Public Policy and Governance – Page 19

Drug Affordability

Most older Americans–make that “most Americans who are paying attention”–know that this country doesn’t have a healthcare system. As a former student put it, we have a healthcare industry. And we pay through the nose for it. A superficial google search will turn up mountains of data confirming the fact that healthcare costs in the United States vastly exceed those of other advanced countries, while giving us a “system” that ranks somewhere between 35th and 37th in the world.

I encountered the data that really made me aware of the insanity of market-driven healtcare several years ago, when I served on a committee organized by a medical-school friend. At the time, seventy percent of all healthcare costs were paid by governments at the local, state and federal levels. Not just Medicare and Medicaid, but through various other programs, and especially through the obligations of government-as-employer of teachers, police and fire personnel, etc. etc.

What really made an impression on me was data showing that those payments by government would be sufficient to pay for all medical care in a national system that eliminated health insurers’ marketing costs, claims processing, overhead and profit.

I’m a big fan of markets in areas where they work. Healthcare isn’t one of those areas. You don’t go “shopping” or comparing prices when you’re having a heart attack.

The Affordable Care Act was a good first step in delivering healthcare to Americans who’d been priced out of the market. It also gave added freedom to those whose medical issues had locked them into their jobs, thanks our insistence on tying coverage to employment. Drug costs, however, remained far higher than in other countries, thanks to the lobbying clout of “big Pharma,” despite the fact that the federal government is the major funder of research and development.

Reducing those costs is among the many under-appreciated accomplishments of the Biden Administration. As the Washington Post reported, “Monumental changes to prescription drug prices for seniors are coming.”

Thanks to the Inflation Reduction Act, one of President Biden’s signature achievements, prescription drugs are set to become substantially more affordable for seniors. Yet many Americans seem unaware of just how monumental these changes will be.

The article listed “six things to look for.” The first of those included eye-popping savings for both individual Americans and the government.

For the first time in history, Medicare can now negotiate directly with manufacturers. For the initial round of negotiations, the Centers for Medicare and Medicaid Services chose 10 drugs that treat common health conditions, including cardiovascular disease, cancer and rheumatoid arthritis.

Each of these medications costs consumers in the United States three to eight times what people pay in other countries. In 2022, Medicare paid an eye-popping $46.4 billion for them. The impact to consumers is equally staggering. As CMS Administrator Chiquita Brooks-LaSure told me, “Some of these drugs are thousands of dollars per year for people who depend on them to live.”

It will take some time for negotiated prices to take effect. Assuming the federal government prevails in the lawsuits filed by pharmaceutical companies, CMS expects lower prices to be in place in 2026.
But that’s only the beginning. Fifteen more drugs will be selected for 2027 and then 20 per year from 2029 and thereafter. The lower prices are projected to save the federal government $100 billion over the next several years. Crucially, this means that the negotiations won’t just benefit people who are on these specific medications; the savings are passed along, indirectly, to everyone on Medicare.

Other changes, thanks to the Biden Administration, will include a cap of $2000 per year on out-of-pocket Medicare spending, and significantly lower costs for insulin. Other changes include an income-based subsidy for the most vulnerable Medicare enrollees, making all adult vaccines recommended by the Centers for Disease Control and Prevention free for everyone with Medicare Part D, and requiring drug companies to pay a rebate to Medicare if they increase prices faster than inflation.

There has been very little media attention to these hard-won changes, presumably because skill at the actual business of governing is less sexy than wall-to-wall coverage of threats to desperate immigrants and hush-money payments to porn stars.

In her “Letters from an American,” Heather Cox Richardson often compares the autocratic and corrupt self-interest of Trump and the MAGA movement to the Biden Administration’s focus on making life better for average Americans.

Reducing the cost of lifesaving prescription drugs– rather than limiting women’s reproductive liberties and forbidding medical providers to assist trans children– is a perfect example of the wildly different priorities of today’s Democratic Party and the Republican MAGA cult.

In November, vote accordingly.

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It’s We, The People

Robert Kagan recently published a lengthy excerpt from his recent book “Rebellion: How Antiliberalism is Tearing America Apart — Again” in the Washington Post.

In it, he dismissed a variety of explanations for the MAGA embrace of Trump–discarding arguments that the movement is a result of rapidly changing technology, widening inequality, unsuccessful foreign policies or unrest on university campuses. Instead, he pinned it on failures of We the People.

It is what the Founders worried about and Abraham Lincoln warned about: a decline in what they called public virtue. They feared it would be hard to sustain popular support for the revolutionary liberal principles of the Declaration of Independence, and they worried that the virtuous love of liberty and equality would in time give way to narrow, selfish interest. Although James Madison and his colleagues hoped to establish a government on the solid foundation of self-interest, even Madison acknowledged that no government by the people could be sustained if the people themselves did not have sufficient dedication to the liberal ideals of the Declaration. The people had to love liberty, not just for themselves but as an abstract ideal for all humans.

Kagan worries that too many of us no longer care about preserving the system the Founders bequeathed us–a system based on the principles of universal equality and natural rights. Preserving that system, he says, “plain and simple, is what this election is about.”

“A republic if you can keep it,” Benjamin Franklin allegedly said of the government created by the Constitutional Convention in 1787. This is the year we may choose not to keep it.

Kagan follows that sentence with an extended recap of what most Americans know–about the intent of the January 6th insurrection, about Trump’s candid announcements of his goals, about the unconscionable failure of the Senate to use impeachment, the mechanism provided by the Founders, to negate the threat of further insurrection. Then he gets to the crux of his argument.

So, why will so many vote for him anyway? For a significant segment of the Republican electorate, the white-hot core of the Trump movement, it is because they want to see the system overthrown. This should not come as a shock, for it is not a new phenomenon. On the contrary, it is as old as the republic. Historians have written about the “liberal tradition” in America, but there has from the beginning also been an anti-liberal tradition: large numbers of Americans determined to preserve preliberal traditions, hierarchies and beliefs against the secular liberal principles of the Declaration of Independence and Bill of Rights. The Founders based the republic on a radical set of principles and assertions about government: that all human beings were created equal in their possession of certain “natural rights” that government was bound to respect and to safeguard. These rights did not derive from religious belief but were “self-evident.” They were not granted by the Christian God, by the crown or even by the Constitution. They were inherent in what it meant to be human.

That paragraph introduced a lengthy historical discussion in which Kagan reminded readers that MAGA is really nothing new. Throughout our history, significant numbers of Americans have rejected the classical liberal foundations of the nation’s constituent documents–and especially the notion of civic equality.

For two centuries, many White Americans have felt under siege by the Founders’ liberalism. They have been defeated in war and suppressed by threats of force, but more than that, they have been continually oppressed by a system designed by the Founders to preserve and strengthen liberalism against competing beliefs and hierarchies. Since World War II, the courts and the political system have pursued the Founders’ liberal goals with greater and greater fidelity, ending official segregation, driving religion from public schools, recognizing and defending the rights of women and minorities hitherto deprived of their “natural rights” because of religious, racial and ethnic discrimination. The hegemony of liberalism has expanded, just as Lincoln hoped it would, “constantly spreading and deepening its influence, and augmenting the happiness and value of life to all people of colors everywhere.” Anti-liberal political scientist Patrick Deneen calls it “liberal totalitarianism”….

Kagan reminds us that the fury on the Right against “wokeness” is nothing new. “Anti-liberal movements in America, whether in defense of the White race or Christianity, and more often both together, have always claimed to be suffering under the expanding hegemony of liberalism.”

There is much more, and it is definitely worth reading in its entirety.

Bottom line: MAGA’s Christian Nationalism is nothing new. In November, We the People will either defend our “natural rights” or we will lose them.

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Doonesbury Nails It

Stinging humor has been one of the more notable characteristics of what I devoutly hope will NOT be known as “the age of Trump.” Late-night comedians have gone where GOP politicians terrified of their MAGA base (and Democrats persuaded to “go high” when Republicans “go low”) have failed to go.

The result has been a situation in which the most biting–and frequently, most accurate–commentary has come from stand-up comedians and the Sunday funnies. Last Sunday, Doonesbury used a fictional psychiatrist to echo observations and conclusions that have been discussed for several months by real mental health professionals: Trump is rapidly slipping into dementia.

Elias–Doonesbury’s fictional “resident psychiatrist”– points to the symptoms: repeatedly mixing people up (not just forgetting names, which happens to all of us, but calling Biden Obama or Haley Pelosi); phonemic paraphasia (“freestyling” off the stem of a word); slurring; semantic aphasia; and tangental speech. The last panel of the cartoon is a warning, showing nonsense words coming out of the White House.

In all fairness, I didn’t find the Sunday strip funny. I did find it educational–and terrifying.

Trump’s “word salads” have been the subject of innumerable Facebook jokes and memes, but mental health professionals and pundits agree that his more recent speeches and outbursts have changed in nature. The Doonesbury labels appear to fit.

Phonemic paraphasia, for example, is defined as a disorder in which incorrect phonemes are substituted. For example, one may say “spot” instead of “pot.” Literal paraphasia could also be switching syllables or creating reverse compound words such as “markbook” instead of “bookmark.” There are differing types; according to Wikipedia,

Wernicke’s aphasia is characterized by fluent language with made up or unnecessary words with little or no meaning to speech. Those who suffer from this type of aphasia have difficulty understanding others speech and are unaware of their own mistakes. When corrected they will repeat their verbal paraphasias and have trouble finding the correct word….

Phonemic paraphasia, also referred to as phonological paraphasia or literal paraphasia, refers to the substitution of a word with a nonword that preserves at least half of the segments and/or number of syllables of the intended word. This can lead to a variety of errors, including formal ones, in which one word is replaced with another phonologically related to the intended word; phonemic ones, in which one word is replaced with a nonword phonologically related to the intended word; and approximations, an attempt to find the word without producing either a word or nonword. These types of errors are associated with Wernicke’s aphasia, among others. Phonemic paraphasias are often caused by lesions to the external capsule, extending to the posterior part of the temporal lobe or internal capsule.

Wikipedia defines “semantic aphasia”as a “progressive neurodegenerative disorder characterized by loss of semantic memory in both the verbal and non-verbal domains. However, the most common presenting symptoms are in the verbal domain (with loss of word meaning). Semantic dementia is a disorder of semantic memory that causes patients to lose the ability to match words or images to their meanings.”

Tangential speech is a communication disorder in which the train of thought of the speaker wanders and shows a lack of focus, never returning to the initial topic of the conversation. (Full disclosure: my kids will tell you I have this one…although usually I do– eventually– return to the initial topic.)

Quite obviously, I am not a doctor, nor do I play one on TV. Neither is Gary Trudeau, the Doonesbury cartoonist. That said, Trudeau hasn’t created this diagnosis out of thin air or political pique–increasing numbers of mental health professionals have raised alarms. It began during his first term, with “The Dangerous Case of Donald Trump” in which 27 psychiatrists evaluated concerning aspects of his personality; and has accelerated with psychologists warning of the dangers posed by more recent evidence of his mental decline. (One example: Harry Segal, a senior lecturer in psychology at Cornell University who has been critical of the former president’s mental health since he was first elected, said Trump was showing clear signs of onset dementia.)

It doesn’t correlate with age. Some people “lose it” at sixty; others are mentally sharp at 100.

And it isn’t simply the bone-chilling prospect of a single, truly demented head of state. The Trump presidency has illuminated a challenge going forward. It has become standard for candidates to share their medical evaluations with the voting public; is it time to require aspirants for high office to be screened for mental illnesses?

And given some of our past Chief Executives, where would we set the bar?

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Allow Me To Translate..And Pontificate

In a recent column in the New York Times, Thomas Edsall once again returned to the subject of political polarization, and–as is his typical approach–quoted scholars on the subject. As a former member of that tribe, I will admit that the problem with quoting academics is the occasional impenetrability of the language. (It’s not a problem limited to academia–not long after becoming Executive Director of Indiana’s ACLU, I was counseled by a member of the national staff to stop sounding like an “ACLU lawyer.” Every career has its jargon…)

At any rate, allow me to quote–and then translate–one of the scholars who responded to Edsall:

Interventions to reduce affective polarization will be ineffective if they operate only at the individual, emotional level. Ignoring the role of polarizing politicians and political incentives to instrumentalize affective polarization for political gain will fail to generate change while enhancing cynicism when polite conversations among willing participants do not generate prodemocratic change.

In other words, polarization isn’t just a matter of individual hostility for those on the other “team.” Political leadership bears considerable responsibility for MAGA resistance to democratic norms. The polarization reflected in our everyday conversations is cultivated by political “culture warriors” like Georgia’s Marjorie Taylor Green and her Indiana clone, Jim Banks. As a different scholar (one evidently more comfortable with normal English usage) put it:

I don’t think any bottom-up intervention is going to solve a problem that is structural. You could reduce misperceptions for a day or two, or put diverse groups together for an hour, but these people will be polarized again as soon as they are exposed once more to campaign rhetoric.

A recent study evidently found that widespread popular opposition to anti-democratic policies is insufficient to prevent their adoption. That research found that what the scholars called “backsliding behavior by elites” occurred irrespective of a lack of public approval or support; and that much of the problem is rooted in the fact that “Americans, despite their distaste for norm violations, continue to elect representatives whose policies and actions threaten democracy.”

In other words–and this will most definitely not come as a shock to any citizen who’s been paying even the slightest attention–virtually all of the current dysfunctions of governance are caused by the various doofuses we’re electing. (I cannot restrain myself from reminding you, dear readers, that it is frequently thanks to gerrymandering that we are electing these performative, anti-democratic culture warriors.)

As another scholar opined,

Whatever techniques might exist to reduce citizen animosity must be accompanied by efforts to reduce hostility among elected officials. It doesn’t matter if we can make someone more positive toward the other party if that effect is quickly undone by watching cable news, reading social media, or otherwise listening to divisive political elites.

In other words–as several of the researchers contacted by Edsall confirmed– positive effects of efforts to intervene and ameliorate polarization “are almost immediately nullified by the hostile rhetoric in contemporary politics.”

A professor of psychological science at the University of California-Irvine attributed the persistence of polarization to what he dubbed a “moralized political environment,” and that phrase resonated with me. I am hardly the only person to see today’s political disputes as evidence that contemporary political combat takes place between partisans who hold significantly different values.

As Edsall noted,

The issues dividing the parties have changed. When the two parties fought over size of government, taxes, social welfare programs, it was possible for partisans to imagine a compromise that is more or less acceptable even if not ideal. Compromise on issues like abortion, gender roles, L.G.B.T.Q.+ rights, the role of religion is much more difficult. So losing feels like more of a threat to people’s values.

From my vantage point, we have moved from good faith arguments about the proper approach to various issues–the “how”–to arguments about “whether.” Rather than debating, say, the best way to feed poor children, we confront self-identified “pro life” politicians who simply oppose spending any tax dollars on food for poor children. Rather than debates about America’s global role and the least dangerous way to approach Putin’s ambitions in Ukraine, political figures like Braun and Banks vote–as conservative George Will wrote–“to assure Vladimir Putin’s attempt to erase a European nation.” Etcetera.

We aren’t having “political” arguments. We are having deeply moral ones.

Survey research confirms that a majority of the American public is on the right side of those moral debates–but that obsolete political structures allow MAGA Republicans–a statistical minority– to ignore We the People.

Political structures empowering ideological minorities are the reason we can’t just “make nice” and “all get along.”

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Complicated–And Consequential

The virtue of America’s current battle over a woman’s right to control her own body is its clarity. Either a woman has the right to determine whether she will give birth, or the government has the right to force her to do so, irrespective of the consequences for her health and well-being.

It’s either/or.

Other threats we face are much more subtle and complicated. Policy changes that may seem innocuous or even reasonable on the surface have the potential to undermine rules that demonstrably serve the common good. An example is the passage this year of bills in Indiana, Nebraska, and Idaho that propose to end “judicial deference.” Judicial deference is a doctrine that requires federal or state courts to “defer” to administrative agencies’ interpretations of agency statutes and regulations. Instead, those bills require courts to apply de novo review — to examine executive agency actions without bothering to give weight to that agency’s interpretation of the statute or regulation in question.

The bills were based on model legislation: the Judicial Deference Reform Act, developed by The Goldwater Institute and the Pacific Legal Foundation. Those bills might not have been necessary, though–our radical, rogue Supreme Court, unconstrained by precedent, appears ready to junk that doctrine, called The Chevron doctrine after the long-ago footnote that established it.

Why should we care about this arcane bit of jurisprudence? As one recent analysis explained, overturning the Chevron doctrine would allow individual judges to implement their partisan policy preferences instead of abiding by agency expertise.

Under Chevron deference, courts have been obligated for the past half-century to defer to career expert civil servants in agencies who created rules based on their statutory authority when the statutes were ambiguous or silent, as to highly specific and technical areas of regulation. Chevron deference has been used in more than 19,000 cases and is the basis on which Congress has enacted broadly worded statutes granting agencies regulatory authority for the past 40 years. Now, the Supreme Court is poised to throw the baby out with the bathwater by overturning the very authority it directed Congress and federal agencies to operate under….

The court also appeared ready to return to the Skidmore v. Swift & Co. doctrine, which preceded Chevron and, ultimately, would give federal courts more power to implement their policy preferences and ignore agency expertise. As Justice Elena Kagan aptly pointed out, Chevron replaced Skidmore because “judges [were] becoming too partisan in interpreting regulations,” which “dampens that kind of ideological division between courts.” She also reasoned that “Skidmore is not a doctrine of [judicial] humility.” Meanwhile, Justice Ketanji Brown Jackson emphasized that Chevron allows Congress to delegate policy choices to executive agencies and voiced concerns that “if we take away something like Chevron, the court will then suddenly become a policymaker.”

As the linked article notes, the conservative legal movement’s long effort to use the legal system to serve the interests of corporate behemoths at the expense of sound policy and the broader interests of the American public seems increasingly likely to succeed.

The doctrine requires “deference”–not submission. If evidence produced at trial shows that an agency’s interpretation of a rule is unreasonable, the courts can and should overturn that interpretation. But discarding the requirement that courts should defer--not “buckle under”–is yet another blow to respect for knowledge and expertise.

Executive branch agencies increasingly deal with matters requiring considerable subject-matter knowledge. Officials of the EPA are highly likely to know more about unsafe levels of arsenic in drinking water than a judge presiding over a case brought by a company that has been fined for exceeding that level in its discharge into a local river. Officials at the FDA have met professional standards for evaluating the safety of food and/or the efficacy of drugs. Recently, we’ve been reminded of the importance of informed FAA oversight of aircraft manufacturers like Boeing. The growing complexities of modern life–in technology, in medical science, in product safety–requires acknowledging the importance of specialized expertise.

The courts have operated under Chevron deference since 1984. That deference has not kept them from invalidating unreasonable or overbroad interpretations of statutes and regulations. It has, however, required judges (who come to the bench with a very different kind of expertise) to listen carefully to the reasons agency personnel interpret a given rule in the way that they do.

Most Americans have never heard of Chevron; in Indiana, Nebraska and Idaho, most citizens are blissfully unaware of the passage of laws discarding the doctrine.

The threat posed by overruling the doctrine is far less obvious than the threat to women’s autonomy–but that doesn’t mean this assault on expert knowledge isn’t significant.

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