Public Policy and Governance – Page 91

We’re Number Eleven…

The problem with living at a time when there are so many problems–and so many truly major ones, at that–is that our focus gets splintered. Climate change. Vote suppression. White Supremicists. Rightwing domestic terrorism. Guns. Government gridlock. The pandemic. Continual wars and the growth of the military-industrial complex …The list is endless.

But a recent report in the Washington Post reminded me of one of our most long-term and shameful problems–America’s perverse refusal to follow the lead of other wealthy (and plenty of non-wealthy) countries and provide universal access to health care. The negative consequences of our refusal to allow anyone to opt in to Medicare (Medicare for those who want it), or just to broaden the scope of the Affordable Care Act, have receded from prominence.

We may be distracted by other policy failures, but the problem remains–and it is as acute as ever, if not more so.

Researchers at the Commonwealth Fund compared the health-care systems of 11 high-income countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the United States.

The United States has the worst health-care system overall among 11 high-income countries, even though it spends the highest proportion of its gross domestic product on health care, according to research by the Commonwealth Fund.

“We’ve set up a system where we spend quite a bit of money on health care but we have significant financial barriers, which tend to dissuade people from getting care,” said Eric Schneider, the lead author behind the findings and senior vice president for policy and research at the Commonwealth Fund, which conducts independent research on health-care issues.

The researchers identified five metrics of a well-functioning health care system: access to care, the care process itself, administrative efficiency, equity and overall health-care outcomes.Norway, the Netherlands and Australia were judged to be the top-performing countries overall.

The high performers stand apart from the United States in providing universal coverage and removing cost barriers, investing in primary care systems to reduce inequities, minimizing administrative burdens, and investing in social services among children and working-age adults, the Commonwealth Fund found.

The latter is particularly important for easing the burdens on health systems created by older populations, according to Schneider. “These sort of basic supports throughout younger age groups reduce, we think, the chronic disease burden that’s higher in the U.S.,” he said.

Since I have a son who lives in Amsterdam, I was particularly interested in the description of the Netherland’s high-performing system. The researchers found that it was a “well-organized system of locally placed primary care doctors and nurses who provide care on a 24/7 basis”–a system that keeps minor problems from turning into major ones.

The U.S. doesn’t come close. (As a former graduate student, a hospital administrator, told me years ago, we don’t have a healthcare system in the U.S.; we have a healthcare Industry.)

The United States was rated last overall, researchers found, ranking “well below” the average of the other countries overall and “far below” Switzerland and Canada, the two countries ranked above it. In particular, the United States fell at the end of the pack on access to care, administrative efficiency, equity and health-care outcomes.

The article noted that the inequities in America’s healthcare, together with our inadequate primary care, put the country in a much weaker position when it came to confronting the pandemic. That fact–together with the GOP’s advocacy of vaccine denial–may account for the fact that the U.S. has the second-highest COVID death rate among the eleven countries in the study.

America’s healthcare industry is costly in both lives and dollars.

Spending on health care as a share of GDP had grown in all of the countries the Commonwealth Fund surveyed, even before the pandemic. But the increase in the United States has “greatly exceeded” those of other nations. The United States spent 16.8 percent of its GDP on health care in 2019; the next highest country on the list was Switzerland, at 11.3 percent of GDP. The lowest was New Zealand, which spent roughly 9 percent of its GDP on health care in 2019.

Meanwhile, health care in the United States is the least affordable.

I hate sounding like a broken record, but this is what happens when racism drives decisions about the social safety net. Political scientists and sociologists confirm that–in addition to the profit motives/special interests of insurance companies and Big Pharma–the fact that White Americans don’t want “their” tax dollars spent on medical care or other social benefits for “those people” has prevented us from installing a less-costly and vastly more effective medical system.

We keep filling in that swimming pool…

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Policy And Procedure

So here’s the problem: as Paul Krugman recently noted in his weekly newsletter, Will Rogers oft-quoted line — “I am not a member of any organized political party; I am a Democrat” —is still accurate.

Today’s Republican Party has morphed into an ideological monolith, mainly constructed around racism and a visceral rejection of the “other.” That has led to a Democratic Party that encompasses, and must appeal to, pretty much everyone else–from the sane centrists fleeing what has become of the GOP to the moderate left to America’s version of the far left. In order to win elections with such a coalition, Democrats have to satisfy multiple constituencies. (As Krugman also observed, there’s a positive side to this reality–“this makes it harder to sell your soul, because it’s not clear who you’re supposed to sell it to.”)

The monolithic nature of the current GOP has helped it hold power despite the fact that we have literally mountains of research attesting to the fact that the party’s priorities are widely–sometimes wildly–unpopular. But (as a political scientist friend of mine recently explained over coffee) we fail to appreciate the extent to which Republican electoral successes are also a consequence of the filibuster.

Bear with me.

Even moderately honest observers realize that GOP legislators routinely put partisan advantage over the common good of the country. What we fail to appreciate is that most Democratic lawmakers–not all, certainly, but most–truly do try to put country first. (Granted, that doesn’t mean that the policies they pursue are necessarily correct, or that their motives are always pure.) Part of putting country first is protecting Americans from some truly awful policies that Republicans want to impose.

Democrats defending the filibuster point to precisely that function. They argue that in an inevitable future, when Republicans gain control of the Senate, Democrats will need the filibuster to keep the GOP from enacting damaging policies. As my friend pointed out, that impulse–to protect the country from policies that are broadly harmful and unpopular–actually helps the GOP.

He provided two illuminating examples.

In Indiana, when the Republican Governor and legislature passed a bill that would have allowed merchants to discriminate against LGBTQ customers, the blowback was intense, and the effort ultimately failed. The law was “clarified” to avoid its obvious goal. The very public nature of the response also “educated” a lot of people who don’t follow politics–and in the more urban parts of the state, at least, did the GOP no favors.

The more recent example is the Texas anti-choice vigilante law. For a number of years, pro-choice voters have relied upon the courts to protect their right to reproductive freedom, leaving them free to vote on the basis of other issues. It remains to be seen how much the outrage over the Supreme Court’s refusal to step in will motivate voters, but at this point, it looks like Texas Republicans have handed the Democrats a powerful issue.

My friend’s point is simple: let the GOP enact their pet policies, many if not most of which research tells us are very unpopular. Don’t use the filibuster to protect the party from the consequences of its own venality. Yes, the country will initially suffer the results –but the likely negative reaction will, once again, “educate” voters, clarifying the importance of registering their disapproval with their votes.

Obviously, there are other structural elements of our electoral system protecting an unpopular GOP from losses it would otherwise incur–as enumerated in this story in Vox. Gerrymandering and the Electoral College are huge hurdles, as is the growing tendency to view political party affiliation as part of one’s tribal identity, and to vote on that basis rather than on reaction to policy. But the less-recognized use of the filibuster as a mechanism to keep Republicans from enacting a toxic agenda is counterproductive.

Also, since it is a rule made by the Senate, it ought to be easier to eliminate. Someone needs to “educate” Manchin and Sinema.

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The Cost Of Luring Jobs

Over the past decade or so, like this blog, Americans’ political discussions and debates have focused on national issues and the increasing gridlock in Washington. There are several reasons for that. The decline of local journalism has meant that local issues that might trigger local activism are increasingly less likely to be covered, while more national media highlights the growing dysfunction of the federal government. And many of the challenges we face are national–or global–in scope.

Although it’s understandable that local policies tend to fly “under the radar,” that doesn’t make those issues unimportant. For one thing, individual citizens who are powerless to change goings-on in Washington can affect many local issues.

Governing Magazine recently focused on one such issue: economic development.

The article pointed out what even casual observers have long suspected, and what the data confirms–most state and local governments approach economic development in costly and unproductive ways. The article’s subhead really sums up the conclusion: “Governments can’t seem to stop offering huge incentives to corporations, even though it’s clear they don’t have much effect on companies’ decisions. Does paying $288,000 for one job really make sense?”

The rather obvious answer to that question is no. But economic development officials are responding to the pandemic by doubling down–ignoring overwhelming evidence and instead doing more of what they know. (This situation reminds me of America’s long, counterproductive drug war. As I said in a speech some years ago, if a doctor performed a hundred identical surgeries and every single patient died, would you insist that the proper response was to have him do more of them? The logic is the same.)

Seeking to create jobs and help their local economies climb out of the pandemic recession, state and local officials are raising the ante on subsidies to big corporations. But if history is any guide, ever-increasing tax breaks and other economic development incentives will likely lead to slower — not faster — growth. Given that state and local governments have already been wasting $95 billion every year in an economic race to the bottom, more subsidies will just dig the hole deeper.

The article highlighted North Carolina’s largest-ever subsidy: $865 million for an Apple research and development center promising 3,000 new jobs. But Apple would probably have chosen North Carolina in any event–without those subsidies.

Smart companies like Apple understand that the real long-term attraction is not subsidies so much as the great economic foundation North Carolina has built: investments in top-notch research universities, a tech-ready workforce and a business-friendly environment. North Carolina is indeed a perfect place to locate a cutting-edge research center. Site Selection magazine has consistently ranked it as a top state for business climate.

Interestingly, when Apple located a facility in Austin, Texas gave the company about $10,000 per job. North Carolina promised some $288,000 per job.

Research tells us that only one in eight subsidies effects a change to a location or expansion decision, and that some 90 percent are a complete waste of money. Companies happily accept the money, but their decisions are based far more on the availability of a talented local workforce, region-specific advantages and access to supply chains and customers.

For example, Google and Fidelity Investments recently announced expansions to their existing operations in the Research Triangle — without asking North Carolina for subsidies. Both emphasized the area’s skilled workforce as the primary draw.

The consensus of academic research is that corporate handouts don’t create broad benefits for the community providing them. That’s because subsidies motivate wasteful corporate investments and create public funding trade-offs. Every dollar spent on subsidies is a dollar that can’t be used to improve infrastructure, education or public safety, or to cut taxes on smaller businesses and households.

This expensive and unnecessary fiscal competition between local units of government adds absolutely nothing to the national economy–after all, nationally, moving enterprise A from city B to city C is a zero-sum exercise. And as the article notes, paying companies to move to your state siphons off funds that could be used for things that actually make your state attractive to those companies–like a first-rate public education system that not only turns out a skilled workforce, but is an amenity valued by the management folks who would be locating in your state.

The evidence shows that one of the most persuasive “subsidies” a state can offer is an attractive quality of life.

When policymakers ignore evidence, when they make decisions on the basis of ideology–or worse, when policy decisions are simply the result of “we’ve always done it this way” or “everyone else does it this way”–the costs aren’t limited to the dollar amount of the subsidies.

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Texas Is About Much More Than Abortion

The angry blowback against Texas’ assault on reproductive rights is eminently justifiable–but as I explained previously, most of the criticism of the law misses the even more ominous threat it poses.

In her newsletter last Saturday, Heather Cox Richardson brought a historian’s perspective to that more ominous reality. She traced the nation’s legal trajectory after WW II, and the resistance to efforts by FDR to use government to regulate business and provide a basic social safety net. And as she reminded readers, racist Southern Democrats furiously fought government’s efforts to ensure racial equality.

After World War II, under Chief Justice Earl Warren, a Republican appointed by President Dwight Eisenhower, and Chief Justice Warren Burger, a Republican appointed by Richard Nixon, the Supreme Court set out to make all Americans equal before the law. They tried to end segregation through the 1954 Brown v. Board of Education of Topeka, Kansas, decision prohibiting racial segregation in public schools. They protected the right of married couples to use contraception in 1965. They legalized interracial marriage in 1967. In 1973, with the Roe v. Wade decision, they tried to give women control over their own reproduction by legalizing abortion.

The Supreme Court used the Fourteenth Amendment to apply the Bill of Rights to state governments as well as to the federal government; among other things, that kept state and local government officials from denying certain individuals the same rights enjoyed by other citizens

From the beginning, there was a backlash against the New Deal government by businessmen who objected to the idea of federal regulation and the bureaucracy it would require. As early as 1937, they were demanding an end to the active government and a return to the world of the 1920s, where businessmen could do as they wished, families and churches managed social welfare, and private interests profited from infrastructure projects. They gained little traction. The vast majority of Americans liked the new system.

But the expansion of civil rights under the Warren Court was a whole new kettle of fish. Opponents of the new decisions insisted that the court was engaging in “judicial activism,” taking away from voters the right to make their own decisions about how society should work. That said that justices were “legislating from the bench.” They insisted that the Constitution is limited by the views of its framers and that the government can do nothing that is not explicitly written in that 1787 document.

This is the foundation for today’s “originalists” on the court. They are trying to erase the era of legislation and legal decisions that constructed our modern nation. If the government is as limited as they say, it cannot regulate business. It cannot provide a social safety net or promote infrastructure, both things that cost tax dollars and, in the case of infrastructure, take lucrative opportunities from private businesses.

It cannot protect the rights of minorities or women.

The Court’s refusal to enjoin the Texas law is a truly terrifying omen. If the law is ultimately upheld, the precedent would threaten far more than a woman’s right to control her own reproduction. As Richardson notes, such a result would “send authority for civil rights back to the states to wither or thrive as different legislatures see fit…there is no reason that this mechanism couldn’t be used to undermine much of the civil rights legislation of the post–World War II years.”

In 1957, Republican President Dwight Eisenhower used the federal government to protect the constitutional rights of the Little Rock Nine from the white vigilantes who wanted to keep them second-class citizens. In 2021, the Supreme Court has handed power back to the vigilantes.

I am old enough to remember the billboards demanding “Impeach Earl Warren.” The rage of rightwing White Nationalists at decisions that they (correctly) believed would curtail their ability to deny equal rights to Blacks and other disfavored minorities hasn’t abated. Much of it went underground: into the establishment of “think tanks” devoted to justifications of “originalism”and rollbacks of federal regulations, the (now successful) effort to pack the federal courts with ideologues and capture the big prize: the Supreme Court.

Logically, under the last fifty years of legal precedent, Texas’ effort to “outsource” its abortion ban to vigilantes–its effort to avoid “state action”– should fail. The state’s legislature created the law. Enforcement of its punitive and dangerous scheme requires participation by the state’s judicial system.

What too few of the people arguing for and against this assault seem to recognize is what is truly at stake right now: the entire edifice of current Constitutional law, which rests on the premise that the Bill of Rights applies to all levels of government–that it sets a civil liberties floor below which states may not go.

This fight is about more than Roe v. Wade.

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The Density Divide

The Density Divide is the title of a very important paper issued in June by Will Wilkinson, Vice President for Research of the Niskanen Center. It looks in depth at the phenomenon that I usually refer to as the “urban/rural divide”–delving into the attributes that make individuals more or less likely to move into cities, and examining the consequences of those differences and the steady urbanization of the American polity.

The paper is lengthy–some 70 pages–but well worth the time to read in its entirety. it is meticulously sourced, and replete with graphs and other supporting data.

Wilkinson confirms what others have reported: a substantial majority of Americans now dwell in the nation’s cities and generate the lion’s share of the nation’s wealth. But he goes beneath those numbers, referencing a body of research demonstrating that people who are drawn to urban environments differ in significant ways from those who prefer to remain in rural precincts. He focuses especially on ethnicity, personality and education as attributes that make individuals more or less responsive to the lure of city life.

He goes on to describe how this “self-selected” migration has segregated Americans. It has not only concentrated economic production in a handful of “megacities”–it has driven a “polarizing wedge” between America’s dense and diverse urban populations and the sparse White populations remaining in rural areas. That “wedge” is what he dubs the “Density Divide.” (Wilkinson is careful to define “urban” to include dense areas of small towns–the divisions he traces aren’t a function of jurisdictional city limits. They are a function of residential density.)

Wilkinson finds that the “sorting mechanism of urbanization” has produced a rural America that is lower-density, predominantly White, and “increasingly uniform in socially conservative personality, aversion to diversity, relative disinclination to migrate and seek higher education, and Republican Party loyalty.”

That sorting has also left much of rural America in economic distress, which has activated a “zero-sum, ethnocentric mindset.” (That mindset is reflected in the angry rhetoric spouted by rural MAGA hat wearers about “un-American” immigrants and minorities, and disdain for “liberal elites”–all groups that are thought to reside in those multi-cultural cities.)

The density divide–together with America’s outdated electoral structures– explains the 2016 election. The “low-density bias” of our electoral system allowed Trump to win the Presidency by prevailing in areas that produce 1/3 of GDP and contain fewer than half of the population. That low-density bias continues to empower Republicans far out of proportion to their numbers.

Wilkinson reminds us that there are currently no Republican cities. None.

As he points out, the increase in return to human capital and density has acted to amplify the polarizing nature of selective urbanization. Temperamentally liberal people self-select into higher education and big cities, where the people they encounter exert a further influence on their political attitudes. They leave behind a lower-density population that is “relatively uniform in white ethnicity, conservative disposition and lower economic productivity.” Economic growth has been shown to liberalize culture; stagnant or declining economic prospects generate a sense of anxiety and threat.( In that sense, the political scientists who attributed Trump votes to economic distress were correct, but the distress wasn’t a function of individual financial straits–it was a reaction to the steadily declining prospects of rural environments.)

Wilkinson argues that there are no red states or blue states–not even red or blue counties. Rather, there is compact blue urban density (even in small cities in rural states) and sprawling red sparseness.

This spatial segregation of people with very different values and world-views is radicalizing; Wilkinson reminds us that a lack of exposure to intellectual diversity and broadly different points of view breeds extremism. Because urban populations are far more intellectually diverse, more homogeneous rural populations have shifted much farther to the right than urban Americans have shifted left.

The United States population is projected to be 90% urbanized by 2050–not too many years after we are projected to become “majority-minority.” Those projections suggest we will see increasing radicalization of already-resentful rural inhabitants.

The prospects for returning to rational politics and a truly representative governance will depend entirely upon reforming an outdated and pernicious electoral framework that dramatically favors rural Americans. Whether those reforms can pass our very unrepresentative Senate is an open question.

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