Robert Pearl: Political and economic pressures set up a health care shift in 2026

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Health care in 2025 was consumed by chaos, conflict and relentless drama. Yet despite unprecedented political turmoil, cultural division and major technological breakthroughs, there was little meaningful improvement in how care is paid for or delivered.

That outcome was not surprising. American medicine is extraordinarily resistant to change. In most years, even when problems are obvious and widely acknowledged, the safest bet is that the care patients experience in January will look much the same in December.

But when meaningful change does occur, it is usually because motivated leaders find themselves in rare political and economic conditions. Think of President Barack Obama in 2009, with unified Democratic control of Congress and widespread voter frustration over health care costs and coverage. By contrast, President Bill Clinton’s ambitious reform effort collapsed in 1993 when it collided with powerful industry opposition and a divided political environment.

If most years prove stagnant, why should anyone expect 2026 to be different? In a word: pressure.

Congress, the president, drug manufacturers and insurers are all confronting forces that make inaction increasingly risky. Three external pressures will drive change:

For Republicans broadly, and for President Trump personally, the 2026 midterm elections present significant political risk. Even a modest shift in “purple” districts could flip control of the House, reshaping committee leadership and reviving the prospect of Trump’s impeachment.

The “Big Beautiful Bill” passed by Congress in mid-2025 locked in permanent tax cuts with a multi-trillion-dollar price tag, narrowing the universe of spending categories large enough to materially reduce the deficit.

With health care accounting for nearly 30% of the federal budget (and other categories such as Social Security and defense politically untouchable), medical spending became one of the few remaining fiscal levers. But pulling it also handed Democrats a potent midterm weapon.

The shutdown compounded the problem. By linking government dysfunction to health care funding and coverage uncertainty, Democrats spotlighted rising medical costs as a symbol of incumbent political failure.

As health care economics worsen in 2026, the pressure will intensify. Premium increases will outpace wage growth. Deductibles will remain high. Tens of millions of Americans face potential Medicaid coverage losses, while 20 million more will see sharply higher exchange premiums.

The likeliest response to pressure: Fearful of losing the House, Trump and congressional Republicans are likely to pursue targeted, high-visibility actions designed to appease voters.

Drug pricing offers a clear example. In November, the White House announced agreements with nine large pharmaceutical companies to lower prices on certain medications under a “most-favored-nation” framework. However, those deals won’t materially lower prices because they apply only to Medicaid and selected drugs, leaving most privately insured patients exposed to persistently high costs.

Other options Congress and the president are likely to pursue include a short-term extension of exchange subsidies paired with familiar proposals such as expanded health savings accounts, “catastrophic” plans and lower limits on premium support.

For decades, the pharmaceutical industry has occupied a uniquely protected position in the U.S. economy. Long patent exclusivities, limited competition from generics and biosimilars and sustained lobbying success have shielded it from price regulation. As a result, pharmaceuticals remain among the fastest growing and most profitable U.S. sectors.

Americans currently pay two to four times more for prescription drugs than patients in other wealthy nations, and roughly one in three prescriptions goes unfilled because of cost. Affordability has become a crisis for employers and voters.

The likeliest response to pressure: Given the growing political pressure, drugmakers face a strategic choice. One path is familiar: resist change through lobbying, campaign contributions and legal challenges. The other is more adaptive: accept lower margins on some products in exchange for higher volumes and reduced political risk.

Based on the recent agreements that brought 14 of the 17 largest drugmakers into voluntary pricing arrangements with the administration, most are likely to continue to follow the second path.

By shielding their most profitable products while conceding selectively on pricing, manufacturers can reduce political pressure without materially sacrificing profitability.

In 2026, employer-sponsored premiums are projected to rise at roughly twice the rate of inflation. The annual cost of coverage for a family of four will be $27,000, with employees paying roughly one-quarter of that total out of pocket.

Patients already delay or forgo care because of cost. Meanwhile, medical bills remain the leading contributor to personal bankruptcy in the United States.

Insurers, who have no control over how medicine is practiced, have relied on tighter prior-authorization requirements, narrower networks and higher rates of claims denial. While these tactics can suppress short-term spending, they have fueled widespread backlash from patients, physicians, employers and lawmakers.

In effect, insurers are being squeezed from both sides: rising costs they cannot fully pass on and a public increasingly hostile to how those costs are managed.

The likeliest response to pressure: When premiums and out-of-pocket costs exceed what payers and patients can bear, the traditional insurance model begins to fracture.

That is where capitation re-enters the conversation. Under capitation, insurers make a fixed, per-patient payment to a physician group or health system to manage most or all care for a defined population. Providers assume responsibility for utilization, coordination and cost control. In return, they gain flexibility in care delivery and the opportunity to share in savings when prevention and chronic disease management succeed.

For insurers, the appeal is straightforward: capitation shifts financial risk downstream and reduces reliance on unpopular utilization controls. But moving from fee-for-service to capitation would require major structural change. As a result, insurers in 2026 are more likely to introduce pilot programs, partial risk arrangements and expanded use of generative AI rather than pursue wholesale transformation.

A new year carries the promise of change. Look for shifting political and economic climates to make 2026 a year of health care improvement, especially compared to 2025.

Robert Pearl, the author of “ChatGPT, MD,” teaches at both the Stanford University School of Medicine and the Stanford Graduate School of Business. He is a former CEO of The Permanente Medical Group. He wrote this column for the Fulcrum, a nonprofit, nonpartisan news platform covering efforts to fix our governing systems.

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Other voices: Bondi’s letter to Minnesota deserves scorn. But it’s a warning we can’t ignore.

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MIAMI — Florida woman Pam Bondi has really distinguished herself this time. The U.S. attorney general who famously botched the handling of the Jeffrey Epstein files has written a letter to Minnesota’s governor — on Saturday, the same day nurse Alex Pretti was shot dead by immigration agents — in what can only be interpreted as an extortion attempt.

Bondi — a two-time Florida attorney general before President Trump tapped her to become the top law enforcement official in the country — is suggesting that Minnesota hand over its voter rolls as a condition for ending immigration operations that have resulted in the deaths of two people at the hands of ICE.

Bondi’s letter was as subtle as a sledgehammer. She said the state could “bring an end to the chaos in Minnesota” if it would just take a few “simple steps.” Then she spelled it out: turn over to the federal government records for food assistance and Medicaid, end pro-immigrant “sanctuary” policies and cough up voter data.

That’s one step away from a mob-style threat: Nice state you have there. Be a shame if anything happened to it.

Is Bondi trying, as she said in the letter, to “bring back law and order”? Or is her letter, as an attorney for the state said in court Monday, really nothing but a “ransom note”? Some important context to consider: There have been no claims of widespread voter fraud in Minnesota. And, critically, the Justice Department is in the middle of suing nearly two dozen states, including Minnesota, for their full, unredacted voter files, which apparently would include dates of birth, driver license numbers and partial social security numbers. That’s the same information Bondi asked for in her missive to Minnesota Gov. Tim Walz.

Reminder: We’re heading toward a midterm election in November in which Republicans increasingly seem to be in trouble. This effort by Bondi certainly sounds as though the government is using the continued threat of ICE enforcement in the state as leverage to access election information — and potentially use it to sow doubts ahead of the elections. That would on brand for Trump. He already tried overturning an election.

The food assistance and Medicaid information is a reference to allegations of fraud in Minnesota. Fine — investigate fraud. But it’s an odd request to include on the list of demands amid the turbulence in Minnesota. As Walz said in a press conference Sunday: ”This has nothing to do with fraud… They’re not sending us forensic accountants.”

He also said that Minnesota already cooperates with the federal government on handing over criminals in the state’s jails — apparently an explanation of the “sanctuary” reference by Bondi. And then he offered a “pro tip” to the attorney general: “There’s two million documents we’re still waiting on in the Epstein files. Go ahead and work on those.” Hard to argue with that.

In her letter, Bondi said the federal government needs access to Minnesota voter data “to confirm that Minnesota’s voter registration practices comply with federal law.” Last year, the feds began trying to compile a national list of voters, as Trump has continued to claim that undocumented immigrants are voting — another way to undermine voters’ perception of the election.

The turmoil and violence in Minnesota is a stain on the country that has now taken two lives. The shooting death of Pretti must be investigated, openly and transparently, and the videos released so far appear to show an officer removing his gun before he was shot 10 times. Those responsible must be held accountable, That’s something that both Republicans and Democrats should be able to agree on.

Using the threat of a continuing surge of ICE agents as a bargaining chip against Minneapolis is a new low for the Justice Department — and an attempt by Bondi to weaponize the agency. But if this is about Bondi setting the stage for a challenge to the election in November, at least now we are on notice.

— The Miami Herald

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Lisa Jarvis: The problem with that ‘Great Healthcare Plan’

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This month, as Americans who rely on Affordable Care Act plans opened their first bills of 2026 and experienced sticker shock, President Donald Trump began pitching them on an alternative: his “Great Healthcare Plan,” which would shift government support away from subsidizing insurance coverage toward putting money directly into accounts that consumers can use to pay for care.

The details, of course, are scant. But the concept of shifting government funds away from an approach that encourages comprehensive coverage to one that might leave many Americans behind is troubling.

Trump has long criticized the Biden administration-era subsidies that allowed millions of Americans to purchase better coverage at more affordable prices, arguing that they lined the insurers’ pockets while consumers’ costs rose. Although lawmakers are still exploring potential solutions to extend the subsidies, the president has threatened to veto any deal that materializes.

“I want to end this flagrant scam and put extra money straight into the health care savings accounts — in your name, and you go out and buy your own health care. And you’ll make a great deal, you’ll get better health care for less money,” he said in a video message this month.

So far, his plan to replace subsidies with Health Savings Accounts (HSAs) — tax-sheltered funds that can be invested and rolled over each year — amounts to little more than a list of bullet points. Among the unknowns are how much money people would receive each year, who would qualify for the help, and whether it would involve changes that expand the utility of HSAs, including whether they could be used to pay for care that falls outside of ACA guidelines (such as plans that can deny coverage based on preexisting conditions or fail to cover certain essential health care benefits).

That last part is important because, despite Trump’s claim that Americans will be able to “go out and buy your own health care,” current rules tightly restrict who is eligible for an HSA and how the money can be spent.

Currently, only people with a high-deductible health insurance plan can put money into an HSA, and the funds can only be used to pay for services, not premiums. That means the only ACA customers who could benefit from the government’s HSA contribution would be those enrolled in the lowest-tier (bronze) plans, which feature low monthly premiums but high deductibles. This year, people with a bronze plan will need to pay an average of $7,476 before their insurance starts covering care, according to KFF.

Diverting the money from subsidies to an HSA “is a reasonable approach for 80% of the population, and a terrible approach for 20% of the population,” says Gerard Anderson, a professor of health policy at Johns Hopkins University’s Bloomberg School of Public Health. Most of us don’t end up in the hospital or needing an expensive drug each year, meaning a savings account would likely cover our health care bills.

But that smaller group — the people who get in a car crash or are diagnosed with cancer — could be much worse off, Anderson says. And the problem is nobody has a crystal ball to predict who will wind up facing enormous health care costs.

Others agree with Anderson’s assessment. In a survey of health policy experts published last month in Health Affairs, 70% of respondents said that a plan that diverted the value of the subsidies into an HSA “would measurably worsen the affordability of health care for Marketplace enrollees.” Just 10% of those surveyed believed a shift to HSAs would improve affordability.

The rest of us could be worse off, too. Someone who is underinsured or uninsured still gets emergency care, but the cost is ultimately borne by insured people. Hospitals and providers eventually pass some of those costs on to private insurers through higher prices.

Health policy experts also point to more fundamental questions, such as, who, in the end, benefits most from HSAs? Among health care consumers, the vast majority of people with HSAs get them through their employer, and typically are wealthier, ahite or Asian, and in very good health, according to a recent analysis by the Government Accountability Office.

Meanwhile, the tax benefits of an HSA have primarily accrued to higher-income Americans, who can afford to put more money into them, not to lower-income people who have historically relied on subsidies to afford care and who might now be forced into this type of plan.

In other words, people with the most disposable income are by far the most likely to put enough money into an HSA to ensure that a health catastrophe doesn’t also lead to a financial one.

And some consumers might miss the fine print associated with their HSA. “The way HSAs are being marketed and discussed, it sounds a lot like free money to people — it’s not,” says Nicole Rapfogel, a policy analyst at the Center for Budget and Policy Priorities. A 2024 report from the Consumer Financial Protection Bureau found that many funds offered such low interest rates that the monthly fees exceeded the gains.

It’s true that the scenario would change if Trump’s plan involved overhauling the way HSA funds can be used, allowing Americans to use the payout to buy health insurance. Yet too many people might still gravitate toward cheaper, riskier plans — and that could end badly for everyone.

Lisa Jarvis is a Bloomberg Opinion columnist covering biotech, health care and the pharmaceutical industry. Previously, she was executive editor of Chemical & Engineering News.

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Even in winter, the sun still shines in these 5 citrus recipes

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PITTSBURGH — Winter, if you’re someone who loves the sun, can be something of a bummer in Pittsburgh. While snow days can be magical and warming your hands around a firepit after an afternoon of ice skating or sledding is fun, the long stretches of cold, gray weather can take a definite toll on our psyches.

But there is a bright spot.

Winter is peak season for some of the most vibrant offerings in your grocery’s produce section — fresh, juicy citrus fruits from California and Florida.

With their kaleidoscope of color, shape and flavor, citrus is a welcome contrast to the dark days of winter. They include sweet and tangy oranges, clementines and tangerines; bright and zesty lemons and limes; softball-sized white and pink grapefruits; and, if you’re really adventurous, tiny and tangy-sweet kumquats.

While it’s not a particularly great year for Florida oranges — the state’s citrus acreage declined 24% compared to last year, according to the Florida Commercial Citrus Inventory report — the U.S. Department of Agriculture projects the country will produce some 10.75 million pounds of citrus fruit in 2026, up from 10.04 million pounds in 2025. So chances are you’ll be able to find your favorite fruit in spades, and oftentimes they’re also on sale.

Why should you indulge? Eating or cooking with citrus is a super-easy way to provide your body with a shot of vitamin C, a nutrient that supports immune function and helps with healing. Citrus also contains flavonoids and carotenoids, compounds that have antioxidant properties and may help protect against infections.

Just one medium-sized orange, for instance, is almost all you need to meet your daily dose of vitamin C, according to the National Institutes of Health.

Because the low-cal sunny fruits are high in fiber, citrus also will help fill you up (good if you’re cutting back after holiday weight gain), and it helps with digestion.

Many citrus fruits are great for eating out of hand in sections or slices, and nothing beats a glass of fresh orange or grapefruit juice, or a wedge of lemon or lime in a cocktail. But the skin, flesh and zest also can be used in cooking.

The five recipes here should help you start thinking outside the box, beyond salads, salsas and beverages. They include quick overnight preserved lemons that will make your palate dance when added to stews, salads, grains or vegetables; a sweet and creamy orange curd that makes a perfect topping for biscuits, pancakes, cakes and ice cream; buttery, melt-in-your mouth thumbprint cookies filled not with jam, as expected, but a creamy key lime filling; a bright and tangy Asian stir-fry accented with sweet and zesty kumquats; and a chewy bittersweet treat made from candied grapefruit peel.

We hope all become favorites.

When buying citrus, opt for firm fruit with bright, colorful skin. You want it to smell slightly sweet and feel heavier in your hand than expected — a higher water content means the fruit will be juicier.

Because citrus zest and peel are best when fresh, make sure the fruit is clean and shiny before pulling out your Microplane or vegetable peeler, even if the fruit is organic. A quick rub with your fingers under warm running water will remove any wax or other debris.

24-hour Preserved Lemon

A staple condiment in North African and Middle Eastern cooking, preserved lemon adds a unique tangy flavor to stews and soups, grain and legume salads, and sauces. Cured in salt, the peels soften and go from bitter to salty/tart.

Making preserved lemons is often an exercise in patience because most recipes call for allowing the cut lemons to ferment in a mixture of salt, lemon juice, spices and (sometimes) sugar for several weeks. America’s Test Kitchen gets the job done in as little as a day.

The lemons won’t have as deep and mellow a flavor or soft and silky texture as those preserved the traditional way, but they’ll definitely add a bright flavor boost to dishes.

If you can’t find organic lemons — always a good choice when you’re using the skins — be sure to scrub them really well to remove any wax or other residue.

INGREDIENTS

3 lemons, scrubbed and rinsed

3 tablespoons sugar

3 tablespoons kosher salt

1/4 cup extra virgin olive oil

DIRECTIONS

Slice lemons thin crosswise, and remove as many seeds as possible.

Toss lemons with sugar and salt in bowl. Stir in oil.

Transfer lemons to bowl or pack into jar, then cover and refrigerate for at least 24 hours or up to 2 weeks.

To use, chop or mince lemon as desired.

Makes about 2 cups.

— Adapted from americastestkitchen.com

Orange Curd

Orange curd is a versatile, tangy-sweet spread that can be used to top everything from pancakes and waffles to scones, toast and yogurt. (Gretchen McKay/Pittsburgh Post-Gazette/TNS)

Why should lemon get all the glory when it comes to making a creamy curd for scones? Orange curd is just as quick and easy to make and is actually a little sweeter (think Creamsicle) because oranges have less acidity than lemons.

The spread is terrific on breakfast breads like toast, English muffins and scones, as well as on pancakes and waffles. But it also can be used as a filling for cakes and tarts or as a topping on ice cream. Or, swirl it in your boring bowl of oatmeal or yogurt for a taste of sunshine.

Don’t forget to top the curd with a sheet of plastic wrap before sticking it in the fridge: It not only will prevent a skin from forming but will also keep the curd from absorbing any fridge odors. It can be refrigerated for 2 to 3 weeks.

INGREDIENTS

1 cup granulated sugar

1 tablespoon grated orange zest

1 teaspoon grated lemon zest

8 large egg yolks, room temperature

1/2 cup fresh orange juice (from about 3 oranges)

2 tablespoons fresh lemon juice (from 1-2 large lemons)

1/4 teaspoon kosher salt

10 tablespoons unsalted butter, cut into 1/2 -inch pieces

DIRECTIONS

In a medium saucepan, whisk together granulated sugar, both zests and egg yolks.

Whisk in citrus juices and salt.

Add butter; place pan over medium-high and cook, whisking constantly, until butter has melted, mixture is thick enough to coat the back of a spoon and small bubbles form around edge of pan, about 5 minutes. (Do not boil.)

Remove pan from heat while continuing to whisk. Pour curd through a fine-mesh sieve into a glass bowl.

Press plastic wrap against surface of curd; refrigerate until cool, about 2 hours.

Makes about 12 ounces of curd.

— marthastewart.com

Key Lime Thumbprints

This recipe pairs two of my husband’s favorite foods — my mom’s thumbprint cookies, which are normally filled with cherry preserves, and key lime pie filling. The result is a lovely mix of sweet, tart and buttery. Yum!

My mother always used oleo — an old-fashioned form of margarine I had to explain to my daughter — for baking, but unless you’re old school too, you’ll probably opt for unsalted butter.

INGREDIENTS

For filling:

1 large egg yolk

1/3 cup sweetened condensed milk

4 teaspoons finely grated lime zest, plus more for serving

2 tablespoons plus 1 1/2 teaspoons fresh lime juice

For cookie:

1 cup oleo or unsalted butter

1/2 cup sugar

1 teaspoon cream

1 egg yolk

1/2 teaspoon baking powder

1 teaspoon vanilla

2 cups flour

DIRECTIONS

Preheat the oven to 325 degrees. Line a baking sheet with parchment paper or a silicone mat.

Prepare filling. In small bowl, stir together egg yolk, sweetened condensed milk, lime zest and lime juice until well combined. Set aside while you make cookie dough.

In large bowl, mix together oleo or butter and sugar with a rubber spatula until creamy.

Add cream, egg yolk, baking powder and vanilla and mix well. Blend in flour until just combined.

Roll dough, 1 tablespoon at a time, into balls.

Place dough balls several inches apart on the prepared baking sheet. Flatten balls lightly with your fingers.

Poke a well into each ball using your thumb or a 1-tablespoon measure dusted with powdered sugar.

Fill wells with lime mixture. Tap the baking sheet against the counter to let the cookies settle.

Bake for 12 to 15 minutes or until light golden brown around the edges. Let rest on cookie sheet for 5 minutes before transferring to a wire rack to cool completely.

If desired, dust a little confectioners’ sugar on top or serve as is.

Makes about 3 dozen cookies.

— Gretchen McKay

Asian-style Kumquat Chicken

Kumquats are an unfamiliar citrus to many; the first time I saw a pack of the olive-sized fruit, I thought they were cherry tomatoes.

Native to southeast Asia, they’re distinctly citrusy with a surprisingly sweet (and edible) skin. You can snack on them raw, but they’re also tasty in any number of cooked dishes. They also can be pickled.

Here, the bright orange fruit adds a sweet and tangy flavor to a quick chicken stir-fry.

When buying, look for fruit that is brightly colored, with unblemished skin. If they’re shriveled, they’re old and drying out.

INGREDIENTS

For marinade:

1 tablespoon soy sauce

1 teaspoon sesame oil

1 teaspoon rice vinegar

1 teaspoon honey

2 cloves garlic, minced

1 teaspoon fresh grated ginger

Pinch red pepper flakes

For chicken:

1 pound boneless skinless chicken thighs, cut into bite-sized chunks

3 tablespoons vegetable oil, divided

1 clove garlic, minced

6 kumquats, thinly sliced

1/2 teaspoon sesame oil

Steamed white or brown rice, for serving

1 teaspoon toasted sesame seeds, for garnish

2 green onions, thinly sliced, for garnish

For sauce:

2 tablespoons hoisin sauce

1 tablespoon soy sauce

1 teaspoon sugar

1 teaspoon corn starch

1/4 cup water

DIRECTIONS

Make marinade: In a large bowl, stir together soy sauce, sesame oil, rice vinegar, honey, garlic, ginger and a pinch of red pepper flakes until well combined.

Add chicken thighs and toss to combine. Allow to sit for 20 minutes.

When ready to cook, heat up a wok or large fry pan. Add 2 tablespoons of vegetable oil. Stir-fry chicken for 3 to 4 minutes or until golden on all sides and cooked through.

Remove from pan to a plate and cover with aluminum foil to keep warm while you make the sauce.

Stir together sauce ingredients in a small bowl.

Heat the remaining 1 tablespoon vegetable oil in the same wok or in a small saucepan. Sauté minced garlic for 20 seconds. Pour in sauce mixture. The sauce will become thick and bubbly very quickly.

Stir in sliced kumquats and cooked chicken and immediately turn off heat. Add sesame oil and toss to combine.

Serve immediately, with or without rice, garnished with toasted sesame seeds and chopped green onion.

Serves 4.

— Gretchen McKay

Candied Grapefruit Peel

Candied grapefruit peel. (Gretchen McKay/Pittsburgh Post-Gazette/TNS)

Looking for a sweet snack that offers fiber along with vitamin C and antioxidants and essential oils? Grapefruit might not immediately come to mind, but maybe it should — the fruit’s peel actually is better for you than the pulp.

Here, in a recipe from Paris-based pastry chef David Lebovitz, strips of peel are blanched several times to remove bitterness, simmered in sugar syrup until they’re tender and then left to dry on a rack overnight. The chewy, sticky treats are then rolled in sugar for a perfect balance of tartness and sweetness.

Candied peels are best the first week or two after they are made, stored at room temperature in an airtight container. They can be stored three to six months in the refrigerator.

For an extra-decadent treat, dip the candied peels in melted chocolate.

INGREDIENTS

3 grapefruits, organic or unsprayed

2 1/2 cups sugar, plus additional sugar for tossing the finished candied peel

2 1/2 cups water

2 tablespoons light corn syrup

DIRECTIONS

Cut each grapefruit in half and juice them. (Reserve the juice for another purpose.) Use a soup spoon to scrape out the pulp and membranes.

Use a chef’s knife to cut the grapefruit peels into strips just shy of 1/2 inch wide. Place the peels in a large pot and cover with water. Bring to a boil and simmer 5 minutes.

Drain the peels and repeat the simmering and draining process with the grapefruit peels two more times.

After you’ve blanched the peels three times, place them back in the pot fitted with a candy thermometer, if using. Add the sugar, water and corn syrup and bring the mixture to a boil.

Reduce the heat to a low boil and cook the peels until they’re translucent and glossy. The temperature should read about 218 degrees and take about 45 minutes.

Drain the peels in a colander, then spread them on a wire cooling rack and let sit 12 hours at room temperature to dry out a bit.

Sprinkle some sugar (about 1/3 cup) on a baking sheet and use your hands to toss the candied peel in the sugar, adding more sugar as needed, and shaking off any excess, until the peels are well-coated and no longer feel sticky.

Makes about 2 cups.

— davidlebovitz.com

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