Wednesday, December 11, 2024
Trump Gears Up to Cut Social Security and Medicare
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.
Tuesday, December 10, 2024
America's Ignored Healthcare Crisis
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.
Monday, December 09, 2024
Trump and the End of The American Century
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?
Sunday, December 08, 2024
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