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Column: GOP targets Medicaid with the return of a terrible idea

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Column: GOP targets Medicaid with the return of a terrible idea

In any contest to name the cruelest and most useless healthcare “reform” favored by Republicans and conservatives, it would be hard to beat the idea of applying work requirements to Medicaid.

Yet, it’s back on the table, teed up by congressional Republicans as a deficit-cutting tool.

In a rational world, this idea would have been consigned to the dumpster long ago, and forever. It’s billed as a way to reduce joblessness, but doesn’t. It’s billed as an answer to the purported complexity of Medicaid, but makes the system more complicated for enrollees and administrators. It’s billed as a money-saving reform, but adds to Medicaid’s costs.

Democrats view Medicaid as a health insurance program that helps people pay for health care…Republicans view Medicaid as a government welfare program.

— Drew Altman, KFF

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So what does it accomplish? It’s very effective at throwing eligible people out of Medicaid.

House Budget Committee Chairman Jodey Arrington (R-Texas) gave the game away last week when he told reporters that a “responsible and reasonable work requirement” for Medicaid would produce about $100 billion in savings over 10 years, or $10 billion a year.

That wouldn’t make much of a dent in the annual cost of Medicaid’s coverage of its 72 million beneficiaries, which came to about $853 billion last year.

Nor would it do much to defray the estimated $4-trillion 10-year cost of extending parts of the 2017 Republican tax cut, which is the ostensible reason for seeking out penny-ante savings in budget categories such as a social safety net, according to the Washington Post.

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Whatever the putative rationale, there are only two ways to extract even $10 billion in savings from Medicaid: Strip benefits from the program, or throw enrollees out.

One other thing about imposing work requirements on Medicaid: It’s illegal. That’s the conclusion of federal judges who reviewed the idea the last time it was implemented, during the first Trump term.

U.S. District Judge James E. Boasberg and a three-judge panel of the U.S. Court of Appeals for the District of Columbia found that the legal waivers that allowed individual states to experiment with work requirements didn’t meet the key prerequisites for such “reforms” according to Medicaid law — that they serve the program’s objectives, specifically the goal of bringing health coverage to low-income Americans.

The courts invalidated work requirement waivers President Trump granted to three red states. When President Biden arrived at the White House in 2021, he canceled the waivers outright and shut down the work-requirement pipeline.

Despite that legal history, Medicaid work requirements remain a beloved hobby horse of conservatives. The idea is a component of Project 2025, the right-wing road map to federal policy changes in a second Trump administration. So let’s take a closer look at the record.

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The place to start is with conservatives’ historic disdain for Medicaid. This derives, as Drew Altman of the health policy think tank KFF astutely observed, in part from the divergent partisan views of the program: “Democrats view Medicaid as a health insurance program that helps people pay for health care.” By contrast, “Republicans view Medicaid as a government welfare program.”

Thinking of Medicaid as welfare serves another aspect of the conservative program, in that it makes Medicaid politically easier to cut, like all “welfare” programs. Ordinary Americans don’t normally see these programs as serving themselves, unlike Social Security and Medicare, which they think of as entitlements (after all, they pay for them with every paycheck).

From the concept of Medicaid as welfare it’s a short step to loading it with eligibility standards and administrative hoops to jump through; Republicans tend to picture Medicaid recipients as members of the undeserving poor, which aligns with their view of poverty as something of a moral failing. Work requirements, then, become both a punitive element and a goad toward “personal responsibility,” a term that appears in Project 2025’s chapter on Medicaid.

The idea that work requirements for Medicaid can have a measurable effect on joblessness is the product of another misconception, which is that most Medicaid recipients are the employable unemployed. As is often the case with right-wing tropes, this is completely false.

According to census figures, 44% of Medicaid recipients worked full time in 2023 and 20% worked part time. An additional 12% were not working because they were taking care of family at home, 10% were ill or disabled, 6% were students, and 4% were retired. Of the remaining 4%, half couldn’t find work and the remaining 2% didn’t give a reason.

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That might account for why Arkansas, the one state that actually implemented work rules under the Trump administration, experienced no increase in either “employment nor the number of hours worked” among the Medicaid-eligible population, in the words of the Congressional Budget Office.

Official state statistics showed that in the first six months of implementation, 17,000 Arkansans had lost their Medicaid eligibility. That figure was what provoked Boasberg to suspend the Arkansas program and block a similar effort in Kentucky before it could even start.

The Trump administration had approved Medicaid work requirements for 13 states and had approvals pending in nine others — all were under the control of Republican governors or legislatures or both — before the waivers ran into the court blockade and ultimately into the accession of the Biden administration.

The Arkansas rules required Medicaid enrollees to show 80 hours per month of employment, job search, job training or community service. Pregnant women, the disabled, students and a few other categories were exempt. Enrollees who didn’t meet the requirement for three months were summarily excised from Medicaid and couldn’t reenroll until the following year.

Evidence compiled by healthcare advocates suggested that administrative snafus largely prevented even employed enrollees from submitting evidence of employment. The work hour reports had to be made online, even though the reporting website was out of order for long stretches and many enrollees didn’t have adequate internet access.

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The effect of the policy on health coverage in Arkansas was calamitous. Medicaid enrollment fell by a stunning 12 percentage points. The percentage of uninsured respondents in the 30-49 age cohort, which was the first group targeted in a stepwise introduction of the requirement, rose to 14.5% in 2018 from 10.5% in 2016.

None of this reality dissuaded the authors of Project 2025 from resurrecting work requirements for Medicaid. Their discussion is redolent with disdain for the program and its enrollees — especially for beneficiaries of the Affordable Care Act’s Medicaid expansion, which added childless low-income households to a program that had chiefly covered families with children.

Since the 1980s, Project 2025 asserted, Medicaid had “evolved into a cumbersome, complicated, and unaffordable burden on nearly every state.”

The truth is, of course, that in the most significant expansion of the program, under the ACA, 100% of the cost of covering the new enrollees was borne by the federal government from 2016 through 2018, gradually declining to 90% in 2020 and thereafter. That’s significantly higher than the federal share of costs for the original enrollee category.

Project 2025’s Medicaid chapter falsely states that the ACA “mandates that states must expand their Medicaid eligibility standards” to include all individuals with income at or below 138% of the federal poverty level.”

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The truth is that this was originally part of the ACA, but it was invalidated by the Supreme Court, which ruled that the federal government must give states the choice of whether to accept the expansion. That’s the state of affairs to this day. The Supreme Court decision came down in 2012, so the Project 2025 authors don’t have much of an excuse for their ignorance of the facts. Anyway, 10 states, most of them deep red, still haven’t accepted the expansion.

Project 2025’s approach to Medicaid validates Altman’s perception that conservatives see the the program chiefly as welfare. Its goal is chiefly to find ways to cut costs, including through block grants (which deprive states of the flexibility they might need to fight disease outbreaks such as the pandemic), benefit caps and lifetime caps.

It proposes reducing or eliminating the 90% federal match rate, which would do nothing for enrollees and strain state budgets while preserving a few dollars for the feds. It calls for reducing Medicaid payments to hospitals, which keep some institutions, especially rural hospitals, fiscally afloat.

It calls for rooting out “waste, fraud, and abuse,” that all-purpose chimera evoked by budget-cutters as a painless way of reducing costs, but which no one ever seems to accomplish. And it calls for eliminating the “cumbersome” process of getting waivers improved — in other words, open the door for conservative political leaders to strip away the healthcare guarantees and standards that make Medicaid an effective deliverer of healthcare.

Don’t be fooled. The Project 2025 folks and their adherents in the coming Trump White House don’t want to make Medicaid more efficient, as they claim. They want to make it less relevant and less effective — and cheaper, the better to preserve those tax cuts. Those 72 million enrollees? They’ll just be collateral damage.

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Advance Auto Parts to close hundreds of stores, shut down West Coast operations

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Advance Auto Parts to close hundreds of stores, shut down West Coast operations

A plan by Advance Auto Parts to stem deepening losses by closing hundreds of stores will result “in a complete exit of certain markets on the West Coast” as the company shutters California locations, its chief executive said.

The national auto supply chain plans to close more than 725 locations around the country as well as four distribution centers on the West Coast, Chief Executive Shane O’Kelly said in an earnings call last week.

Although he didn’t specify which stores would close, O’Kelly signaled that the downsizing would focus heavily on California and the Pacific Northwest, saying that stores supplied by the four distribution centers marked for closure will also be shut down.

“Our four distribution centers on the West Coast serve a lower concentration of stores,” O’Kelly said in the earnings call. “We believe that investing in other core areas of the business will help deliver stronger profitability.”

Advance Auto Parts currently has 139 locations in California, according to its website. The North Carolina-based company operates about 4,700 stores along with 1,100 independently operated locations, which are primarily in the U.S. but also in Canada, Mexico and the Caribbean islands. Operations in Canada will not be affected, O’Kelly said.

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The automotive aftermarket is a roughly $300-billion industry, said Bret Jordan, a research analyst at Jeffries. Supply chain efficiency is key for auto part retailers, he said, something Advance Auto Parts has struggled with. Whereas Advance Auto generally receives shipments from distribution centers about once a week, competitor O’Reilly Auto Parts gets shipments once a day, Jordan said.

For the record:

6:07 p.m. Nov. 21, 2024An earlier version of this story incorrectly said the auto parts industry is a roughly $300 million industry. It should have said a roughly $300 billion industry.

“What they’re doing on the West Coast is getting out of regional markets where they don’t have an effective supply chain or the density to build an effective supply chain,” he said. “They’re trying to improve company wide profitability by cutting out the least profitable regions.”

The reduction in its footprint is part of the company’s “strategic plan to improve business performance,” according to a statement released as part of its recent quarterly earnings report. The company also plans to increase the pace of new store openings in higher-performing regions, the release said.

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The car parts seller, which stocks batteries, motor oil and more, posted underwhelming third-quarter results this month, reporting a net loss of $6 million on revenue of $2.1 billion. The figures marked an improvement compared with the $62-million loss it posted for the same period last year on $2.2 billion in revenue. The company’s stock closed Thursday at $38.69, down more than 37% this year.

Advance Auto Parts closed a $1.5-billion sale of Worldpac, its car parts wholesale distribution business, to investment firm Carlyle this month.

O’Kelly did not comment on the number of employees expected to be affected.

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Column: Trump's anti-science backers go after water fluoridation, a historic healthcare success

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Column: Trump's anti-science backers go after water fluoridation, a historic healthcare success

Regular visits to the dentist to fill cavities used to be a shared ordeal for millions of American children and adults. The reason that hasn’t been the case for late baby boomers and subsequent generations is that the fluoridation of drinking water became common starting in the late 1940s and continuing today.

So it’s right to question why Donald Trump’s nominee to head the Department of Health and Human Services, Robert F. Kennedy Jr., has placed the ending of fluoridation atop his list of first-day initiatives in his campaign against American public health.

“On January 20,” Kennedy tweeted a few days before the election, “the Trump White House will advise all U.S. water systems to remove fluoride from public water.”

‘Fluoridation is the most monstrously conceived and dangerous Communist plot we have ever had to face.’

— The unhinged Gen. Jack D. Ripper in the 1964 film ‘Dr. Strangelove’

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The reason, he asserted, is that “fluoride is an industrial waste associated with arthritis, bone fractures, bone cancer, IQ loss, neurodevelopmental disorders, and thyroid disease.”

That’s all flatly untrue or grossly misleading. Kennedy’s screed against fluoridation is part and parcel of a policy package that has legitimate scientists warning of a public health catastrophe in the making.

Fluoridation of tap water has generated local controversies ever since it was introduced in the U.S. in 1945. But it remains fully supported by a majority of Americans and by professional organizations including the American Dental Assn. and the American Academy of Pediatrics. That suggests that the proper stance of a Health and Human Services secretary would be to voice support for the practice. Kennedy has done just the opposite.

According to the Centers for Disease Control and Prevention, fluoridation is one of the 10 great public health achievements of the 20th century, up there with vaccination, family planning and recognition of the health dangers of tobacco.

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Fluoridation revolutionized dentistry, especially for children. Fluoridation of tap water was credited with reducing the incidence of tooth decay by as much as 70% when it was first introduced; by the mid-1980s, when other sources of fluoride, such as fortified toothpastes, were available, the effects of tooth decay in children were still 18% lower among those living in fluoridation communities than in those without it.

Who would benefit from the end of community fluoridation and a recrudescence of tooth decay? Dental supply companies, investors in which are rubbing their hands in glee at the prospect of more demand for their products. For example, shares of Henry Schein Inc., a distributor of specialty dental products, have risen more than 9% since RFK Jr. was named as Trump’s choice for HHS secretary.

Kennedy’s tweet about fluoridation exemplifies the anti-vaccine crowd’s method of casting doubt on established public health policies. There are two elements. One is to portray rare adverse health effects — some so rare that their very existence is questionable — as major and acute threats. The second is to downplay the beneficial effects of a policy. That leaves the public believing that the policy has only adverse effects, and that those are immediate and severe.

Tooth decay is a little-recognized public health problem, in part because fluoridation has made it rarer than it used to be. But it hasn’t disappeared. The American Academy of Pediatrics calls it “one of the most common chronic diseases in children,” and one that can have “lifelong consequences.” It disproportionately affects children who are racial minorities, come from low-income families or have special needs.

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It’s not only about the occasional toothache or cavity needing filling. Tooth decay can produce “incapacitating pain,” bacterial infection that may spread throughout the body, and, of course, to the loss of a tooth. In the first part of the last century, the only remedy for decay was to pull the tooth.

As of 2012, two-thirds of Americans had access to fluoridated tap water. Thanks to fluoridation, the CDC says, “tooth loss is no longer considered inevitable, and increasingly adults in the United States are retaining most of their teeth for a lifetime.”

More baby boomers reached 60 with “a relatively intact dentition at that age than any generation in history,” the CDC says. Interestingly, that makes water fluoridation more important than ever, since it means that seniors have more teeth vulnerable to decay than before.

Communities that have ended fluoridation have seen dental illnesses soar. Since fluoride was removed from drinking water in Calgary, Alberta, Canada, in 2011, Alberta Children’s Hospital has seen dental infections requiring treatment with IV antibiotics increase by 700%, a hospital specialist told the City Council in 2019. Half of those infections were in children younger than 5.

Windsor, Ontario, Canada, voted in 2018 to resume fluoridation five years after it had ended the program, after discovering that the number of children with tooth decay or oral conditions requiring urgent care had increased by 51% in the interim.

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Opponents of fluoridation have played on paranoid fears for decades, but into the 1960s, these were popularly dismissed as ravings from fringe organizations. In the 1964 film “Dr. Strangelove,” the unhinged Gen. Jack D. Ripper declares that “fluoridation is the most monstrously conceived and dangerous Communist plot we have ever had to face” — echoing the position of the John Birch Society.

The anti-fluoridation camp has long claimed that the process “increased the risk for cancer, Down syndrome, heart disease, osteoporosis and bone fracture, acquired immunodeficiency syndrome, low intelligence, Alzheimer disease, allergic reactions, and other health conditions,” the CDC noted in 1999. “No credible evidence supports an association between fluoridation and any of these conditions,” the agency stated.

More recently, critics object that fluoridation “is being imposed on them by the states and as an infringement on their freedom of choice,” the National Research Council reported in 2006 — similar to the elevation of individual “freedoms” over communal interests that animates the anti-vaccine movement.

The anti-fluoridation camp scored a legal victory in September, when federal Judge Edward M. Chen of San Francisco, an Obama appointee, ordered the Environmental Protection Agency to review its safety standard for fluoridation in tap water. Chen concluded not that “fluoridated water is injurious to public health” but that “there is unreasonable risk of such injury,” triggering a legal mandate that the EPA take a closer look.

Chen’s findings were heavily based on a government study with a checkered research history. More on that shortly. Despite the limitations of his order, it may well be taken as a validation of suspicions about fluoridation.

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What of RFK Jr.’s roster of adverse health effects? Let’s take them one by one. To begin, although fluoride can be a byproduct of industrial processes, it’s also a mineral naturally present in soil, groundwater, plants and food.

Arthritis? The National Research Council’s 2006 analysis of government fluoride standards identified “no indications” in the existing scientific literature implying “that fluoride had a causal relationship with … rheumatoid arthritis.”

Bone fractures? The 2006 analysis determined that the leading evidence for fluoride’s effect on bone strength pointed to lifetime exposure to fluoride at concentrations at or exceeding 4 milligrams per liter, which is more than five times the concentration in fluoridated tap water. The effect was found chiefly in people prone to concentrating fluoride in their bones, such as those with kidney disease.

Bone cancer? The main source of this claim appears to be a 15-year study led by the Harvard School of Dental Medicine, published in 2006 in the journal Cancer Causes and Controls.

In the same issue of the journal, however, two Harvard experts cast doubt on the study, noting that the original researchers were unable to replicate their findings when they repeated their study with new subjects. The results, they said, “do not suggest an overall association between fluoride and osteosarcoma” (that is, bone cancer).

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Evidence of “thyroid disease,” as Kennedy tweeted, is similarly inconclusive, especially at the approved levels of fluoride in tap water.

That brings us to Chen’s ruling in the San Francisco lawsuit. His findings relied heavily on a monograph by the National Toxicology Program first published in 2019. The paper initially concluded that “fluoride is presumed to be a cognitive neurodevelopmental hazard to humans,” based on findings that children exposed to high concentrations of fluoride showed lower IQs than others.

The survey focused on the effect of water with more than 1.5 milligrams of fluoride per liter, more than twice the approved level in the United States. It acknowledged that it had only “moderate confidence” that such concentrations could result in lower IQs, and stated that it had “insufficient data” to determine that the 0.7 mg/liter concentration in fluoridated tap water affects IQ.

There were lots of problems with the National Toxicology Program’s monograph. Two peer reviews by the National Academies of Sciences, Engineering, and Medicine essentially ripped it apart, rejecting it both times. The program “had not adequately supported its conclusions,” the peer reviewers wrote.

The monograph lacked a “rigorous statistical review.” The reviewers recommended that the program “make it clear that the monograph cannot be used to draw any conclusions regarding low fluoride exposure concentrations … typically associated with drinking-water fluoridation.” Among other changes in the final monograph published this summer, the program removed references to a “neurodevelopmental hazard to humans.”

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Critics also pointed out the inherent problems with treating IQ as an all-purpose measure of intelligence, since it’s well-known that IQ can be affected by “socioeconomic, physical, familial, cultural, genetic, nutritional, and environmental factors,” the American Academy of Pediatrics observes.

Kennedy’s mindset is curious: He has promoted treatment of COVID-19 with ivermectin and hydroxychloroquine, which have been proven to be useless for the purpose, but he campaigns against fluoridation, which has demonstrated a health benefit over nearly eight decades. Is this any way to run a public health agency such as the HHS?

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With Trump as president, can TikTok in the U.S. survive?

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With Trump as president, can TikTok in the U.S. survive?

The fate of TikTok in the U.S. has been up in the air since 2020, when President Donald Trump moved to ban the popular video app because of national security concerns.

That set off four years of back-and-forth between the app’s Chinese owners and the U.S. government, with a possible ban scheduled to go into effect one day before Trump’s inauguration in January.

One hitch: Trump recently changed his mind, joining TikTok in June and posting on social media, “Those who want to save TikTok in America, vote for Trump.”

“We’re not doing anything with TikTok,” he said.

That has given some creators hope.

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“The fact that Trump did a whole 180 and wants to wait and reassess how everything is going with TikTok — I think we’re going to be OK,” said creator Kat Vera, 34, who posts fitness and car content and has 457,000 followers on TikTok.

But there are factors that complicate the app’s position. Several legal experts and tech industry observers said the path forward for TikTok is still precarious.

“It’s just a huge mess, and it isn’t clear,” said Carl Tobias, a law professor at the University of Richmond.

In April, Biden signed a law passed by Congress that would require TikTok’s Chinese parent company, ByteDance, to divest its ownership of TikTok by Jan. 19 or face a ban in the U.S. due to security concerns about the app’s ties to China.

Biden has the option to extend ByteDance’s deadline, but some legal experts said that is unlikely. Changing the law would require approval by Congress, they said. Instead, some believe that the matter could be settled in the D.C. Circuit Court of Appeals.

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TikTok and ByteDance sued the U.S. government in May, alleging that banning the app would violate 1st Amendment rights to freedom of speech and that the new law “offers no support for the idea” that TikTok’s Chinese ownership poses national security risks.

Experts said they expect that the court will make a decision next month. If the court rules in favor of TikTok and ByteDance, then the law will be declared unconstitutional and the government is unlikely to appeal under the incoming Trump administration.

But if the court rules against the app and the tech giant, they could appeal to the Supreme Court and ask to have the new law paused, said Michael Stovsky, a partner at law firm Benesch in Cleveland.

“They’re gonna probably ask the court to say, ‘Look, don’t enforce the law. Don’t require it to divest until the Supreme Court has heard the case,” Stovsky said.

Representatives for TikTok and the Trump administration did not respond to requests for comment.

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In a court filing, TikTok and ByteDance said that they’ve tried to work with the U.S. government’s Committee on Foreign Investment to address security concerns since 2019.

Under the terms of a deal spelled out in a 90-page draft agreement, data collected about TikTok users in the U.S. was to be handled by U.S. tech giant Oracle. The proposed agreement also called for Oracle to inspect TikTok’s programming code for vulnerabilities and for the platform’s content to be subject to independent monitoring.

If TikTok did not comply, the draft agreement called for financial penalties and also included the possibility of suspending TikTok’s operations in the U.S. TikTok and ByteDance said it‘s unclear why the committee ultimately determined the proposed agreement was insufficient.

Meanwhile, Trump has changed his tune about TikTok, at least in part for apparently personal reasons and his animus for the app’s rivals. Earlier this year he called himself a “big star on TikTok.”

“If you get rid of TikTok, Facebook and Zuckerschmuck will double their business,” Trump wrote on Truth Social in March, referring to Mark Zuckerberg, the CEO of Facebook’s parent company, Meta. “I don’t want Facebook, who cheated in the last Election, doing better. They are a true Enemy of the People!”

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Republican leaders have accused the social media site of censoring conservative viewpoints, which Facebook refuted, saying it has guidelines that “do not permit the suppression of political perspectives.”

Trump, who has 14.6 million followers on TikTok, joined the popular video app months after he met with Jeff Yass, a ByteDance investor, major Republican party donor and co-founder and managing partner of Susquehanna International Group, but Trump told CNBC they did not discuss TikTok.

People who had worked for Trump also have joined TikTok’s cause. Club for Growth, a conservative economic organization, hired former Trump aide Kellyanne Conway to advocate for TikTok in Congress, according to Politico.

But the Trump administration will have to deal with differing viewpoints within the Republican party on TikTok, with some preferring a hard line toward China.

“I think it’s going to become a chip in a much larger game involving tariffs with China, security agreements, all that, and that TikTok is going to be part of a bigger equation,” said Freddy Tran Nager, associate director of USC Annenberg’s Digital Social Media master’s program.

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TikTok has a significant presence in Culver City, employing roughly 440 people there, according to city estimates. The company, which has 170 million U.S. users, has been a significant tool for promoting content by video creators, small businesses, music artists and Hollywood studios.

Earlier this year, TikTok notified the state of California that it would lay off 58 employees in Culver City in July “due to restructuring.” Positions affected included senior business analysts and global product specialists.

Many creators have already diversified into publishing their content on other platforms, so they aren’t solely reliant on TikTok. Some say the money-making opportunities are better on rival services.

Theodora Moutinho, a fitness creator and actress from Glendale, said she has learned to always adapt in the fast-changing world of social media.

The 25-year-old became a creator in 2017 and today has 4.2 million followers on Instagram, 1.3 million on TikTok and 421,000 on Snapchat. These days, she’s putting more effort into her Snapchat and Instagram accounts, while keeping an eye on newer platforms such as Bluesky.

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“Ever since it was up in the air that they were going to take it off, not take it off, I kind of stopped really focusing on it,” Moutinho said of TikTok. “Because why try to grow something if it might come down?”

Times news researcher Scott Wilson contributed to this report.

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