Last week, internal Republican Party divisions spilled onto the floor of the House of Representatives in a way rarely publicly seen in Washington. In this installment of the FiveThirtyEight Politics podcast, the crew looks at why it took 15 votes to get Rep. Kevin McCarthy elected House Speaker and what that process says about the two years ahead and the GOP more broadly. They also consider how Rep. George Santos’s scandals will affect his tenure in Congress and whether he would have been elected at all if his fabricated biography had received more scrutiny during the campaign.
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An addiction medicine physician explores how policy changes could reverse progress and increase preventable deaths.
Getty Images, Cappi Thompson
Why Is Harm Reduction on the Chopping Block?
Apr 20, 2026
“Do you lick your needles when you inject?” This is one of the questions that I, an addiction medicine doctor, regularly ask my patients. The answer is often yes. Their reasons vary: checking needle patency, enacting an entrenched ritual, or, most poignantly, “cleaning” the needle.
I explain to my patients that licking introduces oral bacteria that can lead to life-altering complications, including sepsis, heart infections, paralysis, and death. Every day, I see the devastating complications that arise not just from inadequate access to sterile supplies but from a misunderstanding of how to reduce harm.
That misunderstanding extends all the way to the White House. Last summer, President Trump signed an executive order entitled “Ending Crime and Disorder on America’s Streets” that, among other things, ordered government agencies to stop funding “so-called ‘harm reduction’ or ‘safe consumption’ efforts that only facilitate illegal drug use and its attendant harm.” As a result, none of the $7.4 billion in federal funding to treat mental health and addiction can be spent on projects that include the words “harm reduction.”
The president’s order revealed a common, but in this case deadly, misunderstanding of harm reduction, a term used to describe a range of evidence-based practices that have been proven to reduce complications from substance use. Examples include needle exchanges, naloxone distribution, and providing medications that prevent HIV.
Because harm reduction does not always involve complete abstinence, some critics charge that these tactics encourage risky behavior. But study after study shows that rather than enabling drug use, harm reduction efforts keep people alive and provide a pathway to health and recovery. By meeting people where they are—not where we want them to be—these interventions reduce overdoses, connect people to addiction treatment, and decrease HIV rates.
For example, many of my patients started out by seeking free needle exchanges or a safe place to inject. After building trusting relationships with the staff, they felt comfortable beginning treatment for their substance use disorders. As for the common concern that overdose prevention centers lead to an increase in crime, studies have found that crime rates around these clinics either stay the same or go down.
Another example involves buprenorphine and methadone, two medications used to treat opioid use disorder that are sometimes considered to fall under the umbrella of harm reduction. Prescribed treatments like these dramatically reduce the rate of overdoses and deaths; for example, a study in JAMA found these medications are associated with a 76% reduction in overdose risk at 3 months.
Harm reduction saves money, too. Access to new needles can represent the difference between a healthy life and a lifetime of medical bills from complications of substance use, such as paralysis from a spinal infection. Unsanitary needles also cause heart valve infections, which on average cost almost $200,000 to treat. Buprenorphine treatment for opioid use disorder is associated with over $20,000 in healthcare savings per year per person.
As for HIV prevention drugs, a study calculated that just a 3.3% annual drop in coverage over the next 10 years in the US would result in so many new HIV infections that the estimated lifetime medical costs to treat them would be an astonishing $3.6 billion. With Donald Trump's goal of decreasing healthcare spending, investing in harm reduction is a cost-effective way to save taxpayer money.
Even if you do not use drugs, the new cuts affect your ability to help those who do. Roughly 75% of annual overdose deaths in the United States involve opioids. Almost all of these deaths could have been prevented if naloxone had been administered in time. I often see EMS bring in a patient who’d stopped breathing from an overdose and survived only because they received naloxone from bystanders. But efforts to make naloxone more widely available are also at risk of losing funding because they focus on harm reduction.
Without harm reduction initiatives, many of my patients with substance use disorders would be dead. These patients come from all walks of life, but they all have benefited from extensively researched, evidence-based strategies that we now know reduce complications of substance use. It is a joy to see them achieve their treatment and larger life goals: becoming actively involved parents, business leaders, community volunteers, artists, and more.
I grieve for the senseless deaths these cuts will cause. States are scrambling to find funds to fill in the gaps, and I worry about the ability to make up for the loss of federal support.
In one area, I agree with President Trump: we should exclusively fund evidence-driven treatment options and research. I just wish this administration would review the scientific literature on the groundbreaking successes of harm reduction initiatives to understand why harm reduction should not be on the chopping block.
Dr. Cara Borelli, DO is an addiction medicine physician who trained at Icahn School of Medicine in New York City. She works on an inpatient addiction medicine consult service and teaches in New Haven, Connecticut. She is the co-editor-in-chief of the Journal of Child and Adolescent Substance Use. She can be found on Twitter/X @BorelliCara. She is a Public Voices Fellow at The OpEd Project. This opinion piece reflects her personal views.
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U.S. President Donald Trump speaks in the Oval Office on April 18, 2026 in Washington, DC.
(Photo by Tasos Katopodis/Getty Images)
When Leadership Becomes a Liability — The Constitution Is Tested
Apr 20, 2026
In American government, loyalty is often praised. But the oath taken by public officials is not to a person or a party—it is to the United States Constitution. At a moment when Americans across the political spectrum are alarmed by the president’s increasingly unpredictable behavior on the world stage, that distinction matters. The framers anticipated moments when instability at the top could endanger the country, which is why the Constitution includes safeguards such as the Twenty‑Fifth Amendment.
Across the country, Americans from every political background are expressing concern that instability at the top is testing the constitutional guardrails of steady leadership, clear judgment, and respect for institutional boundaries. Strained alliances and impulsive communication in moments of global tension place additional pressure on those safeguards. Many Americans worry that the president’s increasingly unpredictable behavior—combined with the silence of those closest to him—is weakening the constitutional guardrails the framers put in place.
Recent polling shows that most Americans—and even many Republicans—believe the president’s behavior has become more erratic. That should prompt attention, not dismissal.
Reporting documented the President's public attacks on Pope Leo, a moment that drew international attention and raised questions among allies about U.S. leadership. Moments like this test the standards of responsible leadership — and even his supporters can care about the president while still insisting on responsible conduct, sound judgment, and the responsible use of power. That is not disloyalty; it is stewardship.
The presidency has long been understood as a stewardship. Theodore Roosevelt described the executive as a “steward of the people,” responsible for upholding democratic norms. Alexander Hamilton connected executive energy to the “steady administration of the laws.” Modern analysis notes that the office requires avoiding behavior that demeans the country, because a president’s conduct shapes national credibility.
These concerns are not occurring in a vacuum. The president’s approval ratings remain low, and polls show Americans uneasy about recent foreign‑policy decisions. A new AP-NORC poll found that 59% believe U.S. military action in Iran has gone too far and are worried about affording gasoline. This week, I paid a little over $95 to fill my gas tank — more than $20 higher than when this crisis began — a reminder that global instability reaches directly into the lives and budgets of ordinary Americans. New AP-NORC findings also show low trust in the President’s judgment on the use of military force overseas and only about one‑third approving of his handling of foreign policy.
Some Americans reassure themselves that the system will “hold” until the next election. But the presidency is not passive. Decisions are made daily, words can shift global events, and rhetoric can strain alliances, complicate diplomacy, and raise the risk of conflict. Recent reporting made those consequences impossible to ignore: news organizations documented a public threat toward Iran that shocked global leaders and unsettled some Republicans. Analysts described confusion over shifting objectives, and lawmakers questioned whether Congress had a clear rationale for the conflict. As former Labor Secretary Robert Reich wrote, ‘No civilized nation threatens to wipe out another civilization,’ a warning that underscores how dangerous such rhetoric becomes.
Those concerns deepened when the President and Secretary Hegseth publicly celebrated what they described as a major ceasefire "victory," even though independent fact‑checking showed that the administration’s four stated objectives had not been met. The contrast between the celebration and the facts was visible not only to Americans, but to foreign governments watching closely. In moments of global tension, that disconnect carries real consequences for national credibility.
That credibility was tested.
International institutions reacted quickly. NATO allies expressed concern about the president’s public statements. European leaders warned that unpredictable rhetoric increases the risk of miscalculation.
Foreign‑policy analysts have also noted that U.S. instability creates openings for strategic rivals. China has used the moment to expand its diplomatic influence, and Russian state media has amplified the turmoil to weaken Western unity. Both countries benefit when American leadership appears divided or unpredictable.
Legal scholars also raised alarms. Hundreds of international law professors argued that the U.S. strikes in Iran violated the UN Charter, and experts questioned whether the escalation was necessary. These assessments emerged alongside reporting confirming loss of life—including American service members and civilians.
Taken together, these patterns paint a picture of instability at the highest levels of government—instability that affects alliances, national security, and the safety of Americans at home and abroad. Several lawmakers, national security experts, and international allies have warned that the President’s escalating rhetoric is undermining U.S. credibility and placing the country at greater risk. Recent AP-NORC findings reinforce these concerns, with majorities saying U.S. military action has gone too far and expressing deep anxiety about the economic fallout.
That is why the Constitution provides guardrails.
The Twenty-Fifth Amendment outlines a clear constitutional process: the Vice President is the central actor, empowered to initiate a transfer of authority if a president is unable to discharge the duties of the office. A majority of the Cabinet must agree. If the president contests the action, Congress becomes the final arbiter, requiring a two‑thirds vote in both chambers. These roles were designed for moments when behavior—not ideology—raises questions about a president’s ability to lead safely.
This concern has become bipartisan. Reporting has noted that Republican lawmakers—including figures who have historically supported the president—have privately expressed alarm about his recent behavior, particularly in the context of the Iran conflict. A 2024 book reported former Republican Leader Mitch McConnell describing the president as having “every characteristic you would not want a president to have” and calling him “irascible” and “nasty.” Members in both parties have discussed the Twenty‑Fifth Amendment as a safeguard because they view the current unpredictability as dangerous.
When threats, celebrations, reversals, and false claims occur in rapid succession, the country is left without the steady leadership national security tests. What the president may view as strength is, to many observers, a sign of instability—a leadership style that appears reactive, unplanned, and disconnected from the facts. The United States is more vulnerable—diplomatically, strategically, and institutionally.
When leadership at the top is tested and the country grows vulnerable, citizens must use their voices—through calls, letters, public dialogue, and civic engagement—to reinforce the Constitution’s guardrails. Calls, letters, and emails to elected representatives are tracked, and they influence priorities. Asking for oversight, briefings, and transparency in presidential decision‑making is not a political act; it is a constitutional one. Public scrutiny—grounded in facts and democratic principles—helps counter misinformation and strengthens civic understanding.
Supporting institutions rather than individuals is another safeguard. The strength of the American system lies in its checks and balances, and citizens play a role in upholding them. It is also important to understand that the U.S. military is bound by law to follow only lawful orders. Under the Uniform Code of Military Justice, the Law of Armed Conflict, and the military’s oath to the Constitution, service members must refuse orders that are unconstitutional or manifestly illegal. Finally, participation in elections at every level—federal, state, and local—remains one of the most powerful tools available to the public.
The framers of the Constitution did not assume perfection in leaders. They assumed human fallibility—and built a system to account for it. But that system is tested by people: elected officials willing to act, and citizens willing to insist that they do.
Waiting is not a safeguard.
Engagement is.
Duty must come before loyalty—especially when the Constitution is tested.
Carolyn Goode is a retired educational leader and national advocate for ethical leadership and civic renewal. She writes on institutional trust, democratic responsibility, and the role of principled leadership in public life.Keep ReadingShow less
Sandra Abrevaya and Brian Wallach give testimony at an Apr. 15 House Subcommittee hearing
(Photo by Stephen Voss, courtesy of I AM ALS)
Congress Poised to Advance Bill Providing ALS Patients Their ‘”Best Chance’” at a Cure
Apr 20, 2026
WASHINGTON — Brian Wallach spoke with his eyes.
The Illinois native and co-founder of I AM ALS has been living with ALS for eight years and can no longer use his voice. Instead, Wallach, 45, types with his eyes, then generates speech by applying artificial intelligence to old recordings of his voice.
He used that software on Wednesday during a hearing held by the House Committee on Energy and Commerce's Health Subcommittee to testify for a bill that would expand investigational therapies treating the disease.
“It is the single biggest investment in ALS research,” Wallach said, as his wife, caregiver, and co-founder, Sandra Abrevaya, gripped his hand.
“Rereauthorizing it is our best chance of finding a cure,” said Wallach, as his wife, caregiver, and co-founder Sandra Abrevaya gripped his hand.
The proposal, introduced in the House earlier this month by Rep. Mike Quigley, D-Ill., would reauthorize a 2021 law bill that authorizedallocated $100 million annually from 2022 to 2026 to study ALS and facilitate more investigational therapies for patients, who typically have a life expectancy of two to five years following diagnosis, said Sheri Strahl, President and CEO of ALS Network.
The measure has drawn broad, bipartisan support with 13 co-sponsors on either side of the aisle. Health Subcommittee Chair Rep. Morgan Griffith, R-Va., predicted a “strong vote” in its favor, he said Wednesday at a press briefing. That would move the bill out of committee and put it to the Senate.
“This is not Republican or Democrat. This is Congress doing its job together, which we can do on occasion,” Griffith told Medill News Service.
Health Subcommittee Chair Rep. Morgan Griffith, R-Va., speaks at an Apr. 15 hearing (Photo by Stephen Voss, courtesy of I AM ALS)
That would be welcome news for ALS patients, who are often restricted from traditional clinical trials, said Strahl. To participate, patients usually need to have a certain vital capacity and to have been diagnosed within the last two years.
“It takes a very long time for people to get diagnosed, the range is 11 months to 20 months,” Strahl said. “You only have four months to get your arms around the research landscape, find a clinical trial, get screened for a clinical trial, and participate.”
The bill would give those shut out of clinical trials access to investigational therapies, Strahl said. Sandra Abrevaya credits one such therapy with helping her husband live eight years past diagnosis.
“We've tried to take advantage of every opportunity we can, both with clinical trials and expanded access programs,” Abrevaya told Medill News Service. “We really do believe that Brian is alive today, in part, because we've leaned in to promising new treatments.”
The proposal would also fund and invest in a study researching the biomarkers of ALS that could allow quicker diagnosis across multiple degenerative diseases, including Parkinson’s, Alzheimer’s, and Huntington’s diseases.
The legislation’s broad applicability and many Congress members’ personal connections to these diseases propelled the legislation forward at what, for Congress, has been breakneck speed, Quigley said.
“It's so important to think of this as the way to get to all the neurodegenerative diseases,” Quigley told Medill News Service. “Some of the best bills get caught up for reasons that defy reason. Somehow, this caught lightning in a bottle.”
Zara Norman is a graduate student reporter covering health for Medill News Service.
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American Cardinal Robert Francis Prevost presides over his first Holy Mass as Pope Leo XIV with cardinals in the Sistine Chapel at the conclusion of the Conclave on May 09, 2025 in Vatican City, Vatican.
(Photo by Simone Risoluti - Vatican Media via Vatican Pool/Getty Images)
A Lesson on “Matters of Morality” for the Vice President
Apr 19, 2026
The Vice President has stepped into the fray between the President and Pope Leo. For those of you who have not been following this, Pope Leo has been critical of various things that Trump has said regarding his war with Iran, including his statement that he was ready to wipe out the civilization. In response, Trump called Pope Leo too liberal and easy on crime. He also said that the Pope was only elected because he was an American, in response to Trump having been elected President. In response, the Pope said that he had no fear of the Trump administration and that his job was to preach the gospel. He said in response to Secretary of War Hegseth's invoking the name of Jesus for support in battle, that Jesus “does not listen to the prayers of those who wage war, but rejects them.”
Into this exchange steps the Vice President, who says he thinks the Pope should stick to "matters of morality" and let the President of the United States dictate American public policy. The Vice President obviously doesn't understand the meaning of morality and its scope.
"Morality" is defined by the Merriam-Webster dictionary as a system of moral conduct, conformity to ideals of right human conduct, or virtue. "Moral", in turn, is defined as the principles of right and wrong in human behavior. "Virtue" is defined as morally good behavior or character.
How do we as a society define what is right and wrong in human behavior? For most of man's history, that standard has been defined by religion, whether Judaism, Christianity, Islam, Buddhism, or other religions. Whether the voice is that of God, Jesus, Mohammed, or the Buddha, each has set the standard for right and wrong behavior towards one's fellow man. And those standards have, in most respects, been virtually identical.
The 10 Commandments are a prime example of religion defining right and wrong behavior. The Golden Rule—do unto others as you would have them do unto you—is a principle underlying all the world's great religions.
The Pope is thus an ideal person to make statements on human behavior and morality. What are some of Trump's statements?
“A whole civilization will die tonight, never to be brought back again.”
“Open the Fuckin’ Strait, you crazy bastards, or you’ll be living in Hell — JUST WATCH! Praise be to Allah,” (this on Easter Sunday)
These are statements that the Pope, as Pope, has every right and responsibility to speak out against. As he said, he will continue to speak "out loudly on the message of the gospel, which is what I believe I am here to do, what the church is here to do.” Further, he said, "Too many people are suffering in the world today. Too many innocent people are being killed. And I think someone has to stand up and say there's a better way."
This is sticking to "matters of morality." The Vice President needs to restudy his catechism. He also needs to understand that the United States was founded on the Enlightenment's principles of morality, as stated in the Declaration of Independence:
"all men are created equal, that they are endowed by their Creator with certain unalienable rights, that among these are life, liberty, and the pursuit of happiness—that to secure these rights, governments are instituted among men."
When Trump dictates American public policy that is contrary to the essence of America's founding principles, then he is not jut being immoral, he is leading the country in a very un-American way.
Ronald L. Hirsch is a teacher, legal aid lawyer, survey researcher, nonprofit executive, consultant, composer, author, and volunteer. He is a graduate of Brown University and the University of Chicago Law School and the author of We Still Hold These Truths. Read more of his writing at www.PreservingAmericanValues.com
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