Public Policy and Governance – Page 170

People Will Die..

How many ways can this administration kill people?

Scientists tell us that changes to environmental protection laws will lead to at least 80,000 additional deaths each decade.

The announcement that acceptance of refugees fleeing war and persecution will be capped at 30,000 per year–the lowest number ever–has been condemned by Amnesty International, The International Rescue Committee and Human Rights First. What those organizations labeled a “shameful abdication of our humanity” will result in untold numbers of deaths.

The GOP’s solicitude for the “rights” of the NRA continues to facilitate more than thirty thousand gun deaths each year.

Those are all fairly high-profile issues, and at least they’ve generated public debate.

Unfortunately, there has been much less publicity about the government’s ongoing refusal to impose rational regulations on Big Pharma. (Here in Indianapolis, our pathetic excuse for a newspaper simply ignored a recent demonstration protesting Eli Lilly’s pricing of insulin– instead, it ran a front-page “warm and fuzzy” article about the company’s new migraine drug). That failure, too, continues to kill.

If you wonder why single-payer healthcare has become such an overriding political issue, the case of insulin pricing may provide a clue.

Diabetes is one of the most common diseases in the U.S. Its incidence continues to climb, and huge numbers of diabetics are insulin-dependent.

According to information provided by an organization called “Insulin4All”

the price of insulin has increased 1123% since 1996. This isn’t because of new discoveries–prices have increased on medications that have been around for decades.
More than 7 million Americans are insulin dependent. More than 25% of those Americans have had to ration their insulin due to cost.
Over 6,000 GoFundMe pages are asking for money to purchase insulin. (Shane Patrick Boyle, an artist who had moved to Arizona to take care of his mother and was in between health insurance plans, died from diabetic ketoacidosis. He was $50 short in his Go Fund Me for insulin.)
Some people are paying $1400 a month for their insulin.

The Insulin4All organization is asking two things. First, it wants pharmaceutical companies to disclose their manufacturing costs and profits, along with their marketing expenditures. Second–and incredibly important for all health care, not just diabetes treatment–they want the government to allow Medicare and Medicaid to negotiate drug prices, like other countries’ governments do.

In all fairness, this isn’t the first administration and congress to place the bottom line of drug manufacturers above the needs of sick people needing medicines. It has to stop.

Big Pharma will claim that R & D costs a lot of money, and that those costs justify high prices for their products. It is absolutely true that research and development is costly–but it is also true that a significant percentage of those costs are covered by taxpayers who also deserve a return on their investment.

Since the election, the federal government has cut back on support for basic research (an enormously self-defeating, “penny-wise, pound foolish” policy). Data from the National Science Foundation shows that, since those cutbacks, federal agencies provided “only” 44% of the $86 billion spent on basic research. Before that, however, the federal share of all research routinely topped 70%, and it was 61% as recently as 2004.

In addition, foundations, state and local governments, voluntary health associations and professional societies support drug research and development.

No one is suggesting that Big Pharma forgo a reasonable profit. What is reasonable, however, cannot be determined without increased transparency about actual costs, and the share of those costs coming out of the taxpayers’ pockets.

People who need insulin are dying because they cannot afford it. A lot of people.

Maybe the drug companies could run fewer television ads prompting people to ask their doctors for Purple Pills and the like, and use those savings to bring down the cost of lifesaving medications.

And maybe an administration and a Congress less beholden to corporate interests and big money would consider policies less likely to kill people.

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What Now?

I cannot recall a time when so many Americans were this angry. Of course, I wasn’t around for the civil war, (although sometimes I feel that old.)

We have certainly been deeply at odds before. Mostly, our conflicts have centered on clashing worldviews: wars, religious conflicts, extensions of civil rights, reproductive liberty, dissent and patriotism. But right now, the fury being expressed by so many ordinary citizens seems different in kind.

It feels very personal.

Americans still have different perspectives on the issues, of course–in spades. U.S. citizens are not just polarized; they occupy different, inconsistent realities. But I think there is another element to the anger I see, an element the Kavanaugh hearings have amplified.

Reasonable Americans (by which I mean everyone who is to the left of Ann Coulter and Tucker Carlson) feel robbed.

There was the 2016 election, of course, in which the presidential choice of the majority was ignored, courtesy of an Electoral College that has outlived whatever utility it may once have had.

There is the growing realization by urban dwellers that their votes–thanks to that same Electoral College– count for less than the votes of the far less diverse inhabitants of rural America.

And that’s when those urban folks get to cast their votes. Anger about increasingly blatant vote suppression tactics has been growing, too, especially among minority constituencies that have been robbed of their ability to redress their grievances via the ballot box.

Perhaps no robbery has rankled as much as the theft of a Supreme Court seat that–in accordance with American history and constitutional norms– should have gone to Merrick Garland. The in-your-face behavior of Mitch McConnell poured salt on that wound. McConnell and the GOP made no effort to cloak their power play in even the thinnest of patriotic excuses; they didn’t bother to pretend that they were acting on some bizarre view of the national interest. Instead, they gloated publicly about their ability to abuse their power, and they were forthright about one reason for their unprecedented behavior: hatred of America’s first black President.

Women, of course, are routinely robbed of equality, respect and status in multiple environments, especially but not exclusively the workplace. Various religions counsel our submission, longstanding networks of “good old boys” dismiss and block our concerns and ambitions, the “powers that be” discount and trivialize our reports of victimization.

Moreover, to an extent only now becoming clear, we are viewed by far too many men as prey–objects to be harassed or assaulted with impunity.

Those on the right are no less angry–they actually may be more enraged–but the reasons are very different. These are primarily White Christians (disproportionately but not exclusively male) who have a well-founded fear that they soon will be robbed of their cultural dominance and privilege. They are reacting with fury to culture change and the increasing claims to a place at the civic table by LGBTQ, black and brown people, and women. Robert Jones has documented their resentment and rage in his recent book, The End of White Christian America.

The Kavanaugh hearings poured gasoline on all of those fires.

It was all there: the “old boys” once again dismissing the experience of a credible and accomplished woman, while simply ignoring the thousands of women who called and wrote and confronted them. The petulant, entitled (and embarrassing) behavior of a privileged white guy outraged by the very idea that he might be called to account. The incivility shown to Democratic committee members by Kavanaugh, Senator Grassley and committee Republicans.

The hearing reopened the wound over Merrick Garland (not least because of the striking contrast in the two men’s judicial demeanor), and it reminded Democrats that–thanks to gerrymandering and the Electoral College– Republicans control Congress and the White House despite the fact that a significant majority of the citizens who cast ballots voted Democratic.

Pent-up fury over all of this– plus the daily outrages of the Trump Administration– is likely to erupt in ways we’ve not previously seen.

I don’t know what comes next, but I’m pretty sure it’s going to be very ugly.

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The Science Of Democracy

“If Scientific Literacy is the Answer, What’s the Question?” is the provocative title of an online article by my friend Eric Meslin. Eric is a native of Canada– a bioethicist who left IUPUI a couple of years ago to become President and CEO of the Council of Canadian Academies. He wrote the article as part of a celebration of Canada’s “Science Literacy Week.”

Canada has a “Science Literacy Week.” Sort of makes an American cry….

I remember when people in the United States respected science. And education. That, of course, was before Trump, Pence and Betsy DeVos scorned bookish “elitists,” elevated religion over science, and job training over education. But I digress.

Eric reported on a 2014 Expert Panel assessment Science Culture: Where Canada Stands that found Canadians having mostly positive attitudes towards science and low levels of apprehension about science compared with citizens of other countries. Nevertheless,

The assessment also found only 53% of Canadians understood that antibiotics were not effective against viruses; only 46% were able to describe what it meant to study something scientifically (that is, using the scientific method); and that around 42% of the population had attained a basic enough level of science literacy that they could grasp general coverage of scientific and technological stories in the media. And yet, these results rated Canada as the most scientifically literate country in the world.

Why should science literacy matter? Eric points to the “tsunami” of information available, and the need to cull what is useful and well-founded from the mountains of speculation, disinformation and conflicting reports (to which I would add outright peddling of snake-oil.)

Maneuvering in a busy world of science information gives one answer to the question, why does science literacy matter? Knowing something about science can help distinguish between claims that are truthful from those that are not, to understand which new information should be heeded and what can be set aside for the moment. Indeed, part of being science literate is knowing where to find the resources to make sense of the scientific evidence.

Perhaps the most important argument for improving science literacy is the connection between a basic understanding of the scientific method and democratic self-governance. As Eric explains that connection:

As important as science literacy is for people to understand science, a science-literate public may also be the best hope for a well-functioning democracy.

This view sees science literacy as an antidote to the many varieties of fundamentalism that undermine pluralistic, cosmopolitan, multicultural democracies. A science literate society not only better understands the science behind a policy (e.g., it is a good idea to know a little bit about stem cell science before deciding whether to fund it), a science literate public also understands how to think carefully about how policy gets made, who decides, and using what criteria. When decisions are made to build bridges, dams or pipelines; to regulate chemicals and food; or to require vaccination, or fluoridate water, a science-literate public is applying its critical thinking skills to policy making in society.

Scientifically-literate citizens won’t always come to the same conclusions, but their debates are far more likely to be illuminating and productive than the arguments between, for example, the scientific community and the troglodytes who use biblical passages to dismiss the threat of climate change.

Eric also quoted a favorite book of mine: Timothy Ferris’ The Science of Liberty. As I wrote a few years ago,

Ferris argues convincingly that the democratic revolution was sparked by the scientific one. The new approach to governing wasn’t merely a function of the embrace of reason, because–as current events keep reminding us–people can reason themselves into all sorts of conclusions that have a tenuous connection to reality. Science was the new ingredient, and while science requires reason, it isn’t just reason. It’s empiricism, experimentation…the same sort of experimentation that is the basis for democratic governance.

It was the advent of science and the scientific method that underscored the importance of decisions based on evidence. As Ferris notes, dogma ruled the world before science came along, and dogma remains the preference of the majority of people today. (If you doubt the accuracy of that observation, look at Congress. Or Texas. Or, unfortunately, the Indiana Statehouse.) But democracy is not a dogma–it’s a method,a process not unlike the scientific method.

It is well to recognize that when strident anti-intellectual political figures attack scholarship as “elitism,” when they dismiss scientific consensus on everything from evolution to climate change, when they call for “repealing” the Enlightenment, it isn’t only science they are attacking.

It’s democracy as we understand it.

The U.S. isn’t doing so well in either science or democracy these days. One more reason to envy Canada…

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Right Diagnosis; Wrong Prescription

I know that this blog tends to reiterate certain themes, but we all have our preoccupations. Those who are regular readers will recognize a couple of mine: the importance of “hiring” (electing or appointing) government officials who actually know something about government; and the critical difference between “what should we do?” and “how should we do it?”

The election of Donald Trump and his subsequent choice of cabinet officials has pretty emphatically made the case for my first premise. (There’s a Facebook meme to the effect of “If you think anyone can run the government, I hope your next colonoscopy is performed by a plumber.”)

My second preoccupation–the difference between “what” and “how”– remains less obvious. I thought of it, however, when I read this column by Catherine Rampell in the Washington Post. As she points out, it’s one thing to correctly diagnose a problem. It’s quite another to devise a remedy that will solve the problem rather than inadvertently making it worse.

By all means, let’s raise the living standards of workers at Amazon, Walmart, McDonald’s and other employers of low-wage Americans.

And, by all means, let’s raise Jeffrey P. Bezos’s taxes, too. The founder of Amazon (and owner of The Post) is the wealthiest man in the world. He didn’t need the tax cut that Republicans just gave people like him.

But the sloppily designed Stop Bad Employers by Zeroing Out Subsidies Act (a.k.a., ahem, the “Stop BEZOS Act”) is a terrible way to do either of these things. It’s virtually guaranteed to hurt the very low-income working families its sponsors want to help.

The bill Rampell is citing addresses an issue that I’ve written about several times: some of the nation’s largest companies (including Amazon) pay their workers so poorly that taxpayers make up the difference with food stamps and other social welfare benefits.. In effect, we are paying a portion of those workers’ wages. Meanwhile, the company’s “savings” go to shareholders as additional profit.

It’s pretty despicable, and it should stop.

The “Stop Bezos Act” would establish a “corporate welfare tax” on firms with at least 500 employees. Companies would pay a tax equal to 100 percent of the value of safety-net benefits their employees receive, including Medicaid, housing subsidies, food stamps and subsidized school lunches.

That certainly sounds good. As Bernie Sanders, the bill’s sponsor, has said,

The working families and middle class of this country should not have to subsidize the wealthiest people in the United States of America. That’s what a rigged economy is all about.

Agreed. The diagnosis is spot on. The prescription, however, would be a disaster; it would hurt the very people it aims to help, because it would discourage firms from hiring workers suspected of drawing benefits.

These workers come, disproportionately, from some of the most vulnerable populations: families with children, older people and workers with disabilities.

Families with children are much more likely to use food stamps. Older Americans who are poor are much more likely to be on Medicaid. And workers with disabilities would face even more barriers to employment under this bill than they already do.

Under this bill, Medicaid-eligible workers with disabilities or other health issues would become thousands of dollars more expensive. Working-age people over 45, who cost Medicaid about twice as much as their younger counterparts, might face even more discrimination in the job market than they already do.

The bill tries to address these issues by barring employers from asking job candidates about benefits. But firms could easily infer which applicants are more likely to get them, based on their races, genders, Zip codes, etc. Such “statistical discrimination” would be difficult to police.

Moreover, employers get information about dependents and marital status when newly hired workers fill out their HR forms. Guess which workers would be at the top of the list when it’s time to downsize?….

Perhaps worst of all, as the Center on Budget and Policy Priorities points out, the bill would ultimately create a new corporate constituency to push for cuts to social programs and stricter eligibility requirements. Suddenly, reductions to Medicaid or school lunches would be directly equivalent to a corporate tax cut.

This bill would also require new oversight, probably spawn multiple lawsuits alleging discrimination, raise equal protection issues (why treat companies with 500 employees differently than those with 480?) and generate numerous new regulations.

Simply raising the minimum wage would go a long way toward solving the problem without creating perverse incentives or requiring additional bureaucracy.

Stop Bezos is a great soundbite. We should do it. How we should do it, however, matters. A lot.

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Why Politics Matters

Do you know folks who think political decisions don’t affect them? Who think voting is a waste of time? Among all of the other reasons they’re wrong, it turns out that a state’s political environment affects how long its residents live.

That was the astonishing conclusion of a study reported by Inc.The study ranked life expectancy in all 50 states, and came to some truly eye-opening conclusions. Among them: residents of Mississippi have the same life expectancy as residents of Bangladesh.

This truly is a fascinating study, pulling together reams of data to create “the most comprehensive state-by-state health assessment ever undertaken,” according to a press release. (The study itself was published in the Journal of the American Medical Association.) It’s unusual because most big studies examine the United States as a whole, and yet there’s a vast disparity of health and longevity among the states.

The report itself focused primarily on the data, rather than on differences in the public policies of the various states, but the following excerpt from the Discussion section is illuminating on that score.

Mortality reversals in 21 states for adults ages 20 to 55 years are strongly linked to the burden of substance use disorders, cirrhosis, and self-harm, and this study shows that the trends for some of these conditions differ considerably across different states. Case and Deaton have called some of these conditions “deaths of despair” and argued that they are linked to the social and economic status of white US adults.

States differ widely in their support of interventions to curb substance and alcohol abuse, and in the availability of programs addressing those dependencies. As far as the statistics on “self-harm,” the language is guarded, but clear: “self-harm” is suicide, and most people who kill themselves use a gun.

The availability of guns is a huge public health issue, and medical and public-health professionals have been arguing for a public health approach to gun violence more forcefully in recent years. The American Public Health Association and the American Medical Association have both issued statements calling gun violence a public-health problem, and advocating more research. (The “Dickey Amendment,” passed by Congress in 1996, effectively prohibited the CDC from even studying the issue.)

The larger “take away” from the data is economic. States where the percentages of low-income Americans are highest have higher incidences of alcoholism, drug abuse and suicide. It shouldn’t come as a shock that Mississippi, where citizens have poor health outcomes also has an economy that ranks in the bottom of American states.

The environment also plays a part: states that do a better job of controlling hazards like lead and coal ash, for example, reduce illnesses and deaths from avoidable environmental pollutants.

All of these influences on lifespan–the economic health of a state, the efficacy of local environmental protection, the easy availability of guns–are direct outcomes of the public policies supported by state and local lawmakers. (It will not shock anyone who follows these issues that the states with the worst outcomes tend to be reliably Republican.)

If the disaster that is Donald Trump hasn’t brought home the importance of voting, perhaps explaining to the disengaged that local political policies have a demonstrable effect on our lifespans and those of our families and friends will do the trick.

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