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and harder for conservative politicians to stand behind the idea that the A.C.A. is just one lawsuit away from being repealed or overturned,” said Kelly Hall, the executive director of the Fairness Project, a national nonprofit that is behind the “Yes on D” campaign.“Our work,” she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.”

Cases are declining nationally, and the deputy coordinator of the White House monkeypox response team said he expected that, over time, they would drop to a trickle.WASHINGTON — With monkeypox cases on the decline nationally, federal health officials expressed optimism on Thursday that the virus could be eliminated in the United States, though they cautioned that unless it was wiped out globally, Americans would remain at risk.“Our goal is to eradicate; that’s what we’re working toward,” Dr. Demetre Daskalakis, the deputy coordinator of the White House monkeypox response team, said during a visit to a monkeypox vaccination clinic in Washington. He added, “The prediction is, we’re going to get very close.”Dr. Daskalakis was joined by President Biden’s health secretary, Xavier Becerra, and the response team’s coordinator, Robert J. Fenton Jr., who echoed his optimism. The visit to the clinic was intended to spotlight efforts by the District of Columbia to close the racial gap in vaccination against monkeypox — a major goal of the Biden administration.“The president said from the very beginning, ‘Get on top of this, and then stay ahead of it,’” Mr. Becerra told reporters. “And we can’t say we really stayed ahead of it if we’re leaving certain communities behind.”Dr. Daskalakis, an infectious disease expert who previously ran the division of H.I.V. prevention at the Centers for Disease Control and Prevention, was brought onto the monkeypox response team by Mr. Biden last month.What to Know About the Monkeypox VirusCard 1 of 7What is monkeypox?

Cases are declining nationally, and the deputy coordinator of the White House monkeypox response team said he expected that, over time, they would drop to a trickle.WASHINGTON — With monkeypox cases on the decline nationally, federal health officials expressed optimism on Thursday that the virus could be eliminated in the United States, though they cautioned that unless it was wiped out globally, Americans would remain at risk.“Our goal is to eradicate; that’s what we’re working toward,” Dr. Demetre Daskalakis, the deputy coordinator of the White House monkeypox response team, said during a visit to a monkeypox vaccination clinic in Washington. He added, “The prediction is, we’re going to get very close.”Dr. Daskalakis was joined by President Biden’s health secretary, Xavier Becerra, and the response team’s coordinator, Robert J. Fenton Jr., who echoed his optimism. The visit to the clinic was intended to spotlight efforts by the District of Columbia to close the racial gap in vaccination against monkeypox — a major goal of the Biden administration.“The president said from the very beginning, ‘Get on top of this, and then stay ahead of it,’” Mr. Becerra told reporters. “And we can’t say we really stayed ahead of it if we’re leaving certain communities behind.”Dr. Daskalakis, an infectious disease expert who previously ran the division of H.I.V. prevention at the Centers for Disease Control and Prevention, was brought onto the monkeypox response team by Mr. Biden last month.What to Know About the Monkeypox VirusCard 1 of 7What is monkeypox?

The president made the remark in an interview that aired on CBS’s “60 Minutes” on Sunday night. By Monday, the backlash was in full swing.WASHINGTON — With 400 to 500 Americans still dying every day of Covid-19, President Biden has declared that “the pandemic is over.”But don’t tell that to people like Debra McCoskey-Reisert, whose mother died in early August. Or Ben HsuBorger, who has chronic fatigue syndrome, a condition often brought on by viruses, including the coronavirus. Or Peter W. Goodman, whose wife died on Aug. 17.“It’s not over for me,” said a tearful Mr. Goodman, 76, who is retired after working as a journalism professor at Hofstra University on Long Island. Both he and his wife, Debbie, 70, became sick with Covid-19 last month. He recovered. She did not.The president made the remarks while speaking in an interview that aired on CBS’s “60 Minutes” on Sunday night. By Monday morning, the backlash was in full swing — as patients said the president was being insensitive at best, and some public health experts said his words were at odds with the science.“We’ve had two million cases reported over the last 28 days, and we know underreporting is substantial,” said Dr. Michael T. Osterholm, an infectious-disease specialist at the University of Minnesota. Covid-19, he said, “continues to be the No. 4 cause of death in the country.”In the “60 Minutes” interview, which was taped during the Detroit Auto Show last week, Mr. Biden did allow that “we still have a problem with Covid.” But he also gave a nod to the unmasked crowds at the show.“The pandemic is over,” he said. “If you notice, no one’s wearing masks. Everybody seems to be in pretty good shape.”A protest in front of the White House demanding action on chronic fatigue syndrome and long Covid.Zeynep Tufekci/New York Times The word from the White House on Monday was that the president was simply expressing what many Americans were already feeling and seeing and what Mr. Biden had been saying all along — that the nation has vaccines and treatments to fight the coronavirus and that for most people, it is not a death sentence.Xavier Becerra, Mr. Biden’s health secretary, echoed the sentiment while getting his booster shot at a community health clinic in New York.Read More on the Coronavirus PandemicUpdated Boosters: As masks have fallen away and quarantines have diminished, the new vaccines are one of the last remaining weapons in America’s arsenal against the coronavirus. So far, the rollout is methodical, but muted.Educational Declines: Test results show the pandemic’s effect on U.S. students: The math and reading scores of 9-year-olds dropped steeply, erasing two decades of progress.Heavy Toll: The average life expectancy of Americans fell precipitously in 2020 and 2021. The decline, largely driven by the pandemic, was particularly pronounced among Indigenous communities.Paxlovid Study: The Covid-19 medication Paxlovid reduced hospitalizations and deaths in older patients, but made no difference for patients under 65, new research from Israel found.“I think the president was reflecting what so many Americans are feeling and thinking,” Mr. Becerra said, “that Covid has disrupted our lives for so long, but we’re also finding that with these effective vaccines, with masking, with the efforts to protect our children, seniors, we are learning how to cope with this virus. But make no mistake. People are still dying.”But it’s one thing for ordinary Americans to think and feel that the pandemic is over; it is another thing for the president to say it. Presidential pronouncements carry policy implications, and the Biden administration had to answer questions on Monday about whether the president’s words would change anything.The short answer: No, they will not.Mr. Becerra’s agency, the Department of Health and Human Services, said the Covid-19 public health emergency, which gives the government flexibility to waive or modify requirements for health-related programs like Medicare and Medicaid, remained in effect.Much of Mr. Biden’s domestic agenda is entangled with the coronavirus pandemic as well. Late last month, his administration announced it was canceling $10,000 in federal student loan debt for certain borrowers to ensure that they were “not placed in a worse position financially because of the pandemic.”The White House is also pressing Congress to appropriate an additional $22 billion to fight the pandemic. The president’s comments could complicate that effort — as well as the administration’s campaign to persuade Americans to take the newly authorized “bivalent” booster shots, just as a possible fall surge is coming, said Jennifer Nuzzo, director of the Center for Pandemic Preparedness and Response at the Brown University School of Public Health.“An unfortunate sound bite,” she said of Mr. Biden’s remarks.Other experts said Mr. Biden was just plain wrong.To begin with, the president does not have the authority to announce an end to the pandemic. The World Health Organization, an arm of the United Nations, designated the coronavirus outbreak a pandemic in 2020. If anyone is responsible for declaring an end, experts say, it would be the organization and its director general, Dr. Tedros Adhanom Ghebreyesus.“We are not there yet,” Dr. Tedros said last week. “But the end is in sight.”In the United States, data show that the pandemic is in what Dr. Osterholm calls a “high plains plateau.”Debbie Goodman.Courtesy of Peter W. Goodman Gone are the peaks and valleys that came and went with the Omicron surge in late 2021 and early 2022. Hospitalizations are now declining, though roughly 32,000 Americans are still hospitalized with coronavirus infection each day, according to a New York Times database. The number of deaths today is far lower than it was a year ago, when the Delta variant was causing nearly 2,000 deaths per day.“We still have 400 to 500 people dying daily in this country,” said Dr. Carlos del Rio, an infectious disease expert at Emory University in Atlanta. “If that’s over, it’s a little too high to me.”And for many Americans who are still experiencing the fallout from the worst public health crisis in a century, Mr. Biden’s remarks — and the suggestion that the nation is moving on — were painful. Many of those who are now dying of Covid-19 are either older (Ms. McCoskey-Reisert’s mother, Roberta, was 81) or have underlying illnesses (Mr. Goodman’s wife had lupus, which made her vulnerable).“Let’s not make premature declarations,” said Ms. McCoskey-Reisert, a retired business professor from Citrus Springs, Fla., whose mother died on Aug. 6. “People are still dying.”The pandemic, she said in an interview, feels like “a hell that I am never going to get out of.” Her husband has a compromised immune system, she said, and she is still wearing masks.“President Biden said, ‘No one’s wearing masks,’ and perhaps that is true,” she said. “But is it wise?”Mr. Goodman, who worked as a music and arts reporter for Newsday before he turned to teaching, got sick shortly after he and his wife, Debbie, had returned from a cruise along the Rhine. He said he had no idea how they contracted Covid-19 — it could have been on the plane, where few people were wearing masks, or in the airport, or on the ship, where someone they ate with had a cough.He said he does not regret the trip; his wife, who also had a lung disorder, consulted with her pulmonologist, who said it was fine for her to go. He is glad, he said, that they had that time together. He said he was trying not to pay attention to statistics.“How many people are still dying a day — is it 400 people a day?” he asked. “It’s not over. It may feel over. Probably if it weren’t for my situation, I might feel that it was over, too, but I’m in a situation where it doesn’t matter whether other people think it’s over. It’s not over for me.”Others say their lives are forever changed.“For us, there is no normal that we can go back to,” said Mr. HsuBorger, seated in a wheelchair. He had just led a group of patients with myalgic encephalomyelitis, a complex disorder also known as chronic fatigue syndrome, in a protest outside the White House. Many have long Covid. Their T-shirts declared: “Still Sick. Still Fighting.”Sharon Otterman and

President Biden has selected Dr. Renee Wegrzyn to lead the Advanced Research Projects Agency for Health, which is aimed at driving biomedical innovation.WASHINGTON — President Biden has selected Dr. Renee Wegrzyn, a Boston biotech executive with government experience, as the director of a new federal agency aimed at driving biomedical innovation, the White House said on Monday.Mr. Biden will announce his intention to appoint Dr. Wegrzyn, along with a series of steps to promote his so-called cancer moonshot initiative, during a speech at the John F. Kennedy Presidential Library and Museum in Boston on the 60th anniversary of the former president’s “moonshot” speech that ushered in an era of space travel.Mr. Biden, whose son Beau died of brain cancer in 2015, has a deep personal commitment to advancing cancer research. He helped create the cancer moonshot when he was vice president and proposed the new biomedical agency this year as part of an effort to reinvigorate the initiative and, he has said, to “end cancer as we know it.”Modeled after the Defense Advanced Research Projects Agency, the biomedical research agency is known as the Advanced Research Projects Agency for Health. (In the argot of Washington, where every agency has an acronym, the defense research agency is called DARPA and the health agency is ARPA-H.)Dr. Wegrzyn is currently a vice president of business development at Ginkgo Bioworks and the head of innovation at Concentric by Ginkgo, the company’s initiative to advance coronavirus testing and track the spread of the virus. She also worked at DARPA and its sister agency, the Intelligence Advanced Research Projects Activity.“Some of the problems we face every day — especially in health and disease — are so large they can seem insurmountable,” Dr. Wegrzyn said in a statement provided by the White House. “I have seen firsthand the tremendous expertise and energy the U.S. biomedical and biotechnological enterprise can bring to solve some of the toughest health challenges.”Congress has appropriated $1 billion for ARPA-H, which is housed within the National Institutes of Health. While its director is not a Senate-confirmed position, Mr. Biden may face pushback from Republicans, some of whom have argued that the new agency duplicates the N.I.H.’s efforts.The White House announcement drew praise from Ellen V. Sigal, the chairwoman of Friends of Cancer Research, a nonprofit that works with industry and government to advance new therapies. Ms. Sigal called Dr. Wegrzyn “an inspired choice,” adding, “She is a proven innovator and leader who knows science, knows how to make government work and understands the urgency for patients across the country.”In addition to announcing his intent to appoint Dr. Wegrzyn, Mr. Biden on Monday issued an executive order establishing a biotechnology and biomanufacturing initiative intended to position the United States as a leader in the field and to center drug manufacturing in the country. The coronavirus pandemic exposed critical weaknesses in the supply chain for drugs and live-saving therapies.“The United States has for too long relied heavily on foreign materials for bioproduction,” the White House said in a statement, “and our past offshoring of critical industries, including biotechnology, presents a threat to our ability to access key materials like including the active pharmaceutical ingredients for lifesaving medications.”

Dr. Anthony S. Fauci, who has advised seven presidents and spent more than half a century at the National Institutes of Health, will leave government service by the end of the year.Dr. Anthony S. Fauci said on Monday that he intended to leave government service in December to “pursue the next chapter” of his career, and that he would step down as President Biden’s top medical adviser and the director of the National Institute of Allergy and Infectious Diseases, which he has led for 38 years.The announcement by Dr. Fauci, 81, was not entirely unexpected. He has hinted for some time that he was thinking of retiring. In an interview Sunday evening, he said he was “not retiring in the classic sense” but would devote himself to traveling, writing and encouraging young people to enter government service.“So long as I’m healthy, which I am, and I’m energetic, which I am, and I’m passionate, which I am, I want to do some things outside of the realm of the federal government,” Dr. Fauci said in the interview, adding that he wanted to use his experience and insight into public health and public service to “hopefully inspire the younger generation.”In a statement on Monday, Mr. Biden thanked Dr. Fauci, whom he called a “dedicated public servant, and a steady hand with wisdom and insight.” The two had worked closely together during a global outbreak of the Zika virus when Mr. Biden was vice president.“Because of Dr. Fauci’s many contributions to public health, lives here in the United States and around the world have been saved,” the president said.Few scientists have had as large or as long-lasting an impact on public policy. Dr. Fauci joined the National Institutes of Health in 1968, when Lyndon Johnson was president; he was appointed the director of its infectious disease branch in 1984, when the AIDS epidemic demanded attention.Dr. Fauci has advised every president since Ronald Reagan — seven in all — and has been adept at navigating the nexus of science and politics. Among his proudest accomplishments, he said, was his work with President George W. Bush in developing a global program to combat H.I.V./AIDS, known as PEPFAR, which has saved an estimated 21 million lives. Mr. Bush — whose father, George Bush, called Dr. Fauci “a hero” during a 1988 presidential debate — awarded him the Presidential Medal of Freedom in 2008.But Dr. Fauci, who catapulted into the spotlight when the coronavirus began spreading in 2020, could not escape the politicization of the Trump era. President Donald J. Trump toyed openly with the idea of firing him (though that would have been difficult because Dr. Fauci is not a political appointee). Conservatives viewed Dr. Fauci as a symbol of lockdowns and masks, which they fiercely resisted.President George W. Bush honored Dr. Fauci with a Presidential Medal of Freedom in 2008.Ron Edmonds/Associated PressDr. Fauci clashed bitterly with Senator Rand Paul, Republican of Kentucky, who publicly accused him of lying about research his institute was funding in China, where the coronavirus emerged. (“If anybody is lying here, it is you, Senator,” Dr. Fauci shot back.) Mr. Paul and other Republicans have vowed to investigate Dr. Fauci if they win control of Congress this fall, and there has been speculation that Dr. Fauci would retire to avoid that possibility.Dr. Fauci dismissed that idea as “nonsense” and also said that he had no intention of going to work for the pharmaceutical industry, as some of his critics have suggested. He said he considered stepping down after Mr. Trump left the White House, but felt he could not refuse a request from Mr. Biden to serve as his medical adviser in the thick of the coronavirus crisis.“So I stayed on for a year, thinking that at the end of the year, it would be the end of Covid, and as it turned out, you know, that’s not exactly what happened,” Dr. Fauci said. “And now it’s my second year here, and I just realized that there are things that I want to do.”In addition to running the allergy and infectious diseases institute, Dr. Fauci also leads an immunology laboratory; he said he would leave that position as well. He said he had told Mr. Biden of his decision, and the president had been “very gracious about it.”Dr. Fauci did not set a specific departure date (he will turn 82 on Dec. 24). He said he hoped that by staying through the fall and into early winter, the United States would “get closer to living with” the coronavirus “in a steady state,” though there are no guarantees.“I’m not happy about the fact that we still have 400 deaths per day,” he said. “We need to do much better than that. So I don’t think I can say that I’m satisfied with where we are. But I hope that over the next couple of months, things will improve.”While he has been working on a memoir, Dr. Fauci said he did not yet have a publisher. In an interview last year, he said he was precluded from contracting with a publisher while he was still employed by the government.During more than five decades as a government scientist, Dr. Fauci has helped shepherd the United States through a number of infectious disease threats. But before the coronavirus, he was best known for his work on H.I.V./AIDS. He was polarizing then as well, a target of activists who accused him of being responsible for the deaths of gay men by not moving quickly enough to push new treatments through the approval process.Over time, he befriended many of those activists. In an email message on Monday, one of the activists, Peter Staley, recalled “parading an effigy of his bloody head on a stick in front of his building at the N.I.H.” But “he still never closed his door to us,” Mr. Staley said, adding, “I’ve never met a more decent human being.”Dr. Fauci was profoundly affected by caring for AIDS patients in an era when nearly all of them died. In a documentary released by National Geographic last year, he recalled arriving at the bedside of an AIDS patient who suddenly no longer recognized him; the man had lost his vision.As Dr. Fauci told the story, his voice cracked. The filmmakers asked why it was affecting him all these years later. He paused to gather himself. “Post-traumatic stress syndrome,” he said, pausing again. “That’s what it is.”Dr. Fauci became a household name in the early days of the coronavirus pandemic. His face was commemorated on sweatshirts, knee socks and mugs; a petition to name him People magazine’s “Sexiest Man Alive” garnered more than 28,000 signatures.When asked in an interview this year about why he had become such a polarizing figure, Dr. Fauci pointed to some of Mr. Trump’s aides, who, he said, sought to pillory him by insisting that everything he said was wrong. He did not take issue directly with Mr. Trump.Dr. Fauci catapulted into the spotlight during briefings at the White House when the coronavirus pandemic took hold in the United States in 2020.Doug Mills/The New York Times“Instead of throwing me out, they tried to discredit me,” Dr. Fauci said. Referring to the aides, he said, “If you are propagating lies, the person who is telling the truth based on science all of a sudden becomes the adversary.”In a formal statement announcing his departure, Dr. Fauci said he would use his remaining months in government to “continue to put my full effort, passion and commitment into my current responsibilities” and to help prepare his institute for a leadership transition.“N.I.H. is served by some of the most talented scientists in the world,” he said, “and I have no doubt that I am leaving this work in very capable hands.”

New Biden administration guidance warned that failing to dispense such drugs “may be discriminating” on the basis of sex or disability, citing other conditions that they can treat.WASHINGTON — The Biden administration warned the nation’s 60,000 retail pharmacies on Wednesday that they risk violating federal civil rights law if they refuse to fill prescriptions for pills that can induce abortion — the second time this week that it has used its executive authority to set up showdowns with states where abortion is now illegal.In four pages of guidance, the federal Department of Health and Human Services ticked off a series of conditions — including miscarriage, stomach ulcers and ectopic pregnancy — that are commonly treated with drugs that can induce abortion. It warned that failing to dispense such pills “may be discriminating” on the basis of sex or disability.The guidance came two days after Xavier Becerra, President Biden’s health secretary, instructed hospitals that even in states where abortion is now illegal, federal law requires doctors to perform abortions for pregnant women who show up in their emergency departments if they believe it is “the stabilizing treatment necessary” to resolve an emergency medical condition.The back-to-back actions make clear that while Mr. Biden’s authority to preserve access to abortion is limited after the Supreme Court eliminated the constitutional right to the procedure last month, he will push those limits where he can. Legal experts on both sides of the issue agreed in interviews that the administration was trying to assert that federal law pre-empts that of states that have banned abortion, a move that would almost surely be challenged in court.“They are trying to identify federal statutes that in some way will supersede state abortion restrictions and bans,” said Lawrence O. Gostin, an expert in public health law at Georgetown University. Of the guidance for pharmacists, he said, “The obvious goal is to have abortion medication in stock to treat a range of medical conditions and to be available for an abortion.”Yet the new guidance is cautiously written, and steers clear of telling pharmacies that they have to provide the drugs for the purpose of medication abortion, which is banned or restricted in certain states. Nor does the guidance address how a provision in federal law called the Church Amendments would apply. That measure allows health care providers, including pharmacists, not to perform or assist in abortions if they have religious or moral objections.At issue are three drugs — mifepristone, misoprostol and methotrexate — that are often prescribed for other conditions but can also induce abortions. Experts said the administration was reacting to reports that women of childbearing age are being denied the drugs after the ruling.Mifepristone is used to manage certain patients with a hormonal disorder called Cushing’s syndrome, and misoprostol is prescribed for ulcers. But they are also authorized by the Food and Drug Administration as a two-drug combination that can be taken to terminate a pregnancy during the first 10 weeks, and can also be used in combination following miscarriages. Methotrexate is used to treat autoimmune disorders, such as rheumatoid arthritis, as well as cancer.“These are very legitimate issues in terms of people being concerned about having access to the basic medications that they have been receiving for years, just because those medications have the capacity to end a pregnancy,” said Alina Salganicoff, the director of women’s health policy at the Kaiser Family Foundation. “It doesn’t sound like they are blocking this for men.”The administration’s moves will almost certainly be challenged in court, and advocates for abortion rights concede that it could be a losing battle. If legal challenges work their way up to the Supreme Court, the administration will have to make its case before the same conservative supermajority of six justices who voted to overturn Roe v. Wade, the landmark legal case that established a right to abortion in 1973.“They’re trying to mandate the stocking of abortion-inducing drugs and the performance of abortions across the nation using tools that don’t grant the federal government that authority,” said Roger Severino, who ran the Office of Civil Rights within the Department of Health and Human Services when Donald J. Trump was president. “They are trying to shoehorn abortion into laws that clearly weren’t designed to address abortion.”Wednesday’s action could put pharmacists in a thorny position. The National Community Pharmacists Association, which represents 19,400 independent pharmacies across the country, said pharmacists “acting in good faith in accordance with their state’s laws” lacked “a clear pathway forward” and needed more guidance from states.“States have provided very little clarity on how pharmacists should proceed in light of conflicting state and federal laws and regulations,” B. Douglas Hoey, the organization’s chief executive, said in a statement. “It is highly unfair for state and federal governments to threaten aggressive action against pharmacists who are just trying to serve their patients within new legal boundaries that are still taking shape.”A spokesman for Walgreens, one of the nation’s largest pharmacy chains, said the company would review the guidelines; he had no further comment.During a background call with reporters, an official from the Department of Health and Human Services said that when state and federal laws conflicted, federal law took precedent. Mr. Biden has been under intense pressure from Democrats and advocates for reproductive rights to take bold steps to preserve the right to abortion after the court’s decision in Dobbs v. Jackson Women’s Health Organization. Among other things, they have been pushing for him to declare a public health emergency — something his administration seems unwilling to do.Wednesday’s guidance was issued by the health department’s Office of Civil Rights. Monday’s guidance for hospitals was accompanied by a letter to health care providers, delineating their responsibilities under the Emergency Medical Treatment and Active Labor Act, known as EMTALA, a 1986 law that requires anyone coming to an emergency department to be stabilized and treated regardless of insurance status or ability to pay.Mr. Severino argued that the guidance to hospitals “flips EMTALA on its head,” because the law defines an emergency as a condition in which the absence of immediate medical attention “could reasonably be expected to result in placing the health of the patient, or (in case of pregnancy, the unborn child) in serious jeopardy.” But Mr. Gostin took the administration’s position, saying that in the case of a pregnant woman in distress, the law permitted abortion “if it was necessary to save her life and there was no other way to stabilize her.”

The demise of Roe v. Wade would make the need for effective birth control more urgent than ever. Yet many American women still have a hard time obtaining it.ROLLA, Mo. — For more than half a century, Tri-Rivers Family Planning has operated on a shoestring budget, providing contraceptives, pregnancy testing, treatment for sexually transmitted diseases and other reproductive health care to a mostly low-income and female clientele here in the Ozark Mountains.The clinic has never performed abortions. But with the Supreme Court widely expected to revoke the constitutional right to abortion that it established in Roe v. Wade, its work has never been more essential — and its nurse practitioners and patients have never felt more threatened.Last year, the Republican-led Missouri Senate voted to ban taxpayer funding for two common methods of preventing pregnancy: intrauterine devices and emergency contraception — the so-called morning-after pill, also known as Plan B — which many abortion opponents regard as “abortifacients” because they can prevent a fertilized egg from implanting in a woman’s uterus. Lawmakers later abandoned the effort, but some have indicated that if Roe falls, they may try again.“The attacks are relentless — any little angle they can chip away at what we do, they are doing it,” said Lisa Ecsi Davis, the clinic’s director of operations, who has worked at Tri-Rivers for 30 years. “It’s exhausting.”The demise of Roe would make the need for effective birth control more urgent than ever. Yet nearly six decades after the Supreme Court guaranteed the right to use contraception, and more than 10 years after the Affordable Care Act mandated that private insurers cover it, many American women still have a hard time getting access.Lisa Ecsi Davis, the director of operations, has worked at the clinic for 30 years.Whitney Curtis for The New York TimesFunding for Title X, the federal safety net program that helps finance family planning clinics like Tri-Rivers, has been flat for more than a decade. Private insurers do not always cover the full cost of contraception, despite the A.C.A. requirement. Six states allow pharmacists to refuse to fill birth control prescriptions for religious or moral reasons, without taking steps to help patients get them filled elsewhere.“This is our daily life,” lamented Rachel Goss, the executive director of the Family Planning Council of Iowa, which administers Title X grants in that state. “You’re fighting this constant uphill battle just to provide safe — and right now, legal — care.”Congressional Democrats, sensing a potent political issue in the upcoming midterm elections, are pushing to expand access to birth control.Last week, they introduced legislation to require insurers to fully cover any F.D.A.-approved birth control pills, including emergency contraception, which costs as much as $50 over the counter — far too much for those struggling financially. Read More on the U.S. Abortion DebateEvolving Language: As they fight for abortion rights, progressive groups and organizations are adopting more inclusive terms, such as “pregnant people” and “cheastfeeding.”Sports: The end of Roe v. Wade could have far-reaching implications for college athletes across the nation — and Oklahoma’s mainstay softball championships in particular.Without Exception: While most of the population supports carve-outs allowing abortions in cases like rape or incest, many of the bans that would go into effect after Roe do away with them.Mental Health: Anti-abortion groups argue that having an abortion can affect a woman’s mental health. But a new study shows that being denied one can be more harmful.But some Republicans on the far right have sought to broadly limit access to emergency contraception, which prevents pregnancy when taken within several days of unprotected sex.“The idea that we might now be facing fights on contraception is something that is very hard to wrap your head around,” said Elizabeth Nash, an expert in state policy at the Guttmacher Institute, a research group that supports abortion rights. If abortion opponents persuade lawmakers to define pregnancy as starting at fertilization, she said, it “could cause complications in being able to provide contraceptive care.”Texas already bars its state family planning programs from paying for emergency contraception. Missouri, one of 13 states with “trigger laws” that would immediately ban abortion if Roe is overturned, is becoming another front in the battle over birth control — and may foreshadow what is to come in a post-Roe world.In February, it became the fourth state — after Arkansas, Mississippi and Texas — to eject Planned Parenthood, a major provider of birth control nationally, from its Medicaid program. Planned Parenthood has asked the Biden administration to intervene, saying the move violated federal law. A spokeswoman for the federal Centers for Medicare and Medicaid Services said the agency was “considering the policy options within its authority.”Pamphlets for family planning were displayed at the clinic.Whitney Curtis for The New York TimesIn the meantime, Medicaid patients must find care elsewhere — and often endure long waits for appointments, said Michelle Trupiano, the executive director of the Missouri Family Health Council, the nonprofit that administers Title X grants in the state.Here in Rolla, a small city of about 20,000 people that sits along historic Route 66, Hailey Kramer, the chief nurse practitioner at Tri-Rivers, said her patients make clear that birth control is a deeply personal decision.Kaitlyn Ball, 24, became pregnant while taking birth control pills and now has a 3-year-old; she does not want to get pregnant again. After consulting with Ms. Kramer, she got an I.U.D.Taylor Gresham, a 25-year-old dancer, has been a patient at Tri-Rivers since the summer before her senior year in high school, when she discovered she was pregnant. After she got an abortion, the clinic provided her with Depo-Provera. Her mother thought it was a good idea, she said, because “a high school kid is probably not going to take a pill every day.”After she graduated, Ms. Gresham opted for an I.U.D.; more recently, she started taking birth control pills again. “I’m on a better routine with my life,” she explained.In 1965, in a case that provided the legal blueprint for Roe, the Supreme Court declared that married couples had a constitutional right to use contraception. Its decision in the case, Griswold v. Connecticut, established a right to privacy that the court said was implied, if not delineated, in the “penumbras” of the Constitution — the same rationale it invoked eight years later in Roe.Kaitlyn Ball, 24, became pregnant while taking birth control pills. After consultation she got an I.U.D.Whitney Curtis for The New York TimesGriswold put contraception at the forefront of the national conversation at a time when policymakers were focused on ending poverty; in 1969, President Richard M. Nixon declared that “no American woman should be denied access to family planning assistance because of her economic condition.” Title X was established by Congress the next year to help pay for the care that so-called family planning clinics provide to low-income patients, who are charged fees based on family size and income.Old newspaper clippings show that Rolla’s mayor came to the ribbon-cutting when Tri-Rivers — initially an affiliate of Planned Parenthood — was founded in 1971, and more than 100 Rolla merchants made donations to get the clinic going.Last year, Tri-Rivers cared for more than 1,800 patients, more than half of whom were uninsured. The clinic gets $250,000 a year, just under half its total budget, in Title X dollars — an amount that has “stayed the same for many years,” said Toni Stubblefield, its president and chief executive.The clinic, which serves roughly a 10-county area and sits halfway between St. Louis and Springfield, once had two satellites. One closed years ago, the other last year, a victim of tight budgets and Covid-19.The State of Roe v. WadeCard 1 of 4What is Roe v. Wade?

WASHINGTON — President Biden and other leaders issued an urgent call on Thursday for the world to step up its fight against Covid-19, and countries including Germany, Canada and Japan pledged large sums to finance tests, therapeutics and vaccines — a commitment Mr. Biden could not make because Congress has refused to authorize new pandemic aid.As the United States approached a harrowing milestone — one million American lives lost to the virus — fear of another deadly variant loomed large over the president’s second global Covid-19 summit, a virtual gathering co-hosted by Belize, Germany, Indonesia and Senegal. But some countries were notably absent. China, in the thick of its own Covid crisis, did not attend. Russia, waging war against Ukraine, was not invited.Senior Biden administration officials said the summit produced more than $3 billion in commitments toward the global response and toward efforts to prevent future pandemics. That is far short of the $15 billion that the World Health Organization says is needed. But the summit did lay the groundwork for a new global preparedness fund.The gathering on Thursday unfolded in a very different climate compared with that of the first Covid summit in September. The war in Ukraine is sapping energy and money from donor nations. The global vaccination campaign has stalled. Testing has plummeted around the globe. Covid antiviral pills, available in the United States, are scarce in many low- and middle-income nations. Many attendees said Covid fatigue had become as big a danger as Covid itself.“There’s still so much left to do; this pandemic isn’t over,” Mr. Biden said in his opening remarks, adding, “We have to prevent complacency.”Global coronavirus cases by regionThis chart shows how reported cases per capita have changed in different parts of the world.

A group of former heads of state and Nobel laureates are calling on the United States to immediately commit $5 billion to combat the global coronavirus pandemic, and activists are pressing President Biden to take a more forceful leadership role in the response as he convenes world leaders for a Covid-19 summit on Thursday.“I want America to recognize that the disease is not over anywhere until it’s over everywhere,” Gordon Brown, the former British prime minister, who is leading the push for funding, said in an interview Monday, adding, “We must not sleepwalk into the next variant.”But Mr. Biden conceded Monday afternoon that “much needed funding” for the Covid-19 response is not coming anytime soon. In a statement issued by the White House, the president said he had been informed by congressional leaders in both parties that including the funding in a new aid package for Ukraine would “slow down action on the urgently needed Ukrainian aid,” and that he was resigned to having the two packages move separately.“However let me be clear: As vital as it is to help Ukraine combat Russian aggression, it is equally vital to help Americans combat Covid,” Mr. Biden wrote, adding that both the domestic and the global response would suffer if the funding is not approved.Mr. Biden has asked Congress to authorize $22.5 billion in emergency coronavirus aid, including $5 billion for the global pandemic, but the request has stalled on Capitol Hill. A compromise proposal for $10 billion in emergency aid includes no money for the global response, meaning Mr. Biden will almost certainly arrive at his own summit empty-handed. Mr. Brown said in the interview that his appeal is intended to place pressure on Congress to release the funds.The White House said Monday that Mr. Biden will address the summit, and that Vice President Kamala Harris and Dr. Ashish K. Jha, the coronavirus response coordinator will also participate. Both Dr. Jha and Mr. Biden have been working behind the scenes to press lawmakers to authorize the funding, officials said.The summit, a virtual gathering that will be co-hosted by Belize, Germany, Indonesia and Senegal, is aimed at reinvigorating the global response. The need is urgent: The drive to vaccinate the world is losing steam; testing has plummeted around the globe and efforts to bring tests and Covid antiviral pills to low- and middle- income nations are stalled, running into obstacles that recall battles fought 20 years ago around H.I.V.Mr. Brown, now the World Health Organization’s ambassador for global health financing, said he is also encouraging leaders of other wealthy nations to make funding commitments. He is the lead author on a letter to the president whose signatories also include Mary Robinson, a former president of Ireland; Helen Clark, a former prime minister of New Zealand; and Joseph Stiglitz, the Nobel Prize-winning economist.“Mr. President — your leadership can revive the global Covid-19 response,” they wrote, adding that “our wholehearted hope is that your administration will step up to provide leadership on financing the global response, encouraging other countries to follow you, as is both urgent and necessary to help save lives across the world.”Global health officials are increasingly concerned about what many are calling “Covid fatigue,” as world leaders deal with crises like the war in Ukraine, or turn to other pressing health concerns.“Donors are predominantly saying, ‘Oh, we want to get back to, you know, whatever it was that they prefer funding like maternal child health, H.I.V., T.B., whatever it is, and they’re saying that there’s a reduced appetite for Covid,” said Dr. Fifa A. Rahman, an adviser to ACT-Accelerator, the consortium backed by the W.H.O. that is leading the global response.The summit is a follow-up to one Mr. Biden convened in September; he will use the gathering to ask wealthy nations to step up their financial contributions for vaccines, tests and treatments. Specifically, he will call on developed nations to donate $2 billion to purchase Covid treatments and $1 billion to purchase oxygen supplies for low- and middle-income countries, according to a senior administration official involved with the planning.The United States, working with international organizations, has donated more vaccine doses than any other nation to the global vaccination effort. Mr. Biden has pledged 1.2 billion doses to other nations; as of Monday, more than 539 million had been shipped, according to the State Department. But countries receiving the doses have had difficulty getting those shots into arms.Activists and advocacy groups are increasingly impatient. Organizations including Public Citizen, the consumer health and safety nonprofit; Prep4All, an AIDS advocacy group; and HealthGAP, a global health advocacy group that operates in Uganda, are circulating a petition that blasts the United States government — though not Mr. Biden personally — for a “lack of leadership” that “is alarming and shortsighted.”The petition urges the president to “act with reinvigorated urgency” and lays out specific demands, including working with international institutions and donor countries to “mobilize $48 billion this year to get the global response on track” and pressing drugmakers to share their intellectual property and technological know-how, not only for vaccines but also for Covid antivirals, which are plentiful in the United States, but not widely available in low- and middle-income countries.“The administration is not spending political capital to demand that Congress act,” Asia Russell, the executive director of Health GAP, said in an interview, adding, “What we know from the global AIDS response is that decades were wasted dithering. Those wasted years translated into human lives lost. President Biden and his Covid chiefs, they have the power to change history.”The administration wants international intellectual property rules to be waived to facilitate the generic manufacture of vaccines. But the waiver request is stalled at the World Trade Organization and does not extend to treatments, drawing objections from a coalition of 170 groups led by Trade Justice Education Fund, a nonprofit that works to advance equitable trade policy.“Americans and people around the world continue to suffer not only preventable deaths and long-term health consequences, but also disruptions to economic activity and global supply chains,” the groups wrote in a letter addressed to Mr. Biden’s trade representative, Katherine Tai, adding “We need every possible tool to overcome barriers and improve equitable access to Covid-19 medical products.”