What now?

So it has come to this. The Republican Party has put its central rallying cry of the last seven years on the legislative agenda, and found that it is unable to pass it even through one house of Congress. Had the bill managed to pass through the House of Representatives, it would have been dead on arrival in the Senate. In the face of unified opposition to repeal of the ACA from Democrats, the deep divisions on the healthcare issue among Republicans have made action impossible.

It is a development that should surprise no one. Healthcare has never been a natural issue for Republicans, who have viewed it as a rule as beyond the scope of federal authority. The haste and secrecy with which the bill was prepared, and particularly the fact that no stakeholders - doctors, hospitals, nurses, insurance companies, etc - were even consulted in its drafting, show that its primary aim was ideological rather than practical. As with any proposal that prioritizes ideological considerations over practical ones, it has provisions that alienate an impressive proportion of the population. The public outcry and subsequent failure of the bill were predictable. The Republicans will likely simply move on to a tax bill, which is a much more comfortable issue for them, but their unity and ability to govern have been called into question by abject failure in their first major legislative push.

It would be easy, and tempting, for someone as critical of the modern GOP as I have been to attribute the ineptitude of the push to the peculiar weaknesses of that party. However, the failure is indicative of a broader trend that extends well beyond the current administration. Scorched-earth partisanship and unified opposition have made a political system intentionally designed with an abundance of legislative bottlenecks utterly ineffective. Since 2010 the leglislative branch has been simply impotent, and only supermajorities for the Democrats before that prevented unified opposition from paralyzing the first two years of the Obama administration as effectively as the last six. What do we do as a country when a political system predicated on legislative supremacy has a series of Congresses unable to act?

In the last six years of the Obama administration, that question was answered. The President, frustrated with the intransigence of his oppostion, decided to push the bounds of executive action as far as he could in an attempt to advance his agenda. In some places he was successful, in others the courts stepped in. President Trump has not only continued but accelerated that trend, specficially with his travel orders. More ominously, he has continued the free use of executive orders in policymaking in spite of the fact that his party controls the Congress. The failure of the Republican health push suggests that control of Congress is in any case only a marginal advantage in the days of Total Opposition.

It is telling that the most intense political battles of the first two months of the Trump Administration have not been between the parties in Congress, but between the executive and the courts. That state of affairs is directly attributable to the long-term incapacity of the legislature to legislate. It should alarm anyone committed to procedural democracy and separation of powers. If congress continues to be inactive the conflict between executive and judiciary will only intensify, and may well become the primary focus of the partisan struggle. Not only policy, but important questions about how our government operates would then be thrown into doubt.

The Healthcare Debate: Costs

Insurance coverage may be the most immediately impactful of the issues relating to health care, but costs are the most complex and the pose the greatest long-term challenge. Really understanding the cost issue requires applying an enormous number of techincial subjects, from demography to economics. Its complexity makes tackling it politically dangerous, and so it has been the least addressed aspect of the healthcare problem by either party. That being said it is not possible to understand the effects of health policy without it.

Healthcare costs have risen over the last several decades in every sense of the word. Not only has the cost of coverage relative to other goods risen, but the healthcare industry as a share of the economy has exploded in the last fifty years.  The overwhelming culprit is increasing lifespans due to medical progress, and the resultant aging of the population. The older someone is as an adult, the more healthcare they require to remain healthy and comfortable. That tends to put upward pressure on prices for everyone. The longer someone lives, the more care they require. The more elderly a population has relative to its overall population, the larger the presssure. Both tendencies have been at work in the United States for several decades running, with no end in sight. The problem is compounded because Medicare and Medicaid are already the largest and still the fastest growing portions of the federal budget. It is no exaggeration to say that the long term fiscal health of the US government depends directly on the trajectory of medical costs. 

Health insurance has gotten significantly more expensive over time because the services it pays for have gotten more expensive. Insurance was originally meant to mitigate prohibitive costs, and still does, but if premiums are unaffordable then it has scarcely achieved its objective. For that reason, extending coverage alone cannot possibly solve the whole problem with healthcare. Access to care is meaningless if people cannot pay for it. Costs must be controlled. As any economist will tell you, that can only be done by increasing supply of care or reducing demand. More doctors and hospitals have been recruited and built over the last decades, but supply has not kept pace with the exploding demand from an aging population with a high rate of chronic illness. Reducing demand, meanwhile, is tricky to do if we are not to deny people essential care. 

In an open market of the sort we participate in every day - for bread, oranges, and so on - costs are controlled through competition. That is, consumers are free to pick among various products, and firms attempt to lure them by providing them at a lower price than their competitors. In the end, if the market satisfies certain competitiveness conditions, the product is provided at the lowest reasonable cost. Many ideological conservatives favor applying this approach to medical care, and reducing the role of medical insurance to deal only with catastrophic care of the sort that families cannot possibly budget for. This will, they reason, reduce unnecessary consumption of doctor services, prescription medications, etc, and thereby reduce their prices at large. The problem with this approach is that markets, while squeezing efficiencies out of firms, also price out people who are unwilling or unable to pay for the good in question. If someone is able but unwilling to pay for their own medical care, that is their choice. On the other hand, pricing those unable to afford regular care out of the market is barbaric. 

The reason that an insurance market is not as effective at controlling costs as a market in which each consumer pays directly for their own services is because once the premium/deductible is paid, any number of covered services can be used without significant concern for the costs involved. Doctors, meanwhile, are free to prescibe as many tests or medicatations as they please, and they have a number of incentives to do so knowing that insurance companies will pay for them. This system is called fee-for-service, for obvious reasons. There is no incentive for consumers to consider cost when recieving nonessential care. Yet, as already discussed, we cannot remove this unfortunate tendency without making medical care a product to be purchased instead of a human right. There is, I maintain, no possible way to avoid this conundrum. One must pick a side. If we are willing to take the position that care is not a human right, then the conservative solution has much to recommend it.

For me, I find the moral implications of that position repulsive. 

The ideal solution would be to control use of care while maintaining the insurance system. But how can that be done? The solution proposed by the Left is a single-payer insurance system of the sort employed by Canada and Western Europe. That is such a can of worms that it will recieve its own post, and I propose to simply note that it has its own pros and cons and promptly ignore it for now.

The Affordable Care Act has taken a more subtle approach. It has used pilot programs to attempt to provide a template for eliminating fee-for-service, by tying payments to hospitals and doctors from federal programs - Medicare and Medicaid - to certain effectiveness and efficiency criteria. Medicare and Medicaid account for such an enormous proportion of medical expenditure that this gives the government significant leverage. In principle, if tied to appropriately produced scientific evidence, calibrating payments in such a way can squeeze efficiencies out of the medical system without compromising access to needed care. The jury remains out on whether this approach can be effective long term, though early results have shown some potential. 

In sum, the issue of controlling medical costs is spectacularly complicated and no easy solution is possible. It is one of those unfortunate issues in public policy which is so important that it cannot be ignored, but also demands that we make difficult choices and recognize unpleasant realities. The first step, as ever, is acknowledging the scope and significance of the problem. 

The Health Care Debate: Coverage

In the last week, a detailed picture of the Republican plan to replace the Affordable Care Act has finally become available. Health care is a hugely complicated issue that cannot possibly be done justice in one post, because costs, coverage, politics, and other aspects all demand a fairly full treatment. Instead I will be writing about it in pieces over the course of the debate. I'll start with coverage, which is the most immediately impactful area of the proposed changes.

The central goal of the ACA (colloquially, Obamacare) was to provide the entire population access to health insurance at a reasonable cost. It requires that people must buy insurance or pay a penalty, and conversely that insurance companies must accept new applicants. Before the ACA, insurance companies would frequently deny people who were already sick new insurance plans, because the company knew it would have to pay out heavily for each chronically sick person it insured. The mandates, as they have become known, solve that problem by making insurance companies take any new customers, but also providing them with enough new customers to mitigate the cost of insuring sick people.

Additionally, the ACA mandates that large businesses either provide insurance for their employees or contribute to the cost of insuring them. For those whose employers do not provide coverage, each state has had to create a marketplace with both online and physical stores, where insurance plans that met a minimum standard of coverage were sold. This gave people access to insurance information and allowed them to shop around for plans, allowed insurance companies to easily find new customers, and made it easy for the government to regulate the quality of plans being sold. Direct subsidies to mitigate the cost of insurance were provided to make sure that those not covered by Medicaid (the government-administered health insurance program for the poor) could afford private insurance, and the income threshold to qualify for Medicaid was raised by a third.

That brings us to where we are. Whatever the benefits and drawbacks of the ACA as a whole, some 20 million more people have health insurance in the United States than did seven years ago when the law was passed. From a coverage perspective, it would seem the ACA has achieved its goals.

The Republicans have stated openly that they do not intend to try to compete with the ACA in terms of numbers insured. Their plan would eliminate the state run insurance marketplaces and the mandate that people buy it, replacing the income-based subsidies for people to buy insurance with age-based ones. Insurance companies would still be unable to deny people coverage, but the new proposal would allow them to charge anyone with a lapse in coverage from the previous year 30% above the market price of their plan.

The most obvious consequence of these changes is that those who do not qualify for Medicaid under the new lower income ceiling would be less able or unable to afford insurance. This is because age rather than income determines the subsidies. A wealthier person would recieve the same amount of financial help buying a plan as a poor person of the same age. Clearly, this means that fewer people of lesser means would purchase insurance. Adding insult to injury, even the subsidies as they exist under the new law will be reduced from the ones under the ACA; meaning that even if insurance prices remain unchanged, out of pocket costs will increase.

There is a final important point to be made about this scheme. The penalties the law allows insurers to impose on those with lapsed coverage would ensure that, once uninsured, people will tend to remain uninsured. Who is most likely to decide that more expensive insurance isn't worth it? The obvious answer is healthy people. If a significant number of healthy people decide against coverage, premiums for those who have insurance will increase at accelerating rates - to make recent increases seem tame by comparison - because the companies will be paying for more medical expenses per customer.

Estimates about the fall in the number of insured Americans range from 6 million (S&P) to 24 million (the Congressional Budget Office). Should reality fall anywhere on that spectrum it will mean at best a sharp spike in insurance costs, at worst a large number of lives lost from insufficient medical care. We shouldn't belittle the issue of medical costs, or how they relate to coverage, but it is difficult to overstate the impact of declining coverage because it translates directly into a lack of proper care. On this front, therefore, the replacement bill is wholly and dangerously inadequate.

Why Trump Tweets

President Trump's indiscriminate use of Twitter has once again put the political world in an uproar. Yesterday morning, he used it to accuse President Obama of ordering wiretaps on telephones in Trump Tower during the campaign. He then asked Congress to include the wiretaps in their investigations of Russian influence in the election. Forceful denials were swift in coming from a variety of players in the Obama administration. Interestingly, they emphasized that Obama hadn't ordered any such tap, and remained suggestively silent on whether there had actually been such a tap. In fact, it has already been reported that the FBI acquired a warrant based on communication between a server in Trump Tower and a Russian bank known to be close to Putin, and that nothing came of it. The obvious question to ask is why Trump would make such a wild accusation, seemingly at random, on an otherwise unremarkable Saturday morning.

I will freely admit my frustration that this sort of thing is still reported on as if it is shocking. In the first place, this is hardly the first or most deranged accusation Trump has hurled at someone in the last two years. Leaving aside the entire birther nonsense, the reader may recall that just before the Indiana primary he implied that Ted Cruz's father Raphael was involved in the Kennedy assassination.* But that leaves open the question of how to interpret Trump's outbursts. It may have become commonplace, but why does he bother with doing it at all?

There is an adage in politics that I have frequently seen attributed to Ronald Reagan; "if you're explaining, you're losing." That is to say, if you are a politician and find yourself having to try to explain away a problem, things are not going well for you. Even a good explanation will only remind people about the original problem. The only solution is to change the subject. Trump's tweets are intentionally provactive, because provocation demands media coverage. The more the press cover What-Trump-Said-This-Time, the less they cover what they were covering the day before. 

This week, Trump had hoped that the press would be covering his well-recieved Joint Session speech on Tuesday. By the end of the week, the dominant story would be not session, but Sessions. The Attorney General's discussions with the Russian Ambassador last year stepped on Trump's ability to capitalize on the speech. The tweets are his attempt to regain control of the narrative.

By injecting his claims about Obama into the investigation, he is attempting to take an issue that the country largely agrees on - Russian influence in our elections is bad - and turn it into a question of party loyalty. By implicating Obama he implies that the entire investigation is politically motivated. At worst for him, it provides a distraction from unflattering questions about his campaign. At best for him, it ultimately neuters the investigation by polarizing attitudes. It is a political sleight-of-hand.

That having been established, it may or may not ultimately be a successful one. The point is that Trump regularly pulls this sort of thing, and I've never seen him do it without some good reason. He is not, his public image and crippling personality flaws notwithstanding, simply a throbbing id in a suit. When examining the statements of any politician it is necessary to look past what is said, and focus on what purpose is served by saying it. It is especially so with Trump, who is more apt to shock us than a conventional politician and therefore more likely to be successful in his games of perception and distraction. 

*He was not. 

Trump's Speech to Congress

"Trump Offers Up A More Hopeful Vision," "Trump Seeks to Turn Post-Speech Boost Into Action," "Trump's Congress Speech Marks A Shift in Tone," "Trump Tries on Normal." If anyone had questions after last night's speech about its likely impact, those headlines - from the New York Times, Washington Post, Wall Street Journal, and Politico, respectively - should say all that needs to be said. From a political standpoint, Trump delivered a very good speech yesterday. His comparatively measured tone has inspired a predictable outbreak of what we might call "Tame Trump" storylines, of the sort that have been published more or less every time he has appeared in public with his feet on the platform instead of in his mouth. That will reinforce the reaction of the waverers in the GOP and the white middle class, for whom this speech was clearly written, that perhaps Trump isn't quite as alarming as he seems. In that sense, it was quite successful.

Though he may not have been frothing through the delivery, the content of the speech was exactly what I have come to expect from Trump, and it shed more light on the substance of his nationalism. The influence of Stephen Miller and Steve Bannon was palpable at many points. Two passages in particular caught my attention. First:

I will not allow the mistakes of recent decades past to define the course of our future. For too long, we've watched our middle class shrink as we've exported our jobs and wealth to foreign countries.We've financed and built one global project after another, but ignored the fates of our children in the inner cities of Chicago, Baltimore, Detroit and so many other places throughout our land. We've defended the borders of other nations, while leaving our own borders wide open for anyone to cross and for drugs to pour in at a now unprecedented rate. And we've spent trillions of dollars overseas, while our infrastructure at home has so badly crumbled. 

The similarity to his inaugural address is striking. Also:

According to data provided by the Department of Justice, the vast majority of individuals convicted for terrorism-related offenses since 9/11 came here from outside of our country... Those given the high honor of admission to the United States should support this country and love its people and its values. We cannot allow a beachhead of terrorism to form inside America. We cannot allow our Nation to become a sanctuary for extremists.

Both of these passages - like much else in the speech and in Trump's previous statments - are inward-looking, but in different ways.

The first is resentful, and actually recalls many favored talking points of the Democrats during the last few years of the Bush administration. Trump is telling his audience that the "establishment" has treated "them" better than "us." Anyone who has had any contact with a white middle class household should immeditely recognize the emotional force this argument has with that group, particularly as applied to immigrants. In the last fifteen years, for the first time since the Depression, the white middle class has suffered. It has not been actively helped by public policy during this period, so latent resentments against those seen by it to have the aid of the government - the very poor, the very rich, immigrants, nonwhites generally - have become open and increasingly intense. "The (othered group) gets (list of benefits), but a hardworking American like me can't get anything" is a common refrain. These people will hear Trump saying he is on their side.

The second passage is similar, but fear rather than resentment is the dominant emotion. The bad guys are coming in from outside and we have to stop them before they kill us. This is obviously meant to justify the controversial travel bans, but as ever with Trump the issue of immigration isn't far behind. This time, legal rather than illegal immigration is the target:

Protecting our workers also means reforming our system of legal immigration. The current, outdated system depressed wages for our poorest workers, and puts great pressure on taxpayers... According to the National Academy of Sciences, our current immigration system costs America's taxpayers many billions of dollars a year. Switching away from thie current system of lower- skilled immigration and instead adopting a merit-based system, will have many benefits: it will save countless dollars, raise workers' wages, and help struggling families - including immigrant families - enter the middle class.

As expected, the justification for this policy is economic. Like his message on trade and foreign policy, it is designed to appeal to the insecurities of poor and middle class whites. More importantly, it is a part of a coherent nationalist policy which views poor immigrants as a burden on the state instead of as aspiring individuals who want opportunities to succeed. It is a misleading and dangerous view. The report he cites states that the benefits of even the least skilled immigrants to society significantly exceed the costs their presence imposes, but only the costs found their way into his speech.

In sum, the tone of the speech may have been altered, but the content was vintage Trump. He made a conscious, and intelligent, move to force the GOP to unite behind him by recasting his message, but the message is the same. It calls for a nationalism defined by hostility to immigration, aversion to multilateral agreements of any kind, and a predatory trade policy. No matter how wide he smiles, his vision is the dismantling of the international system of trade and alliances the United States constructed after the World Wars and the Cold War. Its implementation would not only undermine international stability, but also do further harm to America's ability to project moral force worldwide by making a mockery of the principles for which we have fought at our best.