Vaccinating people who have had Covid 19: Why doesn't natural immunity count in the US ?

The US CDC estimates that SARS-CoV-2 has infected more than 100 million Americans, and evidence is mounting that natural immunity is at least as protective as vaccination. Yet public health leadership says everyone needs the vaccine. Jennifer Block investigates

When the vaccine rollout began in mid-December 2020, more than one quarter of Americans—91 million—had been infected with SARS-CoV-2, according to a US Centers for Disease Control and Prevention (CDC) estimate.1 As of this May, that proportion had risen to more than a third of the population, including 44% of adults aged 18-59 (table 1)

The substantial number of infections, coupled with the increasing scientific evidence that natural immunity was durable, led some medical observers to ask why natural immunity didn’t seem to be factored into decisions about prioritising vaccination.234

“The CDC could say [to people who had recovered], very well grounded in excellent data, that you should wait 8 months,” Monica Gandhi, an infectious disease specialist at University of California San Francisco, told Medpage Today in January. She suggested authorities ask people to “please wait your turn.”4

Others, such as Icahn School of Medicine virologist and researcher Florian Krammer, argued for one dose in those who had recovered. “This would also spare individuals from unnecessary pain when getting the second dose and it would free up additional vaccine doses,” he told the New York Times.5

“Many of us were saying let’s use [the vaccine] to save lives, not to vaccinate people already immune,” says Marty Makary, a professor of health policy and management at Johns Hopkins University.

Still, the CDC instructed everyone, regardless of previous infection, to get fully vaccinated as soon as they were eligible: natural immunity “varies from person to person” and “experts do not yet know how long someone is protected,” the agency stated on its website in January.6 By June, a Kaiser Family Foundation survey found that 57% of those previously infected got vaccinated.7

As more US employers, local governments, and educational institutions issue vaccine mandates that make no exception for those who have had covid-19,8 questions remain about the science and ethics of treating this group of people as equally vulnerable to the virus—or as equally threatening to those vulnerable to covid-19—and to what extent politics has played a role.

The evidence

“Starting from back in November, we’ve had a lot of really important studies that showed us that memory B cells and memory T cells were forming in response to natural infection,” says Gandhi. Studies are also showing, she says, that these memory cells will respond by producing antibodies to the variants at hand.91011

Gandhi included a list of some 20 references on natural immunity to covid in a long Twitter thread supporting the durability of both vaccine and infection induced immunity.12 “I stopped adding papers to it in December because it was getting so long,” she tells The BMJ.

But the studies kept coming. A National Institutes of Health (NIH) funded study from La Jolla Institute for Immunology found “durable immune responses” in 95% of the 200 participants up to eight months after infection.13 One of the largest studies to date, published in Science in February 2021, found that although antibodies declined over 8 months, memory B cells increased over time, and the half life of memory CD8+ and CD4+ T cells suggests a steady presence.9

Real world data have also been supportive.14 Several studies (in Qatar,15 England,16 Israel,17 and the US18) have found infection rates at equally low levels among people who are fully vaccinated and those who have previously had covid-19. Cleveland Clinic surveyed its more than 50 000 employees to compare four groups based on history of SARS-CoV-2 infection and vaccination status.18 Not one of over 1300 unvaccinated employees who had been previously infected tested positive during the five months of the study. Researchers concluded that that cohort “are unlikely to benefit from covid-19 vaccination.” In Israel, researchers accessed a database of the entire population to compare the efficacy of vaccination with previous infection and found nearly identical numbers. “Our results question the need to vaccinate previously infected individuals,” they concluded.17

As covid cases surged in Israel this summer, the Ministry of Health reported the numbers by immunity status. Between 5 July and 3 August, just 1% of weekly new cases were in people who had previously had covid-19. Given that 6% of the population are previously infected and unvaccinated, “these numbers look very low,” says Dvir Aran, a biomedical data scientist at the Technion–Israel Institute of Technology, who has been analysing Israeli data on vaccine effectiveness and provided weekly ministry reports to The BMJ. While Aran is cautious about drawing definitive conclusions, he acknowledged “the data suggest that the recovered have better protection than people who were vaccinated.”

But as the delta variant and rising case counts have the US on edge, renewed vaccination incentives and mandates apply regardless of infection history.8 To attend Harvard University or a Foo Fighters concert or enter indoor venues in San Francisco and New York City, you need proof of vaccination. The ire being directed at people who are unvaccinated is also indiscriminate—and emanating from America’s highest office. In a recent speech to federal intelligence employees who, along with all federal workers, will be required to get vaccinated or submit to regular testing, President Biden left no room for those questioning the public health necessity or personal benefit of vaccinating people who have had covid-19: “We have a pandemic because of the unvaccinated ... So, get vaccinated. If you haven’t, you’re not nearly as smart as I said you were.”

Staying firm

Other countries do give past infection some immunological currency. Israel recommends that people who have had covid-19 wait three months before getting one mRNA vaccine dose and offers a “green pass” (vaccine passport) to those with a positive serological result regardless of vaccination.19 In the European Union, people are eligible for an EU digital covid certificate after a single dose of an mRNA vaccine if they have had a positive test result within the past six months, allowing travel between 27 EU member states.20 In the UK, people with a positive polymerase chain reaction (PCR) test result can obtain the NHS covid pass up until 180 days after infection.21

Although it’s too soon to say whether these systems are working smoothly or mitigating spread, the US has no category for people who have been infected. The CDC still recommends a full vaccination dose for all, which is now being mirrored in mandates. A spokesperson told The BMJ that “the immune response from vaccination is more predictable” and that based on current evidence, antibody responses after infection “vary widely by individual,” though studies are ongoing to “learn how much protection antibodies from infection may provide and how long that protection lasts.”

In June, Peter Marks, director of the Food and Drug Administration’s Center for Biologics Evaluation and Research, which regulates vaccines, went a step further and stated: “We do know that the immunity after vaccination is better than the immunity after natural infection.” In an email, an FDA spokesperson said Marks’s comment was based on a laboratory study of the binding breadth of Moderna vaccine induced antibodies.22 The research did not measure any clinical outcomes. Marks added, referring to antibodies, that “generally the immunity after natural infection tends to wane after about 90 days.”23

“It appears from the literature that natural infection provides immunity, but that immunity is seemingly not as strong and may not be as long lasting as that provided by the vaccine,” Alfred Sommer, dean emeritus of the Johns Hopkins Bloomberg School of Public Health tells The BMJ.

But not everyone agrees with this interpretation. “The data we have right now suggests that there probably isn’t a whole lot of difference” in terms of immunity to the spike protein, says Matthew Memoli, director of the Laboratory of Infectious Diseases Clinical Studies at the NIH, who spoke to The BMJ in a personal capacity.

Memoli highlights real world data such as the Cleveland Clinic study18 and points out that while “vaccines are focused on only that tiny portion of immunity that can be induced” by the spike, someone who has had covid-19 was exposed to the whole virus, “which would likely offer a broader based immunity” that would be more protective against variants. The laboratory study offered by the FDA22 “only has to do with very specific antibodies to a very specific region of the virus [the spike],” says Memoli. “Claiming this as data supporting that vaccines are better than natural immunity is shortsighted and demonstrates a lack of understanding of the complexity of immunity to respiratory viruses.”

Antibodies

Much of the debate pivots on the importance of sustained antibody protection. In April, Anthony Fauci told US radio host Maria Hinajosa that people who have had covid-19 (including Hinajosa) still need to be “boosted” by vaccination because “your antibodies will go sky high.”

“That’s still what we’re hearing from Dr Fauci—he’s a strong believer that higher antibody titres are going to be more protective against the variants,” says Jeffrey Klausner, a clinical professor of preventive medicine at the University of Southern California and former CDC medical officer, who has spoken out in favour of treating prior infection as equivalent to vaccination, with “the same societal status.”3 Klausner conducted a systematic review of 10 studies on reinfection and concluded that the “protective effect” of a previous infection “is high and similar to the protective effect of vaccination.”

In vaccine trials, antibodies are higher in participants who were seropositive at baseline than in those who were seronegative.24 However, Memoli questions the importance: “We don’t know that that means it’s better protection.”

Former CDC director Tom Frieden, a proponent of universal vaccination, echoes that uncertainty: “We don’t know that antibody level is what determines protection.”

Gandhi and others have been urging reporters away from antibodies as the defining metric of immunity. “It is accurate that your antibodies will go down” after natural infection, she says—that’s how the immune system works. If antibodies didn’t clear from our bloodstream after we recover from a respiratory infection, “our blood would be thick as molasses.”

“The real memory in our immune system resides in the [T and B] cells, not in the antibodies themselves,” says Patrick Whelan, a paediatric rheumatologist at University of California, Los Angeles. He points out that his sickest covid-19 patients in intensive care, including children with multisystem inflammatory syndrome, have “had loads of antibodies ... So the question is, why didn’t they protect them?”

Antonio Bertoletti, a professor of infectious disease at Duke-NUS Medical School in Singapore, has conducted research that indicates T cells may be more important than antibodies. Comparing the T cell response in people with symptomatic versus asymptomatic covid-19, Bertoletti’s team found them to be identical, suggesting that the severity of infection does not predict strength of resulting immunity and that people with asymptomatic infections “mount a highly functional virus specific cellular immune response.”25

Already complicated rollout

While some argue that the pandemic strategy should not be “one size fits all,” and that natural immunity should count, other public health experts say universal vaccination is a more quantifiable, predictable, reliable, and feasible way to protect the population.

Frieden told The BMJ that the question of leveraging natural immunity is a “reasonable discussion,” one he had raised informally with the CDC at start of rollout. “I thought from a rational standpoint, with limited vaccine available, why don’t you have the option” for people with previous infection to defer until there was more supply, he says. “I think that would have been a rational policy. It would have also made rollout, which was already too complicated, even more complicated.”

Most infections were never diagnosed, Frieden points out, and many people may have assumed they had been infected when they hadn’t. Add to that false positive results, he says. Had the CDC given different directives and vaccine schedules based on prior infection, it “wouldn’t have done much good and might have done some harm.”

Klausner, who is also a medical director of a US testing and vaccine distribution company, says he initiated conversations about offering a fingerprick antibody screen for people with suspected exposure before vaccination, so that doses could be used more judiciously. But “everyone concluded it was just too complicated.”

“It’s a lot easier to put a shot in their arm,” says Sommer. “To do a PCR test or to do an antibody test and then to process it and then to get the information to them and then to let them think about it—it’s a lot easier to just give them the damn vaccine.” In public health, “the primary objective is to protect as many people as you can,” he says. “It’s called collective insurance, and I think it’s irresponsible from a public health perspective to let people pick and choose what they want to do.”

But Klausner, Gandhi, and others raise the question of fairness for the millions of Americans who already have records of positive covid test results—the basis for “recovered” status in Europe—and equity for those at risk who are waiting to get their first dose (an argument being raised anew as US officials announce boosters while the virus spreads in countries lacking vaccine supply). For people who did not have a confirmed positive result but suspected previous infection, reliable antibody tests have been accessible “at least since April,” according to Klausner, though in May, the FDA announced that “antibody tests should not be used to evaluate a person’s level of immunity or protection from covid-19 at any time.”26

Unlike Europe, the US doesn’t have a national certificate or vaccination requirement, so defenders of natural immunity have simply advocated for more targeted recommendations and screening availability—and that mandates allow for exemptions. Logistics aside, a recognition of existing immunity would have fundamentally changed the target vaccination calculations and would also affect the calculations on boosters. “As we continued to put effort into vaccination and set targets, it became apparent to me that people were forgetting that herd immunity is formed by both natural immunity and vaccine immunity,” says Klausner.

Gandhi thinks logistics is only part of the story. “There’s a very clear message out there that ‘OK, well natural infection does cause immunity but it’s still better to get vaccinated,’ and that message is not based on data,” says Gandhi. “There’s something political going on around that.”

Politics of natural immunity

Early in the pandemic, the question of natural immunity was on the mind of Ezekiel Emanuel, a bioethicist at the University of Pennsylvania and senior fellow at the liberal think tank Center for American Progress, who later became a covid adviser to President Biden. He emailed Fauci before dawn on 4 March 2020. Within a few hours, Fauci wrote back: “you would assume that their [sic] would be substantial immunity post infection.”27

That was before natural immunity started to be promoted by Republic politicians. In May 2020, Kentucky senator and physician Rand Paul asserted that since he already had the virus, he didn’t need to wear a mask. He has been the most vocal since, arguing that his immunity exempted him from vaccination. Wisconsin senator Ron Johnson and Kentucky representative Thomas Massie have also spoken out. And then there was President Trump, who tweeted last October that his recovery from covid-19 rendered him “immune” (which Twitter labelled “misleading and potentially harmful information”).

Another polarising factor may have been the Great Barrington declaration of October 2020, which argued for a less restrictive pandemic strategy that would help build herd immunity through natural infections in people at minimal risk.28 The John Snow memorandum, written in response (with signatories including Rochelle Walensky, who went on to head the CDC), stated “there is no evidence for lasting protective immunity to SARS-CoV-2 following natural infection.”29 That statement has a footnote to a study of people who had recovered from covid-19, showing that blood antibody levels wane over time.

More recently, the CDC made headlines with an observational study aiming to characterise the protection a vaccine might give to people with past infections. Comparing 246 Kentuckians who had subsequent reinfections with 492 controls who had not, the CDC concluded that those who were unvaccinated had more than twice the odds of reinfection.30 The study notes the limitation that the vaccinated are “possibly less likely to get tested. Therefore, the association of reinfection and lack of vaccination might be overestimated.” In announcing the study, Walensky stated: “If you have had covid-19 before, please still get vaccinated.”31

“If you listen to the language of our public health officials, they talk about the vaccinated and the unvaccinated,” Makary tells The BMJ. “If we want to be scientific, we should talk about the immune and the non-immune.” There’s a significant portion of the population, Makary says, who are saying, “‘Hey, wait, I’ve had [covid].’ And they’ve been blown off and dismissed.”

Different risk-benefit analysis?

For Frieden, vaccinating people who have already had covid-19 is, ultimately, the most responsible policy right now. “There’s no doubt that natural infection does provide significant immunity for many people, but we’re operating in an environment of imperfect information, and in that environment the precautionary principle applies—better safe than sorry.”

“In public health you are always dealing with some level of unknown,” says Sommer. “But the bottom line is you want to save lives, and you have to do what the present evidence, as weak as it is, suggests is the strongest defence with the least amount of harm.”

But others are less certain.

“If natural immunity is strongly protective, as the evidence to date suggests it is, then vaccinating people who have had covid-19 would seem to offer nothing or very little to benefit, logically leaving only harms—both the harms we already know about as well as those still unknown,” says Christine Stabell Benn, vaccinologist and professor in global health at the University of Southern Denmark. The CDC has acknowledged the small but serious risks of heart inflammation and blood clots after vaccination, especially in younger people. The real risk in vaccinating people who have had covid-19 “is of doing more harm than good,” she says.

A large study in the UK32 and another that surveyed people internationally33 found that people with a history of SARS-CoV-2 infection experienced greater rates of side effects after vaccination. Among 2000 people who completed an online survey after vaccination, those with a history of covid-19 were 56% more likely to experience a severe side effect that required hospital care.33

Patrick Whelan, of UCLA, says the “sky high” antibodies after vaccination in people who were previously infected may have contributed to these systemic side effects. “Most people who were previously ill with covid-19 have antibodies against the spike protein. If they are subsequently vaccinated, those antibodies and the products of the vaccine can form what are called immune complexes,” he explains, which may get deposited in places like the joints, meninges, and even kidneys, creating symptoms.

Other studies suggest that a two dose regimen may be counterproductive.34 One found that in people with past infections, the first dose boosted T cells and antibodies but that the second dose seemed to indicate an “exhaustion,” and in some cases even a deletion, of T cells.34 “I’m not here to say that it’s harmful,” says Bertoletti, who coauthored the study, “but at the moment all the data are telling us that it doesn’t make any sense to give a second vaccination dose in the very short term to someone who was already infected. Their immune response is already very high.”

Despite the extensive global spread of the virus, the previously infected population “hasn’t been studied well as a group,” says Whelan. Memoli says he is also unaware of any studies examining the specific risks of vaccination for that group. Still, the US public health messaging has been firm and consistent: everyone should get a full vaccine dose.

“When the vaccine was rolled out the goal should have been to focus on people at risk, and that should still be the focus,” says Memoli. Such risk stratification may have complicated logistics, but it would also require more nuanced messaging. “A lot of public health people have this notion that if the public is told that there’s even the slightest bit of uncertainty about a vaccine, then they won’t get it,” he says. For Memoli, this reflects a bygone paternalism. “I always think it’s much better to be very clear and honest about what we do and don’t know, what the risks and benefits are, and allow people to make decisions for themselves.”

Say the Liberals Win, Then What

An article form The Atlantic by Elaine Godfrey

If Democrats manage to hold the House of Representatives and win back the Senate and the White House in November, the party will have full control of the federal government for the first time in 11 years. Police reform, climate change, and health care are all on their agenda. But before newly empowered Democrats get to any of that, they will very likely pass a relief package to address the coronavirus pandemic and the associated economic crisis. Then, they will aim to fundamentally change how voting and government work in the United States by expanding voting rights, reducing the influence of money in politics, strengthening ethics rules, and maybe even ending the Senate filibuster—reforms they hope will make America’s democracy work better and the rest of their agenda easier to carry out.

“If there is any political capital to be spent, the concerns over democracy reform take a front seat to everything in the agenda,” a senior aide to a progressive senator told me (the aide requested anonymity because he wasn’t authorized to speak on the record). It “would mean so much just in terms of building long-term power,” a senior aide to a progressive House Democrat added.

By starting with these reforms, Democrats are taking a risk: They’ll likely have only a short window of time in the majority to accomplish their most pressing agenda items. Prioritizing one item could mean sacrificing another—and failing to deliver on key issues.

But the Democratic lawmakers, staffers, and activists that I spoke with view government and voting reform as a kind of precursor to accomplishing any of their other policy goals. “The first attention will be to the economic implosion, but there are a group of [other] issues on people’s minds,” Senator Jeff Merkley of Oregon told me. “We are at that moment where we have to succeed now in restoring the integrity of the American vision.” Democrats have given these process changes, which they call “democracy reform,” top billing on their legislative docket before. The For the People Act, more commonly known as H.R. 1, was the first piece of legislation the Democratic-controlled House passed in 2019. It contained a grab bag of reforms: establishing automatic voter registration for all Americans, making Election Day a national holiday, ending partisan gerrymandering, requiring presidents to disclose their tax returns, and creating a public-financing system for federal campaigns. These reforms would make it easier for most Americans to vote. They’d also, Democrats hope, make it easier for Democrats to win elections.

The Democrats’ plan is informed by experience. The last time Democrats controlled both the White House and Congress, they—under the leadership of President Barack Obama—attempted, at least at first, to foster a good working relationship with Republicans. Yet, after weeks of negotiations, the 2009 stimulus bill received only three GOP votes in the Senate. Not a single Republican voted to pass the Affordable Care Act, after a year of negotiations and floor debate—despite the fact that the legislation was modeled, in part, on a Republican template, and GOP amendments had been accepted to the bill. Obama had hoped to reach a “grand bargain” with Republicans but instead became acquainted with what his aides came to call “the party of no.” Many Democrats believe those times offer a lesson: They need to fix the structural issues that have long given Republicans political power disproportionate to the number of votes the party wins.

Republicans, naturally, are deeply resistant to many of the proposals included in H.R. 1. They argue that the provisions amount to extreme government overreach, and that expanding voting access through mechanisms such as automatic registration will open America’s elections system up to voter fraud. Not a single Republican voted to support H.R. 1 in the House last year, and Senate Majority Leader Mitch McConnell has blocked it from coming to a vote on the Senate floor. “They’re trying to clothe this power grab with cliches about ‘restoring democracy’ … but their proposal is simply a naked attempt to change the rules of American politics to benefit one party,” he wrote in a Washington Post column.

With McConnell and House Republicans opposed to most of their priorities, Democrats will have to structure their agenda carefully—and move quickly. Some Democrats would prefer to take advantage of the increased appetite for health-care reform to pass Medicare for All or a public option in the first weeks of a Joe Biden presidency. Others see climate-change legislation as the first priority. But voting-rights expansion and campaign-finance reforms would likely be simpler and faster to pass, given that the framework already exists in H.R. 1, the Democrats I spoke with said. And everyone agreed that both health care and climate change could be addressed—at least to some extent—in an initial coronavirus-response package; Biden’s “Build Back Better” economic-recovery proposal already promises investment in clean energy sources.

By January 2021, America will likely still be experiencing the twin public-health and economic crises brought on by the coronavirus pandemic, and voters will likely have gone through a drawn-out and chaotic November election. Appetite for political reform will be high, Democrats argue. “Over four years, we’ve learned of weaknesses in our democracy,” Neera Tanden, the president of the Center for American Progress, a Washington-based liberal think tank, told me. “To move a progressive agenda, we need to restore faith in government.”

Another reason that many Democrats would like to prioritize H.R. 1: It’s one of the few issues that unites nearly all factions of the party, so it’s politically feasible. Every single House Democrat voted in favor of the bill. “There’s gonna be an element of, how can you show progressives that you’re in it to win it and willing to go big? There are some things on democracy reform that will really send that message and really do that,” said one aide to a centrist senator, who was not authorized to speak on the record. “Leadership knows that is an issue that would make the left very happy and allow the moderates to deliver on what they’ve promised,” Lanae Erickson, a senior president at the think-tank Third Way, told me.

Democrats believe their reform agenda could be a political winner. “Ending the culture of corruption in Washington” was the top issue for 75 percent of voters in swing districts in 2018, according to a poll from Greenberg Quinlan Rosner Research. That year, 72 percent of candidates on the House Democrats’ list of highly competitive races rejected donations from corporate political action committees, a pledge that became a litmus test during the campaign. That was up from just 6 percent in 2016, according to End Citizens United, a political action committee working to pass campaign-finance reform.

Before they can pass their “democracy reform,” though, Democrats have to decide exactly what that entails. Most progressives interpret the phrase to include not only expanding voting rights, but also establishing D.C. statehood and abolishing the Electoral College, two proposals that are still controversial among rank-and-file members. Public support for both ideas is mixed: More than 60 percent of U.S. adults oppose D.C. statehood, according to a recent Gallup poll, while a majority of Americans support amending the Constitution so the presidential candidate who wins the popular vote wins the election.

But far and away the most serious threat to the effectiveness of a Biden presidency and a Democratic House and Senate is the filibuster, the Senate rule that requires 60 senators, instead of a simple majority of 51, to move forward on most legislation. Even if Democrats win the Senate in November, they very likely won’t have 60 votes, meaning that Republicans could still block legislation from being debated. Progressives have long wanted to abolish the supermajority voting threshold, but the idea has begun to gain traction among other Democrats, too, in recent weeks. Perhaps, some Democrats argue, the filibuster is a natural place to launch their democracy-reform initiative: They can put forward a slew of policies strengthening ethics guidelines and expanding voting rights—including a bill that would restore the Voting Rights Act of 1965—and dare Republicans to vote against it. (The VRA had strong bipartisan support until the mid-2000s.) “It’s a pretty easy argument to make,” the aide to the centrist senator told me. “Democrats would be happy to be like, Look at these fuckin’ guys! They still want to make it difficult for people of color to vote!”

Progressives are enthusiastic about that plan. “If I had to guess how it’s going to happen, it’s going to be, If we can’t pass the VRA, we’re going to get rid of the filibuster,” Adam Green, the co-founder of the Progressive Change Campaign Committee, told me. “Starting with H.R. 1 is a good idea,” Representative Ro Khanna of California told me. “The filibuster could come right next.”

Then again, Democrats might not have any of these options in January. Trump could win the election; Republicans could hold the Senate or even win control of the House. The Democrats could sweep, but have something else at top of mind. Or, some of my Hill sources suggested, Biden may want to start off his first term by pursuing legislation that is more amenable to Republicans, though none of the aides I spoke with could identify what that unifying project might be. When asked about Biden’s own legislative priorities, a campaign spokesperson responded that his No. 1 goal will be “repairing and rebuilding from the economic ruin and public-health crisis caused by Donald Trump’s utter failure to fulfill his basic duty as president: protect America.”

Even if they win full control, though, Democrats won’t have a lot of time. As my colleague Ronald Brownstein noted recently, “the last four times a president—of either party—went into a midterm with unified control, voters have revoked it. … No party has controlled all the levers of government for more than four consecutive years since 1968.” And a President Biden and an incoming Democratic Congress will be facing a mountain of tasks. There will almost certainly be early battles over government funding and coronavirus-response packages.

If Democrats find themselves in the majority again for the first time in more than a decade, though, they are determined not to squander the opportunity. In his July eulogy for Representative John Lewis, Obama implored lawmakers to quickly make changes that protect and expand the right to vote—not for partisan advantage, he insisted, but in an effort to form a more perfect union. Republicans remain skeptical. But Democrats were listening.