Category Archives: Public Policy and Governance

Up in the Air

The New Yorker ran an especially good cartoon recently: a man standing up in coach on a plane–and others evidently cheering him on–saying something like “Who else is fed up with the smug attitudes of the so-called pilots who fly this plane? Who else would prefer that I fly it?”

The parallels to our Presidential election are too obvious to require added discussion.

I thought about that cartoon when I read another airplane analogy, this time in connection with the Republicans’ hell-bent-for-leather determination to repeal the Affordable Care Act–aka “Obamacare”–without having the slightest idea what they will replace it with, without any evident concern for the more than twenty million people who will lose coverage, and without any concern for the financial chaos that even their allies have warned will ensue.

As Josh Marshall at Talking Points Memo put it:

“The AMA, which has been rather comically pro-Trump to date, came out today and told Republicans that they shouldn’t repeal Obamacare without a clear replacement. Notably, even two of the most conservative health care economists at AEI, came out yesterday and said that ‘repeal and delay’ would be a disaster. The truth is that ‘repeal and delay’ is the policy equivalent of taking off from JFK to Heathrow with 2,000 miles worth of gas and saying you’re going to figure it out en route. No one who knows anything about health care economics, even people who are staunch free marketeers and hate Obamacare, think that makes any sense.”

From time to time on this blog I have referred to my cousin, an eminent cardiologist (and former Republican). I consult him when addressing issues that require medical expertise that I lack. He has shared with me the following statements on the proposed repeal from both the AMA and the American College of Physicians:

Chicago, IL, January 3, 2017––The American Medical Association (AMA) released the following letter today to congressional leadership from Chief Executive Officer and Executive Vice President James L. Madara, MD, concerning legislative efforts to reform the health care system.

Dear Majority Leader McConnell, Leader Schumer, Speaker Ryan and Leader Pelosi:

On behalf of the physician and medical student members of the American Medical Association (AMA), I am writing regarding our ongoing commitment to reform of the health care system and potential legislative actions during the first months of the 115th Congress.

The AMA has long advocated for health insurance coverage for all Americans, as well as pluralism, freedom of choice, freedom of practice, and universal access for patients. These policy positions are guided by the actions of the AMA House of Delegates, composed of representatives of more than 190 state and national specialty medical associations, and they form the basis for AMA consideration of reforms to our health care system.

Health system reform is an ongoing quest for improvement. The AMA supported passage of the Affordable Care Act (ACA) because it was a significant improvement on the status quo at that time. We continue to embrace the primary goal of that law—to make high quality, affordable health care coverage accessible to all Americans. We also recognize that the ACA is imperfect and there a number of issues that need to be addressed. As such, we welcome proposals, consistent with the policies of our House of Delegates, to make coverage more affordable, provide greater choice, and increase the number of those insured.

In considering opportunities to make coverage more affordable and accessible to all Americans, it is essential that gains in the number of Americans with health insurance coverage be maintained.

Consistent with this core principle, we believe that before any action is taken through reconciliation or other means that would potentially alter coverage, policymakers should lay out for the American people, in reasonable detail, what will replace current policies. Patients and other stakeholders should be able to clearly compare current policy to new proposals so they can make informed decisions about whether it represents a step forward in the ongoing process of health reform.

We stand ready to work with you to continue the process of improving our health care system and ensuring that all Americans have access to high quality, affordable health care coverage.

Sincerely, James L. Madara, MD

Washington, DC, January 3, 2017––In a letter sent today to leaders in the Senate, the American College of Physicians (ACP) implored them to vote no on a budget resolution that would start the process of repealing the Affordable Care Act (ACA). The College cautioned that this process could destabilize coverage, resulting in tens of millions of Americans losing coverage, benefits and protections established by current law.

The letter expressed concern that the pathway established by the resolution, which will lead to a subsequent vote on a budget reconciliation bill to repeal major elements of the ACA, with the effective date of such repeal being delayed while Congress attempts to develop an acceptable replacement plan, is unworkable and disruptive.

“Independent and non–partisan analyses show that enactment of such a ‘repeal, delay and replace’ bill, especially without an alternative being offered now that could be thoroughly evaluated based on its impact on quality, access, and coverage, would create chaos in insurance markets, causing plans to pull out of the markets with more than 7 million losing coverage in 2017 alone,” said Nitin S. Damle, MD, MS, MACP, president of ACP in the letter. “Full repeal could result in nearly 60 million people becoming uninsured.”

ACP noted that the College welcomed the opportunity to make improvements in the law. Specifically ACP welcomes discussion of ways to stabilize insurance markets by bringing more young people into them without disadvantaging older and sicker patients; to expand consumer choice of insurance products and of physician and hospitals; to ensure network adequacy; to support state innovation including in Medicaid provided that current eligibility, benefits, and protections for current and future enrollees are not undermined, to reduce administrative burdens on physicians and their patients, and to support the critical role played by primary care physicians in providing accessible, high quality and cost–effective care to all types of patients.

“While we acknowledge that the ACA is not perfect (and no law is) and improvements to it can and should be made, our continued support for the ACA is grounded in the fact that it has reduced the uninsured rate to the lowest ever, a major stride toward providing affordable coverage to all Americans,” said Dr. Damle. “We encourage Congress to first put forward ideas for improvements rather than committing to a process that would repeal the ACA’s coverage and protections for many millions of people.”

But what do pilots know about flying planes…?

Oh Wisconsin….

And the hits keep coming…

It’s bad enough that every day brings a new outrage from those a reader of this blog aptly dubbed “the four horsemen of the apocalypse” –Trump, Pence, McConnell and Ryan. What is even more depressing at a time when our hopes for sanity lie with local resistance to the anti-intellectualism, self-dealing and demagoguery in Washington is news of similarly destructive behavior by state-level fools and toadies.

Remember Wisconsin’s Scott Walker? A perfect contemporary Republican–a corrupt lackey of big money, antagonistic to education, dismissive of science? Of course you do.

When I read a friend’s post to the effect that Wisconsin’s DNR webpage had been scrubbed clean of all uses of the word “climate”–and altered to imply a lack of scientific consensus about anthropogenic global warming–I checked with Snopes.

Turned out to be true.

In a 26 December 2016 op-ed published by the digital newspaper Urban Milwaukee, environmental writer James Rowen reported that a section of the Wisconsin Department of Natural Resources’ (DNR) web site, originally titled “Climate Change and Wisconsin’s Great Lake,” had been substantially altered:

Gone are references to known “human activities” contributing to a warming planet, warming’s contributions to changes in rainfall and snowfall patterns, extreme weather events, drought, species and economic losses are among other truths whitewashed off this official, taxpayer-financed website.

Snopes reproduced the former text, which had accurately reported the relevant science, and that which replaced it; the new language says that reasons for changing conditions “are being debated and researched by academic entities outside the Wisconsin Department of Natural Resources.”

Responding to our request for comment, Wisconsin DNR Communications Director James F Dick stated that their office’s official position is that the science is not settled and that the page was updated to reflect this view.

Of course, the science is settled. As Snopes concludes,

The overwhelming scientific consensus from the climatological community is that the climate is indeed warming and that human activity is contributing to that process.

Here’s what mystifies me: if the settled science is right, and we do not act, we will face massive planetary devastation. If the settled science is wrong, and we do act, the worst thing that will happen is we’ll get cleaner air and water, and cheaper and more renewable energy.

This doesn’t seem like a difficult choice.

Oh yes– fossil fuel companies will make less money. But I’m sure that has nothing to do with climate change denial….

When the history of this era is written–assuming there are survivors left to write that history–it will undoubtedly be called “the age of insanity.”

THIS is What is so Worrisome

Fareed Zakaria is one of the more astute observers of American politics. Perhaps because of his familial background in the Middle East, where stability is rare and democratic institutions rarer, he has a focus on the institutions and norms that make liberal democracies possible. I remember being really impressed with his 2003 book, The Future of Freedom.

Last week, he had a perceptive and deeply troubling column in the Washington Post. As he began

Two decades ago, I wrote an essay in Foreign Affairs that described an unusual and worrying trend: the rise of illiberal democracy. Around the world, dictators were being deposed and elections were proliferating. But in many of the places where ballots were being counted, the rule of law, respect for minorities, freedom of the press and other such traditions were being ignored or abused. Today, I worry that we might be watching the rise of illiberal democracy in the United States — something that should concern anyone, Republican or Democrat, Donald Trump supporter or critic.

As he points out, what we think of as democracy is really a marriage of two separate systems: the choice of political leadership by popular vote, and laws protecting fundamental individual liberties from both the government and those same popular majorities. Hence “liberal democracy.” Zacharia notes that in several countries, the two strands have separated, with democracy (in the form of the vote) persisting, but liberty “under siege.”

Here is what I believe to be his most important–and worrisome–point:

What stunned me as this process unfolded was that laws and rules did little to stop this descent. Many countries had adopted fine constitutions, put in place elaborate checks and balances, and followed best practices from the advanced world. But in the end, liberal democracy was eroded anyway. It turns out that what sustains democracy is not simply legal safeguards and rules, but norms and practices — democratic behavior. This culture of liberal democracy is waning in the United States today.

I shared similar concerns in a post just last month. As Zakaria writes, we are now seeing what our American democracy looks like when those norms of democratic behavior and honorable public service erode, and populism becomes demagoguery.

The parties have collapsed, Congress has caved, professional groups are largely toothless, the media have been rendered irrelevant…What we are left with today is an open, meritocratic, competitive society in which everyone is an entrepreneur, from a congressman to an accountant, always hustling for personal advantage. But who and what remain to nourish and preserve the common good, civic life and liberal democracy?

I just finished reading an important book that gives “chapter and verse” on how we got to the place Zakaria describes. American Amnesia was written by eminent political scientists Jacob Hacker of Yale and Paul Pierson of U.C. Berkeley, and it details (as the subtitle promises) “how the war on government led us to forget what made America prosper.” I will discuss the book’s research and conclusions in blogs to come, but suffice it to say that their copious documentation amply supports Zakaria’s observations.

We can turn this around, but time is running out.

Peter the Citizen and “Less Appealing” Indiana

On Wednesday, I shared portions of an analysis of TANF–welfare after “reform”–from Peter the Citizen, a conservative policy analyst who has deep experience with social welfare policies.

Among the many papers he has written on the subject is one I found particularly interesting, because it references poverty and welfare policy in my home state of Indiana–and because Peter’s analysis is consistent with my own understanding of conditions in the Hoosier state.

In this particular paper, Peter was responding to an article attributing the “success” of welfare reform to the fact that such reforms have made welfare “less appealing.” (I suspect that many recipients would be shocked to discover they were accepting help because they found it “appealing.”) His rejoinder is worth reproducing at some length.

TANF is best viewed on a state-by- state basis and digging deeper suggests that there are limits to Winship’s argument about making welfare “less appealing.” Some states have tried to focus on real “welfare reform” (to the extent they can given the limitations of TANF’s block grant structure and dysfunctional federal requirements), while others use it primarily as a slush fund and have adopted very harsh policies to push families off the welfare rolls. Using a simplistic pre-post approach, one can easily compare states over time based on the harshness of their policies. (Note: This is not the evaluation approach I prefer, but it seems to resonate with conservatives.)

Robert Doar, now at the American Enterprise Institute, says he ran a “model” TANF program in New York – both at the state level and in New York City. (Doar’s bio states: “Before joining the Bloomberg administration, he was commissioner of social services for the state of New York, where he helped to make the state a model for the implementation of welfare reform.”) Doar is proud of New York City’s track record in reducing poverty:

In America’s biggest cities, more and more Americans are now living in poverty. From 2000 to 2013, the poverty rate in America’s 20 largest cities grew by 36 percent, to an average of 22.7 percent. Nationally, the poverty rate has risen too, from 11.3 percent in 2000 to 14.8 percent in 2014.

But there’s one stand-out exception to this phenomenon: New York City.

Over the last decade, New York City’s poverty rate has defied national trends by declining. While New York once suffered one of the highest poverty rates among the country’s large cities, today it boasts one of the lowest…

Indeed, Doar presents data to show that between 2000 and 2013, the percent change in poverty in New York City was minus 0.9 percent – the lowest in the nation among major cities, followed by Los Angeles and San Diego (plus 3.6 and plus 7.5 percent, respectively). At the opposite end of the spectrum, with the largest increases, were Indianapolis (81.5 percent), Charlotte (67 percent), and Detroit (57.9 percent).

Notably, both New York and California (the states with the top three cities) have much more appealing TANF programs than Indiana, North Carolina, and Michigan (the states with the bottom three cities) and they have become relatively more appealing over time. New York and California didn’t eliminate the entitlement (an important component of “welfare reform” for conservatives), they don’t impose full family sanctions or enforce the federal 5-year time limit (California removes the adult’s needs after 48 months but children continue to receive benefits; New York simply continues assistance with state funds.) Both states have among the most generous benefits, paying over $700 a month for a family of three. In contrast, the states with the cities in the bottom three have lower benefits ($272 to $492 a month for a family of three), do impose full-family sanctions and do enforce the federal 5-year limit and two have shorter time limits (24 months in Indiana – for adults – and 48 months in Michigan – for the entire family).

While Indiana, North Carolina and Michigan were “less appealing” in 1996 (and 2000) than both California and New York, they have become much, much less appealing over time. For example, between 1996 and 2014, the TANF-to-poverty ratio (the ratio of families receiving cash assistance per 100 poor families with children) fell from 101 to 65 in California and from 79 to 40 in New York. The declines were much larger in Indiana (61 to 8), North Carolina (74 to 8), and Michigan (88 to 18).15 The maximum benefit for a family of three fell 23 percent in real terms in California and 10 percent in New York; compare that to Indiana (-34 percent), North Carolina (-34 percent), and Michigan (-30 percent). TANF is failing as a safety net everywhere, but much more so in some states than others.

I’ve written before about the United Way of Indiana’s description of ALICE families (Asset Limited, Income Constrained, Employed) and the huge gap between what those families need simply in order to survive and the public and private resources available to them.

There’s a lot of faux concern about “welfare dependency” expressed by people who are quite comfortable themselves. What those people worry about is “takers” getting too comfortable with those appealing “handouts”.

Peter the Citizen uses the term properly, to describe people who depend upon social welfare programs in order to survive.

There are many things policymakers could do to decrease that real-world dependency: raise the minimum wage, reinstitute Reagan-era tax brackets, eliminate the ACA in favor of “Medicare for All”…and jettison a self-satisfied ideology that equates poverty with a lack of moral fiber and “middle-class values.”

 

 

Labels Aren’t Analyses

Not long ago, in response to one of my periodic posts decrying policies that ignore evidence in favor of ideology, I got an email from Peter Germanis, who writes as “Peter the Citizen” and  takes the unusual approach of evaluating policies on the basis of whether they actually work, rather than whether they are labeled conservative or liberal.

Peter attached an exchange from Poverty and Public Policy that reproduced three of his articles on poverty and welfare.

Peter’s background certainly entitles him to his chosen label, which is conservative: between 1986 and 1996, he helped President Reagan develop and implement his welfare reform policies, and he has worked with the Heritage Foundation and the American Enterprise Institute, both of which are  very conservative advocacy and research organizations.

Here are some of the things Peter says about TANF, the much-ballyhooed “bipartisan welfare reform” that is considered a great success by Paul Ryan and others intent upon reducing expenditures on social welfare.

  • The suggestion that TANF helps people out of poverty is–by any objective analysis–wrong.
  • TANF is not welfare reform; it is welfare to states, not the needy.
  • TANF is really revenue sharing; states use a considerable share of TANF funds to supplant state expenditures.

Peter points to Texas as an example of how TANF actually works. He notes that in 2014, for every 100 poor families with children, only five received TANF cash assistance, and the state invests little of its TANF block grant to provide education, training or work supports for the working poor. In fiscal year 2014, Texas used just 20% of its TANF funds to provide what Peter designates as “core welfare reform activities”–basic assistance, work activities and child care.”

In the wake of the election, Paul Ryan and the House Republicans plan to apply TANF’s “success” to other social welfare programs, and they have issued a proposal along those lines titled “A Better Way.” As Peter writes,

The Task Force’s Report for reforming the safety net is a seriously flawed document–it would not solve problems, it would add to them…As described above TANF is not “welfare reform”; it is not a “success” it is Truly a National Failure (TANF). The fact that conservatives do not understand this suggests that they do not have “A Better Way”–they have “The Wrong Way.”

Conservatives like Peter the Citizen represent a once-vibrant and now-dwindling strand of intellectually honest conservatism, and the recognition that the labels we employ–liberal, conservative, libertarian, socialist–are frequently short-hand for categorizing and discarding (or embracing) policies without bothering to evaluate them. More of his work can be accessed at this link.

Perhaps I am cynical, but I think there is one other difference between the bygone conservatism of people like Peter and what passes for conservatism today. The conservatives who used to be engaged with poverty policy genuinely wanted to help poor people. They might disagree with liberals about the best way to go about it, but the shared goal was to enable impoverished Americans to become self-sufficient. Today’s “conservatives” aren’t simply uninterested in honest analysis; they are uninterested in actually helping poor people. Their idea of “success” is spending less money on social welfare so that they can reduce taxes on the wealthy.

Because after all, poor people don’t vote, don’t contribute and don’t employ lobbyists.