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Somehow, America’s desire for Ozempic is only growing. The drug’s active ingredient, semaglutide, is sold as an obesity medication under the brand name Wegovy—and it has become so popular that its manufacturer, Novo Nordisk, recently limited shipments to the U.S. and paused advertising to prevent shortages. Its promise has enticed would-be patients and set off a pharmaceutical arms race to create more potent drugs.

Part of the interest stems from its potential in teens: In December, the FDA approved Wegovy as a treatment for teenagers with obesity, which affects 22 percent of 12-to-19-year-olds in the United States. The drug’s ability to spur weight loss in adolescents has been described as “mind-blowing.” In January, the American Academy of Pediatrics recommended that doctors consider adding weight-loss drugs such as semaglutide as a treatment for some patients in its new childhood-obesity-treatment guidelines.

But although many doctors and obesity experts have embraced semaglutide as a treatment for adults, some are concerned that taking it at such a young age—and at such a precarious stage of life—could pose serious risks, especially because the long-term physical and mental-health effects of the medication are still unknown. Others, however, believe that not using this medication in adolescents is riskier, because obesity makes teens vulnerable to serious health conditions and premature death. In part because of the apprehension among doctors, prescriptions for semaglutide in teens are not taking off like they are for adults. At this point, whether these drugs will ever catch on as a treatment for teens remains deeply uncertain.

Semaglutide isn’t just effective for teens. It may be even more effective than it is in adults. In a large Novo Nordisk–funded study published in The New England Journal of Medicine, “the degree of weight reduction in adolescents was better than what was observed in the adult trials,” Aaron S. Kelly, the co-director of the Center for Pediatric Obesity Medicine at the University of Minnesota Medical School, told me.  In another Novo Nordisk–funded study published last week, a team led by Kelly showed that the drug, combined with counseling and exercise, nearly halved the number of teens with obesity after 68 weeks of treatment. Both for adolescents and adults, the weekly injection doesn’t “magically melt away body fat,” Kelly said, but instead works by triggering a sense of fullness and quieting hunger pangs.

Teenagers’ experience with obesity is different—in some ways more intense—than that of older people. Puberty is a time of lots of growth and development, so the body fights off attempts at weight loss “with every mechanism that it has,” Tamara Hannon, a pediatric endocrinologist at the Indiana University School of Medicine, told me. Teenagers may also have less control than adults over what they eat or how much activity they get, because these are largely circumscribed by their family and school, as well as social pressure to conform to how their peers eat. “Making good choices means doing something different than the majority of the other kids,” Hannon said. “At every corner, there’s something that is in direct opposition to losing weight.”

Because obesity is a chronic disease, developing it early can be devastating. In many cases it can result in illnesses such as type 2 diabetes and fatty liver at a young age. Children with obesity are five times more likely than their peers to have it in adulthood; as teens with obesity become adults with obesity, they can “develop very, very aggressive disease,” Fatima Stanford, an obesity-medicine physician at Massachusetts General Hospital and Harvard Medical School, told me. Weight-loss drugs give doctors the ability to intervene before the effects of obesity snowball, she said, which is why AAP’s new childhood-obesity guidelines advocate for using them as part of early, aggressive treatment—along with many hours of in-person health and lifestyle therapy. Used early enough, semaglutide or other medications could possibly reroute the trajectory of a teenager’s entire life.

But semaglutide could also possibly throw a teen’s trajectory off course. Because treatment is considered a lifelong endeavor—stopping usually leads to rapid weight regain—adolescents who start the medication will be taking it for many decades. “We have no way of knowing whether these drugs, used so early in life for so long, could have unanticipated adverse effects,” David Ludwig, an endocrinologist at Boston Children’s Hospital, told me. Although adults face many of the same unknowns, the risks for teens could be more severe because their body and brain are in constant flux. Of particular concern are the drug’s potential impacts on physiological changes specific to adolescence. “We need to keep an eye on pubertal development and menstrual history for girls,” Hannon said. In addition, the drugs can lead to unsavory side effects such as gastrointestinal issues and may have other impacts, including significant muscle loss and rewiring of the brain’s reward circuitry. Scientists are just beginning to understand these effects; at this point, only two major studies have been conducted on semaglutide in teens, and neither have involved a long follow-up period.

The repercussions of semaglutide treatment on mental health, an important aspect of obesity care, are even less understood. Teens are “more likely than an adult to have intermittent access to medication,” Kathleen Miller, an adolescent-medicine specialist at Children’s Minnesota hospital, told me—and skipping several doses in a row could pose physical and well as psychological risks. Another concern is that the overall effect of taking semaglutide—a decreased appetite, which leads to eating less—is essentially the same as that of dieting. When teens go on very restrictive diets, whether or not they involve weight-loss medications, “we know that may be harmful to their mental health and promote disordered eating,” Hannon said. Because their brain is so plastic during puberty, “there’s a risk of ingraining those patterns in adolescence,” Miller said.

With so many unknowns, would teens with obesity be better off avoiding semaglutide? At least for now, many pediatricians are reluctant to prescribe it. “The idea of using anti-obesity pharmacotherapy was challenging even in adults a couple of years ago,” says Angela Fitch, an assistant professor at Harvard Medical School and the president of the Obesity Medicine Association; acceptance of its role in pediatric care is even further behind. But denying teens the drug, she told me, is the biggest risk: Teens develop an unhealthy mentality about their body when they don’t get help losing weight, she argued. Explaining to a teen that obesity is not their fault, and correcting the underlying biological issue with medication or other treatment, helps them to develop “a better body image about themselves,” she said.

None of the experts I spoke with flat-out said that semaglutide should never be used in adolescent treatment. Even those who were wary of the drug acknowledged that it might be medically appropriate in teens who really struggle with their weight and have little success losing it through any other means. That argument may only strengthen as more convenient  drugs—or those with fewer side effects—are approved for use by teens. This week, both Novo Nordisk and Pfizer announced that pill versions of these medications were successful in early trials.

Even without all of the answers on how this drug might affect teens in the long term, Fitch predicted that “the uptake of semaglutide and other anti-obesity medications in pediatric clinical care will be slow and gradual.” Eventually, they may come to be seen as just one of several weight-loss tools to help set up kids for healthier lives. Treating adolescent obesity shouldn’t be an “either-or” choice, Ludwig said. “It’s everything-and.” He has proposed that combining semaglutide with a low-carbohydrate diet, for example, could have synergistic effects on adolescent weight loss.

For the foreseeable future, semaglutide isn’t poised to take off for teens in the way that it has for adults. In spite of all the hype surrounding Ozempic, experts and their patients are left with a difficult choice based on different assessments of risk: what might happen if teens are treated with drugs, and what might happen if they’re not. Either way, teenagers have the most to benefit—and the most to lose.

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The budget cuts that House Republicans are demanding in their high-stakes debt-ceiling standoff with President Joe Biden sharpen the overlapping generational and racial conflict moving to the center of U.S. politics.

The House GOP’s blueprint would focus its spending cuts on the relatively small slice of the federal budget that funds most of the government’s investments in children and young adults, who are the most racially diverse generations in American history.

Those programs, and other domestic spending funded through the annual congressional-appropriations process, face such large proposed cuts in part because the GOP plan protects constituencies and causes that Republicans have long favored: It rejects any reductions in spending on defense or homeland security, and refuses to raise taxes on the most affluent earners or corporations.

But the burden leans so heavily toward programs that benefit young people, such as Head Start or Pell Grants, also because the Republican proposal, unlike previous GOP debt-reduction plans, exempts from any cuts Social Security and Medicare. Those are the two giant federal programs that support the preponderantly white senior population.

The GOP’s deficit agenda opens a new front in what I’ve called the collision between the brown and the gray—the struggle for control of the nation’s direction between kaleidoscopically diverse younger generations that are becoming the cornerstone of the modern Democratic electoral coalition and older cohorts that remain predominantly white and anchor the Republican base.

The budget fight, in many ways, represents the fiscal equivalent to the battle over cultural issues raging through Republican-controlled states across the country. In those red states, GOP governors and legislators are using statewide power rooted in their dominance of mostly white and Christian nonurban areas to pass laws imposing the conservative social values and grievances of their base on issues including abortion, LGBTQ rights, classroom censorship, book bans, and even the reintroduction of religious instruction into public schools. On all those fronts, red-state Republicans are institutionalizing policies that generally conflict not only with the preferences but even the identity of younger generations who are much more racially diverse, more likely to identify as LGBTQ, and less likely to identify with any organized religion.

[Read: Why Biden caved]

The House Republicans’ plan would solidify a similar tilt in the federal budget’s priorities. Because Social Security, Medicare, and the portion of Medicaid that funds long-term care for the elderly are among Washington’s biggest expenditures, the federal budget spends more than six times as much on each senior 65 and older as it does on each child 18 and younger, according to the comprehensive “Kids’ Share” analysis published each year by the nonpartisan Urban Institute. Eugene Steuerle, a senior fellow there who helped create the “Kids’ Share” report, told me, “We are already in some sense asking the young to pay the price” by cutting taxes on today’s workers while increasing spending on seniors, and accumulating more government debt that future generations must pay off.

Spending on children 18 and younger now makes up a little more than 9 percent of the federal budget, according to the study. But that number is artificially inflated by the large social expenditures that Congress authorized during the pandemic. By 2033, the report projects, programs for kids will fall to only about 6 percent of federal spending.

One reason for the decline is that spending on the entitlement programs for the elderly—Social Security, Medicare, and Medicaid—will command more of total spending under the pressure of both increasing health-care costs and the growing senior population. Under current law, in 2033 those programs for seniors will expand to consume almost exactly half of federal spending, the “Kids’ Share” analysis projects.

By protecting those programs for seniors from any cuts, and rejecting any new revenues, while exacting large reductions from programs for kids and young adults, the GOP plan would bend the budget even further from the brown toward the gray. The implication of the plan “is that children will get an even smaller slice of federal spending” than anticipated under current policies, Elaine Maag, an Urban Institute senior fellow and a co-author of the “Kids’ Share” report, told me.

Federal spending on kids is particularly at risk because of how Washington provides it. The federal government does channel substantial assistance to kids through tax benefits, such as the child tax credit, and entitlement programs, including Medicaid and Social Security survivors’ benefits, that are affected less by the GOP proposal. But many of the federal programs that benefit kids and young people are provided through programs that require annual appropriations from Congress, what’s known as domestic discretionary spending. As Maag noted, the programs that help low-income and vulnerable kids are especially likely to be funded as discretionary spending, rather than entitlements or tax credits. “Head Start or child-care subsidies or housing subsidies are all very targeted programs,” she said.

The GOP plan’s principal mechanism for reducing federal spending is to impose overall caps on that discretionary spending. Those caps would cut such spending this year and then hold its growth over the next nine years to just 1 percent annually, which is not enough to keep pace with inflation. Over time, those tightening constraints would result in substantially less spending than currently projected for these programs. If the GOP increased defense spending enough to keep pace with inflation, that would require all other discretionary programs—including those that benefit kids—to be cut by 27 percent this year and by almost half in 2033, according to a recent analysis by the Center on Budget and Policy Priorities, a progressive advocacy group. If the GOP also intends to maintain enough funding for veterans programs (including health care) to match inflation, the required cuts in all other discretionary programs would start at 33 percent next year and rise to almost 60 percent by 2033.

[Read: This debt crisis is not like 2011’s. It’s worse.]

As Sharon Parrott, the president of the Center on Budget and Policy Priorities, told me this week, by demanding general spending caps, the GOP does not have to commit in advance to specific program reductions that might be unpopular with the public. “What they are trying to do is put in place a process that forces large cuts without ever having to say what they are,” Parrott said.

Federal agencies have projected that the cuts required under the Republican spending caps would force 200,000 children out of the Head Start program, end Pell Grants for about 80,000 recipients and cut the grants by about $1,000 annually for the remainder, and slash federal support for Title I schools by an amount that could require them to eliminate about 60,000 teachers or classroom aides. The plan also explicitly repeals the student-loan relief that Biden has instituted for some 40 million borrowers. Its cuts in the Temporary Assistance for Needy Families program, generally known as welfare, could end aid for as many as 1 million children, including about 500,000 already living in poverty, the Center on Budget and Policy Priorities has calculated.

The appropriations bill that a House subcommittee recently approved for agricultural programs offers another preview of what the GOP plan, over time, would mean for the programs that support kids. The bill cut $800 million, or about 12 percent, from the Special Supplemental Nutrition Program for Women, Infants, and Children. Parrott noted that to avoid creating long waiting lists for eligibility, which might stir a more immediate backlash, the committee instead eliminated a pandemic-era program that gave families increased funding through WIC to purchase fruits and vegetables. “They are saying the country can’t possibly afford to make sure that pregnant participants, breast-feeding participants, toddlers, and preschoolers have enough money for fruits and vegetables,” she said.

Parrott doesn’t see the GOP budget as primarily motivated by a desire to favor the old over the young. She notes that the GOP plan would also squeeze some programs that older Americans rely on, for instance by reducing funds for Social Security administration or Meals on Wheels, and imposing work requirements that could deny aid to older, childless adults receiving assistance under the Supplemental Nutrition Assistance Program.

Instead, Parrott, like the Biden administration and congressional Democrats, believes that the GOP budget’s central priority is to protect corporations and the most affluent from higher taxes. “To me, that’s who they are really shielding,” she said.

Yet the GOP’s determination to avoid reductions in Social Security and Medicare, coupled with its refusal to consider new revenue or defense cuts, has exposed kids to even greater risk than the last debt-ceiling standoff. Those negotiations in 2011, between then-President Barack Obama and the new GOP House majority, initially focused on a “grand bargain” that involved cuts in entitlements and tax increases along with reductions in both discretionary domestic and defense spending. Even after that sweeping plan collapsed, the two sides settled on a fallback proposal that raised the debt ceiling while requiring future cuts in both domestic and defense spending.

The House Republicans’ determination to narrow the budget-cutting focus almost entirely to domestic discretionary spending not only means more vulnerability for programs benefiting kids, but also less impact on the overall debt problem they say they want to address. Even some conservative budget experts acknowledge that it’s not possible to truly tame deficits by focusing solely on discretionary spending, which accounts for only about one-sixth of the total federal budget. Brian Riedl, a senior fellow and budget expert at the conservative Manhattan Institute, supports Republican efforts to limit future discretionary spending but views it only as an attempt to “prevent the deficit from getting worse.”

Riedl told me that in his analysis of long-term budget trends, he found it impossible to prevent the federal debt from increasing unsustainably without also raising taxes and significantly slowing the growth in spending on Social Security and Medicare. But, as he acknowledged, the GOP’s willingness to consider reductions in those programs has dwindled as their electoral coalition in the Donald Trump era has evolved to include more older and lower-income whites. “As the Republican electorate grew older and more blue collar, they revealed themselves as more attached to entitlements [for seniors] than previous Republican electorates,” he said.

Trump in 2016 recognized that shift when he rejected previous GOP orthodoxy and instead   opposed cuts in Social Security and Medicare. Trump has maintained that position by publicly warning congressional Republicans against cutting the programs, and attacking Florida Governor Ron DeSantis, who entered the 2024 GOP race yesterday, for supporting such reductions in the past. Biden has also pressured the GOP to preserve Social Security and Medicare.

Though it’s not discussed nearly as much, the GOP’s refusal to consider taxes on high earners also has a stark generational component. With the occasional exception, older Americans generally earn more than younger Americans (the top tenth of people at age 61 earn almost 60 percent more than the top tenth of those age 30). Older generations are especially likely to have accumulated more wealth than younger people, Steuerle noted. As part of the economy’s general trend toward inequality, Steuerle said, older generations today are amassing an even larger share of the nation’s total wealth than in earlier eras.

Refusing to raise taxes on today’s affluent while cutting programs for contemporary young people subjects those younger generations to a double whammy. Not only does it mean that the federal government invests less in their health, nutrition, and education, but it also increases the odds that as adults they will be compelled to pay higher taxes to fund retirement benefits for the growing senior population.

Although Biden also wants to avoid cuts in entitlements for seniors, his call for raising more revenue from the affluent still creates a clear contrast with the GOP. By proposing higher taxes, Biden has been able to devise a budget that protects federal spending on kids and other domestic programs while also reducing the deficit. Biden’s budget proposal achieves greater generational balance than the GOP’s because the president asks today’s affluent earners, who are mostly older, to pay more in taxes to preserve spending that benefits young people. If Biden reaches a deal with congressional Republicans to avoid default, however, their price will inevitably include some form of spending cap that squeezes such programs: the real question is not whether, but how much.

Looming over these choices is the intertwined generational and racial re-sorting of the two parties’ electoral coalitions. As Riedl noted, especially in the Trump era, the GOP has become more dependent on older white people who are either eligible for the federal retirement programs or nearing eligibility. According to a new analysis published by Catalist, a Democratic electoral-targeting firm, white adults older than 45 accounted for just over half of all voters in the 2022 and 2018 midterm elections and just under half in the 2020 and 2016 presidential campaigns. But because those older white Americans have become such a solidly Republican bloc, they contributed about three-fifths of all GOP votes in the presidential years, and fully two-thirds of Republican votes in midterm elections.

Democrats, in turn, are growing more reliant on the diverse younger generations. Catalist found that Democrats have won 60 to 66 percent of Millennials and members of Generation Z combined in each of the past four elections. Those two generations have more than doubled their share of the total vote from 14 percent in 2008 to 31 percent in 2020. Adding in the very youngest members of Generation X, all voters younger than 45 provided almost 40 percent of Democrats’ votes in 2022, Catalist found, far more than their overall share (30 percent) of the electorate.

The inexorable long-term trajectory is for the diverse younger generations to increase their share of the vote while the mostly white older cohorts recede. In 2024, Millennials and Gen Z may, for the first time, cast as many ballots as the Baby Boomers and older generations; by 2028, they will almost certainly surpass the older groups. In the fight over the federal budget and debt ceiling—just as in the struggles over cultural issues unfolding in the states—Republicans appear to be racing to lock into law policies that favor their older, white base before the rising generations acquire the electoral clout to force a different direction.

Ron DeSantis is the governor of one of the most scenic states in America. Reelected by eye-popping margins in 2022, he does not lack for superfans. And yet, instead of launching his presidential campaign in front of palm trees and adoring crowds, he did so last night on Twitter, in an awkward audio-only exchange with Elon Musk that took place only after 25 minutes of excruciating technical difficulties.

It might seem strange for a presidential candidate who is arguing that Republicans should not tie their fortunes to an impulsive, internet-poisoned millionaire to announce his campaign by wedding it to an impulsive, internet-poisoned billionaire. But DeSantis’s choice of venue makes sense in context: It is the latest in a series of appeals to his party’s most online activists, who idolize individuals such as Musk and monopolize Twitter, the social-media site that Musk owns. Cultivating the base and wealthy donors is smart politics, and DeSantis is a better politician than both his progressive and pro-Trump critics admit. But as the Twitter-launch fiasco demonstrated, his obsession with the online could seriously hamper his prospects offline. Campaigns that mistake social-media virality for electoral reality tend to end poorly.

One of the many misguided lessons that politicians learned from Donald Trump’s 2016 success was that Twitter wins elections. But in fact, Trump’s first victory owed little to social media and more to traditional media. His candidacy capitalized on a decades-old reputation for business acumen that he had built through reality TV and the tabloids. The telegenic Trump then overwhelmed his Republican primary opponents by garnering ample media coverage, with cable news channels racing to air his raucous rallies live.

By contrast, one of the few things that even Trump’s own supporters repeatedly told pollsters that they didn’t like about him was … his tweets. This shouldn’t surprise. Social-media sites—and Twitter in particular—are rife with conspiracy theories, hoaxes, and niche jargon that have little resonance in the real world. This is why when politicians start talking like Twitter feeds, they start losing voters—which is exactly what happened to many Democrats in 2020.

[David Frum: DeSantis’s launch was not the only thing that crashed]

Consider the case of “Defund the police.” That mantra, alongside its more radical cousin “Abolish the police,” emerged as a rallying cry during the 2020 protests after the killing of George Floyd, momentarily turning a previously marginal approach to policing into a mainstream one. Channeling righteous anger into a radical proposal, “Defund” quickly became an online litmus test, and many progressive politicians racked up retweets by embracing it. Judging by its online impact, the slogan was a smashing success.

It’s also not how anyone in the Democratic Party talks today. “I think allowing this moniker, ‘defund the police,’ to ever get out there, was not a good thing,” Keith Ellison, the progressive Minnesota attorney general, told the Washington Post reporter David Weigel in November 2021. “We should all agree that the answer is not to defund the police,” said President Joe Biden in his first State of the Union address, to a bipartisan standing ovation. “It’s to fund the police—fund them!” In late 2021, New York City elected Mayor Eric Adams, a Black former cop who promised to invest more in law enforcement, not less. This month, Philadelphia’s Democratic primary voters picked Cherelle Parker, a Black city-council member with an uncompromising tough-on-crime platform, to be the city’s likely next mayor. Meanwhile, Brandon Johnson, the newly elected mayor of Chicago, backed away from his previous “Defund” position to secure his victory.

What happened? It turned out that although “Defund” was popular among the activists who disproportionately drive online progressive discourse, it was deeply unpopular with voters. Polls found that most Americans, including Black voters, overwhelmingly rejected defunding the police, and the slogan proved to be a millstone around the neck of many candidates, even in relatively progressive regions. The Democratic lawmakers and donors who echoed this rhetoric neglected one basic truth: Twitter is real life for the people who are on it, but most people are not on Twitter. According to the Pew Research Center, just 23 percent of U.S. adults use Twitter, and of those, “the most active 25% … produced 97% of all tweets.” Simply put, almost all tweets come from less than 6 percent of American adults—far from a representative slice of the broader public.

[Read: Twitter is a far-right social network]

But one Democrat didn’t fall into the Twitter trap. Not coincidentally, Joe Biden is now the president. In the 2020 Democratic primary, while his rivals competed to cater to the latest enthusiasms of the online left, the former vice president consolidated the party’s more moderate mainstream. In the general election, Biden’s aggressively offline campaign helped Democrats avoid the worst consequences of their 2020 Twitter excesses, as he was not implicated in them, and tended to treat social media as a place to be managed by staffers, not mirrored by the candidate. Trump, on the other hand, dove down every internet rabbit hole, ranting during speeches and debates about obscure bit players in online conspiracy theories at a time when a pandemic was ravaging the country. He lost by 7 million votes.

No politician can or should ignore social media, which still drives a lot of public discourse and engages many activists. The sweet spot is rather to be aware of the internet but not consumed by it. My colleague Derek Thompson refers to this as being “optimally online.” And for a while, it looked like Ron DeSantis had mastered this maneuver. He hired an army of pugilistic spokespeople, most notably his former press secretary Christina Pushaw, who reveled in trolling reporters and liberals on Twitter, including labeling Democratic politicians as “groomers.” By delegating this operation to staff, DeSantis was able to appeal to his party’s most rabid Twitterati while maintaining distance and deniability from their actions, preserving his appeal to everyday voters even as he provided virtual red meat to the online base.

But it’s starting to look like this wasn’t a strategy but rather just the first stage of internet poisoning that now threatens to overwhelm DeSantis’s presidential campaign. In recent months, the governor has sounded less like a populist politician and more like an instantiation of his party’s worst Twitter talkers. Take DeSantis’s hard turn against transgender rights. “Transgenderism must be eradicated from public life entirely,” declared The Daily Wire’s Michael Knowles, who has nearly 1 million followers on Twitter, in March. His colleague Matt Walsh regularly dubs transition care for minors as “abuse” and “mutilation” to his 1.8 million followers. But what excites reactionary Twitter doesn’t move voters: Most Americans oppose discrimination against transgender people, even as they express apprehension over medical transition for minors or the participation of trans athletes in women’s sports. And yet, earlier this month, DeSantis signed and celebrated a bill that, in his words, “permanently outlawed the mutilation of minors.”

In other words, the ill-fated launch event with Musk wasn’t a one-off miscalculation. It was the latest instance of DeSantis losing sight of the electorate in favor of online obsessions. Tellingly, in his 67-minute appearance last night, the governor repeatedly derided the “woke” left but never mentioned Trump—the candidate DeSantis must dethrone if he is to claim the nomination.

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