The federal government shut down on October 1st over a question that seems simple: Should 24 million Americans continue receiving help to afford health insurance? Republicans call the enhanced Affordable Care Act subsidies “too expensive”—$335 billion over ten years.
Yet this debate is only the visible tip of a broader project. Over the past year, the administration has pursued policies that methodically erode medical authority itself: rescinding the EPA’s scientific finding that greenhouse gases endanger public health; cutting Medicaid and NIH budgets; and firing the CDC’s vaccine advisory committee in the midst of a measles outbreak.
These are not isolated moves. They represent a playbook that conservatives have refined for decades, that is, undermining the legitimacy of expertise by framing scientific consensus as ideological, then use that delegitimization to justify slashing collective spending on health. The tactic was previously honed on climate science and has now migrated wholesale into medicine.
This isn’t really a fight about cost or efficiency. It’s a struggle over who decides what counts as medically necessary, and whose judgment defines public health. Increasingly, that answer is no longer doctors.
1. Cultural Wedges
Every campaign to delegitimize science starts with a wedge issue that can be recast as moral or political rather than empirical.
Vaccines
In June, Health and Human Services Secretary Robert F. Kennedy Jr. fired all seventeen members of the Advisory Committee on Immunization Practices, the group that had guided the country’s vaccine policy for decades. Kennedy alleged “conflicts of interest” but provided no evidence. His replacements included several outspoken vaccine skeptics. Within weeks, the committee recommended against thimerosal-containing flu vaccines, revised MMRV guidance, and revived long-debunked controversies.
By August, a measles outbreak in West Texas had caused 159 cases and three deaths, two of them children. Instead of urging vaccination, Kennedy promoted cod-liver oil and clarithromycin—an antibiotic used to treat bacterial infections but is useless against viruses—and encouraged vitamin A supplementation that in some children caused liver injury. At the same time, dozens of CDC school-based vaccine clinics have been canceled. National MMR coverage has slipped below 95 percent, the threshold needed to maintain herd immunity. For the first time since 2000, the United States risks losing its measles-free status.
Abortion
Abortion has become the other ideal wedge. Texas now imposes up to 99 years in prison and $100,000 fines on physicians who perform abortions outside narrow exemptions; Idaho allows the procedure only when a patient faces “imminent risk of death.” The American College of Obstetricians and Gynecologists warns that “it is impossible for a law to appropriately capture how or whether a ‘medical emergency’ exception applies.”
After Idaho’s ban, 25 percent of OB-GYNs left the state, and six pregnant women were air-lifted out for emergency care. Texas’s maternal-mortality rate rose 56 percent in 2022—a 95 percent increase among White women—and a JAMA analysis of 14 states with bans found 478 excess infant deaths. Overall, states with abortion restrictions record 62 percent higher maternal mortality (28.8 vs. 17.8 deaths per 100,000 births).
Vaccines and abortion share a crucial feature: both can be framed as “personal choice” versus “government mandate.” That framing lets politicians portray professional consensus—the CDC’s immunization schedule, ACOG’s clinical guidelines—as ideological rather than scientific. Once expertise is recast as bias, every subsequent medical judgment can be dismissed the same way.
2. From Wedge to Delegitimization
The administration’s goal isn’t reforming vaccine schedules or protecting fetal life. It’s establishing a precedent that scientific expertise itself is suspect.
During this shutdown fight, Vice President J. D. Vance claimed, “Democrats are shutting down the government to fund health care for illegal aliens.” In reality, the dispute covers about 1.4 million lawfully present immigrants, including refugees, asylum seekers, and DACA recipients, not undocumented people barred from federal benefits since 1996. Yet the charge works because it transforms “Should 24 million Americans keep health insurance?” into “Are Democrats giving your tax dollars to illegal immigrants?”
The effect is to make collective health spending culturally toxic, regardless of the evidence. Polls show 78 percent of Americans, including 59 percent of Republicans, favor extending the subsidies. The policy is popular so the only way to get rid of it is to attack on moral grounds.
A similar pattern guides the EPA’s proposed repeal of the 2009 greenhouse-gas endangerment finding. Administrator Lee Zeldin asserts that “much has changed” since 2009, although scientific consensus on climate risk has only strengthened. The proposal boasts $54 billion in annual savings, but the Federal Register explicitly excludes health damages from the calculation. Independent analysis finds those damages two to four times larger than the claimed savings—a net cost approaching $800 billion.
Once climate scientists are “political,” vaccine experts “corrupt,” and OB-GYN guidelines “ideological,” every form of medical authority becomes expendable. And that is the ultimate goal.
3. What Gets Cut When Expertise Loses
The current budget fight shows the next step. The $335 billion price tag for ACA subsidies dominates headlines, while the human cost of losing coverage is treated as secondary. The so-called One Big Beautiful Bill Act cuts $1.02 trillion from Medicaid while offering $50 billion for rural health over five years—barely five percent of what it removes.
The National Institutes of Health, too, faces deep reductions. The proposed FY 2026 budget slashes the National Cancer Institute by 37 percent to $4.5 billion, threatening thousands of clinical trials. By mid-2025, NIH had already terminated about 2,300 grants worth $3.8 billion. These are not partisan numbers; they are the scaffolding of modern medicine.
When evidence loses authority, infrastructure collapses with it. In 2023, Republican-leaning states averaged 75.5 years of life expectancy versus 77.7 in Democratic-leaning states. This gap has grown over the last two decades. Medicaid-expansion states cut uninsured rates among Black adults by 67 percent, while non-expansion states left rates 7 points higher. During the post-vaccine COVID era, Republican counties saw 43 percent higher excess death rates than Democratic ones.
These are measured outcomes, not forecasts. They show what happens when ideology outweighs evidence in matters of life and death.
4. Clinicians Caught in the Crossfire
For doctors, political abstraction has become personal. A Vanderbilt study coined the term hesitant medicine to describe physicians who must weigh legal risk against patient needs. In ban states, emergency providers must document every step of decision-making—which tests were ordered, what consultations obtained, why transfer wasn’t attempted—in anticipation of possible prosecution.
Seventy-six percent of physicians now say they would not work in states with abortion restrictions. OB/GYN residency applications in those states dropped 6.7 percent last year; emergency medicine applications fell 7 percent. Almost 40 percent of medical students report that state reproductive-health laws shape their residency choices. Idaho has already lost a quarter of its obstetricians.
These aren’t acts of political protest. They’re forms of self-preservation in a system where following evidence-based guidelines may invite a 99-year prison sentence and ignoring them may lead to malpractice suits.
It’s true that public-health agencies have earned skepticism. The CDC’s failed COVID test rollout—just 1,235 tests performed nationwide by March 5, 2020—was catastrophic. But reforming incompetence is not the same as declaring expertise itself corrupt. The former seeks accountability, while the latter destroys the capacity for evidence-based governance altogether.
5. The Stakes in Lives and Years
The October shutdown is not just a budget fight. It is the logical next point in a strategy that uses the culture war to erode the authority of science, then leverages that erosion to withdraw collective care and limit expenses it doesn’t want to incur for people it doesn’t want to support.
When measles elimination status is at risk for the first time in a quarter century; when maternal mortality is 62 percent higher in states that criminalize medical judgment; when NIH cancer research faces near-half budget cuts while 618,000 Americans are expected to die of cancer this year—the results are not just ideological. They are fatal.
As climate scientist Andrew Dessler has said of similar tactics, this approach “mimics the doubt-sowing strategy the tobacco industry used to delay regulation.” It works because it feeds on legitimate frustration with bureaucracy and failure but offers no functional replacement for expertise once it’s been called into question.
The data are clear. The strategy is deliberate. And the question for physicians, scientists, and citizens alike is no longer whether this is a crisis. Rather, it is how to defend evidence-based medicine in a political world that no longer trusts the evidence at all.