Thursday, March 23, 2017

Battle over the AHCA

In NRO, I look at the possibility of the American Health Care Act (which is supposed to be voted on Friday) exacerbating tensions between conservatives and populists:
While it achieves many longstanding priorities for Beltway Republicans, [the AHCA] contains some provisions that could alienate members of the working class, such as Medicaid cuts. It is telling that elements of the Right who have been very sympathetic to populist themes — such as Ann Coulter, many Breitbart writers, and Arkansas senator Tom Cotton — have been unsparing in their criticism of the AHCA. The bill itself is currently extremely unpopular, supported by only 17 percent of Americans according to the latest numbers from Quinnipiac.
It might be especially divisive for the Republican coalition. Donald Trump’s presidential campaign was premised upon outreach to working-class voters, and an improved performance with this demographic was crucial for breaking the “blue wall” at the presidential level and for the GOP’s successful defense of its Senate majority.
You can read the rest over there.

Things are so fluid with the AHCA that I'll defer making any predictions.  Instead, a few random observations.

If the AHCA does pass tomorrow, President Trump's decision to say that he'll stop negotiating tonight (pass the current bill, or I'll move on) could make him look like he's someone who knows how to work his will on Congress.  So it could foster an image of him being a "strong leader."  Of course, the AHCA passing also means that House Republicans will have signed on to a less-than-popular bill, one with real potential to divide the GOP coalition.  It also means that President Trump will get either the credit or the blame for this bill.  It's also hard to see what happens in the Senate in taking up the AHCA; it's very possible that the things that made this bill pass the House will make it very hard for it to pass the Senate.

If the AHCA fails, the White House and Republicans may be free to move on to other policies, ones that might be more popular.  Michael Brendan Dougherty, for instance, has suggested that the GOP consider some of the policy areas that were at the center of the Trump campaign, such as infrastructure, trade, and immigration.  They might also be able to take on healthcare in a way that circumvents some of the tensions heightened by the AHCA (see my NRO post for more thoughts on that).  The failure of the AHCA might cause a few negative newscycles ("Republicans in disarray!!!1"), but it's unclear whether a defeat tomorrow will have a lasting effect on the GOP agenda.

The GOP runs grave political risks if it does not attempt to promote policies that deliver for the working class. It might be especially politically risky for President Trump to disappoint the core of his populist support.

Reforms to make healthcare cheaper and to expand the insurance market could be a way for the GOP to promote healthcare reform in a less politically risky way; this approach might also do a lot of good to improve access to medical care.

A good bill passed slowly is far better for a governing party than a bad bill passed quickly.

Wednesday, March 22, 2017

Some Assorted Links

An interesting treatment in The Chronicle of Higher Education of the Claremont Institute, Straussian thinking, and some intellectuals who support Donald Trump.  (It could be seen as a kind of companion piece to this NYT story on the new journal American Affairs.)

Henry Olsen worries that the current iteration of the American Health Care Act may disappoint the working-class voters who were crucial for the GOP victory in 2016.

Ross Douthat reflects on the worries of some who fear that Jane Austen has too many "alt-right" fans.  A particularly striking claim: efforts by the far left to "abolish canons and police certain forms of memory" may in part be motivated by a desire to suppress the diversity of cultural expression in the past.

Tuesday, March 21, 2017

On Political Winning

In light of the current debate over health-care reform,  few points about "winning":  In the Beltway, there tends to be an assumption that a president "wins" when he gets Congress to pass the legislation he supports.  Than can be a victory, but that "win" can sow the seeds for a greater defeat later.

For instance, President Obama "won" by getting Congress to pass the ACA on a party-line vote.  It was a substantial legislative achievement, and components of it could very well have a long legacy.  But the ACA's passage also crippled the rest of the Obama administration's agenda and contributed to the evisceration of the Democratic party's bench.  Maybe that trade was worth it, but it exacted a high long-term political price, too.

The experience of the Obama administration might prompt the Trump White House to think about what its real policy priorities are and how it can advance those priorities without endangering a critical mass of public support.

Saturday, March 18, 2017

Maintaining Judicial Norms

Judge Derrick Watson's ruling on the Trump travel ban has ignited commentary about the role of the judiciary vis-a-vis the presidency and existing constitutional norms.  At Lawfare, Benjamin Wittes and Quinta Jurecic raise a potentially quite troubling permutation: the rise of the judiciary as a partisan political actor.  For this model of the judiciary, norms about institutions and constitutional principles would pale before the way judges feel about the holders of certain offices:
Imagine a world in which other actors have no expectation of civic virtue from the President and thus no concept of deference to him. Imagine a world in which the words of the President are not presumed to carry any weight. Imagine a world in which far more judicial review of presidential conduct is de novo, and in which the executive has to find highly coercive means of enforcing message discipline on its staff because it can’t depend on loyalty. That’s a very different presidency than the one we have come to expect.
It’s actually a presidency without the principle that we separate the man from the office. It’s a presidency in which we owe nothing to the office institutionally and make individual decisions about how to interact with it based on how much we trust, like, or hate its occupant.
A world where the judiciary interprets law based not on precedent and institutional principles but instead on its feelings about individuals would be one where judicial philosophy would become much less stable (if we could even call it a "philosophy" at all).  It would likely endanger public faith in the judiciary as a responsible institutional actor and could contribute to greater public distrust about important constitutional stakeholders.

Partisan politics can blind us to the consequences of our actions, but civic (and ethical) responsibility demands that we try to account for these consequences.  That responsibility weighs especially on those in the judicial branch.

(Over at the Corner, I think about the consequences of Judge Watson's ruling for future immigration legislation.)

Thursday, March 16, 2017

Leverage

Jim Geraghty raises an interesting point: The GOP is offering the AHCA as "Phase 1" in a three-phrase process.  The second "phase" is President Trump's rewriting of the Obama administration's ACA regulations, and the third would be more market-oriented (and perhaps more popular) legislative reforms, such as selling insurance over state lines.

Geraghty, though, wonders whether there will be enough bipartisan energy to pass "Phase 3":
Assume the American Health Care Act passes the House, at least 50 Republicans in the Senate vote for it and Trump signs it into law.
For "Phase Three," will eight Senate Democrats be eager to vote with Republicans to make further reforms? If you’re a Democrat, after AHCA passes, Republicans "own" the status quo on the health care system. You can blame AHCA for anything any constituent doesn’t like about their insurance, their premiums, their co-pays, their deductibles, or their quality of care. It may or may not be accurate, but let’s face it, accuracy has never mattered much in attack ads.
Perhaps naively, I believe that there could be a chance getting at least 60 Senate votes--including at least 8 Democrats--to support broadly popular reforms that would increase efficiency in the health-care market.

However, there is a possibility that this chance gets slimmer after the passage of "Phase 1."  Currently, Republicans can still blame the many shortcomings of the current health-care system on the legacy of the Affordable Care Act.  They can try to use these shortcomings as a way of putting pressure on Democrats in swing and lean-Republican states: We're trying to fix the broken system left to us by Obamacare, and you're just obstructing.

That dynamic changes, however, if a major piece of health-care legislation (like the AHCA) is passed on a party-line vote.  Then, it gets much harder to blame a "broken system" on the ACA alone.  Passing the AHCA gives vulnerable Senate Democrats an obvious retort: Nuh-uh, you guys broke the system with Trumpcare.

With this political cover, Democrats would have the temptation to obstruct any further changes to the health-care system leading up to the 2018 elections.  The obvious strategy would be to attack (fairly or not) the AHCA for denying care to the poor and vulnerable in order to give tax-cuts to corporations and "the 1%".  Democrats saw how well attacking a major piece of health-care reform passed on a party-line vote worked for Republicans in 2010; they might try to repeat that in 2018.

The recent political cycle has laid to waste many predictions, so any predictions about the future political dynamic should be made in a hypothetical rather than categorical mode.  Nevertheless, it seems as though Republicans could lose some leverage over Senate Democrats if they pass a party-line major health-care reform.  That leverage may be crucial if they hope to pass later reforms to health-care law this Congress; these reforms would require 60 votes in the Senate and so would need some Democratic support.

If Republicans want to enact major changes in health-care regulations (not just government financing), they might have more political leverage before passing a party-line bill than after passing such a bill.

(Two related points: Some folks have raised a possible counterargument to this narrative of leverage: Once the ACA is reformed through a party-line vote on the AHCA, Democrats will have less incentive to defend the ACA in its entirety and will be more willing to compromise on other areas.  At that point, it will no longer be about defending President Obama's "legacy" and more about pragmatically working to improve national health-care.  In a less politically polarized time, this counterargument would have more force, but it could still be plausible.

Also, if something like the AHCA did pass in its current form, one possible bargaining chip to get Democrats to support a later wave of reform would be to offer to increase Medicaid subsidies.)

Wednesday, March 15, 2017

The Health-Care Bind

One of the more interesting pieces published today was this one by Christopher Ruddy, the head of Newsmax and a friend of President Trump.  Ruddy argues that the president should reject the calls of Republicans who want to limit Medicaid and other subsidies in the American Health Care Act; instead, President Trump should call for an expanded Medicaid program (albeit one that has more power delegated to the states).  Ruddy worries about the political effects of trying to push entitlement reform in replacing the Affordable Care Act:
Today, I am amazed that House Republicans haven't given up on their political death wish.
Interestingly, Ryan Plan II accepts key parts of the Obamacare law that benefit the insurance industry. But it ends the Medicaid expansion program that benefits the poor and keeps costs down.
Instead, Ryan II forces poor individuals back into the private health insurance market with the help of tax credits. I wonder who that benefits?
According to the AARP, Ryan Plan II also cuts Medicare, a program Trump voters clearly want protected.
The CBO is estimating 14 million Americans will lose coverage compared to Obamacare.
This number may be inflated, but limiting Medicaid coverage for the poorest will most certainly leave millions without coverage.
The most significant problem is that Ryan Plan II doesn't fulfill Trump's own vision of universal healthcare while removing the onerous requirements of Obamacare.
When even the CEO of Newsmax calls for an expanded Medicaid program, it's clear that the political dynamic is quickly evolving.  Ruddy's sentiments echo those of others in the Trumposphere who fear that there could be a significant political price to be paid if the Republicans try to push through health-care reform that causes some Americans to feel as though they're losing access to health-care (the CBO numbers from yesterday surely have added fuel to that burning worry).

Whether or not an expanded Medicaid program is the right answer, it seems clear that the GOP is torn between those who fear that the AHCA does not cut subsidies enough (such as the Freedom Caucus) and those who fear that the already existing reduction of subsidies in the AHCA could ignite a political backlash among working-class voters.  It remains unclear whether the GOP can thread the needle and appease enough of both sets of Republicans in order to get 218 votes in the House and 51 votes in the Senate.

The battle over health-care subsidies divides the GOP and risks alienating the blue-collar voters who are a central component of Trump's coalition.  One way around these risks is to defer fighting this battle and instead focus more immediately on market-oriented reforms to the health-care market itself.  Expanding and diversifying health-care markets, reforming licensing laws, pushing for more transparency in medical pricing, and other efforts are far less divisive for GOP voters and could also win some support from Democrats and independents.  As David Frum has noted, the American health-care system stands in need of more market efficiency, and Republicans could be well positioned to champion that cause of efficiency in a way that will ease government budgets and the concerns of health-care consumers (i.e., voters).

If policymakers can lower health-care costs or at least reduce the rate of growth for health-care costs, more room opens up for negotiations over government mechanisms to pay for health-care.  A more market-oriented health-care system might facilitate more market-oriented ways of financing this system.

Of course, these market-oriented reforms can't for the most part be passed via reconciliation.  As a result, right now some in Republican leadership are fighting on the ground of health-care reform where the party might be most vulnerable and leaving more favorable territory for a later day.

Monday, March 13, 2017

Debating Marcuse

In National Review Online over the weekend, I discussed the unrest at Middlebury in the context of Herbert Marcuse's theory of "discriminating tolerance."  A prominent member of the Frankfurt School, Marcuse offered a flawed model of tolerance that, I fear, fosters a breakdown of public debate.

Marcuse must have been in the air last week, because Stephen L. Carter also had an interesting critique of Marcuse over at Bloomberg View.

(And if you're in the mood for more on Marcuse, you might check out George Kateb's extended comments on him from a 1970 issue of Commentary.)

Saturday, March 11, 2017

Hidden Costs

Christopher Caldwell's survey of the opioid epidemic, featured in the latest issue of First Things, has understandably been getting a lot of attention.  Caldwell explores the personal and social costs of opioid epidemic rocking many communities in the United States.  The death-rate from opioids currently far exceeds the death-rate from the headline drugs of other crises:
A heroin scourge in America’s housing projects coincided with a wave of heroin-addicted soldiers brought back from Vietnam, with a cost peaking between 1973 and 1975 at 1.5 overdose deaths per 100,000. The Nixon White House panicked. Curtis Mayfield wrote his soul ballad “Freddie’s Dead.” The crack epidemic of the mid- to late 1980s was worse, with a death rate reaching almost two per 100,000. George H. W. Bush declared war on drugs. The present opioid epidemic is killing 10.3 people per 100,000, and that is without the fentanyl-impacted statistics from 2016. In some states it is far worse: over thirty per 100,000 in New Hampshire and over forty in West Virginia.
As Caldwell notes elsewhere in his story, four times as many Americans died from overdoses in 2015 as died from gun homicides that year.

Federal data shows how quickly deaths from heroin and opioids more generally have skyrocketed over the past decade.  Heroin deaths across the nation jumped from around 2,000 in 2006 to about 12,000 by 2015.  The number of deaths from opioid overdoses has over doubled since 2004.  The number of overall drug overdose deaths has over doubled since 2002.

The causes of this increased rate of opioid abuse are complex.  Caldwell suggests that the normalization of increasingly powerful opioids by the medical community played a role, as did an influx of cheap heroin.  The story also frames the opioid crisis in the context of broader socioeconomic forces that have battered many communities.

Of course, we cannot measure the current opioid epidemic only in terms of lives lost.  Drug addiction can be lethal, but its costs can also be measured in other ways--in broken families, frayed communities, daily struggles, grappling with despair, and the haunting of personal disappointment.  All these things suggest that drug abuse remains a serious civil issue.

Wednesday, March 8, 2017

AHCA Tensions

At National Review, I reflect on some of the political tensions facing the GOP in terms of reforming health-care.

Ross Douthat also considers some of those challenges in the NYT today.  He argues that fractures in the Republican party have put it in a place of policy confusion.  Leadership and imagination can remedy some of that confusion, but they will have to be demonstrated.

Thursday, March 2, 2017

On Sessions

Attorney General Jeff Sessions has recused himself from investigations into foreign involvement in the 2016 election.

Over at National Review, I note that members of Congress on both sides of the aisle have had contact with the Russian ambassador to the United States.