A lot of people are looking for ways to improve, preserve, and prolong their brain’s health. Just look at the seemingly endless amount of self-help books, podcasts, phone apps, TikToks, and Instagram Reels dedicated to the subject.

And, frankly, it makes sense. Alzheimer’s disease and dementia — conditions that fundamentally involve the loss of one’s sense of identity and sense of time and place — are distinctly terrifying compared to physical ailments. They rob a person and their loved ones of what should be a special period of their lives. After all, Americans are living longer than ever. It’s only natural that we want to be as present as we can be to enjoy it.

But despite the many promises you may hear about how to “exercise” or “train” your brain to improve your cognition long-term, there’s still a lot we don’t know. In fact, when I reached out to experts about how to exercise your brain, I received a fair amount of skepticism. Multiple studies that have used tailored tasks or games to test whether they can improve a person’s longer-term general intelligence have found negligible benefits; here’s one from 2019 and another with markedly similar results in 2025.

“It seems to be the case that no one has discovered a way to do cognitive training that transfers from the training task to anything general or interesting,” said Michael Cole, an associate professor in the Center for Molecular and Behavioral Neuroscience at Rutgers University and author of Brain Flows: How Network Dynamics Compose the Human Mind.

Still, the science of brain health has come a long way in the past 20 years, and we have better, evidence-based strategies for staying sharp as you age. There are no simple answers, but by combining frameworks from leading experts on learning, flourishing, and cognitive aging, there is a playbook. Making a point to do these things can make life right now more fulfilling — and it could also pay off as you get older.

Eat right and exercise

First things first: If you want to have a healthy brain, you should take good care of your overall health in the boring-but-effective ways you’ve heard a million times by now: Eat a healthy diet, exercise regularly, do your best to reduce stress, and try to get enough sleep. 

High blood pressure is associated with a higher risk of dementia. Chronic inflammation, another modern fixation, could also play a role in cognitive decline. On the flip side, exercise does seem to be associated with cognitive benefits: One major meta-analysis of the relevant research concluded that “exercise, even light intensity, benefits general cognition, memory and executive function across all populations.” 

Scientists have also repeatedly found that exercise seems to protect against the risk of Alzheimer’s or dementia. One study published last year found that the adults who are active in the middle and later periods of their lives had a more than 40 percent lower risk of all-cause dementia.

So, a heart-healthy diet and exercise are the first steps toward taking care of your mind’s hardware.

Learn smarter

But what about exercising your brain itself?

If you do want to know how best to learn anything, you should get familiar with the concept of “desirable difficulty.” Advanced by Nate Kornell, a psychologist focused on memory and learning at Williams College in Massachusetts, the basic idea is this: If something comes too easily, it won’t stick. You need some friction when learning new skills. To do that, you should space out learning and mix it up; Kornell proposes the notions of “spacing” (taking a break from new material and returning to it) and “interleaving” (mixing new material with old material) as effective strategies for learning.

These frameworks are about not improving your cognitive health, per se, but they could make it easier for you to learn something new when that is what you want to do.

“As a larger point in terms of cognitive health, it’s really not changing how your mind processes things,” Kornell told me. “It’s just putting yourself in situations that are more advantageous.”

But even if narrowly defined brain “training” may not have any established long-term benefits, that doesn’t mean we shouldn’t try to challenge ourselves mentally or intellectually. We should just have realistic expectations about what those exercises can do. At the same time, developing new interests is still part of a healthy aging mindset, because it helps nurture some of the good habits that are solidly linked with less cognitive decline, like social connections and curiosity.

Cultivate curiosity

Learning a new skill demonstrates curiosity — and research continues to show that curiosity has benefits for the aging mind. Take one paper from last year, co-authored by Alan Castel, a professor in the Department of Psychology at UCLA and author of Better With Age: The Psychology of Successful Aging.

The researchers uncovered a nuanced relationship between aging and curiosity. They did find that what scientists call “trait” curiosity — your innate interest in seeking out new things to discover — does tend to drop with age. But at the same time, your “state” curiosity — your interest when presented with new or unexpected information — tends to start increasing in your fifth and sixth decades compared to middle age.

“We think that has some implications for cognitive health and brain health,” Castel told me, “that those individuals who are stimulating their brain, who are focusing on hobbies, or interested in lifelong learning, continued engagement with life and learning new things, are less likely to get dementia.”

These findings could lead to more productive forms of “brain training” than a random computer game supposedly designed to improve your intelligence. Instead, based on their findings, an older person may find their curiosity more piqued by something that is relevant to their own self-interest or something they already know about. For example, a person who’s gardened in the past might be stimulated by reading a book or magazine about gardening, joining a gardening club, and learning some new gardening skill — and the research suggests they’ll reap cognitive benefits from that curiosity.

“If you’re interested in gardening and you’re out and doing it and you’re trying to cultivate a new plant or determine how much rainfall there’ll be in the next week, this is all very stimulating, and you’re interpreting it at almost a different level than the novice person,” Castel said. “We think that this sort of engagement is really important as we get older to stimulate knowledge structures that are in place.”

So don’t get stuck in your ways as you age. Castel writes in his book that even changing up your old habits — hiking a familiar trail in the opposite direction, taking your dog for a morning walk, or even shopping at a different market — can benefit your brain.

Find your purpose

Despite experts’ initial skepticism, I would still encourage you to learn a new game or pick up a hobby — but think of it less as “training” your brain in a way that will lead to a perceptible increase in your intelligence. It’s more about trying to form connections with other people and feel a sense of purpose as you age.

Experts at the University of Wisconsin’s Center for Healthy Minds have characterized this mindset as “flourishing” — and it could also have the long-term benefits to our cognition that so many of us are seeking.

“Cultivating these positive qualities of the mind changes the brain in ways that are very clearly conducive to increased brain health,” Richard Davidson, founder and director of the Center for Healthy Minds, told me. “We know, for example, that objective metrics of brain aging are changed by these practices.”

Davidson and his colleague Cortland Dahl recently wrote a book called Born to Flourish: New Science Reveals the Four Practices of Thriving. In it, they say flourishing has four main components:

• Awareness (being attentive to what’s happening around you right now)
• Connection (to other human beings)
• Insight (into yourself and why you feel the way you do)
• Purpose (feeling as if you have something to strive for)

Each of these qualities can have benefits for your long-term cognitive health, Davidson said, but purpose is a particular area of interest. As Davidson and Dahl write in their book, based on research from their group, “a strong sense of purpose supports healthy aging, particularly in brain regions tied to learning and memory that are susceptible to stress.” People who feel they have a purpose generally experience less severe cognitive decline and better longevity overall. “Having a strong sense of purpose is probably the most important psychological predictor of longevity,” Davidson said.

And as I think about these different strategies for nurturing your mind, both right now and for the long term, I see the ways that learning new skills and taking on new hobbies is good for a healthy mind as you age because it will stoke your curiosity and relieve stress. And if it’s something you can do in conjunction with other people, it may help you feel that sense of connection and purpose that is associated with better cognitive well-being over the course of your life. The synthesis across these neuroscientists was striking at times: Davidson spoke of the value of purpose, while Cole has outlined how pursuing goals that align with your values can lead to more effective learning. Castel, in our conversation, emphasized that stimulating your curiosity is even better when done with a dose of human connection, another pillar of the program Davidson and Dahl laid out. So don’t just dive deeper into birdwatching on your own, but consider joining a nature walking club.

Think of this work less as taking your brain to a mental gym and more as cultivating the strange and wondrous garden that is your mind. You’re training your brain not to be “smarter,” but to be more present, more connected to other people, and more attuned to what gives you an all-important sense of purpose. 

I’ve been playing chess lately, for the first time in my life. I do find it prods my brain to think differently. But after reporting for this story, I’m thinking of finding a local chess club. The game itself may not be a prophylactic for my brain, but finding the community of like-minded people, a sense of connection, and a sense of purpose that stokes my curiosity, just might.

We’ve been bringing the 1980s back — including, unfortunately, the cocaine. 

While opioid overdose deaths are mercifully on the decline, more Americans are now using and dying from stimulants, particularly cocaine and methamphetamine. A decade ago, in 2016, there were 10,375 deaths from cocaine overdoses; in 2023, there were 29,449. Meth has seen a similar spike in fatalities, from 9,438 deaths in 2017 to 33,283 in 2023. The drug of choice varies depending on where in the US you are: Cocaine is still king in some parts of the Northeast, while methamphetamines are more commonly used elsewhere.

The surge in stimulant use at the same time the opioid overdose crisis has started to ebb is a warning that drug use doesn’t simply end — it evolves. And the image of somebody being solely a heroin user or a cocaine user is outdated: People use multiple drugs, and they choose different ones for different reasons — which can also increase their risk of death. The drugs themselves are now more complex and likely to be synthetic, adding to the risk that you could be taking something without fully understanding what’s in it.

These shifts present real challenges to the public health system and public health messaging. The United States spent a generation building treatment and recovery programs to address the opioid crisis. The focus was on prescription painkillers, heroin, and later fentanyl; dependence was managed through proven medications like methadone and buprenorphine, and overdoses could be stopped with a spray of naloxone. There was a dedicated effort to get treatment into the hands of primary care doctors, first responders, and ultimately, people in need.

We have none of the same interventions for cocaine or methamphetamine addiction, or for preventing death once an overdose has started. 

“There is no medication for cocaine or methamphetamine,” said Keith Humphreys, professor of psychiatry and behavioral sciences at Stanford University. “Everything under the sun has been tested and nothing has worked.”

The behavioral treatments that do exist are still largely reserved for specialty clinics and aren’t available in the primary care offices that are often people’s first stop in the health care system. The signs and symptoms of a stimulant habit or overdose are not the same as they are for opioids, which means people who use these drugs and their loved ones might not be as likely to recognize them. 

If we want to prevent the next drug crisis from becoming as devastating as the last, we’ve a lot of work to do on the specifics. But we can — and should — adopt the same principles that have led to our recent successes in bringing down opioid deaths.

“The technical specific treatment intervention might be different,” Dr. Brian Hurley, an addiction physician and immediate past president of American Society of Addiction Medicine, told me. “But the principles of working with the community, helping create connection, giving people access to evidence-based options are the same.”

How drug use in America is changing

The story of America’s relationship with hard drugs goes something like this: Heroin surged in the post-Vietnam era; cocaine and later crack cocaine became a scourge in the ’80s, provoking the harsh and unforgiving response during the Reagan era; and meth appeared on the scene in the ’90s. By the 2000s, powerful prescription painkillers had seeded the next drug crisis, while cocaine and meth use dropped off sharply. Before stimulants made their recent comeback, opioids — first prescription meds, then heroin, and finally powerful synthetic iterations like fentanyl — were the dominant concern for the better part of two decades.

“Many of the doctors who were out providing treatment in the late 2010s and early 2020s, they had only ever dealt with opioids,” said Richard Rawson, a long-time addiction researcher who is affiliated with the University of California Los Angeles and the University of Vermont. “They really had no idea what to do with this thing.”

But dating back to the mid-2010s, experts say, cocaine and meth have seen a resurgence. Meth has also gotten more potent in the past decade, after its production was taken over by drug cartels. One of the most striking trends in recent drug overdose deaths has been the more recent rise in deaths involving both a stimulant and an opioid. 

The experts that I spoke to put the simultaneous use of opioids (particularly fentanyl) and stimulants including cocaine and meth into three different buckets:

• Unintentional co-use. Some people think they are buying cocaine, but they are actually getting cocaine laced with fentanyl. (When researchers have sampled drugs that were confiscated off the street, they have found that a small but meaningful amount of cocaine in the US contains one of those powerful synthetic opioids that sent overdose deaths skyrocketing last decade.) And ingesting even a tiny amount of fentanyl can have deadly consequences, especially for people who have no tolerance for it. 
• Intentional recreational co-use. Some people take opioids and stimulants at the same time on purpose because that’s the high they are chasing. 
• Symptom management. This is the scenario that has shattered existing beliefs about people being a user of one specific type of drugs. Researchers say that people will take both stimulants and opioids intentionally to manage their addictions. For example, they’ll take a little cocaine to avoid nodding off on fentanyl. If they are going through opioid withdrawal, they will take methamphetamine to reduce the pain and convulsions.

Whatever the reason is, taking opioids and stimulants at the same time puts an even greater strain on your health. Your body can oscillate between different extremes — sometimes going from a sedate state with shallow breathing to being overly amped with heart palpitations — in a matter of minutes. Over the longer term, this kind of frequent drug use taxes your heart and can lead to chronic health issues aside from overdose that we should account for when thinking of the toll of the drug crisis.

We need better tools to address cocaine and meth abuse

The public health system is now trying to adapt to the resurgence of stimulants.

Right now, the most proven treatment for stimulant dependency is called contingency management: In essence, it’s a rewards system that offers people an incentive not to use drugs, and it has been effective in randomized trials. Participants will come to a clinic, give a urine sample, and if their urine is drug-free, they receive a gift card. California received approval in 2021 to launch a pilot program that’s treated more than 10,000 people, Rawson said, with folks staying in their treatment longer and testing negative more often than in the behavioral therapy programs of the past.

Funding has been scarce elsewhere, however: Access to contingency management through Medicaid and most private insurance benefits is limited. Some states, like Rhode Island and Vermont have tapped into their opioid lawsuit settlement money to set up their own programs. But more fundamentally, the concept has drawn opposition from some policymakers and even doctors who don’t like the idea of “rewarding” drug users for not using, Rawson said. Even with political support, it will still require serious time and financial resources to implement.

As the public health system works to scale up contingency management programs, we should be doing more to advance medication-assisted treatment. Success is typically measured by whether patients fully abstain from using drugs. But some experts told me they think that’s misguided.

“The only benchmark right now for getting a treatment approved is whether people stop using for a sustained period at the end of the trial,” said Karla Wagner, a behavioral scientist at the University of Nevada Reno. “But those medications do produce some meaningful impacts on other outcomes that are not abstinence-based.” For example, some clinical trials that involved using a prescription drug to manage cocaine or methamphetamine addiction found that a subset of people do feel fewer cravings and engage in less risky behavior, even if they didn’t always completely hold off on taking narcotics. 

“All of those things can be really meaningful and impactful and improve quality of life,” Wagner said.

She took heart in a blog post last year from the director of the National Institute on Drug Abuse, which argued for considering measures other than abstinence when evaluating medications for substance abuse. And the American Society for Addiction Medicine has endorsed the off-label use of stimulant medications that have shown some effectiveness in managing cocaine and meth dependency.

What everyone should know about the rise in stimulant use

Finding a Narcan-like solution that can stop cocaine and meth overdoses once they start is a problem for medical science. But more public knowledge about the symptoms of a stimulant overdose and what to do if you’re with someone who’s experiencing them could still help avert the worst outcomes. 

These are the signs to be alert to, according to the experts I spoke with:

• Heart palpitations
• Rise in body temperature
• Erratic behavior, including hallucinations
• Sensitivity to light and sound

If you’re with someone who experiences these symptoms, there are things you can do to help, said Pia Marcus, director of overdose prevention at OnPoint NYC. First, she said, if it’s someone you know well, try to calm them down. Turn off the lights or any sources of sound to create a more peaceful environment. She said you should also try to physically cool them, and recommended ice or ice packs to do that. 

“You have to rely on soothing mechanisms to help ground this person,” Marcus said. “It’s a person that’s not necessarily rooted in space and time, and your job is to try to root them.”

It is possible to bring somebody back from danger with these interventions in a community setting, Marcus said. But if these measures don’t appear to be working, the person seems to be having a cardiac event, or if it’s not someone you know well and you don’t feel capable of soothing them, you should call for emergency medical care.

The lesson of the falling opioid death count is that public health interventions can make a real difference. Now is our moment to try to use a similar playbook to get ahead of the cocaine and meth crisis before it gets any worse.

The newest Bachelorette season is canceled, right on the cusp of its premiere — and it may inadvertently spell the end of the franchise. 

It probably should.

This season was slated to debut on Sunday with Taylor Frankie Paul, star of the Hulu reality show The Secret Lives of Mormon Wives, in the title spot. Everything about the 22nd season’s marketing signaled that it was a new era: Paul is an established reality TV star on another Disney-owned franchise, not a veteran of The Bachelor, as almost all of her predecessors were. And the show was moving from its typical weeknight slot to a coveted Sunday primetime airing.

Then allegations against Paul of domestic violence resurfaced in the week leading up to the premiere. ABC appeared to be doing its best to salvage the season, sending Paul out on Good Morning America on Wednesday  morning. (“I’m a person that will always speak my truth,” she told host Lara Spencer in the interview. “That’s what I’m known for. So when the time is right, I will be.”) But after TMZ published a 2023 video on Thursday that showed Paul throwing a chair during an argument with her former partner Dakota Mortensen while her child cried nearby, the network decided to cancel the season three days before it was supposed to start. (Later on Thursday, Mortensen filed for a restraining order against Paul.)

So what was supposed to be a fresh start for The Bachelor franchise — a series that helped usher in reality TV’s golden era when it debuted in 2002 — has instead spiraled into one of the worst PR debacles yet for a show that seems to specialize in them. As its ratings fall and other shows take up the mantle of must-see reality TV, I find myself as a viewer asking: Is it time for the Bachelor to be over?

The Bachelor has been besieged by controversies and audience disinterest for a while

The first season of the Bachelor franchise that I watched was Colton Underwood’s in 2019 — in which the lead became so exasperated by the pressure he was under that he literally leaped over a fence to try to escape. It was riveting television and so memorable that it was still inspiring thoughtful essays from high-minded cultural websites like Bright Wall/Dark Room years later.

But, with the benefit of hindsight, Colton’s season may have also been the beginning of the end of a franchise that has become too toxic to continue.

He ended the season with Cassie Randolph, but their relationship quickly ended and the situation then turned dark: Randolph alleged Underwood had been stalking her, even putting a tracker on her car, and she filed a restraining order. The Bachelor universe was always premised on a fairly traditional view of gender roles and sexuality — it was, after all, centered on pushing young heterosexual couples into an engagement within a matter of weeks — and audience interest dwindled as the world moved forward, particularly once we entered the Me Too era that challenged long-held relationship norms.

Meanwhile, the show had always been blindingly white, and in the years that followed Colton’s season, the Bachelor’s uncomfortable relationship with race also made it seem increasingly out of touch. The season with the franchise’s first Black Bachelor, Matt James, ended with him choosing Rachel Kirkconnell…who, as it turned out, had attended a plantation-themed party while in college. Longtime host Chris Harrison came to Kirkconnell’s defense and made his own racially insensitive comments in the process, in an interview with franchise veteran Rachel Lindsay, the first Black Bachelorette, who herself has accused the show of being a toxic environment. A fierce backlash followed — and Harrison was forced to step down.

The last time I wrote about The Bachelorette was in 2024, when the show put its lead, Jenn Tran, through an embarrassing and shameful spectacle after her engagement to Devin Strader disintegrated. The treatment of Tran, the first Asian American lead of the show, made it feel like the show was nearing the point of no return.

Paul’s casting was, in my eyes, a desperate last grasp for relevance. The culture that franchise helped to create seemed to have passed it by. Love Is Blind and Love Island command much more attention. The audience for the Bachelor shows has shrunk to less than half the size they were a decade ago and a fraction what they were back in the 2000s. Meanwhile, The Secret Lives of Mormon Wives had such a strong debut after its first eight episodes dropped on Hulu in 2024 that the network renewed it and ordered 20 more within a month of the premiere. It makes sense that ABC thought Paul could pull in viewers, despite the fact that she was arrested for domestic violence in 2023, and despite rampant fan speculation that she was secretly in a relationship or at least emotionally unavailable while filming The Bachelorette. 

Now that franchise reboot is over before it had even begun. The Bachelor franchise has always been a problematic farce, but at its best, the drama was low stakes — over shrimp, for example — and, at times, riveting. I’ll never forget watching Colton leap that fence. It was raw and captivating, everything we ask reality TV to be for our entertainment.

But as the controversies have piled up, and now a lead contestant’s alleged domestic violence caught on camera, it’s become impossible to simply enjoy the mess and ignore the real-life trauma behind it. Maybe the world doesn’t need The Bachelor anymore.

Maybe this has happened to you: Your doctor is talking to you about your health, saying you need a test or a medication, and suddenly your brain leaps to a question that has nothing to do with your medical needs:

How much is this going to cost?

Health care in America is too expensive. According to a Gallup poll released this month, about one-third of Americans, equivalent to more than 82 million people, said that they had cut back on other expenses — groceries, gas, even utilities — in order to afford medical services. According to KFF, 36 percent of Americans say they have put off medical care in the past 12 months due to the costs.

So of course many of us think about money in those moments. It would be nice if your provider, the person tasked with looking out for your well-being, could be an ally in navigating the complex web of insurance benefits, prior authorization, and prescription drug formularies that ultimately determine how much you pay for medical care. 

But unfortunately, while Americans wish they were having these conversations with their physician, many of them aren’t. A 2024 survey of 1,500 people who have cancer or autoimmune conditions found that 62 percent said they wanted to have a cost discussion — but only 32 percent of them had. In a 2023 survey of 1,000 US adults, 41 percent said their doctor never brought up the financial side of their care.

The unavoidable reality is, we each have to act as our own advocate when it comes to our health. If our provider isn’t bringing it up, we need to. But that can be intimidating: Many of us already fear being judged by a physician. I’ve certainly felt that way. Here’s a secret: Even doctors feel that way sometimes when they are the patient.

“I have found health care billing in my own experience to be inconsistent and to be surprising and to be shrouded in a lot of mysteries,” Dr. Cailly Howell-McLean, a Toledo, Ohio pediatrician and member of the American Academy of Pediatrics, told me. “So I can’t imagine for someone who is not in that kind of role that I am.”

To help people with how they can approach those tough talks, I spoke to two doctors — Howell-McLean and Dr. Sarah Nosal, president of the American Academy of Family Physicians — to get their advice.

Here’s what I learned.

When in doubt, ask

Here’s one assumption I had: There might be some times when it doesn’t make sense to ask your doctor about finances. But that’s really the wrong way to think about it. As both Howell-McLean and Nosal put it to me, the doctor can’t help you if they don’t know there’s a problem.

“At the end of the day, as providers, we can’t assist with concerns we aren’t aware of,” Howell-McLean said. “So err on the side of bringing it up. And if it’s not something your doctor can help you with, they’ll tell you that. But better to ask.”

Many clinics have staff dedicated to handling billing or financing questions. If nothing else, your doctor will be able to connect you with those people — but, again, you have to ask.

“None of us are perfect as humans or doctors. I have definitely had patients where I only found out that they didn’t get a medication because of cost when their, for instance, diabetes was out of control,” Nosal said. “And I feel so bad that I didn’t explain to them that they can get in touch with us.”

Ask your doctor direct questions when you’re in the room with them

Some of the questions you’ll need to ask will partly depend on your own circumstances: your insurance coverage, your medical needs, your overall financial situation. One question to ask before you ever step foot inside the doctor’s office: Are you in my health insurance plan’s provider network? What about the blood or imaging labs you work with?

Then when you’re seeing a doctor and they are proposing new treatment — a scan, a specialist visit, a new medication — there are some stock questions that are usually worth asking:

• Is this likely to be expensive?
• What are the risks of not doing this?
• If this is not covered by my insurance, what do next steps look like? Are there lower-cost options?
• Could we wait and follow up soon to see if treatment is really needed?

If your prescriptions are surprisingly expensive, don’t just let it go

Every time you get a new prescription, Nosal said you should ask about a generic version of the drug. Doctors may write you a prescription for the brand-name version without thinking about it, while there is a cheaper generic available that can save you a chunk of money.

If you get to the pharmacy and discover a prescription is more expensive than you expected, don’t just let it go. Call your doctor. 

You can also ask your provider to try to make your life easier in other ways. Howell-McLean singled out albuterol, the asthma inhaler medication, as one drug that she tries to assist patients with. Insurers limit the prescription to one per month, but it can be helpful to have multiple inhalers (one at school, one at home; one at mom’s house, one at dad’s house). 

To make things simpler for her patients, she will simultaneously write one prescription for the current month and another for the following month during one visit. That way, her patients can get what they need without the hassle of having to get back in touch with their physician.  

There’s a good chance your provider will have ideas like this that will make your life easier and save you money, and the best way to know for certain is to ask them.

If you’re not sure how to start, focus on how the costs affect your health 

In an ideal world, your doctor would proactively bring up the cost of your care or, at the least, take an active interest if you bring it up. But we do not live in an ideal world and sometimes, even if you try to initiate a cost conversation with your doctor, they might seem uninterested or reluctant to engage. What do you do then?

First, you might have better luck getting your doctor’s help if you frame the question around your medical care, Nosal told me, rather than strictly finances. So instead of saying you don’t think you can afford your new prescription, say you don’t think you’ll be able to take it. It’s a subtle difference, but it’s more likely to send up a red flag to your provider.

“The doctor is most worried about getting you the right clinical care,” Nosal told me. “Where those two things meet might be an easier way to open that conversation and [get] the doctor to realize, ‘Oh, I need to think about that.’”

And at the end of the day, everyone should be able to be honest with their health care provider; that’s the foundation of a healthy and trusting doctor-patient relationship. If you don’t feel comfortable talking to the  provider you’re currently seeing about your financial concerns, you might want to consider finding a new one.

Plan ahead as much as you can for emergency care

This is the other nightmare scenario that I brought up to Nosal and Howell-McLean: You or your loved one needs treatment right now. The financial stakes are high, too: While there have been efforts to make sure people don’t get surprise bills from the hospital, it still happens, and those bills can be tens of thousands of dollars. 

The tension between wanting the best emergency care and not wanting to go bankrupt is acute. But don’t panic.

One thing to do right now, before you’re in an emergency situation, is research the hospitals in your area. What’s in your insurance network and what isn’t? If you’re in a bad car crash, you may not have a say about where you get treated, but if it’s a situation when you’re taking yourself or a family member, checking around ahead of time could save you a lot of stress in a high-pressure moment.

If you have a medical situation that demands attention but you have a little wiggle room in terms of time, you might want to call a nursing referral service before getting into your car or calling the taxi. Some health plans have started denying coverage for ER visits they deem to be unnecessary. A quick call to have a clinician confirm that you actually need to go to the hospital could save you some headaches with your insurer later. However, Nosal noted, if you’re having signs of a serious imminent medical event — like chest pains that suggest a heart attack — you should head straight to the ER and worry about the costs later. 

And once you’re at the hospital, many facilities actually have billing support staff who might be able to answer your questions or address your concerns. Ask to talk to one of them as soon as possible.

That’s the overarching advice here: Even if you’re intimidated or embarrassed or think there’s nothing they can do, ask. In most cases, your providers really are on your side.

“We want to help,” Howell-McLean said. “We want our treatment plans to be successful. We want our patients and families to be as healthy as they can be.”

Have you ever caught yourself squinting at the acronyms next to your health care provider’s name? MD, DO, NP, PA…

The medical workforce has changed. While the United States has long faced a doctor (MD or DO) shortage, there are now more nurse practitioners (NPs) and physician assistants (PAs) than ever before. More states are giving them a broad license to perform medical services on their own. A PA could prescribe you medication during a hospital stay. An NP could set up their own clinic in your area and run it like the family doctors of the last century.

If you’re looking for a primary care appointment, but have limited options (as many of us do), you may find more appointments with an NP next to the name than an MD. Or you might find an NP running the minute clinic at your local pharmacy.

What do all these letters mean? How should people think about these different credentials in different contexts? These are questions with major implications for both the US health system as a whole, and for each individual seeking care. Here’s what you need to know.

The acronyms, explained

Though the rules can differ depending on where you live, here are the broad strokes of what these different certifications mean:

• MDs (medical doctors) and DOs (doctors of osteopathic medicine): These are the positions that we’d commonly call “doctor.” They get an undergraduate degree, attend medical school, and then go through several years of residency under the supervision of more experienced physicians. DOs have historically placed an emphasis on a “holistic” approach to treating their patients, but as medicine overall has trended in that direction, there is less of a difference in practice between these two positions as there used to be.
• NPs (nurse practitioners): These providers have a bachelor’s degree (as all registered nurses do) and then got a postgraduate degree (either master’s or PhD) to become an NP. Depending on your state, they can either run their own practices or they must collaborate with an MD/DO who oversees their work. According to Grant Martsolf, a nursing services researcher at the University of Pittsburgh, the NP category was originally created because there were a lot of long-serving nurses who were more experienced and frankly more knowledgeable than younger MDs and DOs. NPs can also work in specialty fields (like cardiology) and in hospitals.
• PAs (physician assistants): These practitioners also get an undergraduate degree with credits in relevant fields like biology or chemistry and receive postgraduate education to become a PA. They always work in collaboration with an overseeing physician — thus the name — and they can be found everywhere from the primary care clinic to the hospital. There is wide variation in how they are allowed to practice across the country: In some states, they can treat and prescribe medicines without a doctor present; in others, a doctor is required to be much more hands on.

There are other acronyms (RNs, or registered nurses; LPNs, or licensed practical nurses) but NPs especially are increasingly practicing medicine autonomously, literally changing the face of health care for many Americans.

In 1999, there were just 44,000 NPs in the United States. Today, while estimates vary, there are in the neighborhood of 400,000. A real shift in the type of provider who offers general care — and even sometimes treatment in a more specialized setting — is underway in America.

What’s driving this rapid growth in nurse practitioners?

The dramatic growth in NPs has coincided with reforms that have allowed them to practice more medicine on their own. In the 1990s, only a handful of states were allowing NPs to have full autonomy, including the ability to start and oversee their own clinic; today, more than half (27) grant them that freedom under state law (called “scope of practice” laws).

Why such a shift? The doctor shortage was the most commonly cited reason in my interviews with researchers in this field. It’s becoming harder and harder for patients to find a doctor, especially for basic primary care, because many doctors are opting for more lucrative specialties over becoming a general practitioner. Authorizing NPs specifically to do that work on their own is theoretically a way to get more providers into underserved communities. While doctors have often resisted these changes, large health systems are more supportive because it is cheaper to hire NPs than MDs.

“The health systems are experiencing shortages of workers everywhere. They just want warm bodies,” Monica O’Reilly-Jacob, a nurse practitioner and nursing health services researcher at Columbia School of Nursing, told me.

So, in theory, you can get more providers delivering the same basic medical services at a lower cost, often to patients who may not have any other options. Even if those benefits are limited, some experts still argue in favor of relaxing the rules and giving more discretion to the individual clinic or health system to decide how their providers practice medicine.

“It seems to me that these scope of practice questions are actually relatively well managed within the institution,” Martsolf said.

Is this good for patients?

The theory seems sound — but the reality is a bit more complicated.

There is some evidence that giving NPs more freedom allows them to deliver care to more patients; one study in particular looked at prescribing for opioid overdose treatment after NP laws were liberalized in some states and found that more prescriptions were being written without appearing to replace the prescriptions already being given by MDs and DOs. That would suggest the NPs were playing a complementary role and addressing an unmet need.

“We see big increases in prescribing behavior in the states where [NPs] can participate in the market compared to states where they can’t, which we interpret as an increase in market access and lower costs,” Mindy Marks, a health economist at Northeastern University and co-author on that study, told me. “There was a need there that’s now being addressed.”

But there may be a limit to how much loosening rules for NPs expands access for the people who need it most. At the same time that more NPs are allowed to start and run their own practices, those NPs are being drawn away from primary care by the same financial incentives that are luring doctors away. They can make more money working with a specialist or in a hospital than they can running their own primary care clinic.

That can also lead to people working beyond what they’ve been trained to do, O’Reilly-Jacob said. While most NPs have received training specifically for primary care, more and more of them are working in acute care settings, like hospitals. While NPs could get certification for those services, not all of them do.

This disconnect between the idea of expanding scope of practice and how it actually plays out in the real world is one of the reasons that patients should still be diligent about who’s treating them.

Should you be worried about seeing an NP?

Despite the caveats, all the experts I spoke to said yes, they would be comfortable with or even prefer getting treated by an NP, particularly for primary care.

“I will wait two months to see my primary care NP rather than the physician that she works with,” O’Reilly-Jacob said, adding that the NP has a longer waiting list but that she’s worth it. “I think NPs just look at the whole person. They focus on preventative care. They’re really patient-centered. They are great at communication. They’re not standing at the door with their hand on the knob waiting to leave. I notice a big difference between primary care in front of an NP and a physician.”

Still, there are some questions that you can ask if you’re looking for a new primary care provider and considering an NP. Ask how long they’ve been practicing and what kind of training they’ve received. If you find a NP who’s worked on their own for 10 years, you’re probably going to get as good of care as you would from a doctor, Martsolf said. Some states, like New York, actually require NPs to perform a certain number of hours with doctor oversight before an NP can practice on their own. But if they are a younger provider, it could be worth asking additional questions about their experience and education to make sure you’re comfortable with having them as your primary contact with the medical system.

Likewise, at a specialty clinic or a hospital, you could ask about how an NP coordinates with a doctor or what kind of specialized training they have received. 

“If I was in the hospital, I would just say, ‘What’s your certification?’” O’Reilly-Jacob said. “And if they’re certified to be practicing where they are, I’m all on board.”

This story was originally published in The Highlight, Vox’s member-exclusive magazine. To get access to member-exclusive stories every month, join the Vox Membership program today.

Another window to stem America’s latest health care cost crisis has closed. Congress set a self-imposed deadline of January 30 to reach a compromise to extend financial assistance available under the Affordable Care Act, and that deadline has passed without an agreement. Already, about 4 million Americans have lost their government aid, and many of them have chosen to go uninsured because they can no longer afford their health insurance premiums without it.

This is the American health care story: political paralysis in the face of unaffordable costs. For the millions of people directly impacted, it is a terrible blow. 

I’ve been working on the beat for 15 years, and health insurance keeps getting more expensive. It is one of the most consistent sources of frustration and pain for voters. It is an embarrassment compared to other wealthy countries that manage to deliver universal health care at a lower cost.

This failure to act, yet again, makes the moment feel more hopeless than ever. 

But it may not be.

Despite lawmakers’ ongoing impasse, the conditions are actually ripening for another serious attempt to improve the American health care system. Here’s the case for a little optimism on the eve of yet another health care policy failure.

The “remedy and reaction” cycle of US health care reform

What’s particularly galling about this week’s (non)event is that nearly two-thirds of Americans believe it is the federal government’s responsibility to make sure people have health coverage.

Now, take a closer look at that chart. 

The last time Americans were this unified around the idea of the government guaranteeing health coverage was around 2008 — shortly before our last major health reform law, the Affordable Care Act, passed. The politics of health care are cyclical. It goes something like this: 

A problem becomes impossible for politicians to ignore, and lawmakers pass (or try to pass) an imperfect plan to address it — and then…

Voters become incensed over that specific plan — and then…

The backlash leaves lawmakers too afraid to try to pass any more significant reforms until the public becomes so fed up again that our leaders feel compelled to act.

Paul Starr, the preeminent historian of American health care, coined a term for this cycle: remedy and reaction. 

For the past 16 years, we have been in a period of reaction to the ACA: Democrats sought to reduce the persistently high uninsured rates among the working class and people in poverty, they came up with the ACA to achieve that goal, voters initially rejected the law after campaigning from Republicans and some corner of the business industry, and the lingering bruises from that backlash made many Democrats reluctant to propose major changes in 2016, 2020 and 2024. 

But now the wheel may finally be coming back around.

The time is ripe for another big health care swing

You need a few things to make a big health care push: that critical mass of political support, serious policy chops, and buy-in from at least some of the major health care business interests. The ACA, for example, resulted from Barack Obama’s massive electoral mandate, decades of policy planning dating back to at least the early Clinton years, and acquiescence from hospitals and Big Pharma that opted not to mount a major resistance.

All three factors are starting to align again. 

We’ve covered the public’s attitude on health care already. The ACA subsidy cliff and Republicans’ Medicaid cuts could deepen their anger and their desire for change. The shift to direct-to-consumer health care sales — like people paying cash for Ozempic at Costco — will further heighten the inequities in our system while squeezing many people’s wallets.

On policymaking, below the surface, the gears have been slowly churning, setting the stage once again for future action. 

This is a key part of the cycle: Momentum builds slowly, imperceptibly except to those paying close attention, before short windows open that allow for bursts of policymaking. 

Democrats went through a robust debate around what their next health care overhaul might look like during the 2020 presidential primary: Medicare-for-all, Medicare for all who want it, more targeted reforms to private insurance. They have been vetting and finetuning these concepts for a decade at this point. More recently, state-level public insurance options have gotten off the ground in states like Washington and started to show promising results; those experiences could be valuable when lawmakers are crafting a national plan, just as an existing Massachusetts health care reform law informed the ACA’s development. 

Right now, there is a new bipartisan group of lawmakers trying to deliver a deal on reforms for pharmacy benefits managers and more. In another sign of the shifting winds, the Trump administration has made moves to reduce drug prices, taking steps — such as trying to align US prices with international prices — that would have been unthinkable for a Republican a decade ago.

On our third point, some major special interest groups are having their own moments of crisis — and they’re in the mood to consider serious reforms. The American Medical Association, long an opponent of single-payer health care, has been gradually softening its stance; it has also advocated for restoring the ACA financial assistance and building upon the law. Even if a true, single-payer system remains a tough sell in the US, these are notable signals that the nation’s most powerful physician lobbying group may not oppose a more muscular government role in providing health insurance and trying to limit costs. 

And as I have reported, some companies are starting to seriously ponder the future of employer-sponsored insurance as the cost of providing it continues to grow. Those employer-sponsored plans, which insure about half the US, have long been considered untouchable because they offer tax-free health benefits — a major value for the private sector. And some companies say they still see that value. But if more firms decide they want to stop playing the role of health insurance administrator, that would be a massive political shift that could open up all kinds of new possibilities. 

So what comes next? 

National politics will be important: Democrats seem more likely than Republicans to mount a major health care reform effort. But even there, you can argue that the stars are aligning more than it might seem: President Donald Trump is so unpopular right now that the Democrats winning the Senate is plausible. Then they only need to take the presidency in 2028, and the window will, at least in theory, be open. Health care is a top priority for voters. That won’t change.

Update February 2, 2026, 9 am ET: This story was originally published on February 2 and has been updated now that Congress’s self-imposed deadline for passing an ACA subsidy deal has passed.