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How Much Right-Wing State Government Costs Us -- In Human Life

How Much Right-Wing State Government Costs Us -- In Human Life

Conservatives often argue against proposals for public remedy on grounds of futility. Public remedy will be ineffectual, they say, because the problems it is meant to fix arise from intractable social conditions or human nature. When the new Speaker of the House Mike Johnson recently responded to demands for gun regulation after a mass shooting by saying that “at the end of the day” the true problem is not guns but the “human heart,” he was making the futility argument.

The “futility thesis,” as Albert Hirschman calls it in his classic The Rhetoric of Reaction, has a long history, but it has special relevance to contemporary politics. It played a major role in the neoconservative attack on liberal programs of the 1960s and subsequent rollback of federal regulation and spending. One of Ronald Reagan’s favorite lines, “We had a war on poverty, and poverty won,” perfectly expressed the conservative charge that liberal reform was futile. That view helped persuade Congress under Reagan and his successors not only to cut programs for low-income communities but also to devolve policy to the states through such measures as block grants that let the states decide how money would be spent.

More from Paul Starr

Although we hardly knew it at the time, the United States was conducting a national experiment: What would be the effect on Americans’ well-being if we turned over a wider array of policies to states controlled by political parties with opposed agendas? Three other developments have made state governments more central in policymaking. One is preemption. Since the 1980s, states in Republican hands have increasingly preempted local laws, preventing Democratic-run cities from adopting such policies as tobacco taxes and anti-smoking regulations, paid sick leave, and higher minimum wages.

The other two developments advancing the power of states are the work of the Supreme Court. By striking down the constitutional right to abortion, the Court has given states leeway to adopt diametrically opposed policies on reproductive rights. And by refusing to impose any limits on partisan gerrymandering, the Court has enabled incumbent state parties to expand their legislative majorities and entrench themselves in power.

These shifts have greatly increased both the importance of state-level policy and divergences between red and blue states. For many purposes, it no longer makes sense to think of the United States as one country. Depending on their state of residence, Americans live under drastically different policies concerning public health, taxes, the stinginess or generosity of public benefits, unionization, gun safety, and many other things that affect their well-being, indeed, their survival.

So what have been the results of the national experiment in putting more policymaking in the hands of states? Survival, as registered in mortality rates and life expectancy, is the ultimate measure of well-being, and the data for the United States in recent decades do not tell a happy story. While life expectancy continued rising in all the high-income countries in the late 20th century, the United States began lagging behind its peers. By 2006, it ranked last, and after 2014, life expectancy in this country began falling. The pattern, however, varies considerably across states.

As state-level policy has diverged since the 1970s (and especially since 2000), so have differences in mortality rates and life expectancy among the states. These differences are correlated with a state’s dominant political ideology. Americans’ chances of living longer are better if they live in a blue state and worse if they live in a red state. The differences by state particularly matter for low-income people, who are most likely to suffer the consequences of red states’ higher death rates. To be sure, correlation does not prove causation, and many different factors affect who lives and who dies. But a series of recent studies make a convincing case that the divergence of state-level policymaking on liberal-conservative lines has contributed significantly to the widening gap across states in life expectancy.

In a 2020 paper, a team of researchers led by Jennifer Karas Montez assembled annual data from 1970 through 2014 on both life expectancy and state policies in 18 different policy domains, including health, labor, the environment, and taxation. In previous work, one of the collaborating scholars, Jacob M. Grumbach, had shown that state-level policies over that period had polarized on a liberal-to-conservative spectrum. According to the new Montez study, which controlled for differences in state populations, the polarized shifts in state policy were associated with changes in life expectancy. States that adopted liberal policies were more likely to experience larger gains in life expectancy (and in recent years to avoid an outright decline). Connecticut and Oklahoma were the two states whose policies shifted the most, Connecticut toward the liberal side and Oklahoma toward the conservative side. In 1959, life expectancy in both states was 71.1 years; by 2017, it had increased to 80.7 years in Connecticut but only to 75.8 years in Oklahoma.

Couldn’t the explanation for such changes lie in changes in education, income, and other characteristics of the states? Montez and her co-authors estimated the association of life expectancy with state policy liberalism, net of other factors such as the composition of the state’s population. Taking those factors into account, their model indicated that if all states’ policies were the same as Connecticut’s in 2014, U.S. life expectancy would have been two years longer for women and 1.3 years longer for men—and if all states’ policies were like Oklahoma’s, Americans’ lives would have been shorter.

In a 2021 study, Benjamin K. Couillard and co-authors approached the question a different way, exploring alternative explanations for the increased geographic divergence in life expectancy. Much recent research on individual mortality rates has pointed to the increase in “deaths of despair” (drug overdoses, suicides, and alcohol-related disease), concentrated among Americans without a college degree. Might those deaths and the share of the college-educated population account for the increased divergence across states? The Couillard study found that it accounts for only about one-sixth of the change.

And what about changes in per capita income among the states? Perhaps life expectancy has fallen in states where incomes have fallen, while it has risen in states where incomes have gone up. It turns out, however, that changes in state incomes don’t predict changes in life expectancy. What does have an impact are differences in levels of state income over the preceding three decades. The longevity of a population today reflects the investments in health made in years past. The Couillard study concluded that “the most promising explanation” for rising geographic disparities lies in “efforts by high-income states to adopt specific health-improving policies and behaviors,” efforts which have “reduced mortality in high-income states more rapidly than in low-income states, leading to widening spatial disparities in health.” These efforts, they write, “include anti-smoking policies, expansions of Medicaid, income support, and norms around health behaviors.”

The full impact on life expectancy of a change in policy often takes years to emerge. For example, higher tobacco taxes may reduce smoking and deaths from lung cancer and other diseases, but mortality rates do not immediately register the effect. Similarly, much of the benefit from providing health care to children shows up only in adulthood. Untreated disease in children affects their energy and performance in school, onset of disabilities, adult health, and overall ability to thrive later in life.

In one of the rare studies that tracks long-term effects of policy, Andrew Goodman-Bacon used state-by-state variations in the original introduction of Medicaid coverage for children between 1966 and 1970 to estimate health and economic effects in adulthood. He found that early childhood eligibility for Medicaid reduced death and disability and increased employment up to 50 years later. In fact, it saved the government more than its original cost because the recipients later received less in public benefits and paid more in taxes.

Another recent study also makes a powerful case against the futility thesis. So many Americans already own guns that it may seem that no policy limiting firearms can make any difference. But in a paper published this year analyzing state-level changes in gun regulations and gun mortality from 1991 to 2016, Patrick Sharkey and Megan Kang found “strong, consistent evidence supporting the hypothesis that restrictive state gun policies reduce overall gun deaths,” including both homicides and suicides committed with guns. They used data on nine categories of gun laws to create an index for each state based on the balance between restrictive policies, such as background check requirements, and permissive policies, such as concealed-carry laws. For 2016 alone, they estimated that restrictive policies passed since 1991 averted 4,297 deaths, about 11 percent of the total gun deaths that year.

The shift of policymaking to the states is often justified on grounds of federalism and the belief that decisions should be left to the level of government closest to the people. But if conservatives genuinely believed in that principle, would they be agitating now for a national law to ban abortion? Would they be hoping that the Supreme Court continues to strike down state and local gun restrictions? Would they continue to support decisions by state legislatures to preempt local laws? What unites the right is not a principled belief in federalism or local control but a preference for making decisions at whatever level of government they dominate.

What also unites conservatives is a complete absence of any self-reflection about the impact of their policies on life and death in America. The futility thesis must be a great consolation to those who believe in it because otherwise they would have to confront the toll that their policies have taken. The balance of power in the states has been literally a life-and-death matter. Liberals and progressives should know that the policies they have struggled to enact have not been in vain.

Paul Starr is co-founder and co-editor of The American Prospect,professor of sociology and public affairs at Princeton University, and a winner of the Pulitzer Prize for general nonfiction and the Bancroft Prize in American history.

Reprinted with permission from The American Prospect.

How The Midterm Elections Unleashed The Supreme Court's Radical Majority

How The Midterm Elections Unleashed The Supreme Court's Radical Majority

The Democrats beat both the historical odds and the pundits’ expectations in the midterm elections. But when the dust settles, it’s likely that only one national institution—the Supreme Court—will have unobstructed power for the next two years, and the question will be how the six Republicans who control the Court decide to use their power.

Before the election, many Democrats were resigned to the loss of Congress as an unavoidable repeat of a well-established midterm pattern. Some may have agreed with one liberal commentator, Gene Lyons, who wrote in late October that midterm elections “just don’t matter a whole lot in terms of serious changes in the body politic. The U.S. Constitution is pretty much set up to prevent it.”

Any Democrat who shared that confidence about the inconsequentiality of losing Congress might not have even bothered to vote. But, contrary to Lyons, the Constitution does not preclude “serious changes” in a divided government. If Republicans end up with even a slim House majority, the impact is going to be considerable, especially because that majority will hinge on the most extreme members of the Republican caucus. When the party controlling even one chamber is willing to risk the failure of government because it sees in that failure not just partisan advantage but confirmation of its whole philosophy, it has a formidable club over the opposition party that believes in government and is trying to make it work.

Deadlock between the legislature and executive also leaves the path open for the controlling majority in the third branch of government to pursue its own agenda. This is the big effect of the midterms that hasn’t yet registered widely. Despite the backlash against the Supreme Court’s decision to overturn Roe v. Wade, the Court’s right-wing majority came out of the election as the least-obstructed branch.

The old line that the Supreme Court “follows the election returns” still probably has some truth in it, and there is no question that Democratic candidates benefited from the Court’s abortion decision. But as good as the election was for Democrats, it almost certainly did not dissuade the conservative justices from proceeding on a long and ambitious agenda to undo the legal foundations of liberal government. This is their moment to entrench their legal principles and partisan preferences.

In the Court’s reversal of Roe, Justice Clarence Thomas signaled that the same logic the majority used in that decision could be its basis for overturning Obergefell v. Hodges, which established a constitutional right to same-sex marriage. The two cases are similar in another respect. In both instances, a Democratic-controlled Congress could respond to the Court by passing legislation to protect the same rights. In its lame-duck session, the current Congress could secure those rights, but once the new Congress takes office in January, it’s unlikely that will still be a possibility.

The threat of congressional repudiation will also probably be off the table in a much wider range of cases where the Supreme Court bases its ruling on its interpretation of statutes. Whenever the Court interprets a law one way, Congress can respond by passing new legislation that makes it unambiguously clear that it intends something else. From 1967 to 2011, according to a study by Matthew Christiansen and William N. Eskridge, Congress overrode Supreme Court statutory decisions 275 times. Earlier this year, the Democratic congressional majority did that again in response to the Court’s 2022 decision in West Virginia v. EPA. After the Court overturned the Environmental Protection Agency’s rules on greenhouse emissions on the grounds that the 1970 Clean Air Act had not specifically given the agency that authority, Democrats used the Inflation Reduction Act to declare that the Clean Air Act did cover greenhouse gases.

Deadlock between the legislature and executive leaves the path open for the controlling majority in the third branch of government to pursue its own agenda.

Although Democrats won on that crucial specific point, they were not able to address a more fundamental question raised by the Court in West Virginia v. EPA. Under the “Chevron rule”—a basic tenet of administrative law since its adoption by the Court in 1984—judges have accepted “reasonable” administrative interpretations of law when Congress, in the Court’s words, “has not directly addressed the precise questions at issue.” As the legal scholar Cass Sunstein writes, “The Chevron principle means that in the face of ambiguity, agency interpretations will prevail so long as they are ‘reasonable.’”

In West Virginia v. EPA, however, without directly overruling Chevron, the Court for the first time followed another principle, the “major questions doctrine,” which holds that if an agency is making a “major” policy decision when the law is ambiguous, the Court should strike down that decision and, in effect, tell Congress and the president to pass a new law if they can agree on it.

Except, of course, when Congress and the presidency are divided, they often cannot pass a new law.

The Chevron rule is an expression of judicial humility, a rule that defers to the specialized knowledge of an administrative agency and recognizes that effective government requires the flexibility to update rules with new knowledge, such as the knowledge about the dangers of greenhouse emissions that was not available in 1970. The vagueness of the major questions doctrine enables the Court to set itself up as a super-executive, overturning agency decisions in the knowledge that Congress and the president will often be too divided to do anything about it.

A case argued before the Court on Election Day, Health and Hospital Corporation of Marion County v. Talevski, illustrates how the likely inability of Democrats to override the Court may result in the loss of long-established rights. Talevski threatens to prevent the nation’s 82 million Medicaid beneficiaries from bringing suits in federal courts to secure their rights under the program. The case arises from a suit on behalf of a nursing home patient whose family accuses an Indiana health system and a private management company of violating Medicaid rules barring negligent treatment (in this case, the use of psychotropic drugs when those drugs don’t serve a legitimate medical purpose). The defendants say that no patient has the right to sue to enforce Medicaid’s rules.

For half a century, courts have upheld the right of Medicaid beneficiaries to sue in federal court under the Civil Rights Act of 1871, which gives people the ability to seek redress when states violate rights that federal law grants. The Indiana nursing home providers say the Medicaid law is not the sort of law that Congress had in mind in 1871. As Sara Rosenbaum, professor of health law and policy at George Washington University, notes, if the Court overturns the right of Medicaid beneficiaries to sue to enforce their rights, it could “implicate the entire constellation of state-administered public welfare programs, including Supplemental Nutrition Assistance Program (SNAP, formerly known as food stamps), child welfare, and federal public housing benefits.”

The federal government lacks the tools to enforce those rights, and nothing would effectively stand in the way of states arbitrarily denying coverage to eligible beneficiaries or failing to enforce federal requirements such as those concerned with the quality of medical care. Although the federal government could hypothetically cut its funding to a state, that would only further jeopardize beneficiaries’ health and well-being. As Rosenbaum points out, federal officials cannot do what a court can do: “immediately order state officials to stop violating the law.” Federal administrative powers are “not designed to achieve rapid, targeted solutions.”

This is the precisely the kind of situation where a Congress controlled by Democrats could override the Court. They could pass legislation that made the legal rights of beneficiaries unambiguously clear.

But when the Court bases a ruling on the Constitution, Congress does not have the same power that it has when judges interpret statutes. The most dangerous decision the Court may make this term concerns an interpretation of the Constitution that could limit the accountability of state legislatures regarding the rules they make for federal elections, including how they draw congressional district lines. Three years ago, in the 2019 case Rucho v. Common Cause, the Court ruled that the federal courts could do nothing about partisan gerrymandering of congressional districts, but it said that in gerrymandering cases “state statutes and state constitutions can provide standards and guidance for state courts to apply.” Now the Court’s right wing is poised to eliminate that check on partisan power over elections too.

Following the Court’s guidelines in Rucho, the North Carolina State Supreme Court in 2022 struck down the Republican-controlled legislature’s congressional redistricting plan on the grounds that it created an unfair partisan advantage that violated North Carolina’s state constitution. In a case to be heard by the U.S. Supreme Court in December, North Carolina Republicans argue that the state court’s action should be struck down under the so-called “independent state legislature doctrine,” which holds that under the U.S. Constitution state legislatures have the plenary and exclusive power to set federal election rules and choose presidential electors, unfettered by state constitutions and courts, state election officials, or any other body.

With Justice Amy Coney Barrett on the Court, Republicans may now have a majority in support of the independent state legislature doctrine, though much may still depend on how they craft their decision. A broadly drawn ruling could put legislative decisions about voting requirements and presidential electors as well as redistricting beyond the reach of a governor’s veto or a state’s highest court. As the conservative former federal judge J. Michael Luttig wrote earlier this year, the Court’s ruling could enable Republicans to accomplish legally what Donald Trump was unable to accomplish illegally after the 2020 presidential election—reversing the choice of the voters.

The implications go beyond 2024. If the Court bars state courts from overturning state legislatures’ rules on federal elections (after earlier barring federal courts from overturning partisan gerrymandering), it will have effectively freed state legislatures from any constitutional oversight on redistricting for purposes of partisan entrenchment.

So forget what you learned in civics about checks and balances. The midterm election did work out better for Democrats than the polls predicted, but for the next two years the power over major issues of national consequence will rest with a conservative majority on the Court that is unchecked itself and bent on reducing other checks on arbitrary power. At least with their decision to overturn Roe, the Court’s majority awakened the public to the danger. But, except for a possible reversal of Obergefell, it will be harder to arouse that kind of response to many of the other critical turns to the right the Court may take. This is going to be a major challenge for both journalism and Democratic politics in the coming years.

Reprinted with permission from Prospect.

constitutional amendment

Trump Corrupted The Pardon Power — And We May Need A Radical Solution

Reprinted with permission from The American Prospect

The barriers to amending the Constitution are so high that I've long thought it pointless to pursue any reform that way. But after four years of Donald Trump, I've changed my mind. In fact, I'm suffering from a bout of what Kathleen Sullivan in 1995 in these pages called "constitutional amendmentitis."

Sullivan—later dean of Stanford Law School—used the term for conservatives' feverish advocacy of amendments in the mid-1990s. The amendments would have, among other things, imposed a balanced federal budget, limited congressional terms, authorized laws banning flag-burning, given the president a line-item veto, and outlawed abortion. It was a good thing those amendments didn't receive the necessary two-thirds approval in both houses of Congress, much less ratification by three-fourths of the states.

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supreme court

How To Rebalance The Supreme Court In 2021-- And Beyond

Reprinted with permission from The American Prospect

As Republicans prepare to confirm a successor to Ruth Bader Ginsburg, Democrats need to think through a strategy for what they ought to frame as "rebalancing" the Supreme Court. If Mitch McConnell succeeds in confirming Trump's nominee, the Court will have a 6-3 right-wing majority, likely to strike down both historic liberal achievements as well as new initiatives for years to come. The chances of dealing with climate change, voting rights, economic inequality, and many other problems will be virtually nil.

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post-pandemic America

Post-Pandemic America: A Spiral Downward Or A Turning Point?

Reprinted with permission from The American Prospect.

For nearly everyone in America today, the COVID-19 pandemic is unprecedented. Nothing in our experience has prepared us to make sense of what is happening or might happen next. But as we struggle to survive this horror, history and epidemiology may at least provide reference points for thinking about the world ahead.

Epidemics can produce lasting effects on society in at least three ways. The most direct is through the impact on the health and demography of populations. In the 14th century, the bubonic plague wiped out a third of Europe's people, chiefly working-age adults, and the ensuing shortages of labor led to rising wages and the end of serfdom in England and other parts of Western Europe.

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How Bloomberg And Sanders Could Decide The Democratic Nomination

How Bloomberg And Sanders Could Decide The Democratic Nomination

The news about Michael Bloomberg’s enormous opening ad buy for his presidential campaign—$30 million for TV ads just this week—raises again the question of what he’s up to. When Bloomberg signaled he was entering the race for the Democratic nomination, commentators overwhelmingly scoffed that he had no chance of winning. That’s almost certainly true, if winning means winning the nomination.

But there’s another possibility. Bloomberg and several other candidates—here I include Bernie Sanders—may be running to accumulate delegates in the hope of influencing the final choice of the Democratic convention, even if they’re not the nominee.

Both in their late seventies, Bloomberg and Sanders are well past the age of any previous major-party nominee and on that basis alone might be counted out. For most of their careers, they weren’t Democrats and consequently don’t have the trust of many people in the party. And just as the convention will likely have an anti-Bloomberg majority, so it will likely have an anti-Sanders majority. But none of this means that one of them can’t be a decisive influence on the party’s nominee, depending on how the nomination battle develops.

Unlike the Republicans, the Democrats don’t have winner-take-all primaries; delegates are allocated proportionally under a complex formula that awards them to candidates who garner at least 15 percent of the primary or caucus vote in a district or statewide. The new rules adopted in August 2018 for the 2020 nomination also deny superdelegates a vote on the first ballot.

Given the continued fragmentation of support among Democrats, these rules make it possible, perhaps even likely, that no candidate will emerge from the primaries with a first-ballot majority. That could trigger a battle for delegates between the last primary and the convention, which could stretch into the convention itself. Candidates controlling large blocs of delegates might then have considerable leverage. If the convention goes to a second ballot, the superdelegates would be back in play.

Earlier in the race, I thought that Sanders and Elizabeth Warren were undermining each other’s chances because they would divide progressive support, possibly holding them both below the 15 percent threshold needed to win delegates in particular districts and states. Although that’s still possible, I’m not convinced that the net effect will be negative. Sanders has more of a working-class base of support, while Warren is drawing more from college-educated professionals. The two together may get more votes, and possibly more delegates, than if only one of them was in the race.

The same analysis may apply to Bloomberg, Joe Biden, and other candidates such as Pete Buttigieg who are competing for centrist support. While they may undercut one another, they may also attract votes from different constituencies and thus draw more support together than any one of them could draw alone.

Thanks to his association with Barack Obama, much of Biden’s support in polls has come from African Americans, who are unlikely to back Buttigieg or Bloomberg. For his part, Buttigieg has attracted some of the white, college-educated voters who aren’t drawn to Biden or Bloomberg; Buttigieg’s rise in Iowa seems to have come in part at Warren’s expense.

Bloomberg’s support, such as it may be, is also likely to be upscale. But in primaries that are open to voters regardless of party registration, Bloomberg may attract independents and moderate Republicans who would otherwise not vote in the Democratic primary at all. Indeed, this could be a key source of support for Bloomberg, much as independents on the left who are not registered Democrats have been for Sanders.

Bloomberg is skipping the early primaries and using his enormous wealth to spend massively in the states holding primaries on Super Tuesday in March and later. Skipping the early states defies precedent and doesn’t seem to make any sense. But Biden has already run into fundraising problems, and along with other candidates he may not have the resources to compete in all or even most of the Super Tuesday states. His candidacy may also fizzle if he does poorly in the early primaries. Bloomberg might then accumulate delegates to shore up the centrist side of the Democratic Party.

Granted, there’s a lot of speculation here. If this year’s Democratic race follows the usual pattern, one candidate will build up momentum from early primary victories and gain a majority of delegates. Or a candidate will win so large a plurality of votes and delegates as to have a presumptive claim to the nomination, perhaps on the second ballot with the help of the superdelegates.

But if at the end of the primaries no candidate is near a majority of delegates, we could be in for a multi-sided struggle for the nomination.

One part of that struggle would likely take place within the progressive and moderate wings, as each consolidates around a single candidate. Let’s say Warren and Sanders together have won about 40 percent of the delegates, and the question is which one could attract the additional delegates to obtain a majority. It would almost certainly have to be Warren because of the stronger opposition to Sanders in the rest of the party. Sanders could presumably exact some promises in return for his support.

The moderate wing would face an analogous question, but the resolution seems to me less clear. This may reflect my own prejudices since I find it hard to imagine Biden, Bloomberg, or Buttigieg as the party’s nominee. If supporters of all three recognize that none of them can achieve a delegate majority, perhaps the moderates will consolidate behind a dark horse—Amy Klobuchar, Deval Patrick, or one of the other centrist also-rans. The entry of Bloomberg and Patrick into the race has not solved the moderates’ problem that no candidate of theirs has inspired much enthusiasm.

Which wing of the party would prevail in a post-primary battle? It’s impossible to say. This could be a free-for-all. The individual delegates chosen in the primaries to represent candidates are not legally bound to vote for them at the convention, much less to follow their directions about supporting someone else.

But if the battle goes beyond the first ballot, the approximately 764 superdelegates at the convention could well decide the outcome. The superdelegates can also vote on rules questions that come before the convention on its first night; how they vote could be a signal of things to come.

Soon after the Democratic National Committee voted to strip superdelegates of their votes on the first ballot but to allow them to vote later, I suggested that those twin decisions were a recipe for a legitimacy crisis for the eventual nominee if the superdelegates proved decisive. But at least the DNC left the superdelegates a backup role. It wouldn’t be the worst thing for the Democrats if the final decision rests with a group that is likely to be interested in one thing above all: who can lead the party to victory over Donald Trump.

Democrats Need To Put First Things First

Democrats Need To Put First Things First

The dichotomies of the current Democratic presidential race—revolution versus restoration, progressive versus moderate—now stand in the way of a rational assessment of what the party has to do to win, and what the times demand.

Democrats need what I’d call a “first-things-first” campaign: a campaign that emphasizes progressive responses to the historically urgent challenges we face and recognizes the difficulties—political, practical, and even philosophical—of trying to check off all at once every item on the progressive wish list.

What are those historically urgent problems? The climate emergency comes first. Candidates call it an “existential threat,” but they aren’t giving it the priority those words imply. In dealing with climate, unlike many other issues, time is of the essence: The more we delay decarbonization, the more costly and political difficult it becomes, until catastrophe will be unavoidable. The basic premise of a Green New Deal also makes political sense: Combine the task of decarbonization with an infrastructure plan that creates jobs and delivers other tangible benefits in transportation, clean water, renewable energy, and other areas.

A second imperative is to preserve democracy in the face of the threats posed by Donald Trump to constitutional norms and by Republican efforts to disenfranchise voters and rig government in their favor. That democracy agenda includes measures to protect voting rights and election security and to limit such measures as partisan gerrymandering and manipulation of the census. (Others have framed this as an “anti-corruption” first agenda.) Closely related, Democrats need to prevent the entrenchment of right-wing power in the judiciary. With one more term, Trump will consolidate control of the Supreme Court, likely turning a 5-4 into a 7-2 Court and enabling an emboldened conservative majority to undertake a wholesale assault on longstanding liberal precedents and principles.

Finally, Democrats need an economic-security agenda that reflects the generational changes in gender roles and family life and addresses the difficulties of young families in affording child care, housing, and other necessities.

There is no equivalence today between the political situations of the Republican and Democratic parties. Republicans are on the verge of consolidating power in ways that Democrats will find difficult to reverse for a long time to come. A second Trump term will give Republicans that long-term advantage. Unlike Democrats, they don’t need legislative majorities in both houses of Congress to accomplish what are essentially negative objectives—stopping Democratic initiatives, declaring liberal policies unconstitutional.

But while one more term for Trump will entrench right-wing power, Democrats are unlikely to make comparable gains from winning the presidency in 2020. They can stop Trump, but they can’t move things as far to the left as Republicans can move them to the right. Unlike Republicans, Democrats do need legislative majorities to accomplish their aims, but there is no chance they will have sufficient majorities in 2021 to enact an across-the-board, New Deal–style agenda.

Here’s the ugly reality. The Senate overrepresents predominantly white, rural states. If Democrats somehow win a Senate majority in 2020, they will win it only by a few votes and depend on the likes of Joe Manchin of West Virginia and other moderates to pass legislation. The House also presents problems. The Democrats won control in 2018 only because of the seats that moderates picked up in affluent suburban districts, and they need to hold those seats in 2020.

It’s not just Congress that looms as an obstacle. Even if Democrats could pass radical legislation, it would be in danger of being struck down by the conservative majority on the Supreme Court.

The historical moment demands bold measures, for sure. A “restoration” is not what we need. I am no fan of “moderation”; I don’t warm to pleas for the middle ground. But, given the political constraints, Democrats have to weigh priorities. While they need to energize their supporters, they also need to persuade skeptics that they’ve got a grip on reality. They have to decide what needs doing now and what can get done now.

In other words, they need to put first things first.

So let me come to the big thing that shouldn’t come first—a comprehensive, single-payer health plan, the kind that goes by the misleading name “Medicare for All” (misleading because it is so radically different from the existing Medicare program).

A Sanders-style single-payer plan doesn’t just pose political problems because it would take away private insurance from people who don’t trust government to replace it. A single-payer plan also requires raising more than $1 trillion in revenue, about as much as is collected through the personal income tax today. There isn’t a snowball’s chance in hell that Democrats are going to be able to enact those taxes.

Moreover—and here’s the key point from the first-things-first standpoint—raising all that revenue to replace private health insurance premiums and out-of-pocket payments would make it impossible to do anything else.

The last two Democratic presidents spent their political capital on health care in their first two years. Bill Clinton failed and Barack Obama succeeded in passing health legislation, but they both lost control of Congress at the first midterm election. Democrats can’t afford to do that again; they need to build power over time, not lose it at the first opportunity.

That’s not to say that Democrats should avoid health-care reform. Attacking the prices of drugs and health care should be part of an economic-security agenda. They ought to try to make Medicare available as an option at age 50 for people otherwise uninsured. What they shouldn’t do is get caught up in another effort to overhaul the health system that will swallow up their entire agenda.

Democrats don’t just need to win in 2020; they need a successful presidency. If they wage a focused, first-things-first campaign, they have a shot at succeeding, building on that success, and earning the necessary support to move on to other progressive aims. They need to show they are a party ready to govern.

Can Democrats Define Their Own Cause — Or Will Trump Dominate?

Can Democrats Define Their Own Cause — Or Will Trump Dominate?

Until Donald Trump’s tweet tirade against the “Squad,” I was getting pessimistic about the chances that Democrats could overcome their divisions for the 2020 election. Now, at least for the moment, Trump has solved that problem—nothing unifies Democrats better than a racist and xenophobic attack. But I’m even more concerned about how Trump continues to dominate the framing of America’s choices in 2020.

This is an election that ought to be about the climate emergency facing America and the world. It ought to be about the continuing economic insecurity of families at a time when the gains from growth—and from Trump’s tax cuts—flow overwhelmingly to the rich. It ought to be about the affordability of housing, health care, education, and other basic needs.

The election ought to be about the corruption that Trump has brought to Washington, his abuse of presidential powers, and the risk he poses to constitutional norms and democracy. It ought to be about the encouragement that Trump has given to authoritarians around the world, his embrace of Vladimir Putin, Viktor Orban, and Rodrigo Duterte, and the decisions he has made to withdraw the United States from arms control treaties and increase the risk of a new global arms race.

Perhaps most of all, the election ought to be about the likelihood that right-wing power will become entrenched if Trump wins a second term, with consequences stretching far into the future. The Supreme Court could go from a 5-4 to a 7-2 conservative majority, make radical rulings that stand for decades, reverse civil rights and other protections for racial and gender equality, and severely weaken the powers of the federal government in dealing with environmental risks, economic inequality, health care, and other challenges.

But if Trump has his way, no one will be focusing on those concerns. This will be an election in which the politics of fear and divisions over race and immigration dominate the national conversation.

Provoking outrage has been Trump’s strategy for years, and it has worked for him. His championing of birtherism put him on the road to power. Every time he stokes the fires of racism and xenophobia he puts Democrats in an impossible position: Ignore what he says at the risk of normalizing it, or answer back and allow him to define the terms of conflict.

Democrats are especially vulnerable just now. With the presidential nomination race wide open, they are effectively leaderless. Trump is taking advantage of that void to make the Squad the faces of the Democratic Party, calculating that they are the perfect symbols to drive his voters to the polls.

Some of the leading 2020 Democratic presidential candidates didn’t help their cause in the June debates by taking a series of unpopular positions, such as banning private health insurance, providing insurance to the undocumented, and decriminalizing border entry. They’re giving Trump and the Republicans plenty to work with.

There’s a real danger of Democrats getting ahead of themselves. Eventually, they should benefit electorally from the rising numbers of people of color and a younger generation with progressive views. But that emerging majority isn’t a majority of voters yet, and the sense that it is on the way is creating a panic among conservative whites. That’s one reason why white conservatives vote at so high a rate. In an article in The Atlantic last month, “The Electoral Time Machine That Could Re-Elect Trump,” Robert P. Jones points out that even as the proportion of white evangelicals in the population has fallen, their share of voters hasn’t. They dropped from 21 percent of the population in 2008 to 17 percent in 2016, but their share of the voters remained constant at 26 percent.

Moreover, Democrats can’t count on that rising new electorate because the presidential election will be decided in a handful of states, including the states in the Midwest with older, disproportionately white populations that gave Trump a victory in the Electoral College in 2016.

Once the Democratic nomination race is resolved, the party’s presidential candidate will be in a better position to define what the campaign and election are about. But that may not be for a long time because of the fragmentation of support among candidates in the primaries and the possibility that the race will go all the way to the convention.

In the meantime, the candidates need to avoid getting caught in Trump’s trap and do everything possible to turn attention back to the real stakes in the election. This has become a crucial test in the Democratic race: Who can compete most effectively in the attention market against the country’s master of outrage, chaos, and distraction? If Trump dominates what Americans are thinking about for the next year, he will have already won a big victory before the votes are tallied.

How To Defeat Entrenched Interests — And Empower The Democratic Majority

How To Defeat Entrenched Interests — And Empower The Democratic Majority

Reprinted with permission from The American Prospect.

Two anxieties are currently driving American politics. On the right, the anxiety is about the demographic and cultural trends favoring Democrats. People of color represent only 21 percent of Americans born before 1946, but they amount to 44 percent of millennials—and, according to a Pew survey, 57 percent of millennials place themselves among liberals, while only 12 percent side with conservatives. Election by election, more liberal voters are coming of age, while more conservatives are dying off.

For decades, the right has been fighting cultural and political change and the demands of women and minorities. Now panic has set in among conservatives as they realize they are losing the future.

That anxiety has fed the obsession with immigration and increasing radicalism on the right—the willingness to support Donald Trump in the first place, and to protect him as president; to suppress the votes of minorities; and to bar the Dreamers and other immigrants from gaining the rights of citizens. Fear of future majorities is what is driving the Republican effort to pack the federal courts with right-wing judges who can be counted on to limit Democrats in office.

The second anxiety driving American politics is a response to the first—a growing anxiety among liberals that the power of the right may get locked in. Conservative power may become entrenched in ways that make it exceptionally difficult for popular majorities to reverse. Control of two governmental institutions in particular, the Supreme Court and the U.S. Senate, threatens to limit progressive possibilities. As a result, liberals are now thinking about reforms that could help rebalance institutional power.

In the 1990s, many of us were talking about an “emerging Democratic majority.” It isn’t emerging anymore; Democrats already have a national majority. They have won the popular vote for the presidency in six out of the last seven elections, going back to 1992. If not for the Electoral College, the entire history of the past two decades would be different. The Senate is a similar story. In all 15 Senates since 1990, according to calculations by Stanford political scientist Jonathan Rodden, the Democrats have won more votes than the Republicans but controlled the Senate only six times. If majority rule had determined control of both the presidency and the Senate, there would be a liberal majority on the Supreme Court too.

Remember how Republicans in the 1960s claimed to represent a “silent majority”? Democrats today are a stymied majority—and not merely in the House of Representatives. What is really stymieing Democrats is the structure of institutional power in America. Three distinct challenges confront them.

The first is the entrenched power of concentrated wealth, magnified in recent decades by increasing economic inequality.

The second is the aggressive use of political incumbency by Republicans to extend and increase their control through such means as voter suppression.

The third consists of the advantages that Republicans derive from the structure of government institutions at a time when Democratic voters have become concentrated in cities and in the most urbanized states. The geography of partisan support is closely related to America’s racial and cultural divisions, and it has skewed not only the Senate but also the House and state legislatures in Republicans’ favor.

Each of these three distinct sources of conservative power requires a different set of responses.

CHALLENGE #1: Rebalancing Power in the Market. Liberals have generally thought about economic and social policies from the standpoint of their first-order effects: whether they help guarantee rights to security and freedom and ensure a widely shared prosperity. In an ideal world, there would be no need to think about the consequences for the distribution of power. In practice, there is.

Fortunately, liberal policies can be dual-purpose, serving both primary interests in rights and well-being and interests in power and political equality. As a recent report of the Roosevelt Institute argues, progressive taxation can serve both as “a deterrent against extraction and wealth hoarding” and as a means of limiting the outsized political sway of the superrich. A revived antitrust policy can reduce “firms’ ability to exploit competitors, consumers, and workers” as well as their ability to manipulate public policy. Empowering workers can enable them to claim a fair share of the economy’s gains and to offset corporate political influence.

The underlying premise here is that policy is necessarily about power, and Republicans have acted more strategically on the basis of that understanding. Democrats haven’t given the same priority to strengthening unions that Republicans have given to weakening them. Even as industries became more concentrated, Democrats paid little attention to antitrust. Changing corporate governance wasn’t even remotely on the public agenda until Senator Elizabeth Warren proposed requiring corporations with more than $1 billion in revenue to obtain a federal charter and take into account the interests not just of shareholders but of all stakeholders, including customers, workers, and local communities. Warren would also give employees 40 percent of the seats on corporate boards and require that political contributions be approved by at least 75 percent of a company’s directors and shareholders.

But since rebalancing private power requires political power, meeting this first challenge takes us to the other two.

CHALLENGE #2: Countering the Abuses of Incumbency. Self-enrichment and self-entrenchment are the elementary forms of political corruption, and Trump-era Republicans are doggedly pursuing both. Voter suppression, partisan gerrymanders, the inclusion of a citizenship question in the 2020 census, and the failure to act on election security after Russia’s interference in 2016 are all aspects of the politics of entrenchment.

Fighting voter suppression today primarily requires its opposite—voter mobilization, beginning with the engagement of a young and diverse generation that is often skeptical and despairing about politics (see Paul Taylor, “The Reluctant Majority,” in this issue). Commitments to sustained, on-the-ground field operations and community organization have become all the more necessary since the Supreme Court’s Shelby decision limited the options for going to court to vindicate voting rights.

Like its decisions on voting rights, the Court’s rulings on campaign finance also offer little encouragement for federal litigation in pursuit of political equality. But reformers have had success at the state level with lawsuits as well as referenda. Pennsylvania’s Supreme Court overturned the Republican gerrymander of congressional districts in time for the 2018 election; Michigan voters adopted an independent redistricting commission.

Yet state-based efforts have their limits. After Floridians passed a referendum to restore voting rights to ex-felons, the Republican legislature effectively reversed that decision by requiring ex-felons to pay off fines and fees before regaining their eligibility to vote. Ultimately, there is no substitute for federal power, and that requires confronting not just the machinations of incumbents but the machinery of government that perpetuates Republican power.

CHALLENGE #3: Rebalancing the Constitutional System. A sharply increased urban-rural divide in voting now affects the working of America’s representative institutions. The effect on the Senate is obvious since the more rural states are disproportionately white and Republican; the effect on the House and state legislatures is also substantial but needs some explanation. Like Britain and others of its former colonies, the United States uses single-member districts for legislative elections, as opposed to proportional representation. In these elections, Jonathan Rodden shows in his new book Why Cities Lose, political parties whose voters are densely clustered in cities tend to win a smaller share of seats than their share of votes. As it happens, the parties that lose out are all parties of the left.

The Democrats are now in this position, which enables the Republicans to control state legislatures and sometimes the U.S. House even while losing the overall popular vote (as they did in the House after the 2014 election). Proportional representation would correct this bias. But although nothing in the Constitution prohibits proportional representation in House delegations, much less in state legislatures, the idea has received little support or attention. So I concentrate on the Senate, which poses the more immediate threat to majority rule and progressive policies.

Senate elections today are overwhelmingly predicted by a state’s partisan lean. As a result, Thomas Edsall writes (citing political scientist Larry Sabato), Republicans are favored in states with 46 senators, Democrats in states with 40. Republicans therefore need to win only five seats in competitive states to control the Senate, while Democrats need to win eleven. What could even up that competition?

No aspect of American government is more firmly entrenched in the Constitution than the Senate’s distribution of seats: Article V rules out any amendment altering the states’ “equal suffrage” in the Senate. But there is a partial workaround: the admission of new states.

Democrats can justify the admission of two new states, the District of Columbia and Puerto Rico, on the inherent merits. Both are anomalies: jurisdictions with substantial populations of American citizens denied full rights of political representation. Admitting both D.C. and Puerto Rico also has a compensatory rationale: The Senate today grossly underrepresents African Americans and Latinos because they are concentrated in highly urbanized states. According to calculations by Michael Ettlinger, African Americans have three-fourths the voting power of whites in the Senate; Latinos have just two-thirds.

Continued urbanization will likely increase this disparity. By 2040, according to demographic projections, 30 percent of the population will choose 70 percent of the Senate. If that 30 percent were chiefly black and Latino, I have no doubt the constitutional obstacles to changing the Senate could somehow be overcome. But, as things stand, the 30 percent will likely be predominantly white; admitting D.C. and Puerto Rico would help correct that bias.

Although Republicans would complain about the partisan consequences, they set the precedent: From the 1860s to the 1880s, their party carved up sparsely populated western territories into reliably Republican states to give themselves more senators.

Republicans also set the precedent for another workaround, in this case for dealing with the Supreme Court: In the 1860s, they changed the size of the Court three times to ensure Republican control—adding a seat under Abraham Lincoln, shrinking it under Andrew Johnson, then re-expanding it under Ulysses Grant. To be sure, Franklin Roosevelt is supposed to have failed when he tried to expand the Court in 1937—except that the Court then changed course, and the New Deal proceeded.

Increases in the number of states and Supreme Court justices would be examples of “constitutional hardball,” the term coined by Harvard’s Mark Tushnet for measures that are clearly constitutional, though outside recent norms. Democrats would not be thinking about hardball if Republicans had not already begun playing it, as they did when they refused even to hold hearings on Barack Obama’s nomination of Merrick Garland to the Court. Contrary to those who worry about violating political norms, Tushnet responds that if the Democrats added two justices to make up for Garland, it would establish a new norm: “You can’t steal a Supreme Court seat and expect to get away with it.”

If, despite the obstacles, Democrats are able to win control of Congress and the White House in 2020, they will have to decide whether to eliminate the Senate filibuster and play hardball. It will be a weighty decision. If they go ahead, the priority should be to admit D.C. and Puerto Rico, which would then make it easier to expand the Supreme Court, though that is better thought of as a last resort if, as in the 1930s, the Court acts in a partisan way to strike down Democratic initiatives.

A new balance in institutional power in both the market and government would only level the playing field, not entrench Democrats. These are all measures—including proportional representation for the House and state legislatures—that would bring the government closer into line with the will of the majority of Americans. And if democracy benefits Democrats, that’s nothing for them to apologize about; rather, it ought to cause Republicans to worry about the course that they have taken. Republicans didn’t have to appeal to xenophobia and white panic; they could have sought to make themselves the party of a rising majority instead of a declining one.

For Democrats, the immediate anti-entrenchment priority is to prevent Trump from gaining a second term when he could increase the Court’s right-wing majority, consolidate control of the executive branch, and use federal investigative and prosecutorial powers to pursue his enemies more aggressively. America’s rising majority has been stymied, but a second term for Trump has even darker possibilities of entrenchment.

IMAGE: Senate Majority Leader Mitch McConnell and leaders of the Senate Republican caucus.

Paul Starr is co-founder and co-editor of The American Prospect, and professor of sociology and public affairs at Princeton University. A winner of the Pulitzer Prize for General Nonfiction and the Bancroft Prize in American history, he is the author of eight books, including Entrenchment: Wealth, Power, and the Constitution of Democratic Societies (Yale University Press, May 2019).

Can America Afford To Underwrite Universal Child Care?

Can America Afford To Underwrite Universal Child Care?

Reprinted with permission from The American Prospect.

When Senator Elizabeth Warren issued a bold plan for universal child care last week, the question some people asked was the usual one: How will she pay for it? Warren has a good answer to that question, which I’ll come to. But there’s a second question that is actually more difficult: How will child care get the necessary public and media attention to make it a top priority?

In 2016, Hillary Clinton issued a proposal for universal access to child care that was similar to Warren’s, though not as extensive. Clinton called for federal subsidies to cap child care costs at 10 percent of family income, whereas Warren proposes to cap those costs at 7 percent. Like Warren today, Clinton wanted to build on existing locally run programs such as Head Start to make child care affordable for all families. And like Warren, Clinton also framed the program as serving the purposes of both economic growth and family well-being, as Katie Hamm and Sarah Jane Glynn of the Center for American Progress explained in a fall 2016 American Prospect article, “Putting Family Policy on the Governing Agenda.”

Some people writing this week about Warren’s proposal seem to have forgotten or to be unaware that the last Democratic presidential candidate wanted to move in the same direction. But if you never heard about that Clinton child-care proposal, it’s hardly your fault. Media coverage of all substantive policy issues was astonishingly limited in the 2016 presidential race. In a study in the Columbia Journalism Review, Duncan J. Watts and David M. Rothschild found that in just the six days after FBI Director James Comey announced the reopening of the agency’s email inquiry, The New York Times published as many cover stories about Clinton’s emails as it had published about all policy issues combined in the two months before the election.

The analog to coverage of Clinton’s emails may be coverage about Warren’s Native American ancestry. Still, the chances may be better this time for putting work-family issues at the center of public debate. The midterms saw an upsurge of political activism among women and a record number of women elected to Congress, and the race for the Democratic presidential nomination has not just one woman in the running but at least four who are in the top tier of candidates.

That’s not to say child care is exclusively a “women’s issue,” just that women in the public arena are more likely to make an issue of it. The changes in gender politics over the past several years could help elevate child care to the prominence it deserves. Let all the candidates, not just Warren, come up with proposals and debate child care the way Democratic candidates in recent elections have debated health-care reform.

Back to the financing: In a column on paying for a progressive agenda, Paul Krugman makes a useful distinction among three types of expenditures: investments that can be paid for through borrowing because they generate an economic return; benefit enhancements that can be paid for through higher taxes on the rich; and major system overhauls that involve such drastic changes in taxes and social arrangements that Democrats would be wise to put them off.

As an example of a major system overall, Krugman points to pure Medicare for All proposals that would replace employer-sponsored coverage with tax-financed public insurance. As he says in an understatement, that would be “a much heavier political lift” than the other two types of expenditures: “You don’t have to be a neoliberal tool to wonder whether major system overhaul should be part of the Democratic platform right now.”

That’s exactly my view of Medicare for All proposals, but that is not tantamount to saying Democrats should refrain from ambitious ideas. On the contrary, those other ambitious ideas—like universal child care—wouldn’t have a chance if Medicare for All, with its staggering fiscal demands, dominates Democratic priorities. As Krugman argues, Democrats have options that are both good policy and good politics for financing both big investments (such as many of the Green New Deal ideas) and benefit enhancements (such as universal child care). Those are the ideas that should be at the top of their agenda for 2020.

Warren calls for financing her Universal Child Care and Early Learning Act with the proceeds from the wealth tax that she proposed earlier—a tax of 2 percent on net worth for people with more than $50 million in assets and an additional 1 percent for those with more than $1 billion in assets. Public opinion surveys have shown strong support for the general idea of higher taxes on the rich and in particular for Warren’s wealth tax. I have some concerns about the wealth tax because of its vulnerability to a challenge in the Supreme Court, given the Court’s current right-wing majority. But I believe its aims could be achieved through changes in the income and estate taxes, where the legal foundations are firm.

In an economic analysis of Warren’s proposal, Mark Zandi and Sophia Koropeckyj of Moody’s Analytics find that the wealth tax would more than cover the cost of the child care plan, which they put at $70 billion annually, when taking into account its first-order economic effects in stimulating consumer spending and increasing labor participation. There are also longer-term benefits from improvements in early childhood learning; to use Krugman’s categories, the child-care proposal is both an investment and a benefit enhancement.

Of course, there’s a lot more that would need to be done to resolve the problems in child care. Warren’s proposal aims to improve the pay of child-care workers and the quality of child-care services, but it would take time and government involvement to build out the capacity to provide that high-quality care on a fully universal basis. An alternative approach presented last week by Matt Breunig calls for more direct government involvement on the supply side and free access to child care (under Warren’s proposal only families with incomes below twice the poverty level would get child care at no charge). Curiously enough, coming from the left, Breunig also criticizes Warren’s proposal for not including payments to parents who care for their children at home and for lacking adequate cost controls (and he may well be right about that).

These are exactly the kind of questions that ought to be front and center in the national debate on child care policy as the 2020 campaign unfolds. It’s time American politics gave young families the attention and help with child-care costs they need. This baby is long overdue.

At Last, Democrats Have Broken The Taboo On Raising Taxes

At Last, Democrats Have Broken The Taboo On Raising Taxes

The Pleasant Illusions Of The Medicare-for-All Debate

The Pleasant Illusions Of The Medicare-for-All Debate

Reprinted with permission from Prospect.

 

Since campaigns for public, tax-financed health insurance began just over a century ago, they have followed a pattern. During the early phase, the advocates of transformative change are convinced that they have a winning cause, only to find out as the battle develops that they have less support and face more intense opposition than they expected.

Crushing defeat was the fate of the health insurance campaigns during the Progressive era and again under Franklin D. Roosevelt and Harry Truman. It was only when reformers retreated to a more limited program for seniors that Medicare passed in 1965, with Medicaid added almost as an afterthought.

The cycle was repeated in the late 20th century. Campaigns for national health insurance in the late 1960s and early 1970s and under Bill Clinton in the 1990s began amid a widespread conviction that Congress would pass a national program. But it was only when reformers retreated to a more limited measure under Barack Obama that the Affordable Care Act passed in 2010.

Now, the cycle is under way again as many people on the left believe that the moment has finally arrived for what has been rebranded as “single payer” or “Medicare for all.”

I’ve spent a good deal of my life writing about the history of health care and health policy and working for universal coverage, including the time I spent in the Clinton White House on it. I agree that at this point we ought to expand Medicare’s framework for health insurance, which works better than the ACA’s. But we also need to appreciate why the more aggressive proposals to expand Medicare are going to meet intense and likely devastating opposition.

Medicare-for-all can mean one of four substantially different alternatives, each with many variations.

Medicare-for-all can mean one of four substantially different alternatives, each with many variations. The Medicare program today consists of both a public Medicare plan and private “Medicare Advantage” plans. (One-third of Medicare beneficiaries choose a private plan.) So the first difference among Medicare-for-all proposals is whether they extend the public Medicare plan alone (“single payer”) or the Medicare program as a whole, including Medicare Advantage.

In addition, Medicare-for-all may mean making Medicare the exclusive framework for health insurance in the United States or making it available as an option to all who want to buy it (which could include employers as well as individuals who buy insurance on their own).

The table below shows these four alternative interpretations of Medicare for all.

These four different proposals vary in their political as well as policy implications. Single-payer would make three big changes that would be guaranteed to generate massive opposition:

  • It would eliminate not only the private, employer-sponsored plans that cover a majority of Americans, but also the private plans within Medicare. If you like your insurance now, you will surely not be able to keep it.
  • It would require that taxes be raised to replace the funds now raised through insurance premiums as well as nearly all out-of-pocket spending (at least in the version Senator Bernie Sanders has called for). To give a rough idea of the magnitudes involved, insurance premiums and out-of-pocket spending in 2017 amounted to $1.6 trillion, just about the same total as the personal income tax raised. So, even allowing for big savings, imagine raising even three-quarters of that in new taxes.
  • It would subject all providers to Medicare payment rates, radically reducing revenues to health-care providers, many of which receive payment from the privately insured at much higher levels. Members of Congress could count on hearing from health-care leaders about the local hospital that will close, the cancer center that won’t be built, and the layoffs that will follow. And not all of this will be untrue.

The other Medicare-for-all alternatives would also generate intense opposition, though not as much as single-payer. A universalized Medicare program—number 2 above—would allow for private insurance options, but it would still disrupt existing employer-based coverage, require more or less the same tax increases, and sharply cut payment rates (although with somewhat more flexibility).

The two Medicare-available-to-all alternatives answer concerns about taking away people’s existing coverage. But, depending on the way the proposals are designed, they could also produce a problem known as “adverse selection” for the Medicare program. Medicare would become more expensive because of who enrolled. For example, the employers that opted into Medicare would likely be the ones with the oldest workers and highest health-care costs.

Much of the discussion about Medicare-for-all proceeds on the assumption that the opposition would come mainly from private insurers. But this grossly underestimates the likely opposition from a fully mobilized health care industry (representing nearly a fifth of the economy) and the protected public, including current Medicare beneficiaries. Seniors are the age group most consistently opposed to Medicare-for-all; many of them fear that in a program for the entire population, they would lose their privileged position.

Then there’s also the likely opposition of Democrats, including many progressives, who would be worried that the huge fiscal demands of Medicare-for-all will preclude raising revenue for all the other good causes they support.

Medicare-for-all does have one great advantage: The term is vague enough so that Democratic leaders who say they support it can downshift to more moderate versions of the idea. They can say that the purer Medicare-for-all alternatives are “aspirational” and that they support many different bills. When cost estimates start coming in and they see the implications for the rest of their agenda, they can downshift still further on the grounds that transitional steps are needed.

This is predictable. Please don’t be crushed when your favorite Democratic presidential candidate or the eventual nominee makes these adjustments. Democrats can do a lot of good by delivering Medicare-for-more without sacrificing everything else they believe in for the sake of Medicare-for-all.

 

Will The Progressive Caucus Dominate The Democratic Party?

Will The Progressive Caucus Dominate The Democratic Party?

Reprinted with permission from The American Prospect.

Are the Democrats, as so many people believe, moving left, or are they gravitating to the center? Actually, the results of this year’s primary and general elections show there is movement in both directions, setting the party up for future conflicts.

Let’s look at the congressional results. Perry Bacon, Jr. at FiveThirtyEight  makes the case that the Democrats are moving left by comparing their House membership in 2010, the last time they controlled the chamber, to their incoming membership. Eight years ago, the Progressive Caucus had 80 members, while the Blue Dog Coalition, the most conservative Democrats, had 54. But in 2019, according to Bacon, the Progressive Caucus will rise to 96, while the Blue Dogs will number only 24. By that measure, the House Democrats have moved sharply to the left.

The picture looks different, however, if we compare the Progressive Caucus with the centrist New Democrat Coalition in the House and focus specifically on the new members who won districts previously held by Republicans. Democrats flipped 42 seats while losing two, for a net pickup of 40 (with one further addition possible in North Carolina).

So far, by my count, 24 of the new members who flipped seats have joined the New Democrats, while only 11 have joined the Progressive Caucus (including four who joined both groups). Altogether, with 89 members, the New Democrats will be only slightly smaller than the Progressive Caucus.

Competing forces are at work. The Democrats who flipped seats did so mostly in suburban districts where they attracted votes from independents and Republican moderates in what was an exceptionally strong year for Democrats. Many of the successful candidates were recruited to run precisely because they would appeal to moderates. That more of them joined the New Democrats than the Progressive Caucus should not be surprising.

At the same time, in urban districts that have previously been Democratic, generational turnover and ethnic succession are leading to a shift toward the left. Alexandria Ocasio-Cortes’s upset of Joe Crowley in New York City is the paradigmatic case.

But the huge publicity given Ocasio-Cortes has obscured what are really two distinct developments: While progressives have gained ground in long-held Democratic areas, more centrist candidates have won the more competitive districts. This second development will limit how far to the left the party can go. The more the party expands into the suburbs, the more dependent it will be on those relatively centrist votes—and that dependence will become a constraint on the policies that Democrats are able to agree on.

Now let’s turn to the states, where Democrats picked up seven governorships in 2018: Michigan (Gretchen Whitmer), Illinois (J.B. Pritzker), Wisconsin (Tony Evers), Maine (Janet Mills), Kansas (Laura Kelly), Nevada (Steve Sisolak), and New Mexico (Michelle Luhan Grisham). Several of these new Democratic governors (notably Whitmer, Mills, and Sisolak) defeated candidates to their left in the primaries; all of them seem to me best described as center-left rather than progressive (in the left sense of that term).

To these new Democratic governors, we can add the two elected in 2017: Phil Murphy of New Jersey and Ralph Northam of Virginia, both of whom defeated primary opponents to their left before winning the general election.

The big gubernatorial wins for progressives in Democratic primaries in 2018 came in Florida (Andrew Gillum), Georgia (Stacey Abrams), Maryland (Ben Jealous), and Ohio (Richard Cordray). Although all four were ultimately defeated, Gillum and Abrams probably were stronger candidates—certainly they were more inspiring—than their more centrist primary opponents, and if not for Republican voter suppression in Georgia and Florida, they might have gone on to win.

But here’s the bottom line. Where Democrats made gains in the House and governorships, nearly all of the candidates were center-left rather than progressive. Somehow this striking pattern has been lost in all the talk about the party moving left.

Despite the growing strength of progressives in the party’s old strongholds, several forces are pulling Democrats to the center. The first is obvious. As the Republicans have moved to the far right, they have opened up ground in the center and created opportunities for Democratic gains. What Donald Trump has done nationally to alienate moderates, far-right Republican governors in Kansas, Maine, and elsewhere have done in their states.

Second, the Republicans’ shift to the right has led to an infusion of financial contributions to Democrats from centrist or even center-right donors. Michael Bloomberg, who gave Democratic candidates $100 million in 2018, is only the best known. Writing at The Intercept, Lee Fang points to a series of major Republican donors switching to Democrats this year and notes correctly, “Though national media attention has focused largely on newly elected democratic socialists and progressive members, the House Democratic caucus has also swelled with pro-business moderates.”

A third factor contributing to centrist gains is the widespread sense of high danger to the country posed by Trump and the Republicans today. Democratic primary voters are so concerned to pick candidates who can win that they may be treating candidates’ policies as secondary to their electability. Where Democrats hold relatively safe seats, Democratic primary voters may feel free to vote their ideological preferences, but they may think about those choices differently in competitive districts and states.

In other words, the same voter might vote for a centrist in a competitive district and a progressive in a safe district. The first vote might help secure a Democratic majority, while the second might push that majority toward more progressive policies.

These considerations, it seems to me, could become important in next year’s Democratic primaries. Democratic voters may be less concerned about which candidate’s views most closely match their own than about which one can defeat Trump (assuming Trump runs again). So they may value a candidate’s ability to attract moderates even if their own views are progressive.

That kind of calculation may help explain a striking result in a Gallup poll conducted November 13-18 that asked Democrats and Democratic-leaning independents whether “you would rather see the Democratic Party become more liberal or become more moderate.” While 41 percent said “more liberal,” 54 percent said “more moderate,” despite a recent tendency that Gallup notes for more Democrats to self-identify as liberal.

If the Republican nomination is a foregone conclusion, moreover, the Democratic primaries may attract a lot of independent or center-right voters who might otherwise have voted in the Republican primaries. This is especially likely in states that don’t require primary voters to have registered in advance as members of a party. Many observers assume that each party’s primaries attract disproportionate numbers of “extreme” partisans, but that may not be so for the Democratic presidential primaries in 2020.

For the moment, the ideological divisions between centrist and progressive Democrats are relatively subdued because Democrats are united against Trump and the Republicans. But if they regain power nationally in 2020, the party’s internal divisions will become more salient, and the results of the congressional races will become more important. The Senate will likely be an even greater constraint than the House. If it isn’t clear now, it will become clear then that while the congressional Democrats are more liberal than they were at the start of the Obama presidency, the centrists will set limits on what the party can do.

Democrats Are Being Pulled Both Left And Center

Democrats Are Being Pulled Both Left And Center

Reprinted with permission from The American Prospect.

 

Are the Democrats, as so many people believe, moving left, or are they gravitating to the center? Actually, the results of this year’s primary and general elections show there is movement in both directions, setting the party up for future conflicts.

Let’s look at the congressional results. Perry Bacon, Jr. at FiveThirtyEight makes the case that the Democrats are moving left by comparing their House membership in 2010, the last time they controlled the chamber, to their incoming membership. Eight years ago, the Progressive Caucus had 80 members, while the Blue Dog Coalition, the most conservative Democrats, had 54. But in 2019, according to Bacon, the Progressive Caucus will rise to 96, while the Blue Dogs will number only 24. By that measure, the House Democrats have moved sharply to the left.

The picture looks different, however, if we compare the Progressive Caucus with the centrist New Democrat Coalition in the House and focus specifically on the new members who won districts previously held by Republicans. Democrats flipped 42 seats while losing two, for a net pickup of 40 (with one further addition possible in North Carolina).

So far, by my count, 24 of the new members who flipped seats have joined the New Democrats, while only 11 have joined the Progressive Caucus (including four who joined both groups). Altogether, with 89 members, the New Democrats will be only slightly smaller than the Progressive Caucus.

Competing forces are at work. The Democrats who flipped seats did so mostly in suburban districts where they attracted votes from independents and Republican moderates in what was an exceptionally strong year for Democrats. Many of the successful candidates were recruited to run precisely because they would appeal to moderates. That more of them joined the New Democrats than the Progressive Caucus should not be surprising.

At the same time, in urban districts that have previously been Democratic, generational turnover and ethnic succession are leading to a shift toward the left. Alexandria Ocasio-Cortes’s upset of Joe Crowley in New York City is the paradigmatic case.

But the huge publicity given Ocasio-Cortes has obscured what are really two distinct developments: While progressives have gained ground in long-held Democratic areas, more centrist candidates have won the more competitive districts. This second development will limit how far to the left the party can go. The more the party expands into the suburbs, the more dependent it will be on those relatively centrist votes—and that dependence will become a constraint on the policies that Democrats are able to agree on.

Now let’s turn to the states, where Democrats picked up seven governorships in 2018: Michigan (Gretchen Whitmer), Illinois (J.B. Pritzker), Wisconsin (Tony Evers), Maine (Janet Mills), Kansas (Laura Kelly), Nevada (Steve Sisolak), and New Mexico (Michelle Luhan Grisham). Several of these new Democratic governors (notably Whitmer, Mills, and Sisolak) defeated candidates to their left in the primaries; all of them seem to me best described as center-left rather than progressive (in the left sense of that term).

To these new Democratic governors, we can add the two elected in 2017: Phil Murphy of New Jersey and Ralph Northam of Virginia, both of whom defeated primary opponents to their left before winning the general election.

The big gubernatorial wins for progressives in Democratic primaries in 2018 came in Florida (Andrew Gillum), Georgia (Stacey Abrams), Maryland (Ben Jealous), and Ohio (Richard Cordray). Although all four were ultimately defeated, Gillum and Abrams probably were stronger candidates—certainly they were more inspiring—than their more centrist primary opponents, and if not for Republican voter suppression in Georgia and Florida, they might have gone on to win.

But here’s the bottom line. Where Democrats made gains in the House and governorships, nearly all of the candidates were center-left rather than progressive. Somehow this striking pattern has been lost in all the talk about the party moving left.

Despite the growing strength of progressives in the party’s old strongholds, several forces are pulling Democrats to the center. The first is obvious. As the Republicans have moved to the far right, they have opened up ground in the center and created opportunities for Democratic gains. What Donald Trump has done nationally to alienate moderates, far-right Republican governors in Kansas, Maine, and elsewhere have done in their states.

Second, the Republicans’ shift to the right has led to an infusion of financial contributions to Democrats from centrist or even center-right donors. Michael Bloomberg, who gave Democratic candidates $100 million in 2018, is only the best known. Writing at The Intercept, Lee Fang points to a series of major Republican donors switching to Democrats this year and notes correctly, “Though national media attention has focused largely on newly elected democratic socialists and progressive members, the House Democratic caucus has also swelled with pro-business moderates.”

A third factor contributing to centrist gains is the widespread sense of high danger to the country posed by Trump and the Republicans today. Democratic primary voters are so concerned to pick candidates who can win that they may be treating candidates’ policies as secondary to their electability. Where Democrats hold relatively safe seats, Democratic primary voters may feel free to vote their ideological preferences, but they may think about those choices differently in competitive districts and states.

In other words, the same voter might vote for a centrist in a competitive district and a progressive in a safe district. The first vote might help secure a Democratic majority, while the second might push that majority toward more progressive policies.

These considerations, it seems to me, could become important in next year’s Democratic primaries. Democratic voters may be less concerned about which candidate’s views most closely match their own than about which one can defeat Trump (assuming Trump runs again). So they may value a candidate’s ability to attract moderates even if their own views are progressive.

That kind of calculation may help explain a striking result in a Gallup poll conducted November 13-18 that asked Democrats and Democratic-leaning independents whether “you would rather see the Democratic Party become more liberal or become more moderate.” While 41 percent said “more liberal,” 54 percent said “more moderate,” despite a recent tendency that Gallup notes for more Democrats to self-identify as liberal.

If the Republican nomination is a foregone conclusion, moreover, the Democratic primaries may attract a lot of independent or center-right voters who might otherwise have voted in the Republican primaries. This is especially likely in states that don’t require primary voters to have registered in advance as members of a party. Many observers assume that each party’s primaries attract disproportionate numbers of “extreme” partisans, but that may not be so for the Democratic presidential primaries in 2020.

For the moment, the ideological divisions between centrist and progressive Democrats are relatively subdued because Democrats are united against Trump and the Republicans. But if they regain power nationally in 2020, the party’s internal divisions will become more salient, and the results of the congressional races will become more important. The Senate will likely be an even greater constraint than the House. If it isn’t clear now, it will become clear then that while the congressional Democrats are more liberal than they were at the start of the Obama presidency, the centrists will set limits on what the party can do.


Header image by David Guralnick/Detroit News via AP

The Way Forward: How To Protect And Improve Affordable Health Care

The Way Forward: How To Protect And Improve Affordable Health Care

Author’s note: The following article, which appears in the Spring 2017 issue of The American Prospect under the title “The Republican Health-Care Unraveling: Resist Now, Rebound Later,” went to press on Tuesday, March 21, before the Republicans gave up on their health-care bill and pulled it from a vote. But while the first section of the article is now moot (at least for the time being), the second part (“Blocking Trump’s Chaos Option”) and the third (“The Next Progressive Health Agenda”) are pertinent to what happens next. 

Imagine if Donald Trump had been a genuine populist and followed through on his repeated promises to provide health insurance to everybody and take on the pharmaceutical and insurance industries. Populists in other countries have done similar things, and Trump might have consolidated support by emulating them.

Of course, Trump’s promises about health care weren’t any more genuine than his promises about Trump University. But even if he had been in earnest, he would have still faced a problem. Unlike right-wing populists elsewhere, Trump did not come to power with a party of his own or well-developed policies. He came tethered to the congressional Republicans, entirely dependent on them to formulate and pass legislation. That dependence will likely complicate Trump’s ambitions in such areas as trade policy. But nothing so far has made more of a mockery of Trump’s populism than the health-care legislation introduced in early March by Paul Ryan and the House Republican leadership and fully backed by Trump.

The Ryan bill is abhorrent for many reasons. It calls for a massive tax cut for people with high incomes, while costing millions of other Americans—24 million by 2026, according to the Congressional Budget Office—their health coverage. It would turn Medicaid from a right of beneficiaries into a limited grant of funds to the states, and it pays for the tax cuts for the rich with cuts in health care for the poor. The bill’s reduced tax credits for insurance make no adjustment for low income, while some credits would go to people with incomes over $200,000.

But what is most amazing about the bill is how badly it treats constituencies and states that voted for Trump and the GOP. The changes it calls for in the individual insurance market would hammer older people (those between the ages of 50 and 64) and residents of red states and rural areas. Republicans appear to be so determined to cut taxes on top incomes that they are willing to sacrifice the interests not only of the poor—we knew that—but of many of their own voters. The same pattern is evident in the federal budget that Trump has proposed.

While the whole effort to “repeal and replace Obamacare” poses an enormous political risk for Republicans, it presents an equally significant political opportunity for liberal and progressive Democrats. I am not talking only about short-term resistance to the Republican rollback of the Affordable Care Act. Now that Republicans have shown their true hand on health care, they are creating new possibilities for long-term progressive organizing and policy alternatives.

The struggles to achieve health insurance for all in the United States have long suffered from one fundamental political handicap. The uninsured and underinsured (people enrolled in plans riddled with exclusions and limits) have been an inchoate population without any organization or voice of their own. The combination of measures America adopted in the mid-20th century produced a large, protected public: employees with good fringe benefits, seniors and the disabled with Medicare, veterans, and the low-income groups that qualified for Medicaid. The people who were left out—mainly low-wage workers, people in part-time work, the unemployed, and individuals with pre-existing conditions—did not share a common identity or cohere politically.

But the Republican effort to undo the ACA could provide the long-missing organizational impetus. It is one thing to go without health insurance; it is another thing to have that insurance threatened or taken away. It also matters who would be losing coverage. Overall, according to the CBO, the Ryan bill would raise the number of uninsured in 2026 to 52 million, or 19 percent of the nonelderly population (compared with a projected 10 percent under the ACA). But the uninsured under Ryan’s legislation would be concentrated among 50- to 64-year-olds. That’s primarily because the bill would allow insurers to charge 60-year-olds five times as much as 20-year-olds, instead of the 3-to-1 ratio in the ACA. (The adjustments for age in the bill’s tax credits do not come close to offsetting the higher premiums; a last-minute amendment, allowing increased tax deductions for medical expenses, provides little or no benefit to low-income people but may be changed in the Senate.) When twenty-somethings don’t have insurance, many give it little thought because they may not expect to need medical care. But older people aren’t so oblivious. Take away their health insurance, and they are going to be angry.

Besides pushing a lot of older people out of coverage, the Ryan bill is brutal on states with high health costs because it would provide a flat tax credit that doesn’t vary according to geography (unlike the ACA, which provides greater subsidies in high-cost states to make coverage affordable). The Ryan bill’s tax credits are substantially smaller on average than those in the ACA, but people in high-cost states would face especially sharp increases in premiums because of the way the bill structures its tax credits.

According to an analysis by the Center on Budget and Policy Priorities, Ryan’s bill would reduce premium tax credits by more than half in Alaska, North Carolina, Oklahoma, Alabama, Nebraska, Wyoming, West Virginia, Tennessee, Arizona, South Dakota, and Montana. The net cost of insurance would rise dramatically as a result. Notice something about those states? They elect a lot of Republicans—or at least they did.

Within states, rural areas generally have higher premiums than urban areas. So the flat tax credits provide less help in affording insurance there, too. The big Medicaid cuts that Republicans are calling for will also have a severe impact in rural areas. The resulting declines in coverage will force some rural hospitals and clinics to close, with spillover effects on middle-class people who depend on the same facilities and services.

Ryan and other House Republicans have touted one CBO finding: After initially increasing insurance premiums, their bill would reduce premiums after 2020 compared with the ACA. But that’s because their measure would force so many older people to drop coverage that the average age of the insured population would drop. It’s nothing to be proud of. Trump and the Republicans promised more coverage and lower costs when they replaced Obamacare. It is now transparently obvious that they can’t deliver on that promise and that they are willing to deny health insurance even to millions of people who voted for them.

Blocking Trump’s Chaos Option

If Trump and the Republican Congress cannot pass legislation this year, they do have a fallback option. They can claim that the ACA is collapsing and make sure that it does. Then they can return to health-care legislation later and say they have no choice except to repeal Obamacare. This is the option Trump at times has seemed to prefer. “Let it be a disaster, because we can blame that on the Dems,” he told the National Governors Association on February 27. “Let it implode, then let it implode in 2018 even worse. … Politically, I think it would be a great solution.”

When Trump talks about Obamacare imploding, he is talking not about the entire program (although he seems to think so), but rather one specific part: the insurance exchanges in the individual market. The danger he and other Republicans invoke is a “death spiral”—a situation where rising premiums drive the healthy out of the market, forcing premiums up and more healthy people out, until the market fails. The exchanges are nowhere near that point. Although rates in the exchanges did rise sharply in 2016, they rose to the level originally projected by the CBO (premiums had come in lower than expected earlier). Moreover, the vast majority of individuals who buy insurance in the exchanges receive subsidies that cap the cost of their premiums; many of them also receive subsidies covering a share of deductibles and co-pays. Consequently, as the CBO and other studies have found, the exchanges have some protection against a death spiral—as long as the subsidies are fully funded and the individual mandate is enforced.

But the insurance exchanges could soon face a dire crisis because the Trump administration has created uncertainty for both insurers and enrollees about the survival of the program and enforcement of the mandate. If the administration doesn’t enforce the mandate—or if Congress eliminates the penalty for failing to insure, as the House bill would do for this year—the incentive for healthy people to pay for coverage will fall, threatening the viability of the market.

Some damage has already been done. As soon as the Trump administration came into office, it canceled outreach efforts in the final phase of the open-enrollment period for 2017. Since individuals who enroll early tend to be those who know they will have high medical costs, while late enrollees are a healthier group, the cutoff of late outreach not only reduced total enrollment but also led to a higher-cost pool. The Trump administration is also proposing to shorten the open-enrollment period for 2018.

Other measures the administration favors could encourage insurers to stay in the market, albeit with mixed effects on enrollees. The administration wants to tighten up special enrollment outside of the open-enrollment period, which may well be justified; it also proposes requiring people to pay any unpaid premiums before enrolling for the next year. In a step that would help keep premiums down, the administration has encouraged states to seek waivers to develop reinsurance programs for the individual market, as Alaska has already done. (Reinsurance spreads the cost of high-cost cases across the entire market.) Alaskans buying insurance individually faced a possible 40 percent rate increase because of 37 very high-cost cases, accounting for one-quarter of claims. The reinsurance measure adopted by the state, using funds from an existing premium tax, kept premium increases by Premera Blue Cross, the sole insurer in Alaska’s exchange, to 9.8 percent.

Insurance companies need to indicate by June whether they will offer coverage in the exchanges for 2018. Uncertainty about the rules is a recipe for chaos. If they believe the mandate will not be enforced, they are likely to jack up premiums or withdraw entirely from the market. About a third of the exchanges, mainly in rural areas, have only one carrier offering coverage this year; additional withdrawals for 2018 could create just the kind of crisis that Trump and the Republicans need as a pretext to undo the ACA.

This problem has a ready solution. If Republicans in Congress do not replace the ACA for the coming year, the Trump administration needs to make clear that it will enforce the law as it stands for 2018 and fully fund the program (including cost-sharing subsidies). Moreover, Republicans cannot plead there is no way to strengthen the individual market. The Ryan bill contains a Patient and State Stability Fund of $100 billion over ten years that the CBO believes states would use largely to cover high-cost enrollees in the individual market and thereby prevent a death spiral. In the absence of comprehensive new legislation, Congress should provide those funds in a separate measure to stabilize the market for 2018. The Republicans cannot blame a collapse on Democrats when they have it in their power to maintain coverage for the millions of people who depend on the market now.

The Next Progressive Health Agenda

Even as they resist the Republican rollback of the ACA and Medicaid, Democrats should be thinking about new initiatives in health care. No doubt the next steps will depend in part on what Trump and the Republicans end up doing. In the wake of federal legislation, many of the critical decisions in the short run may move to the states. But Democrats cannot limit themselves to defensive efforts to salvage the ACA at either the federal or the state level. They need to think about a more attractive national agenda in health care that reflects the lessons of the ACA and new political realities.

The coming national Democratic debate is going to focus on extending Medicare—to whom, how quickly, and under what rules will be the questions. The strategy for universal coverage in the ACA relied on the extension of Medicaid for the poor, but the limitations of that approach should now be clear. In its 2012 health-care ruling, the Supreme Court effectively made it impossible to use Medicaid as a foundation for universal coverage. As a mixed federal-state program, Medicaid affords states the opportunity to limit coverage, and the ACA experience has shown how far red states will go in doing that. Republicans may also succeed in eliminating Medicaid’s status as an entitlement, which will be hard to restore.

As a national program with deeper public support as an entitlement and no role for the states, Medicare does not suffer from these problems. When Medicare was enacted in 1965, its backers hoped to use it to cover other groups besides seniors, and in 1972 Congress did extend it to the disabled and patients with end-stage renal disease. (The disabled become eligible for Medicare two years after they qualify for federal disability insurance, a delay that leaves many people with high costs in the individual market.) But the expansion of Medicare then stopped, and in the 1980s Democrats in Congress obtained Republican support for incremental expansions of Medicaid to cover low-income pregnant women and young children. This was the path that led to the ACA’s further Medicaid expansion, a strategy that the Supreme Court and Republicans have now brought to an end.

Many people will equate an expansion of Medicare with a “single-payer” plan. But even Medicare-for-all would not be a single-payer system since about one-third of current Medicare beneficiaries use the program to buy coverage in a private Medicare plan. Medicare today is a marketplace—but a marketplace with a dominant public plan and not just a “public option,” which might turn out, if badly designed and established separately from Medicare, to be a relatively small and weak player in the market.

Medicare-for-all faces two enormous obstacles. Moving everyone under age 65 into Medicare would require a huge increase in taxes; employees who now receive health care as a fringe benefit would inevitably look at those taxes as an additional burden, even if reformers try to assure them that their wages would rise once health care was financed by taxes.

Moreover, many seniors insist that Medicare is their program, and they fear—or can be made to fear—that extending the program to others will jeopardize their coverage. They also see Medicare as an earned benefit, and many of them resist extending it to people who they believe haven’t earned it.

But there is a way forward: create a new part of Medicare for the older population below age 65—the older population who have also earned Medicare coverage by paying taxes and who are directly threatened by current Republican legislation. My name for this new program is “Midlife Medicare,” which would be open to people age 50 to 64 not otherwise insured (for example, by an employer). Seniors would be more likely to accept this extension than any other; for one thing, AARP welcomes as members all Americans 50 years of age and older. Earlier versions of this idea have been referred to as a “Medicare buy-in”; I have in mind a program that would be partly financed by taxes and that would automatically provide a basic level of coverage (no mandate needed), which those in midlife could increase by paying income-related premiums (as seniors do now).

Midlife Medicare would have advantages for both its beneficiaries and those age 49 and below remaining in the individual insurance market. The enrollees in Midlife Medicare would benefit from the countervailing power that Medicare exercises. Medicare pays provider rates that are substantially below those paid by private insurers in the non-Medicare market, yet providers accept Medicare patients, who consequently do not face the “narrow networks” in most plans in the individual and small-group markets. Americans who continue to have employer coverage will have the assurance that if they need to retire early, they will have health insurance as good as they would now get at age 65. Midlife Medicare is also a response to the rising death rates and declining health that economists Anne Case and Angus Deaton have demonstrated among non-Hispanic whites in midlife.

Moreover, by pulling the 50- to 64-year-olds out of the individual insurance pool covering people 49 years of age and under, Midlife Medicare would make coverage for the younger population substantially cheaper. The younger enrollees in the individual market would, in effect, no longer be shouldering part of the cost of the more expensive 50- and 60-year-olds. This is a much better way to reduce rates for 20-year-olds than the Republicans’ proposal to let insurers charge 60-year-olds five times as much as young adults.

An additional step to relieve the burden on the individual market would be to eliminate the two-year delay in the eligibility of the disabled for the existing Medicare program. Combining this step with Midlife Medicare and a strong reinsurance program would stabilize and make coverage in the individual insurance market significantly less expensive. With these measures in place, the system could be more or less workable even if Republicans eliminate the individual mandate in favor of a 30 percent premium surcharge on individuals who fail to maintain continuous coverage (as the Ryan bill would do). Although I don’t think that would be a good thing to do, I also don’t think Democrats want to focus their next health agenda on restoring the individual mandate.

Formulating a new health-care agenda requires acknowledging that although the ACA has done much good, it has not worked out as well as its supporters originally hoped. The Supreme Court and the red states have limited how far the strategy could go in achieving health care for all. High deductibles and narrow networks have meant that many people are unhappy with the coverage they are receiving. Trump and the Republicans cynically played on public dissatisfactions, suggesting they would provide something better when, in fact, their alternatives would intensify the problems Americans face. We need to move in a more promising direction that takes into account the difficulties that progressive reform has long faced in health care. Midlife Medicare could be a big next step toward a system that works better for everyone.

 

Who Are We Americans Now? And Who Will We Become Under Trump?

Who Are We Americans Now? And Who Will We Become Under Trump?

Reprinted with permission from The American Prospect.

“That’s not who we are,” Barack Obama often says when appealing to Americans to oppose illiberal policies such as torturing prisoners, barring immigrants on the basis of their religion, and denying entry to refugees. But now that Americans have elected a president who has called for precisely those policies, Obama’s confidence about who we are may seem misplaced. Questions about the defining values of our common nationality have haunted us before at critical moments in American history, and now they do again: In the wake of Donald Trump’s election, what does it mean to be an American? Will Trump and Republican rule change not just how the world sees us but our self-understanding?

National elections create a picture of a people, and they send a signal about changes the voters want. The picture and the signal may be distorted and subject to interpretation, but they cannot be ignored. The 2016 election left many people angry at pollsters for failing to predict the outcome, but it revealed a more serious misapprehension among Democrats and on the left about the future. Eight years earlier, Obama’s victory had seemed to demonstrate the historical inevitability of a more diverse and progressive America, and his reelection seemed to confirm it. Yes, Republicans had their base, but it was old and nearly entirely white. Misleading but widely influential demographic forecasts indicated that the United States was destined to become a majority-minority society. The growing acceptance of LGBT rights, especially among the young, suggested that the cultural backlash against the 1960s was receding. Political analysts interpreted demographic and cultural changes as ushering in an inexorable social and political shift that would favor Democrats and that Republicans would have to accommodate.

We cannot be certain that the arc of the universe ultimately bends toward justice, but we do know that for long periods it has been bent the other way.

A historical perspective should have urged caution. Progressive changes have been arrested before. Alongside the civic, universalistic conception of American identity—the idea that people of any race and religion can come from anywhere in the world and be fully American—there has always been an exclusive view of the country’s core identity as white and Christian. When Americans imbued with that understanding have felt under threat, they have struck back. We cannot be certain that the arc of the universe ultimately bends toward justice, but we do know that for long periods it has been bent the other way. After Reconstruction in the 19th century and the civil-rights struggle a century later, the South—the white South—did rise again. Nothing is guaranteed politically by changes in demography, economics, or culture. Every battle for justice and equality must be fought again and again.

So Trump’s victory may not be the “last gasp” of an old and dwindling white majority. It threatens instead to be a tipping-point event. Although the outcome hung on only a sliver of the electorate in three states, it may produce a disproportionate swing of power to the right and a remaking of American society. Only concerted political action—informed by an accurate understanding of our national situation—can stop that from happening.

The Shock of Two Impossibilities

Before Obama’s election, a black man as president had seemed an impossibility, and before the 2016 primaries, Trump as a major-party nominee, let alone as president, had also seemed an impossibility. Historians decades from now will be asking how these two impossibilities followed one another in immediate succession. If elections create a picture of a people and send a signal about the changes voters want, Americans could not have created two more different pictures of themselves and sent two more different signals than they have now.

When the improbable happens, we may have just gotten the odds wrong. When what we believed to be impossible happens, it tells us we were wrong in a more fundamental way, in this case about our fellow citizens. The victories of Obama and Trump, however, sent two conflicting error messages about who we are.

Obama’s victory seemed to demonstrate that, contrary to what we may have thought, the greatest shame in our history might finally be history. Perhaps the American people were willing to judge a man by the content of his character rather than the color of his skin. To those who rejoiced at that thought, Obama’s election was not just a hopeful sign of racial healing but an act of national redemption. It was an event, moreover, of global significance, promising a renewal of America’s reputation for equality and decency in the eyes of the world, a fitting culmination of an era of sweeping worldwide change. Hadn’t the Berlin Wall fallen and South African apartheid ended? Obama’s presidency was one more sign of the triumph of tolerance, pluralism, and democracy.

It would be easier to make sense of Trump’s victory if Obama had become unpopular and the voters were repudiating his administration. As of November, however, Obama enjoyed a healthy approval rating. Nonetheless, Americans elected the very man who spread the birther lie about Obama and came to epitomize the hard-right view that his presidency was illegitimate.

Perhaps Trump’s election shouldn’t have been a surprise. The antecedents can be found in the radicalization of the Republican Party in recent years, and the parallels can be found in the resurgent combinations of populism, xenophobia, and oligarchy in other countries. But Trump’s triumph was shocking because he acted so often in ways that would have sunk any other candidate. He didn’t just disregard the norms of civility, for example, by bragging about the size of his penis and insulting leaders of his own party. He openly appealed to prejudice when he denounced the Indiana-born judge in the Trump University case as a “Mexican” and called for a ban on Muslim immigrants. As he had with the birther lie, he resorted to obvious and outrageous falsehoods such as the claim that Ted Cruz’s father had been involved in John F. Kennedy’s assassination (or the more recent lie that millions voted illegally for Hillary Clinton). He violated the norms of democracy by encouraging violence against protesters at his rallies and refusing to say before the election that he would accept the results.

Trump’s brazenness didn’t just reveal who he is and how he might govern. Of course, we shouldn’t project all Trump’s views onto all those who voted for him. But when Trump’s statements and actions didn’t prove disqualifying, they revealed something first about the Republican Party and then about the voters in November who chose him as president. This was the real shock: Trump’s ability to get away with violating norms against incivility, violence, prejudice, and lying told us something that we didn’t know, or may not have wanted to believe, about America itself.

Which American Story?

Successful political leaders usually offer a narrative about their country and the world that encourages voters to see them in command. The story about America told by Trump has deep historical roots, though it is fundamentally different from one that Ronald Reagan, the Bushes, the Clintons, and Obama have been telling. Trump’s story is nationalistic, inward-looking, dark, and divisive but well-calculated to mobilize a coalition of the resentful and the opportunistic. His two campaign slogans, “America First” and “Make America Great Again,” each encapsulate that story while attacking those who he implies have betrayed the country and dragged it down.

The plain implication of “America First” is that our political leaders have not been putting the nation first. Although few may have recognized it, “America First” was the name and slogan of the leading isolationist group that before Pearl Harbor opposed going to war against European fascism and Japanese imperialism. Trump’s revival of the phrase was not unrelated to its original use. It highlighted his attack on internationalism, as in the television ad late in his campaign that denounced international bankers and displayed photos of Jewish financiers. “America First” also fit perfectly with his phony charges against the Clinton Foundation as a source of foreign influence when Clinton was secretary of state.

The genius of Trump’s attacks on globally oriented elites is that the 2016 election did include a candidate who owns a global business empire with financial interests abroad that pose unprecedented conflicts of interest in decisions about foreign policy—and that candidate, of course, was Trump. Moreover, Trump’s business is aimed precisely at catering to wealthy global elites. But by dressing himself up as the “America First” candidate, he telegraphed a message about national betrayal directly to people who believe that wealthy global elites have slighted them.

“Make America Great Again” appeals to the same belief that the leaders of the country have failed it and suggests that Trump, a winner himself, will bring that winning game to the nation. At a time when the president was black and a woman was running to succeed him, it hardly needed to be spelled out for Trump’s followers what was great about the past that needed to be restored. While Obama and Clinton symbolized an increasingly diverse America that was increasingly comfortable with its diversity, Trump embodied the discomfort with diversity among whites, particularly men. He artfully summoned up all the smoldering resentments of the Obama years—against blacks, against immigrants, against women, against the media, against “political correctness.” To all those unhappy with the changes since the 1960s, Trump presented himself as their way of taking back America—taking it back to an older, exclusive vision of who Americans are and must continue to be.

It’s tempting to say that there’s nothing new about these ideas. “America First” and “Make America Great Again” could have been slogans of nativist movements in the 19th and early 20th centuries. We have had a long line of racial and religious originalists who have insisted that America’s greatness stems from its white, Christian founding, rather than from the civic ideals of freedom and equality. The exact lines of conflicts between the forces of closure and those of openness have shifted, but the logic has been the same. When older-stock, native-born whites, typically more small-town and rural, see their power slipping away, they try to shut the gates and reclaim control. That was the impetus behind the immigration restrictions of the 1920s, which were designed to limit the entry of eastern and southern European Catholics and Jews. The same social and cultural forces also typically line up against internationalism and free trade.

Yet, as familiar as Trump’s narrative is, it was not the story about America that recent Republican presidents have told. Reagan was as sunny as Trump is dark. Even when using coded messages to appeal to whites, Reagan and the Bushes stayed within the norms of American politics, declining to incite hostilities, much less violence. The story they repeated was the exceptionalist, civic story of America as a city upon a hill, a beacon of freedom in the world. This is the vision sometimes called the American Creed.

Rhetorically, in fact, there is a more direct line from Reagan to Obama than from Reagan to Trump. Obama has sung the old exceptionalist saga, albeit in a liberal key. Here, for example, is Obama at his second inauguration:

…what binds this nation together is not the colors of our skin or the tenets of our faith or the origins of our names. What makes us exceptional—what makes us American—is our allegiance to an idea articulated in a declaration made more than two centuries ago: ‘We hold these truths to be self-evident, that all men are created equal ….’

The patriots of 1776 did not fight to replace the tyranny of a king with the privileges of a few or the rule of a mob. They gave to us a republic, a government of, and by, and for the people, entrusting each generation to keep safe our founding creed.

Starting with this familiar invocation of “our founding creed,” Obama then takes the story in a progressive direction:

We do not believe that in this country freedom is reserved for the lucky, or happiness for the few. We recognize that no matter how responsibly we live our lives, any one of us at any time may face a job loss, or a sudden illness, or a home swept away in a terrible storm. The commitments we make to each other through Medicare and Medicaid and Social Security, these things do not sap our initiative, they strengthen us. They do not make us a nation of takers; they free us to take the risks that make this country great. …

It is now our generation’s task to carry on what those pioneers began. For our journey is not complete until our wives, our mothers and daughters can earn a living equal to their efforts. Our journey is not complete until our gay brothers and sisters are treated like anyone else under the law—for if we are truly created equal, then surely the love we commit to one another must be equal as well. Our journey is not complete until no citizen is forced to wait for hours to exercise the right to vote. Our journey is not complete until we find a better way to welcome the striving, hopeful immigrants who still see America as a land of opportunity—until bright young students and engineers are enlisted in our workforce rather than expelled from our country. …

Obama’s use of the American Creed to make the liberal argument infuriates conservatives. Christopher Scalia, the late Supreme Court justice’s son, writes that when Obama criticizes conservative positions by saying, “That’s not who we are,” he is accusing conservatives of being “un-American.” (Scalia cites a count by a conservative website that Obama has used the line “That’s not who we are” 46 times.) But Obama never questions conservatives’ patriotism or loyalty. When he says, “That’s not who we are,” he is saying, “That’s not who we are when we are at our best. That’s not who we should strive to be.”

Obama’s version of the optimistic, exceptionalist narrative has been a way for him not only to reappropriate it from Reagan, but also to speak for the nation, rather than as a “minority” leader. As a black politician, Obama has continually had to guard against the danger of being seen as representing blacks alone. The American story he has told, beginning with his speech at the 2004 Democratic Convention, has enabled him to lay claim to national leadership. Democrats will need to remember that lesson, especially as they confront the nationalism of the Trump presidency.

Will Trump Change Us?

We are now on the verge of one of the greatest U-turns in the history of national policy and politics. It may well change the basic workings of our government and private institutions and the role of the United States in the world. The impact is likely to be profound. Since government is a national looking glass, Americans will see themselves reflected in their government in an altogether different way from the Obama years. Many will look at that reflection and insist, “That’s not who we are.” But to the world—and to many Americans—that is who Americans will be, unless we organize and resist.

When a party controls all three branches of the federal government, it has the power to change society, not just policy. During the past 74 years, Republicans have controlled both Congress and the presidency for only six years (1953–1954, January–May 2001, and 2003–2006). Republicans now have their biggest opportunity since before the New Deal to consolidate a regime of their own making. Largely shorn of their moderate wing, they are a radical party with a radical president, eager to seize a rare moment to undo not only Obama’s legacy but many earlier achievements of Democrats going back three-quarters of a century—and to institute their own regime in ways that will be hard to reverse.

It is a peculiar fact of our political system, but a fact nonetheless, that a president’s loss of the popular vote has no effect whatsoever on his power. The fewer than 100,000 people in Pennsylvania, Wisconsin, and Michigan who gave Trump an Electoral College majority have altered the course of American history—the only question is by how much. The 2016 election was literally a tipping-point election for the Supreme Court. Trump and the Republican Senate can immediately tip the majority back to the Court’s conservatives, and with additional seats likely to be filled, they will probably push the balance further to the right. With little to fear from the Court, Republicans can also pursue more vigorously the course they have already adopted through voter suppression and gerrymandering to make it difficult to vote them out of office. The power of incumbency in American politics is notorious. Since 2010, Republicans have used that power to consolidate their hold on state governments, and they are now poised to entrench themselves federally.

Many of the policies favored by Republicans for ideological reasons do double duty as means of political entrenchment. Policies weakening labor laws and unions strike at an organizational base of the Democratic Party. Deporting undocumented immigrants who have lived in America with their families for years, instead of providing them a path to citizenship, throws those communities into disarray. Privatizing government transfers not just functions but power and influence to private companies. Turning Medicare into a voucher and Medicaid into a block grant to the states eliminates the rights of beneficiaries under federal law and the role of federal agencies in upholding those rights. Defunding climate science at the Environmental Protection Agency and NASA defunds troublesome climate scientists.

Trump adds another element to the Republican potential for entrenchment. Immediately after the CEO of Boeing criticized Trump’s views on trade in early December, Trump tweeted that it was time to cancel the company’s contract to develop a new design for Air Force One. The message to corporate America was clear—that he would use all means at his disposal to punish any criticism. During the campaign, Trump threatened Amazon founder Jeff Bezos, owner of The Washington Post, with federal investigations because of the Post’s coverage. This is standard practice in populist governments, and not only with respect to the media. Through a combination of favors and threats, the regime turns business into an arm of the state. Republicans were supposed to prefer small government and oppose crony capitalism; they are bringing America the exact opposite.

If Trump does consolidate power in this way, it will have ramifying effects on American thought. Political leaders shape public knowledge and public opinion, even how people think about themselves. Never has more of a bully occupied the bully pulpit of the presidency. Americans identify with winners, and Trump has made winning the supreme good of his public philosophy. Winning governmental power does confer legitimacy as well as power. Those who win power can communicate their view of the world from a privileged, official position. When Trump was mainly known for birtherism, the media could treat him as a political crank. When he steps to the podium to speak as president, he must be accorded the respectful attention due the office. It is the greatest platform for grandiosity and falsehood the world offers.

From that position and the power that comes with it, Trump is going to affect who we are—but it may not turn out the way he intends. After assaulting the norms of American politics during the campaign, he seems a good bet to assault the norms of government and international relations as president. His bluster and recklessness will lead to crises, perhaps to war—and that is where the twin possibilities of Trump’s presidency may become clear. Populist leaders often look to crises as a means of enlarging their powers and suppressing dissent; war especially puts the opposition in the difficult position of appearing unpatriotic if it does not join in cheering on the troops. A people’s sense of their national identity may change in the process.

But crises are also the undoing of governments; leaders who take their countries to war often miscalculate their odds of a quick and easy victory. Crises may arouse a discouraged opposition and enable it to get back on its feet after being knocked down. When reversals of fortune come—whatever the occasion—the opposition must be ready with its own alternatives and its own story.

Remembering Who We Can Be

Trump and the Republicans now hold the upper hand. But an election in which Trump lost the popular vote by more than 2.7 million does not erase what Obama’s election disclosed about America. The United States is a divided society; many people may wonder whether it is even possible any longer to talk about “we Americans.” Trump’s America and Obama’s America may seem to be two entirely different countries. One and the same nation, however, made Obama its president twice and has now elected Trump, and our common reality is not one choice or the other but the contradiction between them.

Nationally, Democrats have been winning majorities and losing elections. They have won the popular vote for president in six out of the past seven elections since 1992. But that support hasn’t been enough to win sustained power under the American political system. In the two elections in 2000 and 2016 that saw Democrats turn over the White House to Republicans, they have won the popular vote but lost the Electoral College. Clustered on the coasts and in cities, the Democratic vote has also been poorly distributed from the standpoint of controlling the House of Representatives, the Senate, or a majority of the states. The metropolitan clustering of Democratic votes undermines their ability to control the House and state legislatures, and in U.S. Senate elections, Democrats “waste” millions of votes running up big majorities in big states like California and New York. Democrats are now strongest in cities, the weakest part of the federal system.

The Electoral College, the structure of the Senate, and other aspects of the American constitutional system may be unfair, but they are not going to change anytime soon. If Democrats are going to regain power, they will have to broaden their support beyond the constituencies that now support them. They cannot expect salvation from demography even in the long run. Many progressives expect that “people of color” will become a majority and shift the balance of power. The very terminology is misleading. In the 2010 Census, 53 percent of Hispanics who chose one racial category identified themselves as “white” and when Hispanics intermarry with non-Hispanic whites (as 80 percent of Mexican Americans do by the third generation), the children overwhelmingly see themselves as non-Hispanic white. As a result of this pattern of “ethnic attrition” and the likely continued redefinition of who counts as white (and perhaps more important, who counts themselves as white), a majority-minority society will probably be a disappearing mirage.

Democrats have made a bet on being the party of diversity, and there is no going back on it. But they have a choice about how to frame their case. They can tell a story about the struggles of separate and distinct groups—racial minorities, immigrants, women, gays—a list that typically leaves out most white men. Or they can tell a story about America that brings whites in by honoring the country’s traditions as well as by emphasizing common economic and social interests. As Obama has shown, the national story can serve as the frame for contemporary struggles for equality. This is not exactly a rejection of “identity politics.” It is an identity politics of a kind—an effort to ground a majoritarian politics in a shared national identity.

The outcome of the 2016 presidential election wasn’t predetermined by demography, economic conditions, or other circumstances. Clinton might well have won the few additional votes she needed if not for intervention in the election by Russia and FBI Director James Comey. But Democrats still would not have won control of Congress or many of the states, and they will not be able to reverse the regime Trump and the Republicans put in place unless they can win that kind of widely distributed majority. Democrats can hone a much stronger economic message, and they should. They can hope that Republicans fall out and fight among themselves, which they may. But if we are to recover from the damage and national dishonor of Trump’s presidency, Democrats need to appeal to all Americans as Americans and help all of us remember how we can be genuinely proud of our country again.