Category Archives: Public Policy and Governance

The Closer You Look, The Meaner It Is

If your eyes glaze over at the prospect of getting down “in the weeds” of the Senate healthcare bill, Josh Marshall’s summary really tells you everything you need to know:

It has always been crystal clear for numerous reasons that the Senate health care repeal bill would be the like the House bill, both versions, just as it will be like the final bill that emerges from a conference committee. McConnell and Ryan knew that ball hiding about scores and legislative language would prevent reporters from saying this: Around 24 million Americans will lose their coverage, everyone will go back to the era of pre-existing conditions restrictions and lifetime limits. The freed up money will go to a big tax cut for the very wealthy. You didn’t need to see the legislative language to know this. It’s been a failure of journalism to pretend otherwise.

If, however, you want several specific compelling reasons to oppose this travesty, there are any number of reports and commentaries that can help. For example, we learn about several “buried” provisions from an article in the LA Times, in a column that describes the bill as a “poorly-disguised massive tax cut for the wealthy, paid for by cutting Medicaid — which serves the middle class and the poor — to the bone.” Then there’s this:

States will have more authority to reimpose lifetime and annual benefit caps and eliminate essential health benefits. This may be the most insidious provision of the repeal bill, and certainly is the most deeply hidden.

As several Governors–including Republican Governors– have noted, this grant of authority to the states will almost certainly be used, because the deep cuts in Medicaid and other federal funding will leave the states no choice.

The Affordable Care Act also had state waivers designed to allow for innovations, especially in state Medicaid programs. But under the ACA, those waivers could not  lead to fewer people being insured, or to the imposition of higher out-of-pocket expenses. The Senate bill repeals those limitations.

Under the measure, the secretary “must” approve a waiver request as long as it won’t increase the federal deficit. As a result, states would be able to eliminate the essential health benefits that all health plans must provide under the ACA — including hospitalization, prescription coverage, maternity care and substance abuse and mental health treatment. Since only essential health benefits are subject to the ban on lifetime and annual benefit limits, high-cost patients such as cancer victims and sufferers from chronic diseases could permanently lose their benefits in the course of their treatment.

And then there’s pre-existing conditions. As the Times reports,

Protection for people with preexisting conditions is destroyed. Senate Republicans claim in their talking points that the measure protects people with preexisting conditions from being denied coverage or priced out of the market. Don’t believe them…The Senate bill will open the door to states forcing people with preexisting conditions into segregated markets that will lead them to pay far, far higher costs than everyone else….This bill will bring the country back to a system in which insurance only works for the healthy, and the sick can’t afford the coverage they need.

There’s lots more. Older Americans will get hosed; under this bill as currently drafted, older Americans could be charged five times what younger, healthier Americans will pay. Meanwhile, the biggest tax cut for the rich is retroactive; a millionaire who already had booked a $1-million gain on a stock sale, for example, would collect a $38,000 benefit.(Even the Wall Street Journal was aghast at that one.)

And most despicable of all:

In fact, all the measure’s tax cuts taken together, valued at about $700 billion over 10 years, would be almost entirely paid for by the bill’s elimination of Medicaid expansion in the 30 states and the District of Columbia that accepted it.

The bill defunds Planned Parenthood. It cuts Medicaid so drastically that hundreds of thousands of elderly Americans will no longer be able to go to nursing homes, and rural hospitals that depend upon Medicaid will close. It will strip coverage from more than twenty million people, and take us back to the days when people had no choice but to use emergency rooms for primary care. The medical cost curve, which had been coming down under the ACA will once again rise more rapidly than the rate of inflation.

And why? To further enrich the already wealthy–and not so incidentally, to destroy the legacy of America’s first black President.

 

Anticipating Unanticipated Consequences

These are horrific political times. It’s hard not to be depressed–every day, it seems, we wake up to a new assault on what we thought were American values, new evidence of deplorable behaviors and attitudes we thought we’d left behind, new efforts to roll back hard-won progress.

But.

We need to remind ourselves that the turbulence and upheaval we see around us is not a new phenomenon. Times of social transition are typically unsettled and contentious. (Think of the Sixties, not to mention the Industrial Revolution, the Civil War…). The question is: what comes next? What are we transitioning to? 

My own prediction–based on history and a lot of hope–is that the election of Trump will prove to be a turning point, that the resistance and increased activism we are already seeing will grow more pronounced, and the political pendulum will swing back toward sanity and concern for the common good. The problem is, in the meantime, Trump and the Congressional GOP are doing incalculable damage to the environment, to the rule of law, to the economy and to America’s place in the world.

Yesterday, McConnell finally unveiled the Senate’s Trumpcare bill, and it is even worse than the House version; it proposes to take health care from millions of struggling Americans in order to give a huge tax break to the rich.

Despicable as it is, I’m not the only person who sees potential for eventual progress lurking in short-term disaster. Take Ezra Klein’s recent article for Vox, “Republicans are about to make Medicare-for-All Much More Likely.”

On Friday, McConnell reportedly “delivered a private warning to his Senate Republicans: If they failed to pass legislation unwinding the Affordable Care Act, Democrats could regain power and establish a single-payer health-care system.”

History may record a certain irony if this is the argument McConnell uses to successfully destroy Obamacare. In recent conversations with Democrats and industry observers, I’ve become convinced that just the opposite is true: If Republicans unwind Obamacare and pass their bill, then Democrats are much likelier to establish a single-payer health care system — or at least the beginnings of one — when they regain power.

And if the GOP successfully unwinds Obamacare, the Democrats are far more likely to regain power in 2018. As Klein says,

The political fallout from passing the American Health Care Act — which even Donald Trump is reportedly calling “mean” — will also be immense. In passing a bill that polls at 20 percent even before taking insurance away from anyone, Republicans will give Democrats a driving issue in 2018 and beyond — and next time Democrats have power, they’ll have to deliver on their promises to voters. Much as repeal and replace powered the GOP since 2010 and dominated their agenda as soon as they won back the White House, if the American Health Care Act passes, “Medicare for all” will power the Democratic Party after 2017.

The bubble that Congressional Republicans occupy has become so divorced from the reality of American life and opinion–so in thrall to a (shrinking) base that is itself divorced from reality–that they no longer connect with most Americans. And presumably, the Democrats will have learned some important lessons from their experience with the ACA.

If Republicans wipe out the Affordable Care Act and de-insure tens of millions of people, they will prove a few things to Democrats. First, including private insurers and conservative ideas in a health reform plan doesn’t offer a scintilla of political protection, much less Republican support. Second, sweeping health reform can be passed quickly, with only 51 votes in the Senate, and with no support from major industry actors. Third, it’s easier to defend popular government programs that people already understand and appreciate, like Medicaid and Medicare, than to defend complex public-private partnerships, like Obamacare’s exchanges….

Obamacare was the test of the incrementalist theory, and, politically, at least, it’s failed. Democrats built a law to appeal to moderate Republicans that incorporated key ideas from Mitt Romney’s Massachusetts reforms, and it nevertheless became the single most polarizing initiative of Obama’s presidency. All the work Democrats did to build support from the health care industry has proven to be worth precious little as Republicans push their repeal plan forward. And the complex public-private design of the Affordable Care Act left the system dependent on the business decisions of private insurers and left Democrats trying to explain away premium increases they don’t control. The result is a Democratic Party moving left, and fast, on health care.

“I have been in contact with a lot of Democrats in Congress,” says Yale’s Jacob Hacker, who is influential in liberal health policy circles, “and I am confident that the modal policy approach has shifted pretty strongly toward a more direct, public-option strategy, if not ‘Medicare for all.’”

As bleak as our current political environment is, Klein and others see Ryan, McConnell and our clueless President unwittingly sowing the seeds of fairer and more cost-effective policies.

The accuracy of that prediction, of course, depends upon the strength, savvy and persistence of the Resistance.

About That Echo Chamber…

As this blog frequently notes, one of the thorniest problems bedeviling our unravelling democracy is the distortion of reality–intentional and unintentional– provided via the Internet. That distortion is immensely aided by our tendency to live in echo chambers populated by friends who think like we do.

Most of us trust links from friends – a vulnerability exploited by phishing sites and other forms of online manipulation. An increasing number of us “unfriend” contacts who post uncongenial opinions or facts inconsistent with our political prejudices.

This is a real problem.

On the one hand, citizens who occupy different realities cannot have productive conversations or negotiate practical solutions to common problems; on the other hand, censorship of electronic media, in an effort to separate wheat from chaff, is neither wise nor possible.

Can technology save us?

Most of us, whatever our political orientation, recognize the problem. As an IU Professor of Computer Science and Informatics puts it,

If you get your news from social media, as most Americans do, you are exposed to a daily dose of hoaxes, rumors, conspiracy theories and misleading news. When it’s all mixed in with reliable information from honest sources, the truth can be very hard to discern.

In fact, my research team’s analysis of data from Columbia University’s Emergent rumor tracker suggests that this misinformation is just as likely to go viral as reliable information.

As he notes, the Internet has spawned an entire industry of fake news and digital misinformation.

Clickbait sites manufacture hoaxes to make money from ads, while so-called hyperpartisan sites publish and spread rumors and conspiracy theories to influence public opinion….

This industry is bolstered by how easy it is to create social bots, fake accounts controlled by software that look like real people and therefore can have real influence. Research in my lab uncovered many examples of fake grassroots campaigns, also called political astroturfing.

In response, we developed the BotOrNot tool to detect social bots. It’s not perfect, but accurate enough to uncover persuasion campaigns in the Brexit and antivax movements. Using BotOrNot, our colleagues found that a large portion of online chatter about the 2016 elections was generated by bots.

The real question–as the author readily concedes–is how to combat technology that spreads propaganda, or “fake news.” As he says, the first step is to analyze how these sites are operating.  Then we can hope that smart people adept in use of these technologies can devise tools to combat the spread of false and misleading information.

Long-term, however, “fixing” the problem of fake news will require fixing the humans who have a need to believe whatever it is that such “news” is peddling. That fix will necessarily begin with better civic education and news literacy, but it can’t end there.

Ultimately, we have a problem of political psychology…It would seem that we humans have invented tools that have outstripped our ability to properly use them.

Power to the People?

As Americans hold our collective breath watching an increasingly deranged Chief Executive (did you see that Cabinet meeting?), political scientists ponder the short- and long-term consequences of this unprecedented Presidency. How much damage will he do, and how long will it last?

Elaine Kamarck of the Brookings Institution has a recent article speculating on what happens next: she describes the possibilities as 1)Trump learning and his presidency becoming more normal or at least adapting to what she delicately terms his “impulsiveness;” 2) the chaos continuing and power moving away from the presidency as a result; or 3) Trump being forced to leave office.

I suppose the good news is that any of these scenarios spells doom for Dick Cheney’s wet dream of a “unitary executive.”

If I were a gambling woman, I’d put my money on #2. The chaos will continue, and the federal government–at least the Executive Branch– will no longer be the center of domestic or international policy. Power abhors a vacuum.

As Kamarck writes,

The second model involves little learning and no adaptation. This is a model for continuing chaos, with the likely result that power will begin to drain from the White House towards other centers. For instance, power can move from the White House to the states and to the private sector. In the area of climate change, California Governor Jerry Brown has already stepped into a leadership role. It is likely that governors and corporate leaders may begin to take action regardless of what the White House thinks. Power can also move to Congress where possibilities for a limited tax bill and some infrastructure spending can move more or less without White House leadership. And internationally, power can move to the heads of Germany and France in Europe and also to China, as the United States pulls back from the world or offers leadership that is too unstable to count on. It’s unclear whether turning the presidency into a sideshow would be permanent or not. But continuing chaos from a Trump presidency could do it at least temporarily.

During the turbulent Sixties, “Power to the People” was a popular slogan, but the scenario painted in Kamarck’s second model is hardly benign. Despite Americans’ longstanding distrust of central authority, numerous aspects of our national life require a measure of uniformity if we are to remain the United States.

In normal times, we would expect Congress to step in to fill the power vacuum. That would certainly be the best-case scenario–if we had a functioning legislative branch. But we don’t. One result of the Republicans’ exceedingly thorough 2011 gerrymander was the election of what has appropriately been dubbed the “lunatic caucus,” reactionary ideologues and culture warriors uninterested in the nitty-gritty details of governance and unacquainted with the concepts of pluralism or the common good. They are “led”–to the limited extent they are tractable–by men who have elevated party over country and power over the rule of law.

Devolving power to the states can help to ameliorate some of the immediate damage being done to American institutions, but the only real solution I see is a “wave” election in 2018 that gives us a Democratic Congress capable of containing Trumpism.

The 64 Thousand Dollar Question is whether the Democrats can get their act together, recruit responsible and attractive candidates, and forgo their usual intra-party fratricide.

The whole world is watching….

Missing the Point

In the wake of Trump’s withdrawal from the Paris Accords, apologists have gone into overdrive. Even those who recognize that climate change is real have pooh poohed the significance of our withdrawal; after all, the goals were voluntary and weak, and anyway, America’s cities and states are stepping up to the plate, so we’ll probably make our goals even without participating in a formal agreement.

A recent article in Time is typical of the many arguments that what looks like a sow’s ear might really be a silk purse in disguise:

Trump knew his decision to withdraw the U.S. from the climate agreement would provoke global outrage, and it did. For Trump, the economy is the priority. But Trump’s promise to revive the coal industry isn’t going to happen; instead, the opposite will occur. And it’s safe to say that by 2020 — the earliest date that the U.S. can technically withdraw from the climate pact — Trump could point to his decision even as he points at all the shuttered coal plants, and say: “See, I told you we didn’t need the Paris deal. America’s emissions went down regardless, and our economy became stronger without it.”

Let’s parse that paragraph. If Trump knew the decision would provoke outrage, he should have recognized that such outrage would make it more difficult to achieve other goals, both domestic and international, so why do it? As even the apologists have conceded, the targets we had endorsed were entirely voluntary; the administration could simply have ignored any that they felt were bad for the American economy.

What we’ve seen of this deeply disturbed man suggests that he withdrew because it would provoke outrage. Trump likes to stir the pot, and he desperately needs to be the center of attention. Achieving his goals quietly (assuming he has goals unconnected to his ego), without fanfare, doesn’t feed his narcissism.

And what about that statement that the economy is his priority? Where’s the evidence that Trump has even the slightest understanding of economic policy? His insistence that he will bring back a coal industry that even coal company CEOs admit is no longer viable should have been a clue to his cluelessness.

And arguing that we will meet our emissions goals without being party to the Paris Accords misses the point. The point is: symbolism matters, and it matters a lot.

When President Obama led the negotiations that produced the Paris Accords, he was signaling that the United States remained the world’s leader. He was demonstrating this nation’s willingness to work with countries around the globe to address common challenges, and our willingness to do the hard work of analyzing relevant science and working through thorny political barriers in order to hammer out an agreement.

Obama’s commitment to the process sent a message to the rest of the world, and it was a message that enhanced American stature and our ability to exercise global “soft power.”

The message sent by Donald Trump’s exit from that hard-won agreement was exactly the opposite: America is no longer a steadfast global presence, no longer a source of reassuring leadership in a dangerous world.

Under a volatile, unpredictable, and profoundly ignorant President and his cabinet of intellectual and moral pygmies, America is withdrawing from global leadership. (As Angela Merkel put it, in her typically understated way, America is “no longer a reliable ally.”)

Whatever the practical effect of withdrawal on our ability to fight climate change, the symbolism was devastating. Far from making America “great,” it diminished us and significantly weakened our influence around the world.

It was yet another unforced error by a man who tweets them daily.