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Trump Is About to Betray His Rural Supporters

For decades now rural voters have largely voted Republican even though actual Republican policies are harmful to the best economic interests of rural areas and rural voters.   Republicans have played upon rural contempt and grievance towards urban areas and the so-called "elites" as well as the perennial GOP push of "god, guns and gays" to induce these voters to vote against their own long term best interests.  One sees this phenomenon over and over in Southwest Virginia and Virginia's other rural areas.  Nationally, the 2024 elections were no exception to this phenomenon and, in fact Donald Trump did better than ever with rural voters even though his proposed policies - tariffs that will harm agricultural producers, mass deportations, cuts to Medicaid that could be the death knell for rural hospitals, and dismantling the Department of Education and school vouchers for private school students - will likely devastate rural areas.   A long piece in The Atlantic looks at the harm Trump's policies may wreak on rural areas and the question of what will it take for rural voters to realize they are being screwed over and revolt from slavish allegiance to the Republican Party that in truth cares nothing about them.  Here are article highlights:

Donald Trump’s support in rural America appears to have virtually no ceiling. In last month’s election, Trump won country communities by even larger margins than he did in his 2020 and 2016 presidential runs. But several core second-term policies that Trump and the Republican Congress have championed could disproportionately harm those places.

Agricultural producers could face worse losses than any other economic sector from Trump’s plans to impose sweeping tariffs on imports and to undertake what he frequently has called “the largest domestic deportation operation” of undocumented immigrants “in American history.” Hospitals and other health providers in rural areas could face the greatest strain from proposals Trump has embraced to slash spending on Medicaid, which provides coverage to a greater share of adults in smaller communities than in large metropolitan areas. And small-town public schools would likely be destabilized even more than urban school districts if Trump succeeds in his pledge to expand “school choice” by providing parents with vouchers to send their kids to private schools.

Still, the most likely scenario is that elected Republicans who represent rural areas will ultimately fall in line with Trump’s blueprint. If so, the effects will test whether anything can loosen the GOP’s grip on small-town America during the Trump era, or whether the fervor of his rural supporters provides Trump nearly unlimited leeway to work against their economic interests without paying any political price.

“I don’t think [the Trump agenda] is going to lead to a dramatic reversal of these partisan shifts, because the truth is that the disdain for the Democratic Party is decades in the making and deep in rural America,” Nicholas Jacobs, a political scientist at Colby College . . . . . But if Trump acts on the policies he campaigned on, Jacobs added, “it’s hard to imagine that rural [places] will not suffer and will not hurt, and it’s hard to imagine that rural will not respond.”

Across his three runs for the White House, Trump gained considerably more support in the most-rural counties than in the nation’s more populous communities. Although he ran no better in the most-urban counties than did the 2012 Republican nominee, Mitt Romney, Trump roughly doubled the GOP margin in nonmetro areas from 20 points in 2012 to nearly 40 this year.

Congressional elections have largely followed the same trajectory. . . . Maps of party control of House seats now show the countryside solidly red in almost every state. Barring a few exceptions in New England, the states where rural residents compose the largest share of the population preponderantly elect Republicans to the Senate as well.

As Jacobs noted, the GOP advances in small-town America feed on these communities’ deep sense of being left behind in a changing America. . . . After years of seemingly inexorable decline in more remote communities, Jacobs believes, rural residents are especially responsive to Trump’s attacks on “elites” and his promises to upend the system. “I think rural people are rejecting the idea that the devil we know is worse than the devil Trump may bring,” Jacobs told me.

Despite the appeal of Trump’s promise of “retribution” against the forces these people believe have held them back, the change he’s offering in the specifics of his second-term agenda may strain those ties. The potential conflicts begin with Trump’s plans for trade. Agricultural producers faced the most turmoil from the tariffs that Trump in his first term . . . . Trump bought peace with farm interests by disbursing more than $60 billion in payments to producers to compensate for the markets they lost when China and other countries imposed retaliatory tariffs on U.S. products such as soybeans, corn, and pork. Those payments consumed nearly all of the revenue that Trump’s tariffs raised. . . .

Trump’s payments to farmers preempted any large-scale rural revolt during his first term. But they nonetheless imposed long-term costs on agricultural producers.

The bruising trade conflicts of Trump’s first term encouraged foreign purchasers of American farm products to diversify their supply in order to be less vulnerable to future trade disruptions, . . . . the United States lost share in those markets and never recovered it. In 2016, for example, the U.S. sold nearly as many soybeans to China as Brazil did; now Brazil controls three times as much of the Chinese market. . . . that means we left a lot of money on the table.”

He’s now threatening much more sweeping levies, including a 10 percent tariff on all imports, rising to 60 percent on those from China and 25 percent for goods from Mexico and Canada. Steinbach believes farmers will “very likely” now face even greater retaliatory trade barriers against their produce than they did in Trump’s first term. “The worst-case scenarios are really bad,” he told me.

Farm lobbies are welcoming Trump’s pledge to slash environmental regulations and hoping that he can deliver on his promise to cut energy costs. But his determination to carry out the mass deportation of undocumented immigrants will create another challenge for farmers. Agriculture relies on those workers as much as any other industry . . . . Removing a significant share of those workers through deportation, Steinbach said, would further erode the international competitiveness of American farmers by raising their labor costs and thus the price of their products.

Eliminating undocumented workers would also put upward pressure on domestic food prices—after an election that, as Trump himself noted, he won largely because of the price of groceries—and would also weaken rural economies by removing those workers’ buying power.

A recent attempt to model how Trump’s tariff and mass-deportation plans would affect agricultural producers found a devastating combined impact. In a scenario where Trump both imposes the tariffs he’s threatened and succeeds at deporting a large number of immigrants, the nonpartisan Peterson Institute for International Economics has forecast that by 2028, agricultural exports could fall by nearly half and total agricultural output would decline by a sixth.

Equally painful for rural America could be Trump and congressional Republicans’ agenda for health care. . . . . Retrenching federal spending on Medicaid and the ACA remains a priority for congressional Republicans. . . . . The Republican Study Committee, a prominent organization of House conservatives, called in its latest proposed budget for converting Medicaid and ACA subsidies into block grants to states and then cutting them by $4.5 trillion over the next decade . . . . Larry Levitt, the executive vice president for health policy at the nonpartisan KFF think tank, told me. “We are looking at cutting tens of millions of people off from coverage.”

Rural places would be especially vulnerable to cuts anywhere near the level that Republicans are discussing. Rural residents tend to be older and poorer, and face more chronic health problems. Rural employers are less likely to offer health insurance, which means that Medicaid provides coverage for a larger share of working-age adults in small towns. . . .

Medicaid is especially important in confronting two health-care challenges particularly acute in rural communities. One is the opioid epidemic. . . . . Medicaid has become the foundation of the public-health response to that challenge. . . . Hundreds of thousands of people are receiving opioid-addiction treatment under Medicaid in heartland states that Trump won, such as Michigan, Pennsylvania, Ohio, Kentucky, and Indiana. In all of those states, a majority of people receiving care are covered through the Medicaid expansion . . . .

Medicaid is also a linchpin in the struggle to preserve rural hospitals. These face much more financial stress than medical facilities in more populous areas. Mann says that over the past two decades, 190 rural hospitals have closed or converted to other purposes, and nearly a third of the remaining facilities show signs of financial difficulty.

That situation makes Medicaid a crucial lifeline for rural hospitals. “With large cuts to federal health spending, it would be very hard for rural health-care providers to simply survive,” said the KFF’s Levitt. “In many cases, rural hospitals are hanging by a thread already, and it wouldn’t take much to push them over the edge.”

In the same way that rural hospitals are especially vulnerable to Trump’s health-care agenda, his education plans could threaten another pillar of small-town life: public schools. Trump has repeatedly promised to pursue a nationwide federal voucher system that would provide parents with public funds to send their children to private schools. . . . . Small-town residents, she said, recognized that rural public schools already facing financial strain from stagnant or shrinking enrollments have little cushion if vouchers drain more of their funding. Regardless of how receptive conservative rural voters might be to Republican attacks on “woke” educators, Coots noted, “if you ask them about their public school or their neighborhood school, they like it, because they know what the public school means for their community.”

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American's Health Care System: Driven By Profit, Not Patient Care

If nothing else, the murder of Brian Thompson, the C.E.O. of UnitedHealthcare has prompted an outpouring of rage against insurance companies and America's broken health care system that increasingly is driven by profits - the higher the better - rather than true patient care.  Hospital systems and for profit corporations have bought up medical practices and control medical care by doctors and for profit hospitals focus ultimately only on the bottom line.   "Non-profit" hospital systems are little better as the engage in monopoly wars with competing systems (years ago I did legal work for a hospital system little focus was on medical care and instead on competing with a rival system that ultimately gobbled up my client) and direct captive medical practices to refer patients to the hospital system even if better treatment options are available through other providers or systems. Then there is the systematic denial of claims by health insurers aimed at boosting profits.  It is ALL about the money even before one factors in the over billing and procedure coding games that drain taxpayer dollars from Medicare and other programs.  America has the most costly health care of any advanced nation and serves the smallest percentage of its citizens compared to other nations.  Sadly, the trend towards profit motive alone is worsen as a long piece in the New Yorker lays out.  Here are highlights:

In 2010, a private-equity firm called Cerberus Capital Management, which is named for the three-headed dog that is said to guard the underworld, bought six Catholic hospitals in Massachusetts and christened the chain Steward Health Care. The state’s attorney general blessed the deal on multiple conditions, including that, during a five-year review period, the hospitals stayed open and their workers stayed employed. A few months after the period ended, however, Steward started selling the land on which the hospitals stood. A $1.25-billion-dollar deal, in 2016, helped to finance more acquisitions. Many facilities, asked to pay rent on land they’d previously owned, struggled.

According to a recent report published by Massachusetts Senator Ed Markey’s office, which covers the period between 2017 and 2024, some Steward facilities had to forgo key investments in staffing, surgical equipment, elevator repairs, and even clean linens. Patients increasingly languished in emergency rooms; many left without receiving care; and mortality rates for common conditions climbed sharply. . . . . A hospital in Florida developed a bat infestation, and another, in Texas, was cited for placing potentially suicidal patients in rooms with materials with which they could hang themselves. Employees at Steward’s Carney Hospital, in Massachusetts, began calling their workplace “Carnage” hospital.

In May, Steward filed for bankruptcy. It has closed two hospitals and plans to sell thirty-one others. Steward’s C.E.O., Ralph de la Torre, who in 2011 purchased a forty-million-dollar superyacht, was subpoenaed by a Senate committee but failed to show up; he was held in contempt of Congress and resigned from his position. . . . . Nonetheless, Cerberus realized a profit of seven hundred and ninety million dollars from its investment in Steward.

Meanwhile, in some places in the U.S., private-equity firms now own more than half of all medical practices within certain specialties. “We are being picked clean by private equity,” a New Jersey-based radiologist said at a recent meeting of the American Medical Association.

2024 was arguably the year that the mortal dangers of corporate medicine finally became undeniable and inescapable. A study published in JAMA found that, after hospitals were acquired by private-equity firms, Medicare patients were more likely to suffer falls and contract bloodstream infections; another study found that if private equity acquired a nursing home its residents became eleven per cent more likely to die. Although private-equity firms often argue that they infuse hospitals with capital, a recent analysis found that hospital assets tend to decrease after acquisition. Yet P.E. now oversees nearly a third of staffing in U.S. emergency departments and owns more than four hundred and fifty hospitals.

Erin Fuse Brown, a professor at the Brown University School of Public Health, told me that private-equity firms have learned that they “don’t have to make things better or make them more efficient. You can just change one small thing and make a ton more money.” They are hardly the only corporations to learn this lesson. Increasingly, health insurers, private hospitals, and even nonprofits are behaving as though they aim first to extract revenue, and only second to care for people. Patients often are viewed less as humans in need of care than consumers who generate profit.

In 1873, Mark Twain co-wrote the novel “The Gilded Age: A Tale of Today,” which satirized an era that was marked by inequality, greed, and moral decay but was painted in a veneer of abundance and progress.

New technologies and treatments sustain the impression that patients have never been healthier, but corporations and conglomerates wield immense power at the expense of the people they’re meant to serve. Welcome to the Gilded Age of medicine.

In recent years, health-care corporations have embraced an approach that can only be described as gamification. In the U.S., all seniors over sixty-five are entitled to health insurance through Medicare, and, for several decades, private companies have offered plans through programs such as Medicare Advantage. The government pays insurance companies a fixed sum based partly on how sick those patients are. The sicker the patients, the bigger the potential payments. But who’s to say, really, how sick a patient is? Let the games begin.

This year, the health-news site STAT revealed that UnitedHealth, the country’s largest private insurer, had set up dashboards for practices to compete on how many conditions they could diagnose in patients. Doctors who completed the most appointments with seniors in Medicare Advantage were eligible for ten-thousand-dollar bonuses, and patients were offered seventy-five-dollar gift cards for getting checkups at which their medical histories could be recorded.

These strategies rack up so many additional diagnoses that, in 2023 alone, the federal government made $7.5 billion in “overpayments” to insurers, according to the U.S. Office of the Inspector General. Insurers are “pouring tremendous resources into developing the capacity to code patients in a way that nets more money from Medicare,” Donald Berwick, a former head of the Center for Medicare & Medicaid Services, told me. “That’s taxpayer money being siphoned away from people who need it.”

Berwick said that his own physician’s practice had recently been acquired by UnitedHealth. One day, he asked his doctor, “Anything different now?” “Two things,” the doctor replied. “I have to see more patients each day. And my patients have new diagnoses that I didn’t put there.” . . . . It did, however, generate higher payments from Medicare. Ask not what your insurer can do for you—ask how much revenue you can generate for your insurer.

The insurance companies in Medicare Advantage tend to argue that they’re simply recording diagnoses, not making them up . . . . But according to the Medicare Payment Advisory Commission, a nonpartisan agency that counsels Congress, private Medicare Advantage plans will cost the federal government eighty billion dollars more per year than if those patients had been in the traditional Medicare program. “You might as well flush most of that eighty billion dollars down the toilet,” Berwick told me.

On December 4th, after I drafted this piece, Brian Thompson, the C.E.O. of UnitedHealthcare, was fatally shot in midtown Manhattan. In the days that followed, the public response was not just one of shock but also of frustration and even rage against the health-insurance industry. . . . . Thompson had become a symbol of a broken system; people who devalued his life, it seemed to me, were engaging in a version of the dehumanizing behavior that they found objectionable within the health-care industry.

It would be nice if nonprofit health care were the antidote to corporate health care. Instead, each year, it seems to look more like for-profit medicine. The Times recently reported that Providence, one of the nation’s largest not-for-profit health-care organizations, sicced debt collectors on poor patients who were entitled to free care. Providence, which was founded in the eighteen-fifties by nuns committed to “serving all, especially those who are poor and vulnerable,” recorded annual revenues in excess of twenty-seven billion dollars in 2021. Like other nonprofits, it benefitted from enormous tax breaks, yet only one per cent of its expenses went to charity care. . . . . other hospitals still have policies of suing patients, obtaining court orders to garnish their wages if they fail to pay, and even placing liens on their homes.

Meanwhile, an increasingly consolidated health-care industry has engendered the kinds of too-big-to-fail behemoths that can single-handedly paralyze the system. Health care accounts for more than seventeen per cent of the U.S. economy, or around four and a half trillion dollars, but the revenues of just two companies—CVS/Aetna and UnitedHealth—account for nearly one in every seven dollars the nation spends on health care.

It’s not that any talk of money should be rejected—hospitals and clinics need to keep the lights on, after all. But we need counternarratives to revive medicine’s social contract and to help curb the kind of financial gamesmanship that has become accepted and pervasive.

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Trump Gears Up to Cut Social Security and Medicare

For decades now, rural and many working class voters in Virginia have fallen for variants of  Republicans' "god, guns, and gays" and a hefty dose of racism and voted Republican even thought the Republican agenda and policies are in most cases directly opposed to these voters' own best economic interest.  In the 2024 election we saw this writ large on a national scale as many of the same types of voters rallied to Donald Trump on his promises to deport non-whites, make gays invisible again, and restore white privilege.  Meanwhile, Trump's regime will do many things against the economic interests of these very same voters, including gearing up to cut Medicaid, Medicare and Social Security in order to fund more huge tax cuts for the very wealthy and corporate America. Add in the higher prices triggered by Trump's promised tariffs and these voters have profoundly screwed themselves over and will inflict suffering on the rest of us. Indeed, the only thing that may save many from themselves is the fear of congressional Republicans who will have to face voters in 2026, assuming Trump doesn't manufacture a reason to postpone elections. As for Trump, he cares nothing for those who foolishly voted for him.  A piece in Salon looks at the possible coming cuts that would harm millions. Here are highlights:

There are a thousand election hot takes and post-mortems floating around these days and I'm sure we'll soon come to some consensus about what drove the Trump victory (now down to a whopping 1.48% margin and shrinking.) But if there's one thing we do know it's that he won both of his elections at least in part by shedding some Republican Party orthodoxy that had been bringing the GOP down for ages. He knows a third rail when he sees one.

And if there's one issue that differentiated Trump from other Republicans from the minute he came down that golden escalator it's his promise to preserve the so-called entitlement programs. . . . . "I'm not going to cut Social Security like every other Republican and I'm not going to cut Medicare or Medicaid," and it may have been the key to his success in that first campaign.

He lied. His proposed budgets cut the programs every year he was in office. As Vox reported back in 2019:

Over the next 10 years, Trump’s 2020 budget proposal aims to spend $1.5 trillion less on Medicaid — instead allocating $1.2 trillion in a block-grant program to states — $25 billion less on Social Security, and $845 billion less on Medicare (some of that is reclassified to a different department). Their intentions are to cut benefits under Medicaid and Social Security.

Obviously, Congress didn't approve those cuts so it didn't happen but it wasn't for lack of trying.

That last budget was put together by the man Trump is bringing back as his Director of the Office of Management and Budget, and one of the principal authors of Project 2025, Russell Vought. It's highly questionable whether Vought will be as circumspect about the plans to cut the programs this time or whether Trump will care because all of that was predicated on Trump's need to run for office again. Without that hanging over their heads they have no need to hold back. Republicans have wanted to do away with those programs since they were first passed. This may be their chance to finally get it done.

As we know, Trump has pledged to create a sexy new government commission led by Elon Musk and Vivek Ramaswamy called the "Department of Government Efficiency" or DOGE . . . . Vought has said that he plans to work closely with the commission to use executive action to accomplish the slashing and burning of government programs they're promising.

Vought hasn't openly called for cutting Social Security retiree benefits but has promoted cutting disability payments and Medicaid and fully privatizing Medicare. His history suggests, however, that given the go-ahead he will gleefully take a meat ax to the program. Musk, however, has been clear that he believes the government has to be cut to the bone immediately which he admits will cause "hardship" that we will just have to bear.

This week, the far-right senator from Utah, Mike Lee, posted a thread on Twitter/X in which he claims that Social Security is a scam that the government mismanages and must be reformed so that people can "invest" their money and avoid "dependence."

It's the same old story. In fact, the last time they tried this after President George W. Bush declared he had a mandate from his re-election victory, it ushered in a massive Democratic congressional takeover in the midterms and a two-term Democratic presidency. The financial crisis hit and everyone in America saw the wisdom of having at least a portion of their old age or disability safety net guaranteed by the government instead of Wall Street. I suppose it's possible that it's ancient history to a lot of people but I kind of doubt it is for anyone over 50.

But it's possible they won't even try to sell it that way. Musk expects people to suffer in order to save the country from bankruptcy which he has decided is imminent. Vought and his right-wing Christian nationalist allies want to completely decimate the "administrative state" so they may just declare that the program is insolvent and cut the benefits across the board.

With what will be a tiny majority in the House it's very hard to see anything like that passing. Unlike Trump, they have to face the voters again. But we do know that Vought is a big fan of "impoundment" which basically says that the president can spend money however he wants regardless of what Congress has intended.

It is highly likely that the DOGE group and Vought at OMB are going to try to use this concept to sidestep Congress completely. Whether they have the nerve to attempt it with something as massive as Social Security or Medicare remains to be seen. But those programs are the right's great white whale and I wouldn't be surprised if they make another attempt to finally kill them.

Donald Trump certainly won't care. He never has to face another voter and that is the only reason he ever promised to keep his hands off of the programs in the first place. Trump can do somersaults on the third rail now and it can't hurt him at all. His party is another story, but he doesn't care about them either. 

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America's Ignored Healthcare Crisis

If nothing else, the murder of UnitedHealthcare CEO Brian Thompson has sparked volumes of complaints about America's broken health insurance system dominated by for-profit companies that are motivated to maximize profits by denying coverage and claims of subscribers.  Some are even applauding the murder and viewing the shooter as a folk hero of sorts. Nothing justifies Thompson's murder, but it is far past time for Americans to demand that politicians do something about a broken system that sees far too many denied coverage for necessary treatments which leads to suffering, death in some cases and/or financial ruin. As noted in a previous post, life expectancies have fallen in America while they have inched up in Europe where there are universal health coverage systems with preventive care coverage and reasonable costs to patients. The differing life expectancies are likely not a coincidence. A lengthy piece in the New Yorker looks at the unseemly applause at Thompson's murder and also some of the profit motivated policies of health insurance carriers.  Will the current conversation lead to systemic change?  Probably not when one looks at the failure of politicians - mostly Republican - to act after each school shooting. Here are article excerpts:

As you know, the C.E.O. of UnitedHealthcare, fifty-year-old Brian Thompson, was murdered on the street in midtown Manhattan, on Wednesday morning, twenty minutes before sunrise. He was in town for an investors’ convention, and had worked for UnitedHealthcare for more than two decades—a company that is part of UnitedHealth Group, a health-insurance conglomerate valued at five hundred and sixty billion dollars. UnitedHealthcare had two hundred and eighty-one billion dollars in revenue in 2023, and Thompson, who became C.E.O. in 2021, had raised annual profits from twelve billion dollars to sixteen billion dollars during his tenure. He received more than ten million dollars in compensation last year.

The particulars of this murder are strange and remarkable: it occurred in public; the suspected shooter went to Starbucks beforehand; he got away from the scene via bicycle; . . . . But the public reaction has been even wilder, even more lawless. The jokes came streaming in on every social-media platform, in the comments underneath every news article. “I’m sorry, prior authorization is required for thoughts and prayers,” someone commented on TikTok, a response that got more than fifteen thousand likes. “Does he have a history of shootings? Denied coverage,” another person wrote, under an Instagram post from CNN. On X, someone posted, with the caption “My official response to the UHC CEO’s murder,” an infographic comparing wealth distribution in late eighteenth-century France to wealth distribution in present-day America. . . . . What on earth, some people must be asking, is happening to our country? Are we really so divided, so used to dehumanizing one another, that people are out here openly celebrating the cold-blooded murder . . . .

There had been prior threats against Thompson, his wife told NBC News, motivated, she said, by, “I don’t know, a lack of coverage? . . . I just know that he said there were some people that had been threatening him.” There had been protests at the UnitedHealthcare headquarters, in Minnesota, in April and July; during the latter, eleven people were arrested. The group responsible for the protests, People’s Action, also confronted Witty, the UnitedHealth Group C.E.O., at a Senate hearing in May. In a statement, People’s Action leaders referenced endless hours on the phone trying to get medical care covered, and denials of coverage for lifesaving medication and surgery.

A recent statement from the group, in response to Thompson’s death, read, “We know there is a crisis of gun violence in America. There is also a crisis of denials of care by private health insurance corporations including UnitedHealth.” They urged political leaders to “act on both.” UnitedHealthcare has the highest claim-denial rate of any private insurance company: at thirty-two per cent, it is double the industry average.

To most Americans, a company like UnitedHealth represents less the provision of medical care than an active obstacle to receiving it. UnitedHealthcare insures almost a third of the patients enrolled in Medicare Advantage, a government-funded program facilitated by private insurance companies, which receive a flat fee for each patient they cover and then produce their own profits by minimizing each patient’s care costs. Reporting in the Wall Street Journal has found that these private insurance companies, which cover more than a third of American seniors on Medicare, collect hundreds of billions of dollars from the government annually and overbill Medicare to the tune of around ten billion dollars per year; UnitedHealthcare has used litigation to fight its obligation to repay fees that were overpaid. 

In 2020, UnitedHealth acquired a company called NaviHealth, whose software provides algorithmic care recommendations for sick patients, and which is now used to help manage its Medicare Advantage program. A 2023 class-action lawsuit alleges that the NaviHealth algorithm has a “known error rate” of ninety per cent and cites appalling patient stories: one man in Tennessee broke his back, was hospitalized for six days, was moved to a nursing home for eleven days, and then was informed by UnitedHealth that his care would be cut off in two days. (UnitedHealth says the lawsuit is unmerited.) After a couple rounds of appeals and reversals, the man left the nursing home and died four days later.

At the same time that news was breaking about the NaviHealth algorithm, the company was fighting—ultimately unsuccessfully—a court decision that it had acted “arbitrarily and capriciously” in repeatedly denying coverage of long-term residential treatment to a middle-school-age girl who repeatedly attempted suicide, and has since died by suicide. Several years ago, government investigators found that UnitedHealth had used algorithms to identify mental-health-care providers who they believed were treating patients too often; these identified therapists would typically receive a call from a company “care advocate” who would question them and then cut off reimbursements. Though some states have ruled this practice illegal, it remains in play across the country.

There is no single regulator for a private health-insurance company, even when it is found to be violating the law. For United’s practices to be curbed, mental-health advocates told ProPublica, every single jurisdiction in which it operates would have to successfully bring a case against it.

Thompson’s murder is one symptom of the American appetite for violence; his line of work is another. Denied health-insurance claims are not broadly understood this way, in part because people in consequential positions at health-insurance companies, and those in their social circles, are likely to have experienced denied claims mainly as a matter of extreme annoyance at worst: hours on the phone, maybe; a bunch of extra paperwork; maybe money spent that could’ve gone to next year’s vacation. For people who do not have money or social connections at hospitals or the ability to spend weeks at a time on the phone, a denied health-insurance claim can instantly bend the trajectory of a life toward bankruptcy and misery and death.

Maybe everyone knows this, anyway, and structural violence—another term for it is “social injustice”—is simply, at this point, the structure of American life, and it is treated as normal, whether we attach that particular name to it or not.

Traditionally, our society fixates on only one version of this: direct physical violence committed by a person intending harm. The pretty girl killed by a boyfriend, the C.E.O. shot on the street, the subway dancer strangled by the ex-marine.

On this point, though, everyone’s really in agreement. It’s just a matter of where you locate the decay—in the killing, or in the response to it, or in what led us here. The only way to end up in a situation where a C.E.O. of a health-insurance company is reflexively viewed as a dictatorial purveyor of suffering is through a history of socially sanctioned death. A person who posted on Reddit’s r/nurses forum, whose profile describes her as an I.C.U. nurse, wrote, “Honestly, I’m not wishing anyone harm, but when you’ve spent so much time and made so much money by increasing the suffering of the humanity around you, it’s hard for me to summon empathy that you died.

Nurses, residents, aides, specialists—they are asked to absorb the rage and panic induced by the American health-care system, whose private insurers generate billions of dollars in profit and pay executives eight figures not despite but because of the fact that they routinely deny care to desperate people in need.

Thompson’s death resurfaced some unsavory details about his industry. We learned, for instance, that Thompson was one of several UnitedHealth executives under investigation by the D.O.J. for accusations of insider trading. (He had sold more than fifteen million dollars’ worth of company stock in February, shortly before it became public that the Department of Justice was investigating the company for antitrust violations, which caused the stock price to drop.) A new policy from Anthem Blue Cross Blue Shield also went viral: the company had announced that, in certain states, starting in 2025, it would no longer pay for anesthesia if a surgery passed a pre-allotted time limit. The cost of the “extra” anesthesia would be passed from Anthem—whose year-over-year net income was reported, in June, to have increased by more than twenty-four per cent, to $2.3 billion—to the patient. On Thursday, the company withdrew the change in response to the public outrage, if only in Connecticut, for now.

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Trump and the End of The American Century

As an older baby boomer, my entire life has been during the so-called American Century where America has been the predominant power in the world, security has been bolstered by treaties such as NATO, and largely free trade and immigration have bolstered America's prosperity.  Now, with his reelection - which, in my views very negative things about far too many Americans - Donald Trump wants to rip that template apart and likely lead to a poorer (at least for those not super- rich) America, with higher prices, increased threats abroad, and dwindling influence. It's akin to what the United Kingdom did to itself with Brexit that has left the UK poorer and with far higher prices. Meanwhile, of course, the delusion of restoring the British Empire never happened.  A piece in Politico looks at the so-called American Century and how Trump will likely destroy it.  His cultist followers are likely in for a shock and things will likely not end well for the majority of Americans.  Here are excerpts:

In February 1941, Henry Luce, the influential publisher of Time and Life magazines, penned an article heralding the “American Century,” a post-war era in which the United States would apply its newfound standing as the “dominant power in the world” to spread “free economic enterprise” and “the abundant life” around the globe. Luce envisioned the United States as “the principal guarantor of the freedom of the seas” and “the dynamic leader of world trade,” and saw in this future “possibilities of such enormous human progress as to stagger the imagination.”

The next several decades would prove Luce right, as the United States emerged from World War II as one of two global superpowers and, arguably, the world’s preeminent cultural and economic force. Luce, who was a Republican, intended his broadside to serve as a template for conservative internationalism — in effect, a powerful response to the party’s isolationist, America First wing. But this concept — of America as a friendly goliath, the “Good Samaritan of the entire world,” promoting democracy, capitalism, trade and international order — guided the thinking of most policymakers and politicians across the political spectrum for the better part of a century.

Until now.

Donald Trump’s second presidential victory represents a sharp break, and perhaps a permanent one, with the American Century framework. It’s a framework that rested on four key pillars:

A rules-based economic order that afforded the U.S. free access to vast international markets.

A guarantee of safety and security for its allies, backed up by American military might.

An increasingly liberal immigration system that strengthened America’s economy and complemented military and trade partnerships with the rest of the non-Communist world.

And finally, in Luce’s words, a “picture of an America” that valued — and exported to the rest of the world — “its technical and artistic skills. Engineers, scientists, doctors … developers of airlines, builders of roads, teachers, educators.”

Though this was the second time Trump won the presidency, the meaning of the 2024 election is different. For one, he won the popular vote — becoming the first Republican to do so in the last 20 years. What’s more, in his most recent electoral bid, Trump and his advisers (including his running mate) made tariffs, rapprochement with foreign dictators, a drawback from NATO and gutting federal agencies core themes of their campaign. . . . . and nearly 50 percent of voters endorsed that program. This time, the president-elect is quite serious about ending the American Century. In fact, he’s already making moves to tear it down.

Just look at his recent cabinet nominations. Tulsi Gabbard, Trump’s pick as director of national intelligence, has defended both Syrian dictator Bashar al-Assad, whom she has met multiple times, and Vladimir Putin’s reasoning for invading Ukraine — hardly an encouraging choice for American allies looking for a guarantee of safety and security. Howard Lutnick, his pick for commerce secretary, is a diehard supporter of Trump’s aggressive tariff agenda, which would drastically curtail U.S. participation in an international free market. The elevation of former acting ICE director — and Project 2025 contributor — Tom Homan to the position of “border czar” carries implications for American immigration policy so obvious they hardly require explanation. And as for trusting in expertise, Trump has appointed anti-vaccine conspiracy theorist Robert F. Kennedy Jr. to lead the Department of Health and Human Services.

Voters might very well want to make a reasoned break with the past. But the American Century framework also underwrote the country’s economic might, political power and security for many decades. What happens if we dismantle it?

In the years immediately following World War II, the U.S. pursued two interconnected goals: It underwrote Western Europe’s and Asia’s post-war recovery and imposed a rules-based economic order to promote greater stability; and it promised its allies military security against Soviet aggression. Both policies required a robust internationalist outlook.

It wasn’t just a question of altruism. Stable and prosperous allies in Europe and Asia would resist the pull of communist parties and align themselves strategically with Washington, D.C. — not Moscow. They would also generate vast markets in which the U.S. could sell agricultural products, fuel and finished goods, and from which the U.S. could import raw materials. The Marshall Plan thus indirectly strengthened American economic hegemony, but it also did so directly: It required that when recipient nations deployed the funds to rebuild, they buy American when possible. In effect, it functioned as a multi-billion stimulus package for American business, agriculture and manufacturing.

American policymakers also spearheaded the creation of a rules-based international order to promote a more enduring free trade environment between its allies.

What was good for America’s allies was often very good for America. Loans from the IMF and World Bank regularly came with stipulations that recipient nations use U.S. contractors, goods and services, creating export opportunities for American businesses. More broadly, by converting Europe and Japan into prosperous and reliable trading partners, the post-war system created thriving markets for American exports.

Prosperity required more than redevelopment and economic stability; it demanded peace. Hence, the other side of the coin was America’s role in safeguarding its allies against Soviet, and later Communist Chinese, aggression. The establishment of the North Atlantic Treaty Organization (NATO) in 1949 and the Southeast Asia Treaty Organization (SEATO) in 1954, which bound each member state to rise to the defense of the others in the event of an attack, helped create a Cold War stalemate between the U.S. and Soviet Union (and later, China). They also bolted member states more tightly into America’s orbit and ensured that the U.S. would enjoy a preeminent position in trade and financial policymaking. . . . . Pax Americana comes with the promise of protection but requires that our allies accept living under the thumb of the U.S. military.

While not originally part of the post-war framework, a liberalized immigration regime was the natural extension of America’s enlightened — and sometimes unenlightened — internationalism. It wasn’t just the free flow of goods and capital that helped make the United States an economic and political powerhouse. It was the free flow of people.

While the 19th and early 20th centuries saw a massive influx of new immigrants from Europe and Asia, the door largely swung shut in 1924, when Congress limited the annual number of immigrants, particularly those emigrating from outside northern European countries.

In 1966 Congress passed, and President Lyndon Johnson signed, legislation that opened the door again. The new law favored newcomers with specialized skills and education or existing family relationships with American citizens or residents, and substituted the old national origins standard — which simply allotted certain countries a set number of immigrants, heavily favoring immigrants from Northern Europe — with annual hemispheric limits: 170,000 immigrants from the Eastern hemisphere and 120,000 from the Western hemisphere, a breakdown that reflected lingering bias toward Europe.

Unlike earlier waves, 90 percent of new Americans after 1965 hailed from outside Europe — from countries like Mexico, Brazil, the Philippines, Korea, Cuba, Taiwan, India and the Dominican Republic.

Presidents from both parties knew it. When Ronald Reagan and George H.W. Bush debated each other during the 1980 Republican primary, both agreed in clear terms that immigration was a distinguishing feature of American strength.

Setting aside the millions of legal immigrants who have made their homes in the U.S., according to Cornell University’s ILR Worker Institute, today, undocumented persons make up 25 percent of the agricultural workforce, 17 percent of all construction workers and 19 percent of maintenance workers. Alongside documented immigrants, they helped the country withstand birthrate and demographic decline, a phenomenon that threatens economic growth, the future of entitlement programs and, more generally, national security.

Trump’s proposed deportation program would shrink GDP by up to 7 percent by 2028, drive up unemployment rates and increase inflation. Whether voters like it or not, robust immigration was a key pillar of the American Century.

A final pillar of the American Century framework might be broadly characterized as expertise — or, more precisely, a veneration of expertise.

Looking back on the early post-war years, the columnist Robert J. Samuelson recalled that “you were constantly treated to the marvels of the time. At school, you were vaccinated against polio. … At home, you watched television. . . . You took prosperity for granted, and so, increasingly, did other Americans.”

Presidents from Truman through Barack Obama — Democrats and Republicans alike — staffed the government with professionally trained scientists, economists and other academics, and the revolving door between elite universities and government swung quickly and constantly.

It’s not at all clear that Donald Trump can, or even intends to, make good on campaign promises to deport millions of immigrants, slap punitive tariffs on America’s allies or gut the professional ranks of the civil service — including doctors and researchers at NIH and the FDA, economists at the Treasury Department, demographers at the Census Bureau and policy professionals at the Departments of Education and Energy.

More clear is that his vice president wants to cut off aid to Ukraine and kneecap NATO. In his first term, the president-elect gestured at sharply reducing American miliary presence abroad, suggesting a possible redeployment that leaves allies more vulnerable to Russian and Chinese aggression. Furthermore, the appointment of cabinet officials with absolutely zero subject matter expertise, such as RFK Jr., and the promise to clean house of the bureaucratic state, augur at a future when experts are booted from the seat of government.

[T]he American Century framework has defined the nation’s trajectory for well over 80 years. For good or bad, it undeniably made the United States a very prosperous and powerful country. It’s what bound allies into strategic, security and economic relationships with the U.S., ensured our continued access to trading partners and lent the country favored status across a broad spectrum of international organizations. We’ve become accustomed to the benefits it delivers, without understanding how quickly those benefits could disappear.

A very reasonable question for voters who now reject that framework is: What’s next?

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