The Little Red Blog

Friday Double Feature

{For ideological balance, I have chosen one excerpt from column A and one from column B. The reader should have no trouble discerning which column I prefer.}

Although I found no mention of Obamacare—the Affordable Care Act—in Robert Kuttner’s infuriating essay “Fantasyland General,” I couldn’t help but think of how the ACA was supposed to be a first step towards simplifying and making transparent our byzantine fee-for-service healthcare system. Mission not accomplished, it seems, not even with the passage of subsequent legislation like the “No Surprises Act” of 2021 that further regulated medical pricing and billing practices. It remains the case that profit-driven individuals and corporations continue to find ways to milk our for-profit healthcare system for their own enrichment. Conservatives love to say that, in economic transactions, money is never left on the table; they usually fail to mention that “economic transactions” include emergency medical procedures, or that “the table” includes the operating table in your local hospital. 

Kuttner concludes, sensibly enough, with this: “The fact that universal socialized systems have no counterpart to the U.S. system of price manipulation, with all of the money spent on administration and gaming, goes a long way toward explaining why the U.S. spends upwards of 17 percent of GDP on health care and the typical OECD country spends about 11 percent. That difference—6 percent of GDP—is about $1.5 trillion a year. Just imagine what else we might do with $1.5 trillion a year. The only solution is to get rid of prices entirely by treating health care as the social good that it is.”

It is infuriating that we are still debating this issue.

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Fantasyland General - The American Prospect

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In a mercifully brief article (at RealClearHistory), Howell Keiser performs a clever bit of intellectual prestidigitation: he links contemporary environmentalism to slavery and contemporary environmentalists to slaveholders.

Watch him pull the rabbit from the hat:

Like antebellum Southerners who, according to historian David Silkenat, used the fear of “environmental destruction” to elevate their low-population agrarian philosophy, environmentalists today see the “impact of population” and industrialization as combining to “deplete natural resources and degrade the environment.” Population and industrial growth, therefore, must be controlled.

See? The rabbit is slavery, and the hat is concerns about industrial activity and its effects on the planet:

But how can this be achieved? Vice President Kamala Harris stated that “when we invest in clean energy, and electric vehicles, and reduce population, more of our children can breathe clean air and drink clean water.” Of course, Harris leaves the best means of implementing depopulation and regulating economic freedom unanswered.

Ultimately, the perspective put forward by Vice President Harris is not entirely different in principle from some of the solutions offered by leading slaveholders.

There you have it! We should note, of course, that the phrase “not entirely different in principle” is doing quite a lot of work on behalf of Keiser’s “argument”. 

In fact, the only solution ever offered by slaveholders, “leading” or otherwise, was that they be allowed to continue holding slaves; whatever else they may have said was mere rationalization. In any case, I will go out on a limb here and say that Vice-President Harris is not recommending or condoning slavery; she is recommending cleaner energy sources (i.e., non-fossil fuels) and birth control (which, for the record, is not the same thing as “depopulation”).

Keiser’s ominous reference to “the best means [of] regulating economic freedom” is the same chestnut that defenders of the free market have been roasting over the open fire of their fearmongering for the past century. Economic freedom is always imperiled, it seems; every proposed regulation is potentially the last straw that will send entrepreneurs en masse to Galt’s Gulch.   

Keiser is correct in noting that, in the nineteenth and twentieth centuries, concerns were expressed by individuals of various political and ideological allegiances over industrial capitalism and its consequences (e.g., the degradation of the environment and the exploitation of labor); nor was the rapid growth of the planet's population merely a Malthusian obsession. Such common concerns did not erase the ideological differences, nor did they render all suggested solutions morally equivalent. 

It was none other than Russell Kirk, the revered Squire of Mecosta and an iconic figure for modern American conservatives, who famously noted that antebellum Southern resistance to industrialization resembled left-wing concerns about capitalism; this led Kirk to dub John C. Calhoun “the Marx of the ruling class,” but even Kirk knew better than to call Karl Marx “the John C. Calhoun of the proletariat.” Defending slavery by criticizing industrial capitalism is not the same as criticizing industrial capitalism by advocating revolution by the working class.

Keiser’s tactic of guilt-by-innuendo against environmentalists (and liberals in general) is all too typical of the modern American Right, which takes innocuous statements uttered by someone on the Left and insinuates that the speaker is a nascent Pol Pot and that genocide is on the horizon. Such insinuations are, quite frankly, both juvenile and tedious. American conservatives have apparently reverted to what Lionel Trilling called “irritable mental gestures” to camouflage their complete inability to make coherent arguments.   

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Past Informs the Present | RealClearHistory

Have as many as you want! Just don't expect affordable healthcare.

On the Bookshelf

{No, I haven’t read these books, but they’re on my current list of ‘must reads,’ which is practically the same as having read them. Besides, I’ve got the publishers’ summaries right in front of me, and I’m sure those are entirely accurate and objective.}

Sathnam Sanghera, Empireland: How Imperialism Has Shaped Modern Britain

According to its publisher, Empireland is “brilliantly illuminating” as well as “revelatory and lucid”. The author’s thesis is that “much of what we consider to be modern Britain is actually rooted in its imperial past.” Every nation has skeletons in its closet, and Britain is no exception; what slavery is to the United States, colonialism and empire are to Britain, which no doubt explains why, for the most part, “empire itself is a subject that is shockingly obscured from view,” despite the fact that “Empire informs nearly everything, from common thought processes to the routines that shape everyday life, from the foundation of the National Health Service to the nature of racism in the U.K., from the British distrust of intellectuals in public life to the exceptionalism that permeated the campaign for Brexit and the government’s early response to the Covid crisis.”

Alas, the lesson Sanghera draws from his investigation is banal: “Cultivating a new, more honest relationship to the past is essential for moving forward.” I’m sure that’s true, and I’m sure that Empireland offers plenty of grist for the mill of revisionist history; but since most people side with Henry “History is bunk” Ford, I don’t know how far forward the book can move us. For that matter, I’m not sure how far forward most of us want to go. 

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David Corn, American Psychosis: A Historical Investigation of How the Republican Party Went Crazy

David Corn is Washington bureau chief for Mother Jones, a prominent left-wing publication. ¹ His American Psychosis purportedly “offers readers a brisk, can-you-believe-it journey through the netherworld of far-right irrationality and the Republican Party’s interactions with the darkest forces in America.” Corn “reveals the hidden history of how the Party of Lincoln forged alliances with extremists, kooks, racists, and conspiracy-mongers and fostered fear, anger, and resentment to win elections—and how this led to Donald Trump’s triumph and the transformation of the GOP into a Trump personality cult that foments and bolsters the crazy and dangerous excesses of the right.”

TBH, this sounds like Rick Perlstein redux (Before the Storm, Nixonland, and Reaganland), less a “hidden history” than a retracing of familiar ground. American Psychosis “covers the last seven decades. From McCarthyism to the John Birch Society to segregationists to the New Right to the religious right to Rush Limbaugh to Newt Gingrich to the militia movement to Fox News to Sarah Palin to the Tea Party to Trumpism, the Republican Party has deliberately nurtured and exploited rightwing fear and loathing fueled by paranoia, grievance, and tribalism.” What a long, strange trip it’s been, and it’s not over yet by a long shot.

If you haven’t read Rick Perlstein, American Psychosis should live up to its billing as a “gripping tale” of how the likes of Donald Trump managed to be taken seriously by, at last count, 75 million American voters. The fact that Rachel Maddow praises the book should be sufficient imprimatur for Corn’s intended audience.

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¹ Caveat emptor: according to at least one reviewer, Corn has “a history of stretching the truth.”  

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Tim Miller, Why We Did It: A Travelogue from the Republican Road to Hell

The story told from the outside by David Corn is told here by Tim Miller from the inside. In Why We Did It, “former Republican political operative Tim Miller answers the question no one else has fully grappled with: Why did normal people go along with the worst of Trumpism?” ¹

In Why We Did It, “Miller conducts his own forensic study on the pungent carcass of the party he used to love, cutting into all the hubris, ambition, idiocy, desperation, and self-deception for everyone to see. In a bracingly honest reflection on both his own past work for the Republican Party and the contortions of his former peers in the GOP establishment, Miller draws a straight line between the actions of the 2000s GOP to the Republican political class's Trumpian takeover, including the horrors of January 6th.”

It appears that Miller has joined the ranks of Republican operatives—e.g., Steve Schmidt, Nicolle Wallace, Michael Steele, and David Frum, to name a few—who have belatedly discovered that tolerating the likes of Newt Gingrich, Sarah Palin, and Michelle Bachmann only encouraged the idea that voting for Donald Trump made perfect sense. For years, Miller and the others had no trouble with Rush Limbaugh’s radio rantings, Glenn Beck’s conspiracist antics, or the lunacies of Ann Coulter and Sean Hannity; but, for them, Donald Trump was simply a bridge too far.

Anyway:

From ruminations on the mental jujitsu that allowed him as a gay man to justify becoming a hitman for homophobes, to astonishingly raw interviews with former colleagues who jumped on the Trump Train, Miller diagrams the flattering and delusional stories GOP operatives tell themselves so they can sleep at night. Why We Did It is a vital, darkly satirical warning that all the narcissistic justifications that got us to this place still thrive within the Republican party, which means they will continue to make the same mistakes and political calculations that got us here, with disastrous consequences for the nation.

If it helps, Nicolle Wallace likes the book.

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¹ Why do good citizens allow evil things to be done in their name? This scene from the film Judgment at Nuremberg is instructive:

(27) Judgement at Nuremberg (1961) - Burt Lancaster Monologue - YouTube

For those of you who favor the written word, here is the text: American Rhetoric: Movie Speech from Judgment at Nuremberg - Ernst Janning Confesses his Guilt to the Tribunal 

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Jonathan Metzl, Dying of Whiteness: How the Politics of Racial Resentment Is Killing America’s Heartland

Dr. Jonathan Metzl goes beyond the familiar “What’s the matter with Kansas?” meme and asks, “What’s the matter with white Americans?” It turns out that the demographic in question frequently allows politics to cloud its judgment on matters of health and safety: for instance, by rejecting Mitt Romney’s healthcare plan when it was repackaged as Barack Obama’s healthcare plan, by refusing Medicaid expansion, or by swilling hydroxychloroquine to ward off COVID while rejecting medically recommended methods of minimizing the risk of infection.   

Metzl’s narrative details how, “In election after election, conservative white Americans have embraced politicians who pledge to make their lives great again. But the policies that result place white Americans at ever-greater risk of sickness and death. Interviewing a range of everyday Americans, Dr. Metzl examines how racial resentment has fueled pro-gun laws in Missouri, resistance to the Affordable Care Act in Tennessee, and cuts to schools and social services in Kansas. He shows these policies' costs: increasing deaths by gun suicide, falling life expectancies, and rising dropout rates."

Recent studies (too recent to be referenced in Dying of Whiteness) have shown that white Americans’ resistance to vaccines and to pandemic risk-reduction measures led to unexpectedly (and unnecessarily) higher mortality rates, especially in “Red” (Republican) states. Such an outcome is sadly ironic for a political party that calls itself “pro-life.”

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Stuart Jeffries, Everything, All the Time, Everywhere: How We Became Post-Modern

Stuart Jeffries is a British journalist who wrote Grand Hotel Abyss, a highly entertaining history of the Frankfurt School. The Frankfurt scholars were pioneers of post-modernism, celebrated (or vilified) for bringing Marxism up to date and using it to radicalize cultural studies the way Marx had radicalized economics.

In other words, Stuart Jeffries knows the territory. That familiarity has enabled him to write “a brilliant history of a dangerous idea, [sketching] a narrative that starts in the early 1970s and continues to the present.” His working assumption is that “Post-modernity is the creative destruction that has shattered our present times into fragments. It dynamited modernism which had dominated the western world for most of the 20th century. Post-modernism stood for everything modernism rejected: fun, exuberance, irresponsibility. It was also the forcing ground of the 'post-truth', by means of which Western values got turned upside down."

For all that, writes Jeffries, the underlying reality of post-modernism has mostly escaped notice: “Beneath its glitzy surface, post-modernism had a dirty secret: it was the fig leaf for a rapacious new kind of capitalism.” Just as consumer capitalism (“Have it your way” and “We put you in the driver’s seat”) enshrined consumer choice as the ‘summum bonum,’ postmodernism—rejecting objective Truth, orthodox canons, and established narratives—enshrined epistemological variety, diversity of perspectives, and previously marginalized narratives.     

Can postmodernism be both Marxist and capitalist? Is consumer capitalism the same thing as postmodernism? Can't we have our cake and eat it too? We will just have to read Everything, All the Time, Everywhere if we are to sort that out.

Of Lice and Men

According to Mary Vought, Executive Director of the Senate Conservatives Fund, the real threat to America’s elderly is not COVID-19, nor is it the Republicans who dismiss the pandemic’s rising death toll on the grounds that it consists mainly of old people, many of them in nursing homes and therefore on their last legs (except for those in wheelchairs) and of no real value anyway. No, says Ms. Vought, the threat to seniors comes from Dr. Ezekiel Emanuel, a monster who, while working for President Barack Obama, attempted to “death panel” every American over the age of seventy-five.

Dr. Emanuel was recently tapped by President-elect Biden to serve on a White House coronavirus task force. Ms. Vought wants us to know what lies in store:

Six years ago, Zeke Emanuel, recently named to Biden’s coronavirus task force, famously wrote an essay that The Atlantic entitled “Why I Hope to Die at 75.” In a 2019 interview, he disclaimed responsibility for the article’s title, but not its sentiments. He then asked a provocative question surrounding the elderly: “whether our consumption is worth our contribution.” This naturally raises concerns about the government’s involvement in difficult decisions regarding end-of-life care.

Vought also documents Barack Obama’s determination to euthanize the olds:

In 2009, then-president Barack Obama said that “the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out there.” He called for “a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place.” The interviewer did not ask him to elaborate, but Obama’s reference to a “difficult” conversation implies his preferred solution to the “problem” of high health spending by chronically ill patients. 

If elitists like Obama and Emanuel had their way, all Americans who cling to their guns or their Bibles or to living beyond the age of seventy-five would be rounded up and put out of our misery. 

In all seriousness, Mary Vought should be ashamed of herself for such insinuations. Republicans wax indignant about proposed “end of life” planning, living wills, advance directives, etc. Their indignation does not change the facts of the matter—a disproportionate share of healthcare spending does go towards end-of-life care—nor does it help individuals, families, and healthcare providers, who, like it or not, will have to make those “difficult” decisions eventually.

Meanwhile, tens of thousands of elderly Americans continue to die in a pandemic that neither President Trump nor his Republican enablers have taken seriously or attempted to mitigate. I promise to keep an eye out for a statement from Mary Vought about that.  

Biden Advisor Disregards Dignity of the Elderly | RealClearReligion

Writing at Slate, Joe Knight inexplicably attempts to demean Russia’s heroic, world-historic defeat of Napoleon in the Great Patriotic War of 1812 (not to be confused with America’s silly War of 1812 in which British troops burned down the White House and Andrew Jackson won the Battle of New Orleans after the war had ended). According to Mr. Knight:

It wasn’t enemy soldiers or the normal privations soldiers experience that devastated Napoleon’s army. Most of his soldiers were battle-hardened young men, so they should have been able to tolerate the cold, hunger, long marches, and fatigue. No, it was a microscopic organism that wreaked havoc and annihilated Napoleon’s army and his grand plans for conquest. A microbe called typhus, spread by a scourge of lice.

Knight goes on to describe, in disgusting detail, what transpired:

Poland is where things started going badly for Napoleon. He found the region filthy beyond belief. The peasants were unwashed, with matted hair and ridden with lice and fleas, and the wells were fouled. The roads were soft with loose dust or were deeply rutted from the spring rains; the supply trains lagged farther and farther behind the main body of soldiers, and it became difficult to provide food and water. Many of the soldiers pillaged the homes, livestock, and fields of the local peasants. Nearly 20,000 army horses died from lack of water and fodder. The homes of the peasants were so filthy that they seemed to be alive with cockroaches. The typical battlefield diseases of dysentery and other intestinal diseases began to appear, and though hospitals were set up in Danzig, Königsberg, and Thorn, they were unable to deal with the large numbers of sick soldiers sent back to the rear.

But Napoleon’s problems were just beginning.

Several days after crossing the Nieman River, a number of soldiers began to develop high fevers and a red rash on their bodies. Some of them developed a bluish tinge to their faces and then rapidly died. Typhus had made its appearance. A lack of sanitation combined with the unusually hot summer made an ideal environment for the spread of lice. Typhus is caused by the organism Rickettsia prowazekii. It would be an entire century after the 1812 campaign before scientists realized that typhus is found in the feces of lice.

The typical French soldier was dirty and sweaty and lived in the same clothes for days; this is the perfect environment for lice to feed on his body and find a home in the seams of his clothing. Once the clothes and skin of the soldier were contaminated with lice excrement, the smallest scratch or abrasion would have been enough for the typhus germ to enter the soldier’s body. To compound the problem, the soldiers were sleeping in large groups in confined spaces for safety; this closeness allowed the lice to jump quickly to soldiers who were not infested.

Only a month into the campaign, Napoleon lost 80,000 soldiers who were either incapacitated or had died from typhus. The French army’s medical and sanitary measures were the finest in the world, but no one could have coped with the scale of the epidemic.

I will pause here just long enough to go take a shower…

To paraphrase General Sherman, war is lousy. As Knight chronicles, lice and typhus accompanied Napoleon’s campaign all the way to Moscow and throughout his retreat, in the face of a bitter Russian winter, back to France. A little more than a year later—March 1814—victorious Russian troops marched into Paris.

Knight may have his facts straight, but I see no need to denigrate Russians’ valiant defense of their homeland (no less valiant because they chose to abandon Moscow rather than to defend it and then put much of the city to the torch on their way out the back door) just because they had a little help from lice. All’s fair in war, after all, and a nation takes its allies where it can find them. 

Knight concludes by adding insult to insult and spoiling a monumental piece of Russian music:

Most Americans are familiar with the ending of Tchaikovsky’s 1812 Overture, commissioned by Russia to celebrate Russia’s defeat of Napoleon. The musical score ends with the sounds of cannons booming and bells pealing; however, if Tchaikovsky wanted to accurately record the sound of Napoleon’s defeat, one would only hear the soft, quiet sound of lice munching on human flesh. An organism too small to be seen by the human eye had changed the course of human history.

The 1812 Overture will never sound the same to me. 

Napoleon march to Russia in 1812: Typhus spread by lice was more powerful than Tchaikovsky’s cannonfire. (slate.com)

If Joe Knight’s article piques your interest, you can get even more gruesome detail from the book The Illustrious Dead:  The Terrifying Story of How Typhus Killed Napoleon’s Greatest Army, by Stephen Talty.

Is Pope Francis Catholic?

At First Things, Gerald McDermott (who holds the Anglican Chair of Divinity at Beeson Divinity School) asks, more in sorrow than in anger but not at all rhetorically, "Is the pope Catholic?" McDermott takes no pleasure in concluding that the answer, alas, is No: in fact, "[Pope Francis] is a liberal Protestant." 

As McDermott details, Pope Francis has all but spit on Jesus' empty grave: 

In 2014, the midterm report of the [pope's] Extraordinary Synod on the Family recommended that pastors emphasize the “positive aspects” of cohabitation and civil remarriage after divorce. [Pope Francis] said that Jesus’s multiplication of bread and fish was really a miracle of sharing, not of multiplying (2013); told a woman in an invalid marriage that she could take Holy Communion (2014); claimed that lost souls do not go to hell (2015); and said that Jesus had begged his parents for forgiveness (2015). In 2016, he said that God had been “unjust with his son,” announced his prayer intention to build a society “that places the human person at the center,” and declared that inequality is “the greatest evil that exists.” In 2017, he joked that “inside the Holy Trinity they’re all arguing behind closed doors, but on the outside they give the picture of unity.” Jesus Christ, he said, “made himself the devil.” “No war is just,” he pronounced. At the end of history, “everything will be saved. Everything.” 

As if all that weren't bad enough, right about the time that Gerald McDermott's indignant critique was being published, Pope Francis issued yet another statement guaranteed to discomfit, if not outrage, his more-Catholic-than-thou detractors. As reported by Clair Giangrave at the Catholic website Crux: 

In a message sent to the president of the Pontifical Academy for Life, Archbishop Vincenzo Paglia, and the European representatives of the World Medical Association who are meeting Nov. 16-17 at the Vatican to discuss “end of life” issues, the pope addressed some of the major concerns regarding healthcare and morality today. 

Francis started off by praising the “growing therapeutic capabilities of medical science,” which have been able to eliminate diseases, prolong life and improve health. 

“While these developments have proved quite positive, it has also become possible nowadays to extend life by means that were inconceivable in the past,” he said in the message dated Nov. 7. “Greater wisdom is called for today, because of the temptation to insist on treatments that have powerful effects on the body, yet at times do not serve the integral good of the person.” 

Francis continued by analyzing the issues tied to “overzealous treatment,” patient and doctor relationships, global inequality in healthcare, the need to be close to the sick and to pay attention to the needs of the most vulnerable...Francis said “[It is] morally licit to decide not to adopt therapeutic measures, or to discontinue them, when their use does not meet that ethical and humanistic standard that would later be called ‘due proportion in the use of remedies.’” 

 While Pope Francis explicitly stated that euthanasia is "always wrong," his concerns about "overzealous treatment," combined with his approval of discontinuing medical treatment in particular cases, will certainly be taken as evidence (by unbending traditionalists like Gerald McDermott) that the pope himself is a spokesperson not for Jesus but for the modern "culture of death". As Crux explains: 

Francis acknowledged that many cases and situations can be “difficult to evaluate,” and that there is no one-size-fits-all rule that can be adopted. “There needs to be a careful discernment of the moral object, the attending circumstances, and the intentions of those involved,” he wrote. 

Francis said “the patient has the primary role” in the discussion regarding his own health. It’s the patient, according to Catholic teaching, who has the right to decide on the necessary treatment by discussing with his or her doctors the proportionality of the remedy and “refusing it if such proportionality is judged lacking,” the pope added. The personal and relational elements of the patient’s life and also death, which the pope referred to as being “after all the last moment in life,” must be considered when evaluating his or her accompaniment and care. 

Traditionalists will be sure to note that "discernment," "circumstances," and "intentions" are precisely the sorts of words associated not with magisterial Church teaching but with the modern heresy of "situation ethics," a heresy which Gerald McDermott cites in his anti-Francis essay: "Like (Episcopalian) Joseph Fletcher, who taught Situation Ethics in the 1960s, the [pope's]exhortation suggests that there are exceptions to every moral rule and that there is no such thing as an intrinsically evil act." 

In all, concludes McDermott, Pope Francis' papacy is enough to make an Anglican despair: 

I take no pleasure in Rome’s travails. For decades, orthodox Anglicans and other Protestants seeking to resist the apostasies of liberal Christianity have looked to Rome for moral and theological support. Most of us recognized that we were really fighting the sexual revolution, which had coopted and corrupted the Episcopal Church and its parent across the pond. First it was the sanctity of life and euthanasia. Then it was homosexual practice. Now it is gay marriage and transgender ideology. During the pontificates of John Paul II and Benedict XVI, we non-Catholics arguing moral theology could point to learned and compelling arguments coming out of Rome and say, in effect, “The oldest and largest part of the Body of Christ agrees with us, and it does so with remarkable sophistication.” 

Those of us who continue to fight for orthodoxy, in dogmatic as well as moral theology, miss those days when there was a clear beacon shining from across the Tiber. For now, it seems, Rome itself has been infiltrated by the sexual revolution. The center is not holding. 

It is an odd, if entertaining, spectacle to see Protestants bewailing the pope's supposed surrender to the zeitgeist. Atheist that I am, who am I to judge? My sympathies, however, in case I haven't made them clear, lie with Pope Francis, who (according to Crux) "underscored the need for particular attention 'to the most vulnerable, who need help in defending their own interests'" and who stressed the need for an approach to healthcare that “effectively promotes the common good in each concrete situation.”  

If such talk scandalizes the orthodox, then more's the pity for orthodoxy. 

https://www.firstthings.com/web-exclusives/2017/11/is-pope-francis-a-liberal-protestant  

https://cruxnow.com/global-church/2017/11/16/pope-francis-calls-european-physicians-morally-withdraw-overzealous-treatment/ 

Let Them Eat Psychic Comfort

Shikha Dalmia (at The Week) has no sympathy for those who decry proposed cuts to Medicaid. In fact, she thinks that we'd be better off if we eliminated the program entirely:  

Medicaid is perhaps the civilized world's worst program. It costs just as much as private plans — about $7,000 per patient — but produces worse outcomes, including higher mortality, than private coverage. So given that one of ObamaCare's dirty little secrets is that many of its Medicaid enrollees are folks kicked off their private plans due to the Medicaid expansion, the law may have actually cost — rather than saved — lives in this cohort.¹ 

Like many people who do not have a column at The Week by which they can misinform the public, Ms. Dalmia confuses health insurance with health care. Medicaid does not produce "outcomes"; it provides access to medical treatment, which treatment then produces outcomes (though qualified, to be sure, by factors such as patients' overall health, pre-existing conditions, compliance with treatment, etc.) 

It would seem difficult to argue that anyone would be better off without insurance for and access to health care, but that's Shikha Dalmia's take on the Medicaid population: 

But what about the uninsured? Extending Medicaid to these people improved their health and diminished mortality, right? Wrong. Plenty of reputable studies suggest that this might not be the case...and even if Medicaid's mortality outcomes were somewhat better for the uninsured, it would still not necessarily follow that extending the program would save lives on balance — or that eliminating the program would do the reverse. In a world with finite resources, one also has to consider the opportunity costs or other ways of spending that may potentially save more lives. 

Indeed, a 2016 study in the journal Health Affairs found that states that spent a smaller portion of their budgets on Medicaid and Medicare than on social programs such as housing, nutrition, and even public transportation, showed "significant" gains on a myriad of health factors, including mortality, over states that did the reverse. It is possible that this is purely coincidental. But it may also be the case that these programs improved general quality of life and lowered stress levels, thus bettering baseline health and preventing people from falling prey to life-sapping illnesses in the first place. 

Citing the "smaller portion of their budgets" that some states spend on Medicaid and Medicare is misleading; the budgetary portion may be smaller because those states are more generous about funding the other items Ms. Dalmia mentions, not because they are less generous with Medicaid and Medicare. It's certainly true that things like housing, education, transportation, nutrition, and the environment all contribute, for better or for worse, to health outcomes; but does Ms. Dalmia actually expect us to believe that Republicans are cutting Medicaid in order to invest more heavily in those other sectors? If you believe that, then Donald Trump has a big, beautiful, solar-powered wall he'd like to sell you. 

It turns out, according to Shikha Dalmia, that health insurance really has little or nothing to do with access to treatment, with keeping people healthy, or with saving lives. No, the purpose of insurance is to "provide a psychic comfort":   

The main advantage of health insurance in general and Medicaid in particular is not really to prevent death but to protect against catastrophic illnesses that wipe out patients financially — in other words, to provide a psychic comfort. But patients are not willing to pay any amount for any insurance product to receive that comfort, presumably because at some point, other uses of the money — like a car fitted with state-of-the-art safety features or a more expensive home in a low-crime neighborhood — can offer an even stronger sense of security...in Massachusetts, buy-in for Medicaid-like programs fell precipitously when patients were asked to bear more of their cost. Medicaid recipients value the program at about one-fifth its actual cost, research shows. 

Medicaid recipients undervalue their coverage because they underestimate the shockingly high costs of medical treatment, not because the coverage itself is not a good value. Ms. Dalmia's argument is that recipients, given the actual monies being expended for their insurance, might prefer (let's say) a voucher which they could use in any way they wanted to attain "psychic comfort". Again, if you believe that there is a constituency that would support replacing access to health care with a program that provides Medicaid-eligible (i.e. poor) individuals and families vouchers to buy better cars or more expensive homes: step right this way, President Trump would like to show you photos of his stupendous, record-setting inaugural crowd.  

http://theweek.com/articles/710150/medicaid-colossal-waste-money

¹ I won't bother pointing out the flaws in Ms. Dalmia's logic or questioning her assertions about the costs and benefits of Medicaid; suffice it to say that Medicaid recipients are poorer than most Americans, that they live in less healthy environments, that they have less education, and that they tend to have, prior to enrolling in Medicaid, a welter of untreated pre-existing conditions.  It shouldn't come as a surprise, then, that their health outcomes and mortality rates are worse than average.

Everybody Into the Pool!

"Nobody dies because they don't have access to health care." (Rep. Raul Labrador, R-Idaho) 

Let's assume, for the sake of discussion, that "high-risk insurance pools" as provided in the new American Health Care Act will provide adequate benefits for those assigned to them—that is, for the chronically ill and for people with pre-existing medical conditions. Let's assume that the insurance companies don't make the premiums unaffordable or the deductibles unreasonably high, and let's assume that the government subsidies set aside for the premiums are sufficient. 

If all that were the case, wouldn't "high-risk pools" be an acceptable way of making sure even our less healthy population receives affordable health care? 

The answer, sadly, is no; and Republicans who don't admit it are being disingenuous in the extreme. The reason that high-risk pools are not a long-term viable solution is that, by creating what is essentially a separate insurance market for the poor and the sick, such pools undermine their own political support. Over time, the younger, healthier, more financially well-off populace will resist paying higher taxes (just as they now resist paying higher premiums) in order to fund treatment for the high-risk demographic. 

Social Security is the primary example of how this works. The reason that Social Security has long been considered the untouchable third rail of American politics is simple: everyone benefits from the program, not just a selected segment (i.e. the poor) of the citizenry. So long as Social Security is not means-tested it continues to have wide popular support; turn it into an entitlement for the poor and that support would crater (or at least diminish)—which is why Republicans often propose doing just that (under the guise of controlling costs and "saving" the program). 

Under the Obamacare "community rating" guidelines, insurers cannot penalize people for having pre-existing and/or chronic conditions. Instead, the extra medical expenses such people inevitably incur are partly subsidized by the government (through taxes) and partly subsidized by higher premiums for healthier people; the combination of those subsidies is designed to keep everyone in the same basic healthcare market and the same basic risk pool. Doing so also ensures that everyone has a stake in seeing that the insurance companies are properly regulated, that health care providers do what is required to keep costs under control, and that the government subsidies (funded by taxes) remain adequate to people's medical needs: in other words, such an approach maximizes political support by making everyone a stakeholder. 

The political impact of financially segregating the sick from the healthy is predictable, and it would be dire.* While plenty of people would still be concerned, out of simple human decency, about the fate of the poor and the sick, it would eventually (and likely sooner than later) prove difficult to overcome the self-interest of healthy individuals and families whose medical needs were being met at manageable cost; and as sick people were increasingly priced out of the market, what broader constituency would demand the higher taxes necessary to subsidize their care? 

"Class warfare" traditionally pits rich against poor; the AHCA's "high-risk pools" will put an insidious spin on this as it inevitably pits the healthy against the sick. That is a form of "divide and conquer" of which we as a country should be ashamed; which is why we as a country should resist this piece of legislation.

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*Not to conflate issues here, but we have some experience in this country with establishing "separate but equal" pools for different groups of people; the lesson of our history is that "separate" cannot be "equal".  We all need to be in the same pool, and we'll all sink or swim together.

The AHCA: "neither conservative nor decent"

It gets harder and harder to defend the idea that there exists a principled American conservatism, one which is not mean-spirited, racist, xenophobic, misogynistic, homophobic, or in other ways retrograde and reprehensible: a basket, in other words, of deplorables. I have frequently tried to make the argument that conservatism at its best is both necessary and, in its own ways, noble; that it promotes respect for tradition and modesty regarding progress, fosters local autonomy and local communities, and understands the limits of both politics and human nature. But finding such a principled conservatism anywhere these days outside my imagination or the dusty stacks of the local college library is an all but impossible task; instead, people like Paul Ryan, Ted Cruz, Rush Limbaugh, and the Fox News menagerie have conveniently (for them) reduced conservatism to a single tenet: hatred of America's federal government and its sometimes clumsy attempts to level the socio-economic playing field.

Just ask Andrew Sullivan, a long-time conservative himself. According to his latest column, Sullivan believes that today's conservatives no longer give a damn about "the vulnerable" among us or about anyone outside their own ambit:

The Trump GOP’s attempt to abolish [Obamacare] is...neither conservative nor decent. It’s reactionary and callous. Its effective abandonment of 95 percent of us with preexisting conditions will strike real terror in a lot of people’s hearts. Its gutting of Medicaid will force millions of the poor to lose health care almost altogether. It will bankrupt the struggling members of the working and middle classes who find themselves in a serious health crisis. It could hurt Republicans in the midterms —though that will be cold comfort for the countless forced into penury or sickness because of Trump’s desire for a “win.” But it’s clarifying for me. It forces me to back a Democratic Party I don’t particularly care for. And it destroys any notion I might have had that American conservatism gives a damn about the vulnerable. It really is a deal-breaker for me. I hope many others feel exactly the same way.

http://nymag.com/daily/intelligencer/2017/05/trumpcare-destroys-notion-that-gop-gives-a-damn.html

Charlie Pierce doesn't think much of Trumpcare, either:

It is a bill born out of everything into which modern conservatism has transformed modern Republicanism: a punitive view of the poor and unlucky, based in Iron Age concepts of the will of the Lord; magic-asterisk economics; a resolute opposition to empirical data and a scalding contempt for expertise; and an ability to torture the English language to the point of unconsciousness.

That man can write.

http://www.esquire.com/news-politics/politics/news/a54921/republican-healthcare-bill-resistance/

And over at The Week: Damon Linker says "The Republicans' health-care disaster will unleash a populist revolt that will destroy them"; Ryan Coopers refers to the GOP healthcare bill as "Paul Ryan's American carnage"; Paul Waldman vows that "Democrats will take revenge on Republicans for their health-care abomination"; and, not to be left out, Pascal-Emmanuel Gobry laments that "Republicans are embarrassingly out of touch with what Americans want from health care."

It might be good at this point to remind everyone that Congress has not yet passed a health-care bill and our so-called "President" Trump has not yet signed one. Only one house of Congress has weighed in, and Obamacare remains the law of the land: an endangered status, to be sure, but still on the books.

In other words: better get sick now while you can possibly afford it.

Sunday Links

At The Federalist, Anna Mussmann writes about book bans and trigger warnings:

Books matter. They can help, they can traumatize, and they can harm. The passion with which progressives and conservatives battle it out—sometimes even in ways that seem contradictory—over the way books ought to be selected, assigned, and taught is a powerful testimony to the power of stories to shape the way we see and approach the world.

http://thefederalist.com/2016/06/14/book-bans-are-political-proxy-wars-and-conservatives-are-losing/ 

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Also at The Federalist, Kyle Sammin ultimately disagrees with Chris Hayes but gives a fair-minded review of Hayes' new book A COLONY IN A NATION:

Chris Hayes’s new book, “A Colony in a Nation,” is above all a book about order and how the people’s desire for it contributes to unequal treatment of different groups of Americans, typically on account of race...Hayes has a fluid writing style, and his prose is enjoyable to read. While his solutions are typical of the left and not fully fleshed out, the problems he identifies are real and well-described here. “A Colony in a Nation” is not ground-breaking, but it is a serviceable synopsis of the civil disturbances of the past several years and the conditions that led to them. What cities like Ferguson and Baltimore await is a solution that is better than just more of the same.  

http://thefederalist.com/2017/03/31/the-conflict-between-racism-and-law-and-order-is-all-about-big-government/  

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At Vox, Sean Illing distills the essence of our so-called "President's" dilemma: Bullshitting is easy, but governing is hard...

Illing goes on to explain:

Trump’s bluster and bombast, so effective on the campaign trail, has backfired spectacularly in office.

As Vox’s Ezra Klein noted this week, Trump is failing on almost every front. His health care bill died — killed by his own party. His approval rating has sunk to 35 percent. His executive orders banning immigrants from seven Muslim-majority countries were struck down by the courts. Russia-related investigations are undermining his agenda. And his administration, plagued by leaks, remains divided.

There is still plenty of time for Trump to turn things around, but so far he appears hapless and lost.

http://www.vox.com/conversations/2017/3/30/15108256/donald-trump-congress-health-care-george-edwards 

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Finally, at The Daily Intelligencer, Jonathan Chait tries one more time to explain to conservatives how insurance works:

The single most unifying idea to change Obamacare among conservatives is to eliminate the law’s “essential health benefits.” These burdensome mandates of which treatments insurance has to cover make Obamacare too expensive, conservatives say. Their problem is that the list of required essential health benefits includes actually only, well, essential ones. If the list did include any frivolous treatments, like cosmetic surgery or some goofy alternative-medicine quack scheme, that’s all you’d hear about. But it doesn’t. So the single example conservatives come up with, over and over, is maternity care. Today it appears in Charles Krauthammer’s column:

Even more significant would be stripping out the heavy-handed Obamacare coverage mandate that dictates what specific medical benefits must be included in every insurance policy in the country, regardless of the purchaser’s desires or needs.

Best to mandate nothing. Let the customer decide. A 60-year-old couple doesn’t need maternity coverage. Why should they be forced to pay for it? And I don’t know about you, but I don’t need lactation services.

The thing to understand is that mandating covering maternity care doesn’t affect the total cost of insurance. It only changes the distribution of the costs. It’s not like Charles Krauthammer’s insurance forces him to actually go through childbirth. It merely means that his premiums help pay for other people’s maternity care.

Conservatives, of course, notoriously hate "redistribution" of any kind. Unfortunately for them, that's precisely what insurance is designed to do: it redistributes both risks and costs in order to make the former more manageable and the latter more affordable. The problem with tailoring insurance coverage to "the purchaser's desires or needs"  is that it actually results in tailoring it to the purchaser's ability (or willingness) to pay; purchasers are not always astute about their actual needs, especially when there is a price tag attached.

http://nymag.com/daily/intelligencer/2017/03/the-gops-best-health-care-idea-is-to-stick-it-to-mothers.html 

Healthy Breakfast Links

How best to describe the Republican Party's current dilemma? Allow Pascal-Emmanuel Gobry to have a go at it:

The GOP today is like a man standing on the edge of a burning oil platform. Jumping into the sea will almost certainly kill him. But not jumping will definitely kill him. As daunting as the jump is, he has to jump.

By "jump," M. Gobry means "repeal and replace Obamacare," a daunting task indeed--but not if the GOP heeds M. Gobry's advice:

An option that has been endorsed by luminaries such as The New York Times' Ross Douthat and (ahem) myself...would accomplish enough of everyone's goals to have a glimmer of hope of passage, and be good policy. It would involve auto-enrolling everyone in catastrophic health-care plans, a sure political winner ("From now on, no one in America will have to lose their house because they have cancer !" Trump can repeat over and over on the stump), radically decentralizing Medicaid (a necessity), directly funding health savings accounts for the poor, generally increasing the use of health savings accounts and nudging people away from employer-funded health insurance towards portable solutions, and many market-based regulatory reforms. Such a package would accomplish progressive goals of universal coverage and conservative goals of decentralizing health care.

It would be good policy and good politics. And it's actually doable! But not if Republicans have already given up.

Why M. Gobry believes that conservatives in Congress will accept a new entitlement ("catastrophic health-care plans for all!") or increased subsidies to the poor is beyond me; as I've noted before, American politics must look very different when viewed from the other side of the Atlantic. Nevertheless, kudos to PEG for (ahem) solving this heretofore intractable problem.

http://theweek.com/articles/688505/republicans-still-fix-health-care-heres-how

Speaking of France, Paul Waldman also favors putting a French twist on our health care system:

If I were making the policy, we'd move toward something like the hybrid system they use in France, in which there's a basic public plan that covers everyone, then most people buy supplemental private insurance on top of that. It means virtually no one is uninsured (which would make liberals happy), and you're free to buy the fanciest insurance you want or can afford (which would make conservatives happy).  

Since Waldman's proposal would make everyone happy, it's a sure-fire winner, right?

Democrats will benefit from the fact that public sentiment has moved decidedly in their direction. It isn't just that approval ratings of the ACA improved as the Republican effort to dismantle it made people realize what it had accomplished. It's also that the presumptions underlying our health-care debate have changed. As Jonathan Cohn notes, the ACA "has shifted the expectations of what government should do ― and of what a decent society looks like." Republicans found, to their evident surprise, that the idea that everyone in America has the right to health care has now been accepted by the public, and no "reform" that treats health care like a privilege will succeed.

Mr. Waldman is more optimistic than I am, at least so far as the short-term fate of healthcare reform is concerned. But then, his entire scenario is predicated on the assumption that Democrats will return to power in Washington some time soon (or at least in our lifetime); to which assumption I can only say, echoing M. Gobry, bon chance...

http://theweek.com/articles/688629/what-democrats-health-care-now

Meanwhile, Robert Verbruggen weighs in on a Republican proposal to promote better health in the workplace:

The GOP bill, called the Preserving Employee Wellness Programs Act, resolves these tensions in an employer-friendly way, declaring, contrary to the EEOC’s interpretation, that some major anti-discrimination laws don’t apply to wellness programs. It would also remove wellness programs from the EEOC’s jurisdiction and place them under the authority of several other executive agencies.

Under the bill, wellness programs could require employees to provide information about family members’ medical histories, and could require employees and their families to undergo genetic testing. Protections against sensitive information being shared directly with an employer would be weakened, though it would still be illegal to discriminate on the basis of that information. The bill would also allow higher incentives for participation, up to 30 percent of the cost of family coverage, not just individual coverage.

What's more American, and more empowering, than mandatory genetic testing and disclosure of your uncle's medical history?  As Verbruggen explains, conservatives believe that employers, unlike the federal government, only have workers' best interests at heart and would never abuse their power: 

Supporters...downplay concerns that employers might acquire and misuse medical information. More broadly, supporters see wellness programs as a free-market-friendly way to bring down health costs and would like to make sure the programs are not overregulated.

Despite clear misgivings, Verbruggen can't quite bring himself to oppose this legislative measure; instead, he points out that it's all the government's fault in the first place:

For decades government policy has given employers a financial stake in their workers’ health--and  thus a strong incentive toward paternalism...The question is the role that employers should play in all this, and the steps we should take to ensure they don’t misuse the information they are privy to. ¹

Not to worry; I'm sure that if your employer discriminates against you based on the genetic information he forced you to provide, the Supreme Court, led by principled conservatives like Neil Gorsuch, will come to your defense.  Or you could always ask your union for assistance--if only you had one.

http://www.theamericanconservative.com/articles/when-your-employer-wants-you-to-take-a-genetic-test/

¹ It's revealing that Robert Verbruggen thinks that, absent government pressures, employers would not have "a financial stake in their workers' health": presumably because sick, disabled, or dead workers are easily replaced?

What Is Government For?

Abbe Gluck (Professor of Health Law at Yale, and writing at Vox) says that our health care debates miss the point:

The fundamental question that every Congress from Truman’s to Trump’s has refused to answer is this: What is a health care system for?

Democrats and Republicans alike have always been disjointed about the basic purpose of a health care system. Whether we are talking about Obamacare or Ryancare, there is no overarching theory that sets out the fundamental values of American health care.

If two people are dying from the same disease, and require the same operation to survive, and one can pay and one cannot, is it okay for the poor person to die? After talking ourselves hoarse about health reform in this country for nearly a century, we still have no definitive answer to this question, because the main players in the debate keep dodging it.

What, many of us wonder, is so wrong, so un-American, about universal health care? Professor Gluck explains:

Part of the problem, believe it or not, is communism. Ronald Reagan, in his efforts to torpedo Medicare in the 1960s, proclaimed government support of health insurance “socialized medicine,” turning a big part of the health care debate into one about the American capitalist ethos and patriotism. (Even before Reagan, the American Medical Association had been sounding this particular alarm). The resonance of Reagan’s message is an important reason why the United States is highly unlikely to ever have a single-payer system, such as a Medicare for everyone. It’s why we keep hearing the term “liberty” to — ironically — justify massive cuts that will have terrible effects on people’s lives.

That is the continuing tension between “us versus me,” and between government and the market, in American health care. It’s our enduring question and it’s clear that this round of health care reform, like all those before it, is not going to debate it openly and honestly.

The real debate is not just about health care but, as Gluck indicates, about the boundaries between government and the market: we have to decide, that is, what we consider “public goods” and what we consider “private”. This is why the relatively small amounts of money that the federal government spends on things like Meals on Wheels, the Corporation for Public Broadcasting, and the National Endowment for the Arts are nonetheless significant: they signal a belief that such things serve a public purpose and are not to be left entirely to the market, even if the market were in fact providing them adequately.  

The proposed Trump budget is not a serious fiscal document; its draconian cuts and wholesale elimination of entire programs and agencies will not pass muster even in a conservative Republican Congress. But the budget--which has been more accurately described as a “manifesto”--makes a serious statement, and the statement is this: Washington’s only legitimate purposes are to guard our national borders and, when necessary, to police the world and arrange it to our liking. Everything else--what the Constitution calls “the general welfare”--is the business of the states, and each state should be left alone by Washington to see to that as it pleases.

If you agree with that philosophy, then you will consider the Trump budget at least a step in the right direction. If you disagree, then you will consider the budget an unprecedented turning of the federal government’s back on the people of this nation.

Presented with the blueprint of Trump-ism, each of us has to answer: Which side are you on?  In that sense (and in that sense only), the Trump budget document is praiseworthy: it has clarified what is at stake. 

http://www.vox.com/the-big-idea/2017/3/6/14826974/health-care-aca-philosophy-republican-obamacare