Last week, President Trump threatened tariffs on pharmaceuticals if manufacturers don't relocate operations to the U.S. On Wednesday, the CEO of Eli Lilly stood with Trump's commerce secretary in Washington, D.C., to announce a $27 billion plan to build four manufacturing "mega-sites" in the U.S.

Why it matters: The commitment illustrates the dance much of Big Pharma is engaged in as it tries to make inroads with a new administration bent on reshoring business activity and reducing dependence on China.

The big picture: Reshoring pharmaceutical manufacturing would be a shift for the industry, which still sources most drug ingredients from overseas and has seen its global supply chains buckle from disease outbreaks and natural disasters. Now, political winds from Washington could force a reckoning.

• Hanging over it all is Trump's focus on cracking down on economic competition from China. CEO David Ricks said his company's expansion would prove key to expanding U.S. capabilities in synthetic chemistry and reduce its reliance on foreign suppliers.
• The pharmaceutical giant — whose products include the blockbuster GLP-1 drugs Mounjaro and Zepbound — focused on its role in economic growth, saying its plan will create 3,000 jobs, as well as 10,000 construction jobs.
• "This is a national announcement, one that will catalyze American health, economic growth and global competitiveness when we see a significant ripple effect, a greater opportunity that will flow to thousands of Americans and their local communities," Ricks said.

State of play: Lilly has a wide footprint in China and most recently announced a $200 million expansion of a manufacturing site in Suzhou. It also partnered with contract research firm WuXi AppTec on the active ingredient in anti-obesity drugs and a drug for lowering blood lipids, per Fierce Pharma.

• Lilly has been on a global expansion binge, launching multibillion-dollar plant projects in Germany and Ireland, per Fierce Pharma.
• The new plants announced Wednesday will come on top of a $3 billion upgrade to an injectables facility it bought in Wisconsin, as well as two new sites in North Carolina and Indiana.
• The company would not disclose how much of Lilly's manufacturing will occur at these sites, but said the new facilities won't replace others elsewhere.

What they're saying: Ricks credited Trump's tax cuts from 2017, calling them "fundamental to Lilly's domestic manufacturing investments."

• When asked about the pain caused by tariffs, he said the company hopes medical supplies are exempt because that adds cost in the near term.
• "It's clear to everyone, including us here today, that the administration intends to use tariffs as a tool to drive the outcomes they're looking for to bring manufacturing capacity back to the U.S. In that sense, it's a stick or it's a punishment," Ricks said in response to a reporter's question.
• "But we point out here today, as a company, that actually tax reform was the carrot," he said.

Between the lines: The pharmaceutical industry has been positioning itself as a key partner for Trump in addressing chronic illness.

Yes, but: The Trump administration's pressure on the pharma industry to bring production to the U.S. may represent a shift from Trump's first term, when lowering drug prices and increasing price transparency were the stated priorities, Anna Chorniy, a health economist at Icahn School of Medicine at Mount Sinai, told Axios in an email.

• Bringing production to the U.S. could ultimately result in higher production costs, which could be passed on to consumers, she said.
• Efforts to onshore drug ingredients for security purposes don't do much if they're not targeted at generic drugs, of which the vast majority come from China, said Mariana Socal, associate professor of health policy and management at Johns Hopkins University.

As the battle over Elon Musk's DOGE-directed cuts to federal medical research continues, institutions already are freezing hiring, cutting back on the number of Ph.D. students they'll accept and making other contingencies.

Why it matters: Capping how much the National Institutes of Health covers the schools' overhead costs could lead to billions of dollars in cuts to scientific research funding and widespread economic fallout.

Driving the news: An economic analysis by software company Implan on Tuesday estimates proposed cuts could lead to a loss of $6.1 billion in the nation's gross domestic product, a $4.6 billion reduction in labor income and result in the loss of more than 46,000 jobs nationwide.

• This includes the direct effects of the research itself, with 17,000 expected job cuts, but also indirect effects through a slowing of business-to-business spending in the R&D supply chain that could support 14,000 more jobs.

What they're saying: "It's not just researchers that are affected. It's not just universities that are affected," said Bjorn Markeson, academic divisional director and economist at Implan.

• "There's going to be impacts on real estate ... there's going to be impacts on legal services. There's going to be impacts on services to buildings, office, administration."

Between the lines: While federal courts have temporarily frozen plans to slash the rate NIH pays for "indirect costs" and the administration's temporary "pause" on federally funded grants and loans, universities are already feeling real pain.

• Institutions have also been reporting delays of NIH grant reviews, in what some legal scholars call a "backdoor" approach to freezing funding, Nature reported.

NIH cuts are most immediately hitting graduate education programs.

• The University of Pennsylvania said it would reduce graduate admissions, pointing in part to the NIH cuts, reported The Daily Pennsylvanian.
• The University of Pittsburgh, Vanderbilt University and University of Southern California are among institutions that temporarily paused Ph.D. program admissions but have since resumed the process, per Inside Higher Ed.
• Meanwhile, Columbia's medical school and MIT, among others, have frozen hiring.

Zoom in: Maryland is among the states that could be hit hardest, with potential annual losses exceeding $2 billion due to Johns Hopkins University and its robust research corridor, Terry Clower, director of the Center for Regional Analysis at George Mason University, told Axios.

• By his calculations, there could be 2,000 to 3,000 jobs eliminated in the state as the result of the new NIH policy on administrative and overhead costs.
• "Losing 3,000 jobs across the state would not devastate the economy, but it's an add-on effect to everything else that's going on now," Clower said.
• "Taking into account job losses elsewhere in the federal government ... it's a hard hit to the local economy," he said, noting the Maryland suburbs of D.C. have not seen job growth rebound to their pre-pandemic levels.

The cuts can have outsized impacts within states that receive much less, pointed out officials at Dartmouth College.

• Dartmouth has about 1,300 employees funded in part by its roughly $97 million in federal NIH grants. Dartmouth Health has another 400 employees whose jobs are funded at least in part by its $18 million in NIH grants.
• "In New Hampshire, that's a lot of people," said Steven Bernstein, chief research officer of Dartmouth Hitchcock Medical Center.
• Officials said they are not discussing layoffs or other changes. But "medium term and longer term, if the research portfolio shrinks, those job opportunities are going to decline," said Dean Madden, vice provost for research at Dartmouth College.

What we're watching: U.S. District Judge Angel Kelley is still considering whether the cut to the funding of indirect costs is unlawful.

The bottom line: The future of research talent and scientific advancements could be at stake with these looming cuts.

• "It will impact our ability to to train the next generation of scientists, because there will be less funding available to help support students while they're in their studies," Clower said. "There will be knock-on effects in the economy in future years."
• "What we can't measure is what those losses would mean to discovery of new medications, new drugs, new medical procedures," he said.

The worst flu season in 15 years has left hundreds of thousands of Americans hospitalized while straining physicians' offices and emergency departments.

Why it matters: The virus is causing more severe complications and hitting young children especially hard.

"The two predominant strains that are circulating right now are known to be more severe and have more severe outcomes, especially in high-risk patients," said Carol McLay, president of the Association for Professionals in Infection Control and Epidemiology.

• "It's really clogging up our ERs and our outpatient facilities. And for the first time, we've seen cases of influenza that have surpassed COVID-19 in hospitalizations and deaths, since the COVID pandemic began," she said.

By the numbers: This flu season is classified as a "high-severity" season, with estimates of at least 29 million cases, the most since the 2009-2010 flu season, according to the latest Centers for Disease Control and Prevention data.

• There have been at least 370,000 hospitalizations, and 16,000 deaths from flu as of Feb. 8, per the CDC. That's on a pace to surpass the previous high recorded during the 2017-2018 flu season.
• Nearly every state is reporting high or very high flu activity, with roughly 32% of tests coming back positive and some areas testing as high as nearly 40% positive.
• "It's lots of more severe illnesses. Of the adults that are being hospitalized, most of them are having pneumonia and requiring intubation and ventilation," McLay said.

Of particular concern is the severity being seen in kids this year. There have also been reports of a limited number of pediatric cases with serious neurological complications associated with the flu.

• There have been 68 flu deaths in kids.
• Pediatric flu deaths hit a record 200 last year, and this season is shaping up to be worse, said Matthew Cook, president and CEO of Children's Hospital Association.

Between the lines: This flu season may be made more severe because rates of seasonal flu vaccination have been falling in recent years for some groups, including children.

• Compounding the problem is the fact that this year's flu vaccine was a bit less effective (35%) than in a typical year (45%).
• People have also had much less exposure to flu in recent years amid the COVID-19 pandemic.
• "We think because people were social distancing and using masks for so long during COVID that we have reduced immunity to it," McLay said.

What we're watching: Public health officials say they are increasingly flying blind since they can't interact with or get flu data from global sharing platforms FluNet and FluID since the Trump administration announced the U.S. exit from the World Health Organization.

• "We are communicating with them but we haven't heard anything back," Maria Van Kerkhove, emerging diseases and zoonoses unit head for the WHO, said in a press conference.
• She added that the WHO had learned about bird flu updates not from the CDC, but from posts by the U.S. Department of Agriculture.
• That also has ramifications for next year's vaccine, since the global body helps determine the composition of seasonal shots.

This especially rough year for season flu coincides with the spread of avian flu throughout U.S. poultry and dairy farms, as well as wildlife.

• The fear is if the two have enough chances to mix, it may eventually create an avian flu strain that could spread between humans and turn into a pandemic.

The bottom line: There's a lot of respiratory virus still going around this season. If you haven't gotten the vaccine yet, it'd still be prudent to get one, experts urge.

• "There is no doubt, the data is out there, if you are vaccinated for the flu, even if you do get the flu, it is much less severe and it prevents you from being hospitalized and, obviously, prevents death as well," McLay said. "It's not too late to go out and get a flu vaccine."

The luster is starting to wear off GLP-1 weight-loss drugs including Wegovy and Ozempic as more clinicians warn patients about side effects and other potential risks stemming from their surging demand.

Why it matters: Research showing the drugs not only work for obesity but could lower the risk of heart attacks, stroke, some cancers and even Alzheimer's disease has overshadowed the substantial cost and the fact that many patients can't stay on them.

What they're saying: "There is almost like a backlash kind of a sentiment going on," said Peter Antall, chief medical officer of digital chronic health company Lark.

• "I don't believe that we're having second thoughts about the power of the medication. But I think the shine is coming off how they're being used in real practice," he said. "That's where many of us are concerned."

The big picture: Millions are now taking anti-obesity prescriptions from Novo Nordisk and Eli Lilly as well as lower-cost copycats from compounding pharmacies.

• There's no denying the drugs have life-changing capabilities. But high sticker prices and uneven insurance coverage skews which patients can get them — and which patients can consistently stay on them.
• And, in many cases, patients have begun taking the drugs with unrealistic expectations and little guidance.

"Everybody just thinks it's this miracle fix," said Ethan Lazarus, an obesity medicine physician based in Colorado and former president of the Obesity Medicine Association.

• "They're not perfect, and the GLP-1s are only going to work as long as you take them, and they're expensive, and there can be side effects. Do I really want to be taking this injection for the rest of my life?"

Between the lines: Study after study shows the majority of patients drop off the drugs within two years, with many spending less than a year on them.

• The reasons most commonly cited included the cost of the brand-name drugs — Ozempic retails for nearly $1,000 a month and Wegovy for hundreds more — periodic shortages, as well as side effects like severe GI distress and, occasionally, pancreatitis.
• "The benefits of these drugs cannot be denied when they are taken as intended — meaning indefinitely. But what happens to the body and mind when these medications are discontinued? This is where the problem lies," wrote obesity specialist and gastroenterologist Christopher McGowan in MedPage Today.

Between the lines: Among the harm concerns is the impact of "weight cycling" or the effect of regaining the weight that's been lost on one's metabolic health.

• "If you're doing it in a casual fashion where you're just getting [the drugs] online whenever you can afford it, that's what's probably not going to be good for us as humans," said Angela Fitch, CEO of Knownwell.
• GLP-1s can lead to loss of muscle mass in addition to fat, and when the drugs are discontinued, it's primarily fat that returns, McGowan wrote.
• "This can leave patients worse off — with less lean mass, a lower basal metabolic rate, and greater difficulty achieving future weight loss," he wrote. "Health consequences include diminished strength, reduced bone density, and a higher risk of fractures."

The FDA has also warned about risks around unapproved versions of GLP-1s that aren't assessed for safety and effectiveness.

• And HHS Secretary-designate Robert F. Kennedy Jr. has weighed in, saying people should first consider lifestyle changes and eating healthier.

Reality check: More randomized trials are needed, for instance, to tease out potential harms associated with going on and off the GLP-1s, including whether yo-yoing on weight hurts patients, pointed out C. Michael Gibson, a cardiologist who both prescribes and takes a GLP-1.

• "It may be that there's something about people who yo-yo that is different than people who don't ... it's the difference in who they are, rather than the yo-yoing that explains the bad outcomes," Gibson said.
• There's also growing data that companies like Knownwell are compiling that show coaching and monitoring patients who are on these drugs leads to far better adherence and outcomes, Fitch said.

What to watch: This is still a massive market with a number of drug candidates under development that could make these drugs easier, cheaper and more tolerable to use.

• Demand could surge even more once there are effective oral versions that don't require injections.
• "I think these prices will come down in a couple of years, and the indications will keep expanding, and the pendulum will swing," Antall said. But for now, he said, the business is a "free-for-all in a way which is unfortunate and not good for people's health."

Attorneys general from 22 states sued the Trump administration on Monday, seeking to freeze a plan that would cap National Institutes of Health payments covering overhead at universities and medical research centers.

• A federal judge later granted a temporary freeze.

The big picture: The billions of dollars in cuts to new and existing grants could lead to layoffs, disrupt clinical trials and shutter laboratories, the states charged in U.S. District Court in Massachusetts.

• The plaintiffs included multiple states known for their research economies, including Massachusetts, North Carolina, Maryland and California.

Driving the news: The states charge the administration acted in an arbitrary and capricious way by not explaining the basis for the cap.

• It said the move also violated a 2018 law governing NIH spending that forbade the federal health department or NIH from developing or implementing a modified approach reimbursing the so-called indirect costs for biomedical research.

Context: NIH on Friday abruptly announced it would lower the indirect cost rate that grantees receive to no more than 15%.

• A post on X stated that $9 billion of $35 billion NIH awarded in fiscal 2023 was used for overhead and administration instead of direct research.

What they're saying: "The administration's decision to cap NIH reimbursement rates could force scientists to shutter their lifesaving research on cancer, diabetes, Alzheimer's, addiction, infectious diseases, and more," New York Attorney General Letitia James said in a statement.

• The University of California submitted a declaration in support of the suit. "A cut this size is nothing short of catastrophic for countless Americans who depend on UC's scientific advances to save lives and improve healthcare," said UC President Michael Drake in a statement.

The Trump administration's shock and awe strategy was meant to overwhelm opponents, disrupt the establishment and bust norms. But it's also sweeping up ordinary Americans who disdain politics but find they can't detach from the barrage of news.

Why it matters: Some will find a way of adjusting their brains to the drama and unpredictability while others will try to tune out.

• That could be difficult, with rollbacks of DEI practices, Immigration and Customs Enforcement raids, trade wars, orders targeting transgender rights and Department of Government Efficiency takeovers of public data potentially touching every segment of society.

State of play: Political anxiety has been building for years as a 24-hour news cycle, social media and algorithms create seemingly endless outlets for strife.

• But President Trump's pugnacious style and the breakneck series of changes he and Elon Musk unleashed has ratcheted everything up, delighting his supporters and leaving his critics panicked and without a single rallying point.
• Mental health professionals say even people who don't see themselves as directly affected by administration actions are feeling frazzled by the dizzying pace and Trump's enduring ability to command attention.
• They may feel it through the venting of a spouse, the distress of a neighbor with a trans child or an anxious friend who works for a government contractor.

"There is an element of chaos right now," said Andrea Bonior, a Georgetown University psychology professor who sees patients in the D.C. area. "A sense of not knowing what's coming and not being able to control what's coming is really hard on the stress response."

• "As humans, we don't love uncertainty. It's something that we don't tend to tolerate well. And then when we're anxious, it's excruciating."

Between the lines: People generally hate surprises. The more unexpected the news, the likelier it is they'll start tuning out details.

• "I think we can take so much of something before the human brain just like peters out and says, 'I can't keep up,'" said New York-based neuropsychologist Sanam Hafeez told Axios.
• Bonior said she's seen an uptick in patients, particularly Democrats, expressing a sense of burnout, guilt and despair at losing an old way of life.
• "There's a fine line between burying your head in the sand and trying to protect yourself. I've been working with a lot of folks to try to find that line," she said.

To be sure, there's reassurance for those on the political right.

• "If you think that the person causing the uncertainty is on your side, you could still be off balance, but you can kind of have general certainty that the changes are in your best interest," said Kurt Gray, a professor of psychology and neuroscience at the University of North Carolina who's studied how moral judgments stem from feeling threatened or vulnerable.
• There's a school of thought that chaos can breed creativity, and that tearing down old institutions can unleash entrepreneurial spirit.
• But most people aren't good at dealing with uncertainty. And in these unprecedented times, Gray said they'd be better off sharing their personal stories than framing the moment in politics and policy.

Threat level: The epicenter of anxiety is focused for now in places like the federal workforce and the immigrant and LGBTQ communities.

• Bonior pointed to federal workers who aren't sure if they'll be let go as well as others concerned about their immigration status or worried about loved ones whose refugee flights were canceled.
• For them, Bonior said: "There is no setting a boundary to get some distance from this stuff."
• "It feels, no matter which way you go, you're like, 'Oh, my God, I'm being ruled by a very different system that I thought I was living in,'" Hafeez said.

And it's not just Trump, say mental health professionals. The world is a brittle place, with disease outbreaks, wars in Gaza and Ukraine and climate change adding to the anxiety.

• "We are in an unprecedented time that we have so many collective stressors going on, and the rapid fire of media coverage of these policy changes, it's just adding to that broader collective stress," said Daniel Relihan, a researcher at the Silver Stress and Coping Lab at University of California, Irvine.
• Research has shown the amount of stress connected to politics that people experience has been steadily rising since 2008.
• And there can be physical consequences: A study conducted by the UC Irvine lab found greater worry about the 2020 election predicted a 10% increase in physical health ailments like cancer, stroke and heart attacks up to three years later, Relihan said.

What to do: Tuning out isn't all bad, if it's possible, experts say.

• "This disengaging is a protective way to reduce stress for mental health, and ultimately to help reduce any impacts of that stress on your physical health," Relihan said.
• It can help people focus on living according to their personal values and what they can control.
• "That involves setting some boundaries so that they can stay informed, but also not despair," Bonior said.

As more schools eye bans on smartphones, a new study finds the average teen with a smartphone is spending nearly a quarter of the school day texting, streaming or scrolling through sites like Instagram.

Why it matters: To understand the risks of too much screen time, researchers say, it's important not just to tally the hours kids spend on devices but to consider what activities are being displaced — in this case, learning.

What they found: The study led by Seattle Children's Research Institute tracked 117 kids ages 13 to 18 who owned a smartphone and had them download an app to measure their usage.

• The teens spent an average of 1.5 hours on their smartphones during a 6.5-hour school day over two study periods in 2023, the researchers wrote in JAMA Pediatrics. 1 in 4 teens spent more than two hours on their phone during the school day.
• Whole-day phone use averaged 5.6 hours.

What were they doing? The top five most-used apps were messaging, Instagram, video streaming, audio and email.

Reality check: Since the study only focused on smartphone use, researchers said, these numbers likely underestimated overall screen use.

The big picture: While the pandemic is often blamed for exacerbating the youth mental health crisis, a growing body of research links the intensifying crisis to the arrival of the smartphone.

• Social media might make them stressed and depressed, but the hours they're spending online keeps rising.

Dozens of newly confirmed cases of avian influenza in wild birds and the first verified U.S. case of a new strain of the virus are raising concern the bird flu crisis may be entering a troubling new phase.

Why it matters: While the developments don't necessarily raise the risk of a pandemic, they could create more havoc for farmers, exacerbate egg shortages and expose more gaps in government disease surveillance.

• The outbreak is intensifying as the Trump administration maintains a pause on most external federal health agency communications, including publication of CDC's Morbidity and Mortality Weekly Report (MMWR), a venerable source of scientific reports on public health.

Driving the news: The Department of Agriculture last week confirmed 81 detections of highly pathogenic avian flu in wild birds collected across 24 states between Dec. 29 and Jan. 17.

• Wild birds can be infected and show no signs of illness, allowing them to spread the virus to new areas and potentially expose domestic poultry.
• Officials in Pennsylvania and New York have culled thousands of wild geese, as well as commercial poultry flocks, after detecting cases of flu.

What they're saying: "If you look at what's happened the last eight weeks, the number of poultry operations that have gone down — and more recently, the duck operations — is absolutely stunning," Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota told Axios.

• The virus is being spread as wild birds comingle with birds in commercial poultry operations.
• Changes in migratory patterns may be worsening the issue in northern states, which now see certain wild birds stay for the winter because water sources aren't freezing, Osterholm said.

"There is a lot of H5N1 out there. And we're going to see more cases in humans," he said.

• But "they're going to be single, isolated cases," he said.

The intrigue: A new strain of avian flu called H5N9 was recently identified on a duck farm in California that had an outbreak of the more common H5N1 flu last fall.

• The new type is a sign that two or more viruses could be infecting the same animal and swapping genetic material. Ducks make good hosts for what scientists call "reassortment" because they aren't badly sickened by many types of avian flu.
• About 119,000 birds on the farm were euthanized following the discovery.

Such mutations, in and of themselves, may not pose a greater threat to human health.

• The H5N9 strain originated in China and is itself a mix of several other strains. It isn't thought to be more of a threat to humans than the H5N1 strain that's widely circulating in U.S. poultry, cattle and wild birds.
• But its presence could become a major problem if there was a reassortment between avian flu and a seasonal human flu, Richard Webby, director of the World Health Organization's Collaborating Center for Studies on the Ecology of Influenza, told the Los Angeles Times.
• That combination could result in a virus that is more easily transmitted between people.

Catch up quick: The bird flu crisis has struck 113 flocks in the past 30 days, affecting more than 19 million birds, per USDA. It's also been confirmed in 943 dairy herds, the vast majority in California.

• The Trump administration hasn't publicly outlined steps it's taken yet to address the spread. HHS didn't respond to a request for comment.
• HHS Secretary-designate Robert F Kennedy Jr. said he intended to "devote the appropriate resources to preventing pandemics" during confirmation hearings this week, leading some Democratic senators to point to past statements he made about giving infectious disease research "a break."

Between the lines: The partial blackout on health communications has effectively blocked publication of a pair of studies on bird flu, including one on whether veterinarians who treat cattle have been unknowingly infected by the virus, KFF Health News reported.

• The other report looked at whether people carrying the virus might have infected domestic cats.
• The reports were due to appear in the MMWR, which hasn't published since January 16 and is subject to the pause ordered by acting HHS Secretary Dorothy Fink to allow the new administration to set up a process for review and prioritization.

The communications freeze has been met with outrage in some medical and science circles. "This idea that science cannot continue until there's a political lens over it is unprecedented," Anne Schuchat, a former principal deputy director at the CDC, told KFF Health News.

• There's a lot of uncertainty around whether the administration is merely pausing communication or making a wholesale change in how the agency functions, Patrick Jackson, a UVA Health infectious diseases expert, said on a call with reporters Friday.
• "Frankly, getting CDC up and running at full speed is going to be essential to keep track of avian influenza," he said.

President Trump's orders to freeze some work and communications at government health agencies and begin a U.S. pullout from the World Health Organization are rattling clinicians and researchers, who fear they're the leading edge of a broad anti-science agenda.

Why it matters: Policy experts and researchers are mobilizing for a fight over the politicization of science that stems from — and could rival — the clashes over the COVID-19 response.

State of play: Health and Human Services this week halted most outgoing communications, travel and grant reviews among its agencies — a directive that even prevented National Institute of Health researchers from purchasing supplies for clinical trials.

• Trump also blocked the disbursement of funds for global HIV work through the President's Emergency Plan for AIDS Relief, or PEPFAR.
• The administration called for the exit from WHO, directing staff to stop working with the global health agency.
• A purge of diversity, equity, inclusion and accessibility programs is expected to sweep up efforts aimed at narrowing health disparities and improving diversity in clinical trials.

The tensions are likely to intensify this week as vaccine critic Robert F. Kennedy Jr. faces confirmation hearings to be the nation's top health official.

What they're saying: "Right now, it sort of feels like we are drinking from a fire hose, and I know that a lot of that is the intention of the administration," said Darya Minovi, a senior analyst at the Union of Concerned Scientists.

• "We have just seen a complete rejection of science," she said.
• The organization is mobilizing its network of roughly 20,000 members and maintaining a database of attacks on science.

An ad-hoc coalition of public health workers, researchers and patient advocates called Defending Public Health has circulated a letter with more than 700 signatures calling on senators to vote down Kennedy's nomination.

• The all-volunteer group is still sizing up where to best focus its efforts, said Gregg Gonsalves, an associate professor at the Yale School of Public Health.
• Liberal-leaning advocacy groups like Protect Our Care are also activating to oppose the Kennedy nomination.

Between the lines: Some scientists see Trump's early moves as payback to experts inside and outside the government who criticized his first administration's response to the COVID-19 pandemic.

• They're particularly concerned about an envisioned overhaul of NIH, a frequent target of conservatives, which funds tens of billions of dollars of work at universities. The agency saw its grant review "study sections" frozen last week, and had to pull job ads and rescind offers, per Science.
• "This is just vengeance, as far as I'm concerned," said Jim Alwine, an emeritus professor of cancer biology at the University of Pennsylvania and a member of Defending Public Health. "I think Trump … saw the whole pandemic as a personal affront to him, and I think he's out to hurt science."

Mainstream research groups and universities so far are holding their fire.

• The Association of American Medical Colleges is reviewing the Trump orders and assessing which weigh heaviest on its members, chief public policy officer Danielle Turnipseed said in a statement.
• "I think academic research centers will speak out, but also with hesitation, because they know that their funding comes from the federal government," Lawrence Gostin, a global health law expert at Georgetown University, told Axios. "Even industry wants to be on the good side of the president."
• For his part, Gostin said he's doing what he can to foster connections between WHO leadership and members of the administration like Secretary of State Marco Rubio and RFK Jr. "How can we get a win-win?" Gostin said. "There's a deal to be made here."

To be sure, every new administration needs time to get settled, and communications pauses and policy reviews following an inauguration aren't unprecedented.

• HHS did not respond to Axios' request for comment.
• "The people voted for a different direction, so it is wise for the incoming Trump team to review and reconsider all decisions that don't reflect the incoming president's agenda," David Mansdoerfer, former deputy assistant secretary for health during the first Trump administration, told Axios.

Yes, but: Putting the brakes on NIH's work, even in the short-term, "can have a devastating effect on our nation's longer term research productivity and success," Monica Bertagnolli, NIH director under the Biden administration, wrote on LinkedIn.

• The actual impact of the freeze will depend on how long it continues, but the freeze itself may still erode researchers' trust in the administration, said Elizabeth Jacobs, a professor emeritus at the University of Arizona.

Science and civil rights groups anticipate possible legal challenges to future administration rules in the same vein, experts say.

• They'll also seek to spell out the ripple effects while clarifying how they affect medical providers, to avoid unnecessary self-censorship of research topics and medical care.

Friction point: It's notable that Trump hasn't trained his sights on the Affordable Care Act, drug prices or Medicaid, opting instead to focus on cultural flashpoints, said Larry Levitt, executive vice president for health policy at KFF.

• "Rolling behind the scenes is this potential tsunami of cuts to Medicaid, which would have big implications for the entire health care system," Levitt said.

HHS Secretary designate Robert F. Kennedy Jr. earned $326,000 from the anti-vaccine group Children's Health Defense and a $100,000 licensing fee for use of the Make America Healthy Again brand, according to financial disclosure forms posted by the Office of Government Ethics.

Why it matters: The forms offer a detailed picture into Kennedy's extensive financial holdings and how he'd resolve potential conflicts of interest if he's confirmed.

• The Senate Finance Committee announced Wednesday that it will hold a confirmation hearing on Kennedy's nomination on Jan. 29. That's expected to be followed by a second hearing in the Senate Health, Education, Labor and Pensions Committee a day later.

The big picture: Kennedy reported more than $11.3 million in earnings, including $8.8 million from the law firm Kennedy & Madonna. He pledged to transfer or forfeit interests in contingency fee cases if confirmed.

• He also earned $481,732 from JW Howard, a law firm he worked for and remains of counsel to. The firm represented a health freedom group in an appellate court challenge to a COVID-19 vaccination mandate imposed by the Los Angeles Unified School District. Kennedy indicated he would not be paid going forward.
• He received $856,559 in fees on contingency cases from Wisner Baum, where he served as co-counsel in suing Merck over patient injury claims from Gardasil, a vaccine approved to protect against human papillomavirus, or HPV, which is a leading cause of cervical cancer.

Between the lines: Kennedy reported income from several other sources including stock investments, books, endorsements and a licensing deal, as well as $100,000 speaking gigs.

• His investment holdings include the biotechs CRISPR Therapeutics AG and Dragonfly Therapeutics, and tech giants Apple and Amazon, which both have health care arms. He pledged to divest if confirmed.
• Per the report, he earned $451,000 from Skyhorse Publishing for author introductions, book ideas and forwards to other authors' works. He is still owed at least $2 million in book advances. He committed to halt all related activities if confirmed.
• He also received $100,000 from Jeff Hayes ,who made a documentary about RFK Jr., in a licensing agreement for using the Make America Healthy Again brand marks.

The intrigue Kennedy reported a $100,000 deal to endorse a $30 app-enabled fitness game called Boxbollen on social media. The game involves hitting a ball that is connected to a strap that's worn on the head. He reported returning $50,000 because he wasn't able to fulfill his duties.

The report also lists financial income sources for his wife, actress and producer Cheryl Hines, including residuals for the HBO series "Curb Your Enthusiasm," as well as a $600,000 book advance.

The spread of influenza A, COVID and RSV is "high" or "very high" across much of the U.S. at the same time norovirus cases are well above normal levels, Centers for Disease Control and Prevention and wastewater surveillance data shows.

Why it matters: The result is a "quad-demic" of illness hitting simultaneously in what's shaping up to be a more active virus season than last year.

The big picture: The simultaneous threats are straining some hospitals to capacity and leading administrators to recommend masking among staff, ABC News reports.

• The surge follows what was a slow start to the respiratory virus season.
• "Predictions for this respiratory virus season were that we would see peak January 1 and that it would likely mirror previous respiratory virus seasons. We're obviously seeing it peak a little bit later," Saskia Popescu, a member of APIC's Emerging Infectious Diseases Task Force, told Axios.

The details: Flu activity is high or very high across 33 states and Washington, D.C., according to the CDC tracking of outpatient visits to health care providers for influenza-like illness.

• Mississippi, Oklahoma and Texas had the highest levels as of the week of Jan. 18, according to the Walgreens Flu Index, compiled using retail prescription data for antiviral medications used to treat the flu across Walgreens locations.
• The CDC data shows flu-like illness is "very high" in New York City while the Walgreens index identifies Oklahoma City; Lafayette, Louisiana; and Montgomery-Selma, Alabama, among the areas with the most activity.

What we're watching: Human metapneumovirus, or HMPV — which comes with symptoms of a cough, fever, nasal congestion and shortness of breath — made headlines in China and has also been spreading in the U.S.

• Activity in the U.S. remains low compared with other viruses, per CDC data, and experts have said it shouldn't be cause for panic. "It is a seasonal bug that we know how to manage," said Popescu, an assistant professor at the University of Maryland School of Medicine.
• For HMPV, as well as these other viruses that are circulating, the tried-and-true advice is particularly worth heeding right now, she said.
• "All of those mitigation efforts that you can do — washing your hands, covering your cough, cleaning, disinfection, being mindful of ventilation in shared spaces — that's all going to help," she said.

The number of prescriptions for GLP-1 drugs jumped roughly 10% in 2024, according to insurance claims data provided to Axios by health analytics company PurpleLab.

Why it matters: The data, which shows double-digit growth in 23 states, offers a snapshot of the sustained growth in demand across the U.S. for the drugs hailed as game-changers in the fight against obesity.

By the numbers: Rhode Island (67.8%), Massachusetts (48%) and New Jersey (35.8%) saw the largest year-over-year growth in prescriptions dispensed between 2023 and 2024.

• There were declines in six states including Arkansas, Louisiana, West Virginia, Idaho, South Dakota and Vermont.

Between the lines: The most prescriptions went to adults ages 55 to 65 (29%), followed by seniors 65 and older (26%).

• The vast majority of prescriptions went to commercially insured patients while only 9% were written for Medicaid patients. 17% went to patients on Medicare.

The data is based on roughly 7.5 billion claims from private insurers, as well as Medicare — which only covers GLP-1s to treat diabetes — and Medicaid.

• The data captures prescriptions for Novo Nordisk's diabetes drug Ozempic, which has been widely prescribed off-label for weight loss, and Wegovy, which was approved for weight loss in 2021.
• It also includes Eli Lilly's diabetes medication Mounjaro and its anti-obesity medication, Zepbound, which was approved by the Food and Drug Administration in November.
• The data lumps the prescriptions together, so it's not possible to tease out how often these drugs are being prescribed for obesity versus diabetes or heart disease.

Spending the holidays with family and friends may be more of an emotional wringer this year if you're a Democrat or independent, according to the latest Axios-Ipsos American Health Index.

Why it matters: While an overwhelming majority of Americans say their emotional well-being is good, our first polling since the elections shows those who didn't vote for President-elect Trump appear to be bracing for added strife.

Driving the news: In the poll of 1,002 adults taken between Dec. 6 and Dec. 9, roughly half of all respondents said spending time with friends or family at the holidays didn't affect how stressed they felt, echoing prior polls.

• But dig a little deeper and there's a big split in those answers: More than 61% of Democrats said spending time with family or friends during the holidays makes them more stressed out. Independents are right behind them at 60%.
• Meanwhile, 39% of Republicans said the same.

Democrats appear likelier to be searching for holiday cheer after a fractious election and GOP trifecta.

• Nearly 1 in 5 Democrats (17%) said their emotional health was poor whereas 7% of Republicans said the same.

But overall, more than 8 in 10 respondents (84%) said their emotional well-being was very or somewhat good — a sign that election anxiety, too many, may have been temporary, or hasn't left lasting scars.

• "For all the gnashing of teeth since the election, people are rating their mental health virtually the same as earlier this year," Ipsos pollster and senior vice president Chris Jackson told Axios.
• "There may have been high anxiety in the electoral context but generally there has not been any change."

The big picture: A recent Harris Poll of more than 2,000 adults conducted for the American Psychological Association found more than 2 out of 5 adults aged 44 and younger are skipping holiday gatherings because of political differences.

• Three quarters of all adults (72%) said they hoped to avoid discussing politics with family this holiday season.
• 83% of respondents said they saw the holidays as a time to put political differences aside — although among those whose candidate lost, that figure was slightly lower (82%.)

The bottom line: Pass the potatoes — and pass on the political talk — this year.

Methodology: This Axios/Ipsos Poll was conducted Dec. 6-9 by Ipsos' KnowledgePanel®. This poll is based on a nationally representative probability sample of 1,002 general population adults age 18 or older.

• The margin of sampling error is ±3.3 percentage points at the 95% confidence level, for results based on the entire sample of adults.

One or two alcoholic drinks a day may reduce the risk of dying more than completely abstaining, according to a review of existing research by the National Academies of Science, Engineering and Medicine.

Why it matters: The findings help inform Health and Human Services and the Department of Agriculture in developing guidance on alcohol consumption in the next Dietary Guidelines for Americans, expected in late 2025.

• Current guidelines come down on the side of temperance, saying it's a choice between not at all or moderation and that "drinking less is better for health."

What they found: The review, which was ordered up by Congress, looked at multiple studies of light to moderate drinking, defined as two drinks a day for men and one for women.

• When it came to cardiovascular health, the moderate use of alcohol was associated with a lower risk of nonfatal heart attacks and strokes, as well as a lower overall risk of death.
• There was some increased risk for breast and colorectal cancer, but no broader conclusion could be made for most other cancers.

Between the lines: The findings appear to contradict studies and a World Health Organization position that "no amount of alcohol" appears to be safe, largely based on increased cancer risk.

• And the National Academies' conclusions come at a time when regular alcohol use has been falling out of favor, particularly with young adults.

The bottom line: One thing everyone seems to agree on: heavy drinking — defined as more than three or four drinks a day — should be avoided.

• While most doctors won't be prescribing booze like the old days, those people who do imbibe could derive some benefit if they keep their consumption levels in check.

After years of dire warnings about Americans' diet, the political winds appear to be shifting to a more critical view of what we eat.

Why it matters: The concerns were evident at a Senate health committee hearing this month as lawmakers on both sides of the aisle dug into the connection between ultra-processed foods and obesity and chronic illness.

• Committee Chair Bernie Sanders (I-Vt.) assailed the way Congress and the Food and Drug Administration allowed big corporations to profit off enticing children and adults to consume ultra-processed foods and beverages.
• Some lawmakers were also surprised that the FDA hasn't reviewed the safety of a food dye called Red 40 in more than a decade, and asked about its potential effects on behavioral health.

What they're saying: "This is the first time that I've heard anybody at that level talk about issues related to the food system in general and chronic disease in particular in a very, very long time," Marion Nestle, an emerita professor of nutrition at New York University, told Axios.

The big picture: The connection between food and chronic disease has been central to HHS Secretary-designate Robert F. Kennedy, whose Make America Healthy Again agenda has targeted everything from dyes to seed oils.

• But it's tapped into a deeper public distrust of corporate influences in public health and the belief that obesity is the top overall health threat, ahead of poor mental health, opioids and gun violence.
• Last week, a Pennsylvania teenager sued Coca-Cola and 10 other big food companies, accusing them of "engineering" ultra-processed products to be addictive and marketing them to kids.
• The surging popularity of GLP-1 drugs also reflects a belief that being overweight or having poor metabolic health is a medical condition, not a lifestyle choice.

Yes, but: There may be limited policy options short of mandates, more spending and the specter of the government dictating what we eat.

• One option could be "food as medicine" — the idea that doctors can prescribe certain foods the way they do medicines to improve patients' health. While a handful of states have tried to tap Medicaid funds for pilot programs, measuring data and getting insurers on board are obstacles, Axios Pro reported.
• Jerold Mande, former deputy undersecretary at the Department of Agriculture, told Axios policies like changing the SNAP program, regulating ultra-processed foods and investing in nutrition and prevention are finally getting attention.
• "We've been waiting for this to be a political priority, and it finally is," Mande said, adding "the messenger is imperfect here," in reference to Kennedy and MAHA.

Zoom in: In a recent op-ed in the Wall Street Journal, former Centers for Disease Control and Prevention director Tom Frieden and former New York City and Philadelphia health commissioner Thomas Farley agreed with Kennedy "that food is driving epidemics of chronic disease."

• "If Kennedy were to ask us for advice, we'd tell him this: Americans eat unhealthy food because the food system is designed to feed it to them. Changes to the system will be fought bitterly by food and agricultural companies, but the fight is worth it," they wrote.

Between the lines: At the Senate hearing, FDA officials, facing sometimes sharp questioning, confirmed they are eyeing a potential ban on Red No. 3, a food dye commonly used in candy and snack foods that has raised concerns about whether it causes behavioral problems in children.

• The FDA is also eyeing front-of-package labeling on processed foods, and intends to issue a rule updating when food makers can claim a product is "healthy," commissioner Robert Califf testified.
• He pointed to the agency's recent reorganization of its human foods program, which included creating a center to review nutrition and conduct post-market reviews of chemicals used in the nation's food supply.
• In July, the FDA moved to remove an additive that had long been used in certain sodas.

But Califf said the agency is decades behind Europe in this effort and has been limited by existing science, legal hurdles and "powerful industry forces."

• "There is good reason to be concerned about the chemicals that are routinely included in much of our food," he testified earlier this month. "The FDA has limited resources to deal with this issue."

Zoom in: Experts are critical of the lack of regulation around ultra-processed foods.

• With industry pressure from snack foods, beverages and other groceries, the current focus in most nutritional guidance in the U.S. is personal responsibility for healthier eating, experts tell Axios.
• Efforts to make ultra-processed foods pricier than healthier options or to beef up FDA scrutiny of additives and how corporations market their products would be far more effective, they say.
• "There's no question that the food that's being sold to us is injurious to health," Mande said. "And yet they don't do anything. So why don't they do anything? And it's really is because they just aren't funded to do that."

Reality check: Congress is highly unlikely to make significant moves in light of the power of the food industry, Barry Popkin, nutrition professor at the University of North Carolina, told Axios.

• "Think of the size of these companies. They dwarf the old tobacco companies," he said.
• Even as Nestle said she's been encouraged by the recent attention to processed foods, it's unclear what might happen to that effort if Kennedy isn't confirmed — or even if he does get the job.
• "Eating healthfully is very bad for business and there are huge economic forces that mitigate against trying to do anything about chronic disease," Nestle said.
• "If Kennedy wants to take on ultra-processed foods in schools, he's taking on the ultra-processed food industry. If he wants to take mercury out of fish ... that's coal-burning power plants. If he wants to get chemicals out of the food supply, he's taking on polluters," she said. "That's a lot to take on."

Efforts to revoke Food and Drug Administration approval of the polio vaccine could provide a preview of how vaccine skeptics plan to challenge decades of federal health policy during a second Trump administration, experts say.

Why it matters: By asserting that the agency didn't do enough safety studies, groups like the Informed Consent Action Network are implying that the risks are greater than the benefits, even though vaccines are more thoroughly tracked than virtually any other medical product, the experts say.

Driving the news: The concerns have amped up in recent days following a report that an ally of Health and Human Services Secretary-designate Robert F. Kennedy Jr. filed a citizen petition in 2022 to revoke the approval of polio vaccines for infants and children.

• Attorney Aaron Siri has also joined Kennedy in questioning and choosing candidates for top health positions, the New York Times reported, citing an unnamed source who witnessed the interactions.

State of play: Siri and others successfully challenged COVID vaccine mandates, sued federal agencies for vaccine approval records and put prominent vaccine scientists through lengthy videotaped depositions, the Times wrote.

• In the case of polio, critics are zeroing in on a vaccine using inactivated, or killed, virus that causes the body to produce its own antibodies against the virus that causes polio and stop it from spreading to the central nervous system.
• The virus can still multiply inside the intestines and be shed in the stool. But the risk of continued circulation is low in the U.S. because of vaccination efforts.

The petition asks the FDA to suspend the vaccine's approval for infants and toddlers "until a properly controlled and properly powered double-blind trial of sufficient duration is conducted."

• It claims that the studies FDA cited in its 1990 approval of updated polio vaccine don't properly investigate the vaccine's long-term safety.
• And it calls for a warning label stating the vaccine "does not prevent intestinal infection and therefore does not prevent poliovirus transmission."

Between the lines: Public health experts say vaccine skeptics, including Kennedy, have repeatedly questioned the safety and efficacy of the shots while insisting they're not anti-vaccine.

• "There is much more behind this than just rhetoric," Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota told Axios.
• "They say 'We just want more studies. We're only concerned about vaccine safety.' The real objective to get vaccines off the market," said Angela Rasmussen, a virologist at the University of Saskatchewan's Vaccine and Infectious Disease Organization.
• She said she expects Kennedy would follow a similar path of calling for more clinical trials and research as a pretext for removing vaccines from federal schedules of recommended shots.

Between the lines: Beyond direct challenges like citizen petitions, vaccines could be undermined by outside committees of advisers, whose recommendations determine the jabs' availability and how they are paid for.

• Kennedy and Siri's vetting of key health positions in the incoming administration also indicates anyone who gets a top job should ascribe to vaccine skepticism, the experts say.
• "Having Siri be the gatekeeper of who gets these positions or not is a worst-case scenario," Rasmussen said. "These picks are all the picks I would pick if I were trying to destroy the U.S. vaccine program."

The other side: In a statement posted online, Siri called the Times report a "hit piece" and said the petition challenging the polio vaccine was filed on behalf of the Informed Consent Action Network and not himself.

• He also said the vaccine in question, IPOL, "is not the polio vaccine of old," saying there are "clear safety gaps in licensing this particular product."
• In 2000, the U.S. stopped using the oral polio vaccine, which blocks the spread of the virus by inducing immunity in the gut but can result in vaccine-derived poliovirus due to its use of a weakened strain of polio.
• Vaccine-derived polio virus can cause outbreaks where vaccine coverage is low, per the Centers for Disease Control and Prevention.

"Vaccines have been so effective we don't appreciate what it was like prior to the vaccines when, during the summer, sending your kid to the swimming pool might result in them living in an iron lung the rest of their life," Rasmussen said.

Reality check: It still will difficult to upend the regulatory system that's in place to vet vaccines for safety and efficacy, Osterholm said.

• "I don't think there's this imminent danger that sometime in January where, all of a sudden, we won't see vaccines available," Osterholm said.
• That's particularly true now that the Supreme Court has scrapped a decades-old legal doctrine that gave the FDA, Centers for Medicare and Medicaid Services and other health agencies the discretion to interpret vague or ill-defined laws. Legal challenges to any vaccine rollback are likely.
• There is also the question of popular opinion. Americans have expressed mistrust of Kennedy on health, with a majority disagreeing with his views about vaccine requirements in schools, per the latest Axios-Ipsos American Health Index.

Americans worried about vaccine safety should be aware the shots are among the most scrutinized medical products, Joshua Sharfstein, a former FDA deputy commissioner and public health professor at Johns Hopkins University, told Axios.

• That doesn't mean safety discussions should be off the table, but that "we don't want to have a conversation about vaccine safety led by people who have irresponsibly called for the removal of vaccines," he added.

What to watch: Kennedy is expected to spend this week on the Hill meeting with senators.

• The New York Times report of Kennedy's collaboration with Siri generated a strong rebuke on Friday from Senate Minority Leader Mitch McConnell, who had polio as a child and is an important vote for Trump's nominees to win over.

Some of the earliest and lasting effects from President-elect Trump's promised immigration crackdowns would be in home health and long-term care, both of which rely on a substantial number of immigrants and undocumented workers.

Why it matters: Reducing an already thin labor market could have serious ramifications for aging adults or those with disabilities — and potentially put more stress on family caregivers.

What they're saying: "Immigration policy is long-term care policy," said David Grabowski, a Harvard Medical School professor who's chronicled how foreign-born workers filled key nursing home roles early in the pandemic.

• He found nursing homes in regions with a higher share of foreign-born nursing assistants provided more direct care and better quality.
• "If you were to tighten up immigration or begin deporting individuals, it's going to lower the available workforce, and this is only going to add to an already challenging labor situation," he said.

By the numbers: Between 2021 and 2031, the long-term care sector will need to fill 9.3 million direct care job openings as demand grows and workers exit the field, according to PHI, a research group that studies care workers.

• With the fast-growing senior baby boomer population, many of the gaps have been filled by immigrants.
• The American Immigration Council estimates more than a third of home health aids in the U.S. are immigrants. In states like California, New York and New Jersey, it's estimated at least 40% of the caregiving workforce is foreign-born.

Trump's proposals call for mass deportations of undocumented workers and would also curb legal immigration and limit asylum.

• Trump transition spokesperson Karoline Leavitt said in a statement that the deportation of criminals, drug dealers and human traffickers would lower costs for families and strengthen the workforce.
• Experts say the effects of tighter immigration policies would be felt beyond communal settings, and especially in home care, where workers, predominantly women, earn around $16 an hour, according to government data.
• Undocumented workers made up an estimated 6.9% of home health aides and 4.4% of personal care aides, according to the American Immigration Council.

Zoom in: There is particular concern about the impact on what's considered the "gray" market of caregivers in which individuals are not working for an accredited agency but directly for an individual or family, said Nicole Howell, director of workforce policy at aging services provider association LeadingAge.

• It's hard to quantify the size of that market, but studies have found families in rural markets are five times more likely to reach for care on the gray market where supply through companies may be limited, Howell said.

The big picture: The effects of mass deportations or other crackdowns on caregiving would not just come from the loss of undocumented workers, Howell said.

• Aggressive immigration enforcement could cause home care workers who might have otherwise legally entered the U.S. to move to countries with friendlier polices. Canada, for instance, announced a permanent residence program earlier this year specifically aimed at incentivizing foreign-born caregivers.
• Many caregivers who are documented immigrants may live in mixed-status households, and deportation — or the threat of deportation — may destabilize those households and force them to go work in other sectors.
• The concern is "this could put our industry under increased strain, that foreign-born workers might just decide the sector is not for them broadly. And clearly, we have so much data that says that they are the lifeblood," Howell said.

The Biden administration's eleventh hour move to expand Medicare coverage for anti-obesity drugs is likely to be popular among seniors, putting the Trump administration — which would ultimately decide whether to carry out the expansion — in the hot seat.

Why it matters: The buzzy class of drugs known as GLP-1 agonists have been hailed as game changers amid an obesity crisis tied to chronic diseases.

• But the drugs are pricey, and insurers, advocacy groups and policymakers warn that opening up coverage for them could be a recipe for runaway costs in an already financially taxed system.

Driving the news: Under current law, Medicare is barred by Congress from covering drugs for weight loss. They're covered only as an optional benefit on state Medicaid plans, and coverage varies by state.

• Biden administration officials say they're reinterpreting the statute by addressing obesity as a chronic condition rather than weight loss.
• "I have heard from countless people about how this coverage exclusion is a barrier preventing people from treating obesity and living healthier lives," Centers for Medicare and Medicaid Services administrator Chiquita Brooks-LaSure said in a call with reporters.

By the numbers: The Biden administration's move, which would take effect in 2026, would expand access to drugs like Novo Nordisk's Ozempic or Wegovy for 3.4 million Americans on Medicare and another 4 million on Medicaid who are obese, per the White House. Officials said they do not expect this would raise seniors' premiums.

• Officials estimated the cost to the federal government of the proposed coverage over 10 years would be roughly $25 billion for Medicare and $11 billion for Medicaid. Biden administration officials estimate states would shoulder roughly $3.8 billion in additional spending during that time.
• Medicare opening coverage to anti-obesity drugs would likely have a much broader impact on access to the drugs via employer coverage, said Kathy Hempstead, a health insurance expert at the Robert Wood Johnson Foundation.
• "The fact that there is such a patchwork of access to this drug is something that strikes a lot of Americans as being unfair. You just sort of randomly might or might not have access to this medication, depending on where you work or what state you live in," she said, adding the current proposal from the White House could be a path to universal coverage.

The other side: It's unclear how the Trump administration will view Medicare coverage of GLP-1s. Health and Human Services secretary nominee Robert F. Kennedy Jr. has slammed use of the drugs while CMS administrator nominee Mehmet Oz has sung their praises.

• The cost is expected to be a key sticking point, particularly as the administration promises to cut back federal spending, Capstone's Hunter Hammond wrote in a note.
• The Trump transition team did not respond to a request for comment.

Between the lines: Generally, rules proposed late in one administration are put on hold or set aside by incoming administrations in favor of their own policy priorities.

• But expanding coverage to the drugs is likely to be popular among seniors who make up a core part of Trump's base.

"We view this more as a parting shot from the outgoing administration, particularly given the likely cost of adding GLP-1 coverage," Evercore ISI analyst Elizabeth Anderson said in note.

• "It's more likely that the proposed ruling may not get finalized (at least not in its current form) given the timing, but helps to raise the profile of this issue further."
• "We have some cautious optimism," Joe Nadglowski, CEO of the Obesity Action Coalition, told Axios. "We've gotten some mixed messages from members of the Trump administration and his team around these therapies. But I think the reality is that obesity is going to be a major issue for the administration."

Between the lines: While a Trump administration might be reticent to put its stamp of approval on a Biden proposal, it may also be a political win to allow this proposal or something like it to cross the finish line, Larry Levitt, executive vice president for policy at KFF, told Axios in an email.

• And members of Congress on "the Hill would be happy to have this done by regulation so they don't have to pay for it."

Friction point: The Alliance of Community Health Plans said the proposal would have "enormous cost consequences for consumers, taxpayers and employers."

• "The proposed expansion is irresponsible without further analysis and stakeholder engagement. It's high time policymakers focus on exorbitant costs and appropriate utilization," it said in a statement.

What to watch: It's unclear whether the proposal would make it through the courts.

• "Even if finalized, legal challenges overturning the rule are highly likely to be successful," Chris Meekins, an analyst at Raymond James who worked at HHS in the first Trump administration, wrote in a note.

The Biden administration on Tuesday proposed requiring Medicare and Medicaid to cover anti-obesity drugs.

Why it matters: The rule would expand access to medications known as GLP-1 agonists for millions of Americans struggling with obesity, who are at higher risk of diabetes, stroke and cardiovascular disease, according to a White House fact sheet.

• The proposal could set up a conflict between pharmaceutical companies and Robert F. Kennedy Jr., President-elect Trump's nominee for secretary of the Health and Human Services Department, who is an Ozempic critic.

Driving the news: Under current law, Medicare is barred from covering drugs for weight loss. That also makes it optional for state Medicaid plans, officials said.

• The new rule proposes a "reinterpretation" of the law, expanding access to the drugs like Novo Nordisk's Ozempic or Wegovy for 3.4 million Americans on Medicare and another 4 million on Medicaid who are obese, per the fact sheet.
• "The medical consensus has evolved. The medical community today agrees that obesity is a chronic disease, it is a serious condition that increases the risk of premature death and can lead to other serious health issues such as heart disease, stroke and diabetes," said Chiquita Brooks-LaSure, administrator for the Centers for Medicare and Medicaid Services, in a call with reporters.
• The proposal could cost taxpayers roughly $40 billion over the next decade, officials said.

State of play: About 40% of American adults are considered obese and therefore at risk of further health complications, according to the Centers for Disease Control and Prevention.

• 22% of people with Medicare had a diagnosis of obesity in 2022, which is more than double the number from a decade earlier and it's believed many more people suffer from obesity without an official diagnosis, CMS administrator Brooks-LaSure said.
• High price tags and insurance restrictions made the drugs difficult to access for many Americans, especially those on Medicare and Medicaid.
• "Without insurance coverage, these drugs can cost someone as much as $1,000 a month," the fact sheet stated.

The big picture: Demand for the drugs has surged in recent years.

• While the drugs were originally approved to treat diabetes, they were later approved for use in obesity as well as heart disease.
• The popularity of Ozempic among celebrities and TikTokers has also contributed to shortages for patients in need.

Go deeper: United States of Ozempic: Where anti-obesity drugs are taking off

Editor's note: This story was updated with additional details.

Robert F. Kennedy Jr. could use Health and Human Services' vast bureaucracy to put a distinct stamp on vaccine policy, drug approvals and food regulation if he's confirmed. But with so many legal requirements and bureaucratic layers baked into the process, it's hardly a foregone conclusion he will.

Why it matters: Experts say RFK Jr.'s public calls for more transparency and vows to shore up the trustworthiness of federal health agencies may translate into more requests for vaccine safety data and into appointing like-minded individuals to advisory panels that could influence coverage of drugs, services and devices.

• They also say it could result in shifting public health funding to chronic disease or environmental health and away from infectious disease, or a diversion of federal investment to study unproven health issues instead of known risks.
• And they're expecting attempts to remove job protections from career federal employees who work in policymaking roles and reduce the ranks of officials who don't align with RFK Jr.'s goals.

Between the lines: In the near term, he's likely to focus on how much influence he might exert on negotiations between the Food and Drug Administration and the health industries it regulates over user fees for companies, which fund a significant portion of the FDA's operations.

• Talks to reauthorize programs for prescription drugs, medical devices and generics are due to start next year and could provide a crucible for Trump appointees to take aim at what they describe as regulators' coziness with industries they police.
• The spotlight could fall especially hard on vaccines, based on Kennedy's criticisms of the federal pandemic response, his calls to revoke emergency use authorizations for COVID shots and his advocacy of hydroxychloroquine and ivermectin, both of which were found ineffective for treating the virus.

The general thinking is RFK Jr. could have more openings to exert his influence through the Centers for Disease Control and Prevention than the FDA, which is tightly bound by the Food, Drug and Cosmetic Act.

• He also stack outside advisory panels like the CDC's Advisory Committee on Immunization Practices, or ACIP, with fellow vaccine skeptics.
• ACIP recommendations influence whether Medicare covers a vaccine at no cost to patients. State Medicaid programs have to cover recommended adult vaccines.
• "They have the ability to change the bylaws or the charters under which those committees run, and essentially have the ability to ignore the committees or disband it entirely if they felt like they needed to," Joshua Michaud, associate director of global health and HIV policy at KFF.

Zoom in: RFK Jr., with the help of Congress, could also seek to make changes to the National Vaccine Injury Compensation Program, which dates to the 1980s and gives vaccine makers legal immunity for any injuries caused by their products, in exchange for a 75-cent tax on each dose sold.

• The program drew criticism from the right during the pandemic, when makers of COVID-19 vaccines were not required to pay the tax because the shots were designated as "countermeasures."
• "We've never had an HHS secretary who wants to blow up the nation's immunization system. So there are questions here that haven't come up before," said Sara Rosenbaum, who served on ACIP between 2009 and 2013.

Zoom out: The HHS secretary still has a great deal of authority at the FDA.

• "The Secretary's role doesn't have to be just routinely sign off on things," said Richard Besser, former acting director for the CDC from January to June 2009 and current CEO of the Robert Wood Johnson Foundation.

Flashback: In the Obama administration, HHS Secretary Kathleen Sebelius made an unprecedented decision to override an FDA decision that would have made emergency contraceptives available over the counter, Besser pointed out. (The decision was later reversed in 2013.)

• "And Mr. Kennedy as the secretary has some strong feelings about what drugs are effective and which ones are not, and what things should be used to promote health," Besser said.

Reality check: HHS's budget and legal mandates are determined by Congress and have limits. Any major regulatory changes must go through public comment periods and comprehensive legal review.

• They would also certainly be subject to lawsuits, particularly after the fall of the Chevron doctrine.

What to watch: There's a question about whether HHS could usurp school vaccine requirements using section 361 of the Public Health Service Act of 1944, which gives it the authority to "control communicable diseases."

• "The answer is not entirely straightforward and would set off legal challenges," Richard Hughes of Epstein Becker Green wrote.

Regardless, experts say some of the most significant effects of an RFK-led HHS may be how health guidance and evidence-based information, including about vaccines, are communicated.

• "If the CDC and the HHS secretary are out there saying we have doubts about the safety of this vaccine ... that might have some downstream effects at the state and local level, which is where those vaccine requirement decisions are actually made," Michaud said.