Avera Health. Both back Amendment D.Greg Jamison, a Republican state representative, said his discussions with uninsured relatives led him to conclude that expanding Medicaid was the right thing to do.Tim Gruber for The New York TimesOpponents of the ballot measure say the health systems, which have poured money into the campaign to pass it, do not need federal help. They note that the former chief executive of Sanford Health, who stepped down in 2020 amid controversy over his statement that he would not wear a mask after recovering from Covid-19, received a hefty payout, which Mr. Jamison acknowledged “doesn’t look good.”But the lawmaker said his discussions with uninsured relatives — “conversations that are bigger and more serious than any I’ve ever had,” he said — led him to conclude that expanding Medicaid was the right thing to do. Mr. Jamison also views expansion as a way to support new mothers in South Dakota, where abortion became illegal, with very limited exceptions, after the Supreme Court overturned Roe v. Wade in June. Now he appears in an ad for the proponents.“This is a risky conversation, since it’s not in our platform,” Mr. Jamison said over breakfast at a diner in downtown Sioux Falls. “But it just makes sense. It’s time to get over it.”The South Dakota ballot initiative would require the state to expand Medicaid eligibility by July 1, 2023. Ms. Noem, a rising star in the Republican Party who is running for re-election in a surprisingly competitive race, has said that if Amendment D passes, she will carry it out.Opponents, including the conservative group Americans for Prosperity, argue that Medicaid needs to be overhauled, not expanded. Keith Moore, the group’s South Dakota director, said that giving free health care to able-bodied people would discourage them from working and would hurt the truly needy by creating long lines for doctors.“With people being put on Medicaid, you’re taking purpose from people, you’re taking dignity from people,” Mr. Moore said. “People need to work.”But advocates say South Dakotans who need health care are already working; the state’s unemployment rate is 2.3 percent, the lowest figure in more than a decade. The prospect of new jobs is one reason the board of the South Dakota Chamber of Commerce and Industry voted to back Amendment D in September after a “healthy debate,” said David Owen, its president and chief lobbyist.“The infusion of money into the health care system will help stabilize and create health care jobs,” he said. “When you look at this in reality, you just have to come to the conclusion that we keep South Dakota money here.”Proponents of expansion are confident because there has already been a test vote. During the state’s primary election in June, voters rejected a ballot measure that would have required a majority of 60 percent to approve any constitutional amendment. That measure, known as Amendment C, was widely considered an effort by opponents of Medicaid expansion to thwart it.“They put all their eggs in one basket,” Mr. Owen said. “It didn’t work.”Once Amendment C failed, donations from Americans for Prosperity and other opponents dried up, said State Senator John Wiik, a Republican leading the fight against expansion. Referring to the state’s major health care organizations, he said, “I kind of feel like I’m up against three big old medical Goliaths, here all by myself.”A recent survey by South Dakota State University that found 53 percent of likely voters supported Medicaid expansion, 20 percent were opposed and 27 percent were undecided. The coalition backing the amendment, which calls itself South Dakotans Decide Healthcare, has raised more than $3 million, most of it from health care organizations, according to campaign finance filings. Mr. Wiik said his side had raised “absolutely zero.”Still, Mr. Wiik said he remained hopeful. He said Republicans in the state’s Legislature had taken steps to expand access to care by increasing reimbursement rates for health providers and helping the South Dakota Farm Bureau improve its health insurance offerings. (The Farm Bureau tilts Republican, while the farmers’ union leans Democratic.)“It’s not like the conservatives in South Dakota have just sat around and said, ‘No,’” Mr. Wiik said.In addition to making an economic case for expansion, advocates have tried to put a human face on the problem of the uninsured by enlisting ordinary South Dakotans to tell their stories.Sarah Houska left a job with the state to spend more time caring for one of her sons, who has serious health issues. Now, she works part time at a dental office and has no coverage.Tim Gruber for The New York TimesThey include people like Sarah Houska, 29, of Sioux Falls. A single mother of two, she left a job with the state — in which she determined whether people were eligible for Medicaid — to spend more time caring for one of her sons, who has serious health issues. Now, she works part time at a dental office and has no coverage. She also volunteers for the American Heart Association’s team working to pass Amendment D.“My dad is a die-hard Republican,” she said. “He was so against expansion until my personal situation. When you are faced with it and it’s family, it’s different.”The ballot initiative strategy, though, has its limits. Of the 12 remaining states that have not expanded Medicaid, just three — South Dakota, Florida and Wyoming — currently allow ballot initiatives. (Mississippi had a ballot initiative process until last year, when it was struck down by the state’s Supreme Court.)Advocates for expansion say their next target is North Carolina, where the power to take action rests in the hands of lawmakers. Republican leaders in the state’s General Assembly have reversed themselves and now express support for Medicaid expansion — using many of the same arguments about tax dollars and financial incentives that the Fairness Project, the national nonprofit running the campaign for Amendment D, is using in South Dakota.The group was created by a California health care workers’ union in 2015, when congressional Republicans were still trying to repeal the Affordable Care Act and state expansion efforts were stalled. Ms. Hall, the group’s executive director, said it had not been “nearly as difficult to have a conversation with voters as it would have been with conservative politicians in state legislatures.”In 2017, Maine voters rebuked their Republican governor, Paul LePage, by passing an expansion initiative, though it took the election of a Democrat, Gov. Janet Mills, to put it in place. In 2018, Idaho, Nebraska and Utah — all states that Mr. Trump had won handily two years earlier — passed ballot measures as well. So did Missouri and Oklahoma in 2020.“We are six for six, in places that you would not expect,” Ms. Hall said. “None of these places are bastions of progressive organizing.”