This article stands on its own, but readers interested in its practical implications for Southern Oregon’s healthcare system may find the three-part series on the Southern Oregon Community Purchasing Alliance — also published by ReImagine Healthcare — a useful companion.
Something happened to us during the pandemic that we have not fully reckoned with.
Not the virus itself, though that was catastrophic enough. What happened alongside it — in the information environment, in our institutions, in the basic social infrastructure of shared reality — is harder to name and harder to reverse. Public trust in the institutions that organize American life collapsed at a speed and to a depth that has no real precedent in modern polling. And while that collapse accelerated during COVID, the data shows it did not begin there, and it has not stopped since.
This essay is an attempt to look squarely at what happened, what drove it, and what it means for the question of community governance — the mechanisms by which people who live near each other make collective decisions about their shared lives. It is not a partisan argument. The data does not support a partisan argument. The collapse of institutional trust has touched the left and the right differently, for different reasons, but it has touched both. What it has left behind is a landscape in which the institutions designed to aggregate and act on community will are increasingly unable to do so — not primarily because they are corrupt, but because the information environment they were designed to operate in no longer exists.
That is a structural argument, not a moral one. And it leads, somewhat unexpectedly, to a hopeful place — because while trust in national and large institutional structures has collapsed, trust at the local level has held. The implications of that asymmetry are worth taking seriously.
The Numbers Are Worse Than the Discourse Suggests
The public discourse around institutional trust tends to treat distrust as a partisan talking point — something that one side deploys against the other. The data tells a more uncomfortable story.
A nationwide survey tracking trust in physicians and hospitals found that public confidence in those two institutions fell from 71.5% in April 2020 to 40.1% by January 2024 — a 31-point collapse in less than four years, according to research led by Northeastern University’s David Lazer and published in JAMA. This is not a partisan finding: the distrust was distributed across all socioeconomic groups, persisting even after controlling for political affiliation, though it was particularly acute among people with lower education, lower income, rural residents, and Black and female respondents.
Trust in the CDC, which had a 78% favorable rating among Democrats as recently as the summer of 2024, sits at 33% among Republicans. Trust in the FDA has dropped by double digits since 2023 alone, from 65% to 53%. Trust in personal physicians — historically the most trusted of all American institutions, more trusted than nurses, firefighters, or the military in most years of polling — fell from 93% in 2023 to 85% in 2025. Trust in medical doctors specifically has fallen 14 percentage points since 2021, the largest single-profession decline Gallup has ever recorded.
These are not marginal shifts. They represent a fundamental change in the relationship between the American public and the professional and governmental structures that manage collective health, safety, and welfare.
The federal government’s numbers are even starker. Only 23% of Americans trusted the federal government in spring 2024, according to the Partnership for Public Service — down from 35% just two years earlier. Only 15% believe the federal government is transparent. Sixty-six percent believe it is incompetent. Only 29% say democracy is working in the United States today.
In a 2022 Pew survey, majorities said the federal government unfairly benefits some people over others, doesn’t respond to the needs of ordinary Americans, and isn’t adequately careful with taxpayer money.
It is worth pausing on this. These are not fringe views. They are majority views, held by Americans across the political spectrum, documented repeatedly by the most rigorous polling organizations in the country. The crisis of institutional trust is not a perception problem that better communication will fix. It is a structural reality that any serious governance proposal has to account for.
What Drove This — And Why Blaming the Algorithm Is Too Simple
The instinct, when surveying this landscape, is to blame social media. The platforms are addictive by design, the argument goes; their algorithms feed users content that enrages and confirms rather than informs and challenges; echo chambers form and harden; and the shared factual basis necessary for democratic deliberation dissolves. There is truth in this account. But the research on echo chambers and algorithmic polarization is considerably more complicated than the popular version, and getting it right matters for understanding what can actually be done.
The strongest version of the algorithm-as-culprit argument does not hold up consistently across the research literature. A comprehensive review by the Reuters Institute for the Study of Journalism found that echo chambers are significantly less widespread than commonly assumed, found no support for the “filter bubble” hypothesis in its strong form, and described a mixed picture on the relationship between social media use and polarization. A landmark study in PNAS found a counterintuitive result: Republicans who were exposed to a liberal Twitter bot for one month became more conservative, not less — suggesting that cross-partisan exposure, rather than reducing polarization, may actually intensify it by heightening awareness of out-group differences.
More fundamentally, research from the University of Amsterdam found that platforms built without engagement algorithms still developed echo chambers — simply through the basic human dynamics of following like-minded people and sharing content with those who already agree. Polarization, in other words, is not a feature the algorithm imposes on otherwise rational users. It emerges from the interaction between human social psychology and any high-volume information environment. The algorithm accelerates and amplifies it. It did not invent it.
The more precise account is this: social media platforms are optimized for engagement, and the content that drives the most engagement is content that triggers strong emotional responses — outrage, fear, tribal affirmation, disgust. These emotions evolved in human neurology for a very different environment than the one we now inhabit, and they are not well-suited to the kind of deliberative, slow-thinking, information-updating cognition that democratic governance requires. The platforms do not force users to consume outrage content. They make outrage content easier to find, harder to avoid, and more socially rewarded than nuanced analysis. Over time, the cumulative effect on the information environment is corrosive — not because any individual is irrational, but because the system selects for and amplifies the least productive modes of collective reasoning.
There is also a deeper structural issue that predates social media: the economics of the attention industry. The advertising-based revenue model that dominates digital media is, at its core, a system that monetizes attention. Attention is most effectively captured by content that triggers anxiety and moral outrage. This means that the incentive structure of the information economy is fundamentally misaligned with the informational requirements of democratic governance. Platforms and publishers are not neutral conduits for public deliberation. They are businesses whose financial interests are served by keeping users emotionally activated and returning frequently — which is not the same as being well-informed and capable of collaborative problem-solving.
None of this is new. The attention economy’s misalignment with democratic health was observable and documented well before COVID. What the pandemic did was pour a stress test of extraordinary intensity through a system already strained to its limits. When official institutions gave conflicting guidance, when political leaders treated public health measures as partisan ammunition, and when the most visible information channels were optimized for engagement rather than accuracy, the result was a perfect environment for the collapse of exactly the kind of shared institutional trust that makes governance possible.
The Specific Damage to Healthcare Governance
The consequences of this collapse for healthcare are worth examining specifically, because they are not abstract.
When trust in physicians and hospitals falls from 71% to 40% in four years, what changes is not just sentiment. What changes is behavior. David Lazer, the Northeastern researcher whose team documented the decline, noted directly that individuals with lower trust in medical institutions were less likely to get vaccinated against COVID or seasonal influenza. Trust in institutions is not a soft outcome variable. It is a mechanism through which public health functions or fails.
If you don’t trust the establishment, if you don’t trust institutions, you’re more likely to go to Facebook groups who are making strange recommendations regarding health-related behaviors. This observation by Lazer captures something precise: the collapse of institutional trust does not leave a vacuum. It leaves an alternative information ecosystem — one that is specifically optimized for emotional resonance rather than accuracy, and one that is structurally incapable of self-correction in the way that scientific and medical institutions, however imperfect, are designed to be.
The damage is also systemic in ways that affect healthcare governance specifically. When communities distrust public health agencies, the coordinated responses that population-scale health problems require become harder to execute. Vaccination campaigns, screening programs, and behavioral health initiatives all depend on a baseline of public trust that has been materially eroded. The cost of that erosion shows up not in any single visible event but in the slow accumulation of deferred care, declined interventions, and community health outcomes that never quite reach their potential.
There is a further consequence for healthcare workforce that is rarely discussed in this context. When trust in physicians falls, the social contract between communities and medical providers weakens. The respect and community integration that once made rural medical practice intrinsically rewarding — the sense of being a trusted and valued community member — erodes alongside institutional trust generally. A physician considering a rural placement is not only doing a financial calculation. They are doing a relational calculation: will I be trusted here? Will my professional judgment be respected? Will I be seen as a community asset or a representative of an institution the community is skeptical of? The collapse of institutional trust changes that calculation in ways that no loan repayment program addresses.
The One Number That Matters Most
Given the uniformity of the collapse in trust at the national and institutional level, one finding stands out with unusual force.
Gallup’s annual update on trust in government institutions finds Americans have the most faith in local government at 67%, and the least faith in the legislative branch of the federal government, or Congress, at 32%. That 35-point gap has been remarkably stable across partisan cycles. In a 2023 Pew survey, 61% of U.S. adults had a favorable view of their local government, while only 22% felt positively about the federal government — a difference of 39 percentage points.
This is not a statistical artifact. It reflects something real about the nature of trust and the conditions under which it survives. Local government officials are closest to the people and more likely to hear directly from unhappy constituents. It is easier to go to your local town hall and access a town official or department head directly than it is to travel to Washington, DC in hopes of meeting someone in a position of authority.
The Deloitte research on government trust identifies this as a proximity effect: people trust institutions they can interact with, whose representatives they can see and question, and whose decisions they experience directly in their daily lives. Survey results indicate that respondents trust individual agencies more than overall government — suggesting that trust in an agency might be based on interactions, while perceptions of the abstraction of “state government” are more likely to be associated with the politics of government and influenced by media reports.
This distinction between interaction-based trust and abstraction-based trust is crucial. The institutions that have lost trust most dramatically — the federal government, Congress, national health agencies — are the ones that most Americans experience primarily through media rather than through direct interaction. They are the abstraction layer of governance, and that abstraction layer has been comprehensively colonized by the engagement-optimized information economy. When your primary experience of an institution is mediated through content that was selected for emotional impact rather than informational value, the resulting portrait is predictably distorted.
Local institutions, by contrast, are experienced directly. You know your county commissioner. You can attend your city council meeting. You can walk into your community health center and meet the people who work there. That directness is protective in an environment where the abstraction layer has become toxic.
Research published in 2024 found that rural Americans trust the federal government less than urban Americans, and that this gap persists regardless of which party holds power — suggesting that there is a deeper, more ingrained skepticism in rural communities that transcends party politics and may be linked to broader feelings of disenfranchisement and the belief that the government is out of touch with rural concerns.
Southern Oregon fits this profile precisely. It is a rural and semi-rural region with a long history of tension between local economic and community interests and the priorities of state and federal policy. The institutions that have lost the most trust are the ones least experienced locally. The institutions that retain trust are the ones closest to the ground: local clinics, community health workers, county health departments, and the small organizations that show up in people’s lives in tangible ways.
What This Means for Community Governance
Democracy and representative politics were designed, in theory, to function as a form of community governance — a mechanism by which people who share a territory make collective decisions about their shared lives. The theory holds that representatives aggregate the preferences of their constituents, translate those preferences into policy, and are held accountable through elections.
The theory has always had gaps between aspiration and practice. But the specific information environment of the past decade has opened those gaps to a width that makes the standard model increasingly unworkable for many practical problems at the local and regional level.
This is not primarily because politicians are unusually corrupt or self-interested compared to historical norms. It is because the information environment they operate in has been restructured in ways that reward performance for a national media audience rather than problem-solving for local constituents. A state legislator whose district includes Medford faces a choice, in every public statement, between messaging that will travel well in the engagement-optimized media environment and messaging that will serve the specific and complex needs of their actual constituents. These are not the same thing, and the incentives push systematically toward the former.
The result is a form of governance theater — not universal, not inevitable, but structurally encouraged — in which the appearance of advocacy substitutes for the hard, unglamorous work of building the cross-partisan, multi-institutional coalitions that actual community problems require. Healthcare access in Southern Oregon is not a legible partisan issue. It does not have a villain that can be identified and defeated in a 30-second clip. It has structural causes that require structural responses, and those responses require the kind of sustained, patient, technically complex coalition work that earns no one a national profile.
This is the governance vacuum that community-based institutions exist to fill — not by replacing democratic politics, but by operating in the space where democratic politics, as currently structured, cannot function effectively. When state-level price transparency legislation fails because the hospital lobby can mobilize organized opposition faster than diffuse public interest can be aggregated, that is not a failure of any individual lawmaker. It is a failure of the information and organizational environment in which policy is made. The response is not to despair of democracy, but to recognize that some problems require a different organizational form: direct community governance, at the scale at which trust still exists, pursuing objectives that are tangible enough to be evaluated by their actual outcomes rather than their rhetorical performance.
The Local Scale Is Where Trust Still Lives — And Where It Can Be Rebuilt
There is an emerging body of evidence that the trust asymmetry between local and national institutions is not merely a residual — not just old trust that hasn’t yet been eroded by the dynamics destroying trust at higher levels. There is evidence that local trust is actively resilient in a way that creates a genuine foundation for governance.
A 2025 survey of Michigan local officials found that 82% rated the functioning of democracy in their communities at 7 or higher on a 10-point scale — a figure that has remained remarkably steady since 2020. While only 17% of Americans currently trust the federal government to do what is right just about always or most of the time, 65% still trust their local government.
Small businesses retain the trust of 86% of Americans, according to Pew — higher than any governmental or institutional actor in most surveys. Local news organizations are trusted by 74% of Americans, compared to 59% for national media. Local elections are viewed as well-administered by 69% of voters, while only 43% say the same about elections nationally.
The pattern is consistent enough to constitute a principle: at the scale at which people can see, interact with, and hold accountable the institutions that affect their lives, trust is recoverable. At the scale at which experience is primarily mediated through the engagement-optimized information environment, trust has been systematically degraded and shows little sign of recovery under current conditions.
What does this mean practically? It means that community governance — the direct kind, built from local institutions that are accountable to the people they serve — is not a consolation prize for the failure of national politics. It is, right now, the only form of governance that retains the public trust necessary to actually function.
This has implications for how we think about solving problems at the regional scale. A proposal to solve Southern Oregon’s healthcare provider shortage through federal legislation faces a trust environment in which the federal government is trusted by 23% of the public, in which rural Americans are specifically skeptical of federal institutions regardless of party, and in which the legislative process itself is widely seen as serving institutional rather than community interests.
A proposal to solve the same problem through a community-governed purchasing alliance — locally controlled, membership-governed, accountable to the people it serves — operates in a different trust environment entirely. It asks people to trust not an abstraction, but an organization they can join, whose board they can vote for, and whose outcomes they can evaluate in their own insurance premiums. That is not a naive distinction. It is the distinction between governance that can actually function in the current environment and governance that cannot.
A Note on What This Is Not Arguing
This essay is not arguing that national institutions are irretrievably broken, or that federal policy does not matter for communities like Southern Oregon. Federal HPSA designations unlock real resources. OHA’s coordinated care model has genuinely changed how Medicaid works in Oregon for the better. The legislative work that Sen. Jeff Golden is doing on wildfire insurance and healthcare cooperatives matters and is worth supporting. National and state institutions remain essential.
What this essay is arguing is that the governance model in which communities identify a problem, elect representatives who develop a solution, pass legislation, and implement a program — while not obsolete — is significantly impaired in its current operating environment, and that communities facing acute, structural problems cannot afford to wait for that model to repair itself.
The impairment is not a permanent condition. Trust is rebuilable. The research on what rebuilds it is actually fairly consistent: transparency, direct interaction, tangible outcomes, and accountability to specific communities rather than to abstract constituencies. These are the design principles of effective local governance, and they are the same design principles that make community purchasing alliances, worker cooperatives, and locally governed health institutions work when larger structures fail.
What is required is the willingness to build at the scale that trust still supports — and to demonstrate, through tangible outcomes, that collective local action can accomplish what the broken abstraction layer of national governance currently cannot.
There is no waiting for the information environment to improve, for social media’s incentive structure to be reformed, or for national political institutions to recover their legitimacy. Those changes, if they come, will come slowly and with no guarantee. The healthcare provider shortage in Southern Oregon is acute now. The wildfire insurance crisis is accelerating now. The cost of living barriers to recruitment are present now.
The institutions that can act on these problems — CCOs, health systems, county governments, large employers, community organizations — retain the community trust necessary to act. Local democracy is holding strong in ways that national institutions are not. The question is whether the people who lead those local institutions will recognize the moment for what it is: not a political problem to be solved through the broken channels of a degraded information environment, but a community governance problem to be solved through direct, local, accountable collective action.
That is what community purchasing alliances are. That is what workforce housing funds are. That is what neighborhood fire resilience cooperatives are. Not technocratic workarounds. Not substitutes for democracy. But democracy functioning at the only scale at which it currently can — close enough to the ground that the people doing the governing can be seen, questioned, and held accountable by the people they serve.
That is not a small thing. In the current environment, it may be the only thing.
ReImagine Healthcare publishes research and analysis on healthcare system design in Southern Oregon. We are a subsidiary of Flourish Charity, a 501(c)(3) nonprofit. We welcome responses, corrections, and partnership inquiries at reimagine-healthcare.org.