President Donald Trump last year promoted unproven ties between the painkiller and autism, telling pregnant women: “Don’t take Tylenol.”

The latest research review, published Friday in The Lancet Obstetrics, Gynecology & Women’s Health, looked at 43 studies and concluded that the most rigorous ones, such as those that compare siblings, provide strong evidence that taking the drug commonly known as paracetamol outside of the U.S. does not cause autism, ADHD or intellectual disabilities.

It's "safe to use in pregnancy,” said lead author Dr. Asma Khalil. “It remains … the first line of treatment that we would recommend if the pregnant woman has pain or fever.”

While some studies have raised the possibility of a link between autism risk and using Tylenol, also known as acetaminophen, during pregnancy, more haven’t found a connection.

A review published last year in BMJ said existing evidence doesn’t clearly link the drug's use during pregnancy with autism or ADHD in offspring. A study published the previous year in the Journal of the American Medical Association also found it wasn't associated with children’s risk of autism, ADHD or intellectual disability in an analysis looking at siblings.

But the White House has focused on research supporting a link.

One of the papers cited on its web page, published in BMC Environmental Health last year, analyzed results from 46 previous studies and found that they supported evidence of an association between Tylenol exposure during pregnancy and increased incidence of neurodevelopmental disorders. Researchers noted that the drug is still important for treating pain and fever during pregnancy, but said steps should be taken to limit its use.

Some health experts have raised concerns about that review and the way Trump administration officials portrayed it, pointing out that only a fraction of the studies focus on autism and that an association doesn't prove cause and effect. Khalil, a fetal medicine specialist at St. George’s Hospital, London, said that review included some studies that were small and some that were prone to bias.

The senior author of that review was Dr. Andrea Baccarelli, dean of the faculty at Harvard T.H. Chan School of Public Health, who noted in the paper that he served as an expert witness for plaintiffs in a case involving potential links between acetaminophen use during pregnancy and neurodevelopmental disorders. Baccarelli did not respond to an email seeking comment on his study.

Overall, Khalil said, research cited in the public debate showing small associations between acetaminophen and autism is vulnerable to confounding factors. For example, a pregnant woman might take Tylenol for fevers, and fever during pregnancy may raise the risk for autism. Research can also be affected by “recall bias,” such as when the mother of an autistic child doesn’t accurately remember how much of the drug she used during pregnancy after the fact, Khalil said.

When researchers prioritize the most rigorous study approaches – such as comparing siblings to account for the influence of things like genetics – “the association is not seen,” she said.

Genetics are the biggest risk factor for autism, experts say. Other risks include the age of the child’s father, preterm birth and whether the mother had health problems during pregnancy.

In a commentary published with the latest review, a group of researchers who weren't involved — from the London School of Hygiene and Tropical Medicine, Children's Hospital Colorado and elsewhere —cautioned that discouraging the use of acetaminophen during pregnancy could lead to inadequate pain or fever control. And that may hurt the baby as well as the mother. Untreated fever and infection in a pregnant woman poses “well-established risks to fetal survival and neurodevelopment," they said.

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The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education and the Robert Wood Johnson Foundation. The AP is solely responsible for all content.

The South Carolina health department reported 124 new cases since Tuesday, bringing the state's total to 558 in a wave of infections centered around an outbreak in Spartanburg County.

Since the holidays, South Carolina's measles outbreak has exploded into the worst in the U.S. Measles also have been reported this year in Arizona, Florida, Georgia, North Carolina, Ohio, Oregon, Utah and Virginia, according to the Centers for Disease Control and Prevention.

Last year was the nation’s worst for the spread of measles since 1991, according to the CDC. The U.S. confirmed 2,144 cases across 44 states. Three people died, all of them unvaccinated.

Measles is caused by a highly contagious virus that is airborne and spreads easily when an infected person breathes, sneezes or coughs. It is preventable through vaccines and has been considered eliminated from the U.S. since 2000, though the country is at risk of losing that achievement.

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The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education and the Robert Wood Johnson Foundation. The AP is solely responsible for all content.

The Centers for Disease Control and Prevention posted data — for flu activity through last week — that showed a big drop in flu hospitalizations and a smaller but significant decrease in medical office visits due to flu-like illness.

The number of states reporting high flu activity also fell — from 44 to 36.

Meanwhile, there have not been large surges in two other winter menaces — COVID-19 and RSV.

CDC officials are calling the current respiratory virus season “moderate.” But that doesn't mean the season is over, especially for flu. Second surges in flu activity often occur after the winter holidays.

“We've had other seasons where we've had a peak, it's gone down, but we've nonetheless had a prolonged season," said Dr. William Schaffner, an infectious diseases specialist at Vanderbilt University in Tennessee.

“Most of us are crossing our fingers,” he added. ”But I don't think we can rely on the concept that flu is abating very early this year."

Medical experts have worried about this season because it has been dominated by a kind of flu virus, called A H3N2, that historically causes the most hospitalizations and deaths in older people.

Even more concerning, about 90% of the H3N2 infections analyzed this season were a new strain that differs from the version accounted for in this year’s flu shots.

So far this season, there have been at least 18 million flu illnesses and 230,000 hospitalizations, according to the CDC. The agency also estimates there have been 9,300 deaths from flu so far, including at least 32 children. For those children whose vaccination status is known, 90% were not fully vaccinated against flu.

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The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education and the Robert Wood Johnson Foundation. The AP is solely responsible for all content.

The cornerstone is his proposal to send money directly to Americans for health savings accounts so they can handle insurance and health costs as they see fit. Democrats have rejected the idea as a paltry substitute for the tax credits that had helped lower monthly premiums for many people.

“The government is going to pay the money directly to you,” Trump said in a taped video the White House released to announce the plan. “It goes to you and then you take the money and buy your own health care.”

Trump's plan also focuses on lowering drug prices and requiring insurers to be more upfront with the public about costs, revenues, rejected claims and wait times for care.

Trump has long been dogged by his lack of a comprehensive health care plan as he and Republicans have sought to unwind former President Barack Obama’s signature legislation, the Affordable Care Act. Trump was thwarted during his first term in trying to repeal and replace the law.

When he ran for president in 2024, Trump said he had only “concepts of a plan” to address health care. His new proposal, short on many specifics, appeared to be the concepts of a plan.

Dr. Mehmet Oz, administrator of the Centers for Medicare and Medicaid Services, described it to reporters on a telephone briefing as a “framework that we believe will help Congress create legislation.”

A White House official who was not authorized to speak publicly and described some details on condition of anonymity said the administration had been discussing the proposal with allies in Congress, but was unable to name any lawmakers who were working to address the plan.

Sen. Bill Cassidy of Louisiana, the Republican chair of the Senate health committee, said in a social media post praising Trump's plan that his committee “has and will take action on the President's affordability agenda.”

Few specifics on health savings accounts

The White House did not offer any details about how much money it envisioned being sent to consumers to shop for insurance, or whether the money would be available to all “Obamacare” enrollees or just those with lower-tier bronze and catastrophic plans.

The idea mirrors one floated among Republican senators last year. Democrats largely rejected it, saying the accounts would not be enough to cover costs for most consumers. Currently, such accounts are used disproportionately by the wealthiest Americans, who have more income to fund them and a bigger incentive to lower their tax rate.

White House press secretary Karoline Leavitt was asked Thursday whether the president could guarantee that under his plan, people would be able to cover their health costs. She did not directly answer, but said, “If this plan is put in place, every single American who has health care in the United States will see lower costs as a result.”

Enhanced tax credits that helped reduce the cost of insurance for the vast majority of Affordable Care Act enrollees expired at the end of 2025 even though Democrats had forced a 43-day government shutdown over the issue.

Sen. Bernie Moreno, R-Ohio, has been leading a bipartisan group of 12 senators trying to devise a compromise that would extend those subsidies for two years while adding new limits on who can receive them. That proposal would create the option, in the second year, of a health savings account that Trump and Republicans prefer.

The White House official denied that Trump was closing the door completely on those bipartisan negotiations, and said the White House preferred to send money directly to consumers.

Plan follows massive cuts to health programs

Trump’s plan comes months after the Republicans’ big tax and spending bill last year cut more than $1 trillion over a decade in federal health care and food assistance, largely by imposing work requirements on those receiving aid and shifting certain federal costs to the states.

Democrats have blasted those cuts as devastating for vulnerable people who rely on programs such as Medicaid for their health care. The GOP bill included an infusion of $50 billion over five years for rural health programs, an amount experts have said is inadequate to fill the gap in funding.

The White House said Trump's new proposal will seek to bring down premiums by fully funding cost-sharing reductions, or CSRs, a type of financial help that insurers give to low-income ACA enrollees on silver-level, or mid-tier plans.

From 2014 until 2017, the federal government reimbursed insurance companies for CSRs. In 2017, the first Trump administration stopped making those payments. To make up for the lost money, insurance companies raised premiums for silver-level plans. That ended up increasing the financial assistance many enrollees got to help them pay for premiums.

As a result, health analysts say that while restoring money for CSRs would likely bring down silver-level premiums, as Trump says, it could have the unwelcome ripple effect of increasing many people’s net premiums on bronze and gold plans.

Lowering drug prices is a priority

Oz said Trump's plans also seeks to have certain medications made available over the counter instead of by prescription if they are deemed safe enough. He mentioned higher-dose nonsteroidal anti-inflammatory drugs and peptic ulcer drugs as two examples.

It was unclear whether the White House is asking Congress to take steps to make more prescription drugs available over the counter. For decades, the Food and Drug Administration has had the ability to do that.

The heartburn drug Prilosec, as well as numerous allergy medications, are among those the FDA has approved for over-the-counter sales. The FDA only approves such changes if studies show patients can safely take the drug after reading the package labeling. Companies must apply for the switch.

The White House said Trump’s plan would also codify his efforts to lower drug prices by tying prices to the lowest price paid by other countries.

Trump has already struck deals with a number of drugmakers to get them to lower the prices. As part of that, the drugmakers have agreed to sell pharmacy-ready medicines directly to consumers who can shop online at the White House's website for selling drugs directly to consumers, TrumpRx.gov.

TrumpRx did not yet have any drugs listed on Thursday. Oz said drugs will be available on the website at the end of the month.

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AP Health Writer Matthew Perrone contributed to this report.

The New York State Nurses Association said its bargaining members began meeting with their counterparts at NewYork-Presbyterian late Thursday, the fourth day of the strike.

They also plan to sit down with officials at other affected hospitals, including those operated by Mount Sinai and Montefiore, on Friday, though the union said some facilities have not yet agreed to resume talks.

Each medical center is negotiating with the union independently, and not every hospital run by the three health care systems is affected by the strike.

The opposing sides haven’t met since Sunday, the day before roughly 15,000 unionized nurses walked off the job.

Hospitals have hired thousands of temporary nurses to keep emergency rooms and other facilities running.

The nurses say they’re seeking to protect their health care benefits, as well as secure contract provisions addressing staffing levels and safety against workplace violence.

Sheryl Ostroff, a Mount Sinai nurse, said nurses often bear the brunt of patients’ frustrations, and interactions can quickly become violent.

“I’ve been scratched in the face. I have been bitten in multiple places. I have been kicked in the ribs where it leaves bruises, spit on, pushed, punched, sexually assaulted — you name it,” she said at a union rally Thursday. “It’s not acceptable, and we want our hospitals to protect us. Why is that a hard ask?”

The hospitals say the unions are seeking “unrealistic” and unaffordable pay raises.

Mount Sinai says the union's proposals would raise the average annual salary of its nurses from roughly $162,000 to nearly $250,000 in three years, while Montefiore says theirs would rise to $220,000.

The union dismissed the claims as “outlandish math,” but declined to provide countering figures.

“We are committed to keep negotiating for a fair and reasonable contract that reflects our deep respect for our nurses and the critical role they play, and also recognizes the challenging realities of today’s healthcare environment,” NewYork-Presbyterian said in a statement Thursday.

Nurses’ union leaders held a rally alongside elected officials and members of other major city labor unions Thursday in front of Mount Sinai’s Morningside campus.

The hospital, located near Columbia University in upper Manhattan, is among those that have not yet agreed to resume contract talks, according to the union.

Simone Way, a nurse at Mount Sinai Morningside, said she and her fellow nurses have “sounded the alarm for years” about proper staffing levels, but administrators have refused to listen.

“It is incredibly hard to deliver the level of care our patients deserve,” she said at the rally. “There are limits to what good nurses can do.”

A Mount Sinai spokesperson didn’t immediately respond to an email seeking comment on the rally or the status of contract talks.

Brendan Carr, the health system’s CEO, said in a video released earlier Thursday that some unionized nurses who have opted to work instead of joining the picket line have been subjected to harassment and intimidation.

“Bullying, intimidating and threatening devalues nurses, undermines our culture, and is not consistent with our values at Mount Sinai,” he said, addressing hospital staff. “You deserve better.”

The union, which has filed a federal complaint against Mount Sinai for terminating the three nurses on the eve of the strike, dismissed the accusations as “baseless.”

The union also confirmed that its member nurses on Long Island ratified new contracts Thursday with Northwell Health, the state's largest health system.

The deals, which were reached last week and averted strikes at three Long Island hospitals, called for roughly 5% raises in each year of the three-year pact, according to the union.

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Follow Philip Marcelo at https://x.com/philmarcelo

Colorado health officials were able to get ahead of the highly contagious virus by tracking its presence in sewer systems, researchers wrote. And Oregon researchers found wastewater could have warned them of an outbreak more than two months before the first person tested positive.

The findings add to evidence that wastewater testing is a valuable weapon in tracking disease, including COVID-19, polio, mpox and bird flu.

But the national wastewater surveillance system, run by CDC since 2020, is newly at risk, under a Trump administration budget plan would slash its funding from about $125 million a year to about $25 million.

Peggy Honein, director of the CDC's division of infectious disease readiness and innovation, said the proposed funding level would “sustain some of the most critical activities” but “it would likely require some prioritization.”

The national system covers more than 1,300 wastewater treatment sites serving 147 million people. It includes six “centers for excellence” — Colorado among them — that innovate and support other states in expanding their testing.

States brace for cuts

The funding cut is still a proposal, and Congress has started pushing back against cuts to health care in general.

But state health departments say they are preparing for a potential loss of federal support regardless. Most state programs are entirely federally funded, Honein said.

Colorado started its wastewater surveillance program in 2020 with 68 utilities participating voluntarily. The program has since narrowed in its focus even as it grew to include more diseases, because it is 100% federally funded, said Allison Wheeler, manager of the Colorado’s wastewater surveillance unit.

The work is funded through 2029, Wheeler said, and the department is talking to state leaders about what to do after that.

“I know that there are other states that haven’t been as fortunate as us,” Wheeler said. “They need this funding in order to sustain their program for the next year.”

Measles found in wastewater before patients are diagnosed

In the Colorado study, which Wheeler co-authored, officials started testing wastewater for measles in May, as outbreaks in Texas, New Mexico and Utah were growing and five cases had been confirmed in Colorado.

In August, wastewater in Mesa County tested positive about a week before two measles cases were confirmed by a doctor. Neither patient knew that they had been exposed to measles. As they traced 225 household and health care contacts of the first two patients, health officials found five more cases.

In Oregon, researchers used preserved sewage samples from late 2024 to determine if sewage testing could have discovered a burgeoning outbreak.

The 30-case outbreak spanned two counties and hit a close-knit community that does not readily seek health care, the study's authors wrote. The first case was confirmed on July 11 and it ultimately took health officials 15 weeks to stop the outbreak.

The researchers found that wastewater samples from the area were positive for measles about 10 weeks before the first cases were reported. The virus concentration in the wastewater over the weeks also matched the known peak of the outbreak.

“We knew that we were missing cases, and I think that's always the case in measles outbreaks,” said Dr. Melissa Sutton, of the Oregon Health Authority. “But this gave us an insight into how much silent transmission was occurring without us knowing about it and without our health care system knowing about it.”

State see value in sewage tracking

Other states, such as Utah, have integrated wastewater data into their public-facing measles dashboards, allowing anyone to track outbreaks in real time.

And in New Mexico, where 100 people got measles last year and one died, the testing helped state health officials shrink a vast rural expanse. The state's system flagged cases in northwestern Sandoval County while officials were focused on a massive outbreak 300 miles (483 kilometers) away in the southeast, said Kelley Plymesser, of the state health department.

The early warning allowed the department to alert doctors and the public, lower thresholds for testing and refocus their resources. The outbreak ended in September. But because measles continues to spread across the Southwest, the state is still using the system to look for new cases.

Sutton, of Oregon, said she's hopeful federal leaders will see the power of the system, its adaptability, affordability and reach.

“The widespread use of wastewater surveillance in the United States is one of the greatest advancements in communicable disease surveillance in a generation,” she said.

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The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Science and Educational Media Group and the Robert Wood Johnson Foundation. The AP is solely responsible for all content.

Then she got a 2 a.m. email Thursday from the Substance Abuse and Mental Health Services Administration reiterating the cuts — and didn't know what to think anymore.

“I just shook my head. It's mass chaos,” said Woike, the CEO of BestSelf Behavioral Health, a mental health and substance use disorder treatment provider in Buffalo, New York. As it turned out, the second termination letter was sent in error. She and roughly 2,000 other grant recipients nationwide were notified later Thursday morning that their federal funding had indeed been restored.

Woike's feeling of whiplash over the past two days has been a common experience for providers, state health agencies and Americans who receive services amid the Trump administration eliminating, then abruptly reinstating, grants that support some of the nation's most vulnerable people.

It builds on what program directors say has become a pattern of uncertainty from this administration, which has repeatedly canceled millions of dollars in federal funding without notice and at times reversed course in decisions about what will and won't be covered. Woike said the unsteadiness makes it impossible for organizations like hers to make long-term plans.

“No one’s looking at expansion or really trying to ramp up services to meet the need in the community,” she said. “Everyone is just retrenching, looking at putting aside every penny and every resource.”

Trump administration surprised grant recipients

The administration first notified grant recipients that their funding was being pulled in emailed letters Tuesday evening, according to copies received by organizations and reviewed by The Associated Press.

On Wednesday, several organizations told the AP they were already making difficult decisions in response to the cuts, including laying off employees and canceling scheduled trainings.

By Wednesday evening, news reports were suggesting the cuts might be reversed — but grant recipients hadn't yet been notified of the change. Some of them said they instead received confusing emails overnight that duplicated their termination notices or instructed them on how to to close down their grants within 30 days.

It wasn't until Thursday morning that grant recipients started getting form emails saying the grant terminations were “hereby rescinded.”

Even then, not everyone could rest easy. Sara Howe, CEO of the Addiction Professionals of North Carolina, said members of her professional association are still nervous about whether their funding is guaranteed.

“Any time this happens, you wind up in a position where you’re like, is it OK to breathe?” Howe said. “It puts everybody on really unsteady, shaky ground.”

An administration official with knowledge of the decision who was not authorized to speak publicly on the matter confirmed the grants were restored, but didn't say why. A spokesperson for the Department of Health and Human Services didn’t answer a question about the administration's reasoning and declined to comment on the confusion that resulted from the situation.

Democrats blast the administration

Democratic lawmakers erupted at the Trump administration for the uncertainty and stress they caused in cutting grants and then abruptly reversing course.

House Appropriations Committee Ranking Member Rep. Rosa DeLauro described Health Secretary Robert F. Kennedy Jr.’s decision-making as dangerous and haphazard after grant recipients began laying off employees based on the original plans.

“He must be cautious when making decisions that will impact Americans’ health,” DeLauro, D-Conn., said in a statement. “I hope this reversal serves as a lesson learned.”

Democratic Sen. Tammy Baldwin of Wisconsin told the AP in a statement that the episode “caused chaos and real harm to Americans — and now, they need to come clean and give families some answers why they caused this mess.”

Providers said they were hustling to undo changes they'd already made in response to the cuts. Honesty Liller, CEO of the peer support organization the McShin Foundation in Richmond, Virginia, said she was working on the logistics of getting five laid-off employees their jobs back.

Ryan Hampton, founder of the nonprofit advocacy organization Mobilize Recovery, said he was relieved the funding was restored to his and other organizations, but criticized the administration for endangering lifesaving services in the first place.

“Restoring these grants was the only acceptable outcome, yet the chaos inflicted on frontline providers and families these past 24 hours is unforgivable," he said. “We cannot normalize a political environment where overdose prevention and recovery are treated as leverage.”

That's when the open enrollment window ends in most states for plans that start in February. About 10 states that run their own marketplaces have later deadlines, or have extended them to the end of the month to give their residents more time.

The date is a crucial one for millions of small business owners, gig workers, farmers, ranchers and others who don't get their health insurance from a job and therefore rely on marketplace plans. A record 24 million Americans purchased Affordable Care Act health plans last year.

But this year, their decisions over health coverage have been more difficult than usual as clarity over how much it will cost is hard to come by. And so far, enrollment is lagging behind last year's numbers — with about 22.8 million Americans having signed up so far, according to federal data.

Last year, for months, it was unclear whether Congress would allow for the end-of-year expiration of COVID-era expanded subsidies that had offset costs for more than 90% of enrollees. Democrats forced a record-long government shutdown over the issue, but still couldn't get a deal done. So the subsidies expired Jan. 1, leaving the average subsidized enrollee with more than double the monthly premium costs for 2026, according to an analysis from the health care nonprofit KFF.

Still, the question of whether Congress would resurrect the tax credits loomed over Washington. Several enrollees told The Associated Press they have either delayed signing up for coverage or signed up with a plan to cancel as they anxiously watch what's happening on Capitol Hill.

Last week, the House passed a three-year extension of the subsidies after 17 Republicans joined with Democrats against the wishes of Republican leaders. But the Senate rejected a similar bill last year.

Sen. Bernie Moreno, R-Ohio, has been leading a bipartisan group of 12 senators trying to devise a compromise and said this week that he expects to have a proposal by the end of the month. The contours of the senators’ bipartisan plan involves a two-year deal that would extend the enhanced subsidies while adding new limits on who can receive them. The proposal would also create the option, in the second year, of a new health savings account that President Donald Trump and Republicans prefer.

Under the deal being discussed, the ACA open enrollment period would be extended to March 1 of this year to allow people more time to figure out their coverage plans after the disruption.

Still, Republicans and Democrats say they have not completed the plan, and the two sides have yet to agree if there should be new limits on whether states can use separate funds for abortion coverage.

President Donald Trump on Thursday announced outlines of a plan he wants Congress to consider that would. It would, among other things, redirect ACA subsidies into health savings accounts that go directly to consumers. Democrats have largely rebuffed this idea as inadequate for offsetting health costs for most people.

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Associated Press writers Mary Clare Jalonick and Lisa Mascaro contributed from Washington.

On Capitol Hill, partisan divides formed as many Democrats pressed for guaranteed insurance coverage for a broader swath of Americans while Republicans, buttressed by medical industry lobbying, warned about cost and a slide into communism.

The year was 1945, and the new Democratic president, Harry Truman, tried and failed to persuade Congress to enact a comprehensive national health care program, a defeat Truman described as the disappointment of his presidency that “troubled me the most.” Since then, 13 presidents have struggled with the same basic questions about the government’s role in health care, where spending now makes up nearly 18% of the U.S. economy.

The fraught politics of health care are on display again this month as millions of people face a steep rise in costs after the Republican-controlled Congress let Affordable Care Act subsidies expire.

While the subsidies are a narrow, if costly, slice of the issue, they've reopened long-festering grievances in Washington over the way health care is managed and the legacy of the ACA, the signature legislative achievement of President Barack Obama that was passed in 2010 without a single Republican vote.

“That's the key thing that I've got to convince my colleagues to understand who hate Obamacare,” said Sen. Bernie Moreno, R-Ohio, who's leading a bipartisan group of lawmakers discussing ways to extend some of the subsidies. “Let's take two years to actually deliver for the American people truly affordable health care.”

Democrats have heard that refrain before and argue Republicans have had 15 years to offer an alternative. They believe the options being discussed now, which largely focus on allowing Americans to funnel money to health savings accounts, do little to address the cost of health care.

“They've had a lot of time,” said Rep. Steny Hoyer, the Maryland Democrat who was House majority leader during the ACA debate.

And with that, welcome back to the health care debate that never seems to end.

The challenge of reaching consensus

The often-tortured dynamics surrounding health care have remained remarkably consistent. Obamacare dramatically expanded coverage but remains — even in the minds of those who crafted the law — imperfect and more expensive than many would prefer.

And Washington seems more entrenched in stalemate rather than marching toward a solution.

“People hate the status quo, but they’re not too thrilled with change,” Rahm Emanuel said as he reflected on the arc of the health care debate that he has watched as a top aide to President Bill Clinton, chief of staff to Obama and Chicago mayor. “That’s the riddle to the politics of health care.”

Major reforms inevitably run into a health industry — a broad group of interests ranging from pharmaceutical and health services companies to hospitals and nursing homes — that spent more than $653 million on lobbying last year, according to OpenSecrets, which tracks political spending.

“Any time you try to figure out how to bring costs down, somebody thinks, ‘Uh oh, I’m about to get less,’” said Hoyer, who announced last week he won't seek reelection after serving since 1981.

When Obamacare was passed, opinion on the law was mixed, although views tended to be more positive than negative, according to KFF polling. But the law has steadily grown in popularity. A KFF poll conducted in September 2025 found about two-thirds of Americans have a favorable view of the ACA.

That's put Trump and Republicans in a bind.

Trump's ‘concepts of a plan’

Since the ACA's passage, Republicans largely dedicated themselves to the law's destruction. Trump issued social media posts calling for a repeal as early as 2011 and spoke in generalities during each of his presidential campaigns about delivering better coverage at lower cost. During his 2024 debate against Democratic rival Kamala Harris, he referred to “concepts of a plan.”

Under pressure to offer more specifics, Trump on Thursday outlined a proposal he dubbed “The Great Healthcare Plan.” The plan doesn't repeal the ACA. But it would focus on lowering drug prices and providing options for Americans to send money directly to health savings accounts to bypass the federal government and handle insurance on their own. Democrats have rejected that as an insufficient way to cover high health care costs.

Throughout his second term, Trump has criticized Obamacare as unfairly subsidizing insurers, a point that could've been addressed had the legislation created a public option that would've competed alongside the private sector. Republicans — and a sizable number of Democrats — objected to that approach, arguing it would give the government an outsize role in health care.

But in a reminder that the past is never really over, a small group of Democrats is aiming to revive the debate over the public option, even if the prospects in a Republican-controlled Congress are dim. Sens. Sheldon Whitehouse of Rhode Island and Elissa Slotkin of Michigan and Rep. Jan Schakowsky of Illinois last week introduced legislation that would create a public health insurance option on the ACA exchanges.

Last year, a record 24 million people were enrolled in the ACA, though fewer appear to be signing up this year as the expired subsidies make coverage more expensive. The Supreme Court has upheld the law, and Republicans have failed to repeal, replace or alter it dozens of times. In the most famous example, Sen. John McCain, an Arizona Republican, cast the deciding vote in 2018 to keep the legislation in place, underscoring the lack of an alternative by noting there was “no replacement to actually reform our health care system and deliver affordable, quality health care to our citizens.”

Democrats successfully turned the repeal efforts into a rallying cry in the 2018 midterms and see an opportunity to do so again this year with the expired subsidies. Sen. Thom Tillis, R-N.C., who isn't seeking reelection, has warned this moment could be even more perilous for Republicans because, unlike the subsidies, voters didn’t lose anything during the 2018 debate.

“Us failing to put something else in place did not create this cliff,” Tillis said. “That’s the fundamental difference in an election year.”

ACA veterans acknowledge challenges

Even those who crafted the ACA concede the health care system created in its wake has problems. Former Sen. Max Baucus, a Montana Democrat who was among the bill's architects as chair of the finance committee, acknowledged “nothing is perfect,” pointing to high health care costs.

“Bending the cost curve, that has not bent as much as we'd like,” he said.

That's in part why some Republicans have expressed openness to a deal on subsidies. They see it less as an endorsement of the ACA than a bridge that would give lawmakers time to address more complex issues.

“We need to get to a long-term solution,” said Rep. Don Bacon, R-Neb.

Veterans of past health care negotiations, however, are skeptical that lawmakers can produce anything meaningful without the type of in-depth negotiations that led up to the ACA.

“It takes a long time to figure all this out,” Baucus said.

Asked whether he's studied that history as he dives into the next chapter of health care talks, Moreno noted that he's only been in Congress for a year.

“I don't know s—-,” he said. “What that means is I don't have scars.”

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Associated Press writers Amelia Thomson-DeVeaux in Washington and Ali Swenson in New York contributed.

House Appropriations Committee Ranking Member Rep. Rosa DeLauro described Health Secretary Robert F. Kennedy Jr.'s decision-making as dangerous and haphazard after grant recipients began laying off employees based on the original plans.

“He must be cautious when making decisions that will impact Americans’ health,” DeLauro, D-Conn., said in a statement. “I hope this reversal serves as a lesson learned.”

The Substance Abuse and Mental Health Services Administration on Tuesday night had canceled some 2,000 grants representing nearly $2 billion in funding, according to an administration official with knowledge of the cuts who was not authorized to discuss them publicly.

But by Wednesday evening, those cuts were being reversed, according to reports in The New York Times, NPR, The Washington Post and others.

Grant recipients who had their funding canceled on Tuesday told The Associated Press they hadn't yet received word of the reinstatements. Some had already made difficult decisions in response to the cuts, including laying off employees and canceling scheduled trainings.

The reason for the reversal wasn't immediately clear, and spokespeople for the U.S. Department of Health and Human Services didn't respond to requests for comment Wednesday night.

Cuts had affected a wide range of programs

The grant cancellations had pulled back funding for a wide swath of discretionary grants and represented about a quarter of SAMHSA's overall budget. They built on other, wide-ranging cuts that have been made at HHS, including the elimination of thousands of jobs and the freezing or canceling of billions of dollars for scientific research.

The cuts had thrown into jeopardy programs that give direct mental health services, opioid treatment, drug prevention resources, peer support and more to communities affected by addiction, mental illness and homelessness.

“Without that funding, people are going to lose access to lifesaving services,” Yngvild Olsen, former director of SAMHSA’s Center for Substance Abuse Treatment and a national adviser at Manatt Health, said earlier Wednesday.

SAMHSA, a sub-agency of HHS, notified grant recipients that their funding would be canceled effective immediately in emailed letters on Tuesday evening, according to several copies received by organizations and reviewed by The Associated Press.

The letters, signed by SAMHSA Principal Deputy Assistant Secretary Christopher Carroll, justified the terminations using a regulation that says the agency may terminate any federal award that “no longer effectuates the program goals or agency priorities.”

Grant recipients who were notified of the cancellations said they were confused by that explanation and didn't get any further detail about why the agency felt their work didn't match up with SAMHSA's priorities.

“The goal of our grants is entirely in line with the priorities listed in that letter,” said Jamie Ross, CEO of the Las Vegas-based PACT Coalition, a community organization focused on substance use issues that lost funding from three grants totaling $560,000.

Grant recipients were already taking action in response to the cuts

Organizations reeling from the news on Wednesday told the AP they had already been forced to cut staff and cancel trainings. In the long term, many had been considering whether they could keep programs alive by shuffling them to different funding sources or whether they'd need to stop the services altogether.

Robert Franks, CEO of the Boston-based mental health provider the Baker Center for Children and Families, which was told Tuesday it was losing two federal grants totaling $1 million, said Wednesday afternoon that the loss of funding would force his organization to lay off staff and put care in jeopardy for some 600 families receiving it.

One of his organization's canceled grants had been awarded through the National Child Traumatic Stress Initiative, a more than 20-year-old program supporting specialized care for children who have been through traumatic events ranging from sexual abuse to school violence.

Franks said his organization’s work directly advances SAMHSA's goals to address mental illness. He said trauma care provided to children through his organization helps people from all walks of life and reduces burdens on other parts of society. He could not be reached late Wednesday to respond to the news of the grant reinstatements.

Both Ross and Ryan Hampton, founder of the advocacy nonprofit Mobilize Recovery, told the AP they hadn't yet been notified of any reversal to the grant cuts they'd been notified of Tuesday night.

The National Association of County Behavioral Health and Developmental Disability Directors, a group that represents local organizations that deliver safety net services, sent a letter to its members on Wednesday noting that multiple of its partners estimated the slashed grants totaled around 2,000 and likely amounted to some $2 billion. The group said the funding pullbacks appeared to focus on grants classified as Programs of Regional and National Significance.

The group said it believed certain block grants, 988 suicide and crisis lifeline funding and Certified Community Behavioral Health Clinics were spared from the cuts.