Peter L. Berger's Blog, page 48

Shared Responsibility: Better Than Single-Payer

Americans are going through another episodic bout of introspection regarding the nation’s floundering health care system. That volatility likely will increase as the 2020 presidential election season unfolds. At least six leading Democratic candidates for president are supporting a “Medicare for All” approach. So did many victorious Democratic candidates for Congress in 2018. Some polls even show a majority of GOP voters supporting it.

But depending on the details of the plan, Medicare for All would likely result in wiping out the private insurance companies that currently provide health care for almost 60 percent of Americans. When this fact is made evident, support for Medicare for All plummets to as low as 13 percent.

Meanwhile, President Donald Trump has famously not only tried to repeal the Affordable Care Act, known as Obamacare, but has also continued to champion the private for-profit insurance system. In a 60 Minutes interview prior to his election as President, Trump said, in his inimitably nimble style, “For most it’s going to be a private plan, and people are going to be able to go out and negotiate great plans with lots of different competition with lots of competitors with great companies, and they can have their doctors, they can have plans, they can have everything.” Never mind the feel-good rhetoric of the impossible, and never mind the messenger: Most Republicans agree with the basic gist.

It’s like we have two polarized health care candidates running for office: the nervous incumbent, “Insurance Corp, Inc.,” and the ascending challenger, “Medicare Über Alles.” Yet the irony is that while there is growing consensus that the current system is broken, Medicare for All is not the best replacement for it. The evidence from other wealthy, advanced nations leads to the inescapable conclusion that there is a better candidate than either the incumbent or the challenger.

Yet this unknown candidate rarely makes an appearance in a polarized U.S. debate that has become stagnant and shallow. Both the Left and the Right are dug deeply into their erroneous assumptions and narrow orthodoxies, and both will do nearly anything to promote their view except learn about other alternatives, and so think anew.

So it has come to pass that both sides seem to believe that all European states use some kind of single-payer, government-run or socialized medicine. That supposed fact established, one side praises it and the other vilifies it. But this supposed fact is not a fact at all. Some states use a single-payer system—the United Kingdom, Italy, and Sweden. But many do not, including Germany, France, Belgium, Netherlands, Austria, and Switzerland. These latter states employ something notably distinct, a “third way” of financing and structuring health care that outperforms both the single-payer and for-profit corporate approaches: it’s called “shared responsibility.”

La santé d’abord: “Health comes first”

What all the diverse types of European health care systems do have in common is that they put people and their health before profits—la santé d’abord, “health comes first,” as the French like to say. That philosophy manifests itself in several ways, but the sum of it all is that it produces better outcomes, and always at lower cost than the U.S. system. A Gates Foundation-funded study found the United States is ranked 29th in the world for health care, with Germany, France, Italy, Canada, Japan, the United Kingdom, and most of Europe (even Greece!) ranked higher. The study measured both access and quality of care for 195 countries.

There are many reasons for our wickedly expensive yet under-performing system, and these reasons can be identified by first separating cost-inflation factors common to all advanced nations from those factors peculiar to the United States. Common factors include improved diagnostic and clinical options that increase demand for medical services, and demographic factors such as aging populations. Factors particular to the U.S. system are several, including the general scourge of over-lawyering that forces medical professionals to engage in resource-wasting defensive medicine. But the overwhelming factor that results in the United States spending two to three times as much on health care as other advanced nations comes down to this: Where the French privilege health first, the counterpart American philosophy appears to be, “Insurance companies come first. Then doctors and health care professionals. Last and the least, patients and consumers.”

The evidence clearly shows that the insurance industry in the United States is one of the largest obstacles blocking affordability, universality, and efficiency—but not for the usual reasons cited. Another misperception about the U.S. health care system is that, because it is dominated by private insurance companies, the sickest Americans will be heartlessly exploited in a bid to maximize corporate profits. But reality is not nearly so simple.

In Germany, for example, the backbone of the health care system is over a hundred private insurance companies. Germany’s system is not government-owned or run, and the insurance companies compete against each other for patients while consumers have the freedom to visit any doctor (most of whom are in private practice). The German system delivers quality, affordable health care while spending only about 56 percent per capita of what the United States spends.

So private insurance companies are not necessarily the problem. However, there is one major difference between these types of companies in Germany and in the United States: In Germany, they are all non-profits.

When you boil it down then, the real dividing line is not single-payer/Medicare for All versus the current expensive, underperforming, over-privatized system we have in the United States. The real divide is for-profit versus non-profit medicine.

Most of us admire the profit-earning companies that form the basic components of a market-based economy. But when it comes to health care the incentives for profit-making have led to perverse outcomes. That includes quasi-monopolistic health care markets throughout the country that deliver poor service for many Americans at an exorbitant cost.

Any for-profit company is always trying to do two things: first, charge as high a price for its product or service as the market will bear; and second, cut costs. The difference between the two is profits. In health care, “consumers,” also known as patients, lack perfect information about options and generally cannot gauge what the market will bear. The normal elasticities of supply and demand just don’t work as well as in most other domains of the economy—after all, no one ever buys an appendectomy just because it’s on sale.  Price signals are thus inherently both weaker and cloudier.

When it comes to health care, for-profit incentives mean charging ever-higher premiums and cutting costs by reducing patient services and invoking various “gotcha clauses,” such as pre-existing conditions, to deny care. No wonder about 28 million Americans (13.7 percent of the population, ages 18-64) remain without any health insurance at all, other than the services of a hospital emergency room, according to the latest Gallup poll. That constitutes an increase of seven million uninsured since 2014, with lower-income, younger adults and women experiencing the greatest increases. In addition, approximately 45 percent of American adults, or about 87 million people, are inadequately insured, meaning they suffered a coverage gap, high out-of-pocket expenses or deductibles, or had no insurance. No other developed nation lets so many of its people fall through the cracks in the health care safety net.

A deeper dive into how profit-maximizing health insurance companies work, and how their behavior distorts health care markets, helps us to understand why even Obamacare, as well-intentioned as it was, could never have succeeded in dramatically lowering costs. As long as the profit-focused system remains in the United States, Americans will not enjoy the quality of care or the affordability realized by most advanced industrial nations.

Open Secret: Monopolies Distort Markets

In the United States, the typical free market cant is all about “competition, competition, competition.” Yet the reality is that health care competition in the United States is more akin to what one might have expected in the old Soviet Union. Some of the reasons, as noted above, inhere in health care; others, however, are cemented into the foundation of the U.S. system.

The American Medical Association issues an annual report on competition in the health care industry, and its 2018 report is illuminating. That report found that, as a result of extreme levels of consolidation among health care companies, competition has declined across 25 states. In 46 percent of U.S. metropolitan areas, one insurer has captured at least 50 percent of the health care market; in 91 percent of cities just one insurer controls at least 30 percent. AMA President Barbara McAneny worries over this landscape, saying, “The slide toward insurance monopolies has created a market imbalance that disadvantages patients and favors powerful health insurers.” The present situation, she says, raises serious anti-trust concerns.

The way these monopoly-like conditions have prevailed in the United States is that dominant insurers in a local market often pay high reimbursement rates to health care professionals as a way of discouraging them from participating in rival insurance plans. This makes it tough for other insurers to hire medical professionals and enter the market. The dominant insurer is then free to raise its premiums to cover the inflated reimbursements. The monopsonizing insurance company makes out, as do the doctors and other health industry professionals—and the patients get stuck paying for it all.

These local insurance market conditions are bad enough, but they work hand in glove with another type of monopoly that exerts control over the supply of doctors. Doctor levels are purposefully limited by the number of medical school slots and medical residencies; those are both set by the Accreditation Council for Graduate Medical Education, a body dominated by physicians’ organizations. Unlike other countries, the United States requires physicians to complete a U.S. residency program in order to practice medicine. In practical terms, this means that American doctors get to legally limit their own competition.

Both of these monopolies contribute not only to driving up health care costs but also ensuring that health care professionals in the United States are paid much more than their international counterparts. Many U.S. doctors are in the upper 1 percent of income earners.

One study by Health Affairs journal compared physician fees in the United States and five other wealthy countries, Australia, Canada, France, Germany and the United Kingdom. After factoring in possible explanations such as physician supply, higher practice costs, volume of services, and medical school tuition costs, this study concluded that private primary care physicians in the United States are paid 70 percent more in fees for office visits than their counterparts in other countries. Orthopedic physicians are paid 120 percent more for hip replacements than their foreign counterparts. Primary care physicians in the United States earned the highest income by far ($186,582), double that of French ($95,585) and Australian ($92,844) primary care physicians, and much higher than their Canadian ($125,104), German ($131,809), and British ($159,532) counterparts. Disparities among orthopedic surgeons were even greater, with U.S. surgeons earning an average of $442,450 while the French earned barely a third that at $154,380, with Australia ($187,609), Germany ($202,771), and Canada ($208,634) all lagging far behind U.S. orthopedic surgeons.

Dean Baker, an economist from the Center for Economic and Policy Research, says we tend to blame the high prices of U.S. health care on things like drugs and medical equipment. But because U.S. doctors earn so much more than their international counterparts, the U.S. economy pays out “an extra $100 billion a year in doctor salaries”—more than $700 per every U.S. household per year. “We can think of this as a kind of doctors’ tax,” says Baker.

The tax has other aspects. Physician wages can be kept high not only by limiting the supply of doctors and imposing restrictive licensing rules, but also by curtailing the activities of nurse practitioners and other lower-paid health professionals who can treat certain routine conditions more cheaply than doctors. Mark Perry of the American Enterprise Institute says the costs of these tactics “have become painfully obvious.” Baker concludes, “Medicine in America . . . looks an awful lot like a cartel.”

But it’s an odd sort of cartel, because it consists of multiple moving parts: physicians’ medical groups, private insurance companies, pharmaceutical companies, and for-profit hospitals and medical-equipment makers. There is no hard evidence of direct collusion among these parts, but there doesn’t need to be collusion. What we have here is a multi-sectional acephalic decision system whose alignment has been gradually formed by converging incentives. That is why it is so difficult to put our finger on it analytically. It is a rare species: another rentier “vampire squid,” to borrow Matt Taibbi’s description of Goldman Sachs, that has spread its tentacles throughout a distributed system and failed to deliver salutary outcomes.

On top of hyper-inflated doctor salaries, insurance companies add another major strata of exorbitantly paid executives and administrators. In recent years, UnitedHealth Group’s CEO hauled in $66 million in annual compensation, over a thousand times the salary of UnitedHealth’s median worker. Before its merger with CVS, Aetna’s CEO vacuumed up $41 million. Between 2010 and 2017, the CEOs of the 70 largest U.S. health care companies cumulatively earned $9.8 billion, an average of $143 million each, far outstripping the wage growth of nearly all other occupations. This “profits-gone-wild” environment helps to explain why even major non-profit health providers, like Kaiser Permanente, or non-profit insurers such as Health Care Service Corp., which is the parent company of Blue Cross Blue Shield in five states, pay exorbitant executive salaries even in the absence of shareholders.

These factors taken together have produced a nasty cumulative effect. One aspect of it is that private insurance companies in the United States spend between 12 and 18 percent on administration costs, compared to the cost of administering Medicare, which is 2 percent or less. Administrative costs in France’s health care system amount to only 3 percent. A recent study in the Journal of the American Medical Association (JAMA) about health care in eleven high-income countries (United States, United Kingdom, Germany, Sweden, France, the Netherlands, Switzerland, Denmark, Canada, Australia, and Japan) found that administrative costs accounted for 8 percent in the United States but only 1 to 3 percent in the other countries. Some estimates have concluded that the United States could save from $380 billion to $500 billion per year just in administration costs by getting rid of bureaucratic overlap in the health insurance industry.

Conservative thinkers like economist Thomas Sowell have criticized liberal proponents of single-payer health care, writing in his classic Knowledge and Decisions, “It is amazing that people who think we cannot afford to pay for doctors, hospitals, and medication somehow think that we can afford to pay for doctors, hospitals, medication and a government bureaucracy to administer it.” But, in fact, all the evidence shows that non-profit medicine, whether government-run or not, is far more efficient and cost-effective than for-profit medicine, especially in reducing bureaucratic costs. According to the World Health Organization, the higher costs of private insurers are “mainly due to the extensive bureaucracy required to assess risk, rate premiums, design benefit packages and review, pay or refuse claims.” Private insurers also incur additional expenses through “advertising, marketing, distribution, reinsurance and the need to generate a profit or surplus.”

Competition is supposed to make the private sector more cost-efficient than the public sector, but the WHO observed that, in practice, private health insurers are more likely to compete not by delivering care at lower cost but “on the basis of risk selection”—that is, by turning away those most likely to generate high medical bills. One estimate found that between two and three million Americans are employed by insurers and health care providers not to deliver health care, but to deny care and to shift costs to other people and institutions.

This helps explain some of the perverse incentives baked into the system: Insurance reimbursement favors fixing sick people, not paying for the preventive care that averts illness in the first place. Some medical researchers argue, plausibly, that as much as 75 cents out of every dollar we spend on health care is for treating chronic, preventable “lifestyle” diseases such as heart disease, stroke, obesity, atherosclerosis,  type 2 diabetes and diseases associated with smoking, alcohol and drug abuse.

Access and Affordability

Evidence from around the world, in many different countries and under a variety of settings, strongly suggests that the most direct way to break the logjam in health care affordability is to introduce a robust non-profit element into the health care market. A Medicare-type single-payer system would accomplish this, but the variant of the system used in Germany, France, Belgium and elsewhere would be a much better choice, for a variety of reasons.

These other states have developed a “third way” hybrid based on the principle of “shared responsibility” between workers and employers, in which each contributes their fair share to the existing insurance fund. Participation for individuals is mandatory, just like getting a driver’s license for operating an automobile.

As is the case in Germany, a core feature of the French system is comprised of private, non-profit insurance companies. Whereas Germany has over a hundred such companies, in France there are just three, called “Sickness Insurance Funds,” or SIFs. These organizations developed after World War II as a series of private mutual insurance arrangements between employers and employees, organized around specific industries and occupations. The SIFs continue today as private organizations but operate under the supervision of national and regional governments.

As in the United States, most French doctors and nurses work in private practices or for private health organizations, not for the government; an individual can pick any doctor or hospital she wishes. Every French citizen holds a green plastic card for health care coverage, the carte vitale d’assurance maladie. This little plastic rectangle is not only a golden ticket to some of the best health care in the world, it also has completely replaced paper billing and medical records. France has switched to digital record keeping, while the United States still lags behind in implementing this important tool for boosting efficiency and cost-effectiveness.

Like in the United States, the French generally get their insurance through their employers. The SIFs are financed by compulsory payroll deductions, with employers paying around 13 percent of a worker’s wage and workers paying 8 percent. For those who cannot afford their share, the government covers their amount. The French health care system is considered among the best in the world, scoring high marks for affordability, abundance of doctors, short waiting times, and cost-effectiveness.

Cost Controls to the Rescue

Besides the non-profit private insurance companies, the second key difference between the French and U.S. health care systems is that the SIFs are subject to firm cost controls. A national agreement is negotiated for all treatment procedures, fees, and rate ceilings among representatives of the health care professions, patient-consumer representatives, the SIFs, and the government. Just as with Medicare, this stakeholder agreement prevents health care costs from spiraling out of control. For an office visit or some services, patients may pay a small co-payment or out-of-pocket fee.

Certainly in other industrial and service markets, cost controls have not always worked well. But when it comes to health care, the combination of negotiated price structures combined with non-profit medicine has produced results that are impressive, especially when compared to for-profit medicine.

These kinds of government-regulated price controls are not only good for health care consumers, they are also good for French businesses, which can forecast their health care costs with greater confidence. Because the U.S. system (outside of Medicare) has nothing like these sorts of price controls, Americans pay far more for health care. This includes coughing up from two to ten times more for top prescription drugs than do the French and other Europeans. One study found that in 2016 the spending per capita on pharmaceuticals was $1,443 in the United States compared to a range of $466 to $939 in ten other high-income countries.

Germany’s health care system, like France’s, is also a “shared responsibility” system rather than single-payer. Workers and employers each contribute a mandatory 7.3 percent of the individual’s salary (which means that German employers contribute much less than the 11-13 percent that U.S. employers pay on average). Prices also are controlled via a national uniform fee schedule negotiated between sickness funds and physicians, overseen by government regulators. “The principle is that the rich pay for the poor, the young for the old, the healthy for the sick,” says Ulla Schmidt, Germany’s former Federal Minister of Health. “Our funding is based on the concept of solidarity. This means that contributions are made according to financial abilities and people receive benefits that correspond to their needs.”

That all sounds vaguely socialistic, yet it is a far more efficient and cost-effective method than the hyper-privatized, for-profit U.S. system. Despite having universal coverage and quality health care, France spends about 11.5 percent of its gross domestic product on health care (working out to about $4,902 per person), compared to 17.2 percent and $10,209 per capita in the United States (where 28 million people still lack access). No other Organization for Economic Cooperation and Development (OECD) country is even close to the sky-high American expenditure levels, with Switzerland the closest at 12.3 percent and $8,009 per person. Germany’s numbers are 11.3 percent and $5,729 per capita, Australia, Italy, Britain and Spain are at 9.1 percent ($4,543), 8.9 percent ($3,542), 9.6 percent ($4,246) and 8.8 percent ($3,371), respectively, with Canada at 10.4 percent ($4,826) and Japan 10.7 percent ($4,717).

The vast differences in the types of countries with non-profit medicine—from geographically large ones like Canada and Australia, to those with large populations like Japan and Germany, to increasingly diverse ones like France and the United Kingdom, to those with a stronger tradition of social capitalism—reveals how much of an outlier the U.S. health care system has become.

Indeed, with comparative numbers like these, it is no surprise that Americans living and working in Europe mark well the stark differences between the United States and various European national health care plans. One American expatriate living in Belgium told me that both he and his sister in the United States had the very same procedure, called a catheter ablation of the heart, to eliminate an irregular heartbeat. While her employer-based insurance covered the lion’s share of the bill, still she spent $2,400 out of pocket for the procedure, which was performed as an outpatient service under a mild sedative. For the same procedure in Belgium, her brother paid just under $100 and received full royal treatment, including two nights in the hospital for observation and post-op recovery. The medicine he now needs to take costs him about $4 for a three-week supply, but in the United States that same medicine costs his sister $19—nearly five times more.

Various studies have found U.S. health metrics lagging behind other countries in a number of areas. The recent JAMA study of health care in 11 high-income countries found that life expectancy in the United States was the lowest of the 11 countries at 78.8 years (the other countries ranged from 80.7 to 83.9 years, with a mean of 81.7 years). U.S. infant mortality was the highest (5.8 deaths per 1000 live births, compared to 3.6 for the other countries). Other studies found the United States performed poorly in areas such as the highest mortality rate for avoidable deaths, hospital admissions for preventable diseases, higher rates of medical, medication, and lab errors, post-operative suture ruptures, mortality rates for various diseases, longer waits for an appointment when patients are sick, and use of the emergency department in place of regular doctor visits.

In other categories, such as recovery from strokes, post-operation recovery, and five-year survival rates for certain cancers, the U.S. system scores well. But considering how much more money Americans spend on health care, the U.S. system should finish at or near the top in virtually every category—and it plainly does not, despite what most Americans seem to think.

Some defenders of the U.S. arrangement claim that these statistics are skewed because America has greater inequality and higher numbers of poor people (and a higher percentage of racial minorities) with worse health. While statistically true–and a pretty lame and insensitive defense—the real question is, how much difference does it really make? In actual fact, several studies have shown that better-off white Americans lag behind their international counterparts as well.

The mortality rate for middle-aged white Americans (aged 45 to 54) is much higher than their European counterparts, nearly double that of Sweden and Austria. A large international study led by the RAND Corporation found that white Americans 55 to 64 years old have significantly higher rates of diabetes, heart disease, stroke, lung disease, and cancer than white Brits in the same age group, even after controlling for income levels, race, and ethnicity. “This study challenges the theory that the greater heterogeneity of the U.S. population is the major reason the United States is behind other industrialized nations in some important health measures,” said Richard Suzman, program director at the U.S. National Institute on Aging.

So the gap between the United States and other developed nations is enormous, and will not be closed by a few tweaks to the existing health care system. That was always the principal defect of Obamacare: It was half a loaf designed to increase universality, but by doing next to nothing to lower costs—because it left too much of the for-profit U.S. system intact—its achievements turned out to be financially unstable and politically unsustainable.

Generally speaking, the profit motive has been wrung out of the health care systems of just about every other developed country in the world, except in the United States, and that, far and away more than the other factors involved in cost inflation, is why Americans spend two to three times more money for health care than those of other countries. When a non-profit system displaces a for-profit one, incentives are no longer aligned toward maximizing huge pay-offs for insurance companies, their stockholders, overpaid CEOs, and doctors accustomed to outsized financial entitlements. That may not be sufficient in all cases for ensuring quality health care delivery—even the European systems sometimes exhibit cracks through which people fall. But it does help liberate the delivery of services to develop in commonsense ways in which people’s health becomes the sun around which the other planetary components revolve.

Shared Responsibility or Single-Payer?

So here’s the $66,000 question: If the goal is to reduce costs, increase affordability, and extend coverage, all without sacrificing the quality of care, which type of health care system would best accomplish this? The single-payer, Medicare-for-all method of Britain, Italy or Canada? Or the “shared responsibility” plan of France, Belgium, Germany, and Japan?

Both are forms of non-profit medicine, and either would be vastly better for most Americans than what we have now. But in talking to many different people in Europe, including a number of American expats, many of whom have lived and worked in different countries and so can compare health care systems, it becomes clear that the shared responsibility systems offer clear advantages over single-payer. They have a better reputation among the people who use them, particularly because they seem to result in shorter waiting periods for surgery and other procedures. It is not uncommon for some patients living in single-payer countries like Britain to travel to shared responsibility countries like France or Belgium to access certain services because the lines are shorter and the care is better.

While the UK’s government-run National Health Service deservedly receives high marks, it’s also true that the UK is falling behind other OECD countries. The NHS has among the lowest per capita levels of doctors, nurses, and hospital beds in the Western world. Another study found that, in the United Kingdom, outcomes for people with potentially fatal diseases fall short of those in Western Europe and Australia.

In addition to better performance, shared responsibility plans would likely provide an easier transition for Americans to non-profit medicine. “Medicare for All” is a great bumper sticker slogan, but abolishing insurance companies will be a very tough sell. Converting for-profit companies to non-profits won’t be easy either, but it is a better fit for American culture and traditions—and, as noted in passing, America already has experience with large non-profit insurance companies, such as Health Care Service Corp.

The irony is that, if you are a member of Congress—whose European-level benefits far outpace those of most Americans—or if you are an elite athlete with a professional sports team, or work for Google, Facebook, Apple, or some other very profitable corporation, you have access to the best that U.S. health care has to offer. The quality of care available in the patchwork U.S. system depends a lot on one’s income level, job situation, and geographical location. For the vast majority of Americans, access to quality care falls far short of that available to most Europeans, Australians, Canadians, or Japanese.

Americans love to be number one and win the “gold,” whether in the Olympics, the Tour de France, the Davis Cup, the World Series, or the Super Bowl. Most Americans especially like the drama of seeing the heroic underdog win. One wonders when that passion will be directed at their own health care plight. It would be grand to beat the French at something so vital to so many people’s lives.

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Remembering Sidney Verba

Fifty-five years ago this month, while idly perusing the newest releases on the front table in Oxford’s storied Blackwell’s bookshop, I stumbled onto a book that became a turning point in my intellectual life, and (more importantly) in our collective understanding of the preconditions for stable democracy.

The Civic Culture, co-authored by Gabriel Almond and Sidney Verba in 1963, was a ground-breaking examination of the attitudes, values, and political behavior of ordinary citizens in America, Britain, Germany, Italy, and Mexico—the first two (then) typifying stable democracies, the last three (then) not so much. Ever since the devastating collapse of Weimar democracy in one of the best educated, most advanced countries in the world, political scientists had been understandably obsessed with the question: “What can account for democratic stability?”

When I had studied political science and psychology as an undergraduate in the early 1960s, the standard answers to that question involved either formal institutions, like electoral rules, or psychopathology, like “the Authoritarian Personality,” or in the far reaches of Marxism, the class struggle. Using the newly invented tools of survey research, Almond and his brilliant twenty-something protégé Verba offered unprecedented evidence that political attitudes and values—“political culture”—could provide a new interpretive lens for understanding stable democracy.

The Civic Culture, like most groundbreaking science, soon spawned an enormous aggregation of follow-up research—and shortly afterwards, the usual critics. It is no longer at the frontier of political science.  What is, more than a half century after publication? But this book marked a crucial turn in the use of rigorous empirical methods to address some of the most urgent political questions of the times—and what could be more urgent, in our times, than understanding the preconditions for stable democracy?

These ruminations are occasioned by the recent death of Sidney Verba at age 86. His life has justly been celebrated for his amazing scholarly productivity, his remarkable administrative leadership at Harvard, and, above all, for his extraordinary personal gifts of gentleness, generosity, humility, and decency. Sid Verba, the son of Jewish immigrants from Moldova, was the ultimate mensch.

In retrospect, The Civic Culture was not even the most important item on Verba’s immense bibliography, though a passionate concern for equality remained the lodestar of all his work.

But at a time in which many are asking how we can stabilize and renew democracy in (ironically) the United States and Great Britain, we should celebrate Sidney Verba’s landmark contribution to our continuing quest to understand the preconditions for democracy. Nowadays it seems obvious that political orders arise out of and depend upon (among other things) values and attitudes deep within them, including tolerance and trust, mutual respect across party lines, civic competence, and civic cooperation. Without the work of Sid Verba and those who followed his lead, this would not be so obvious.

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Volodymyr Zelensky Is Ukraine’s Anti-Trump

The shocking rise of performer Volodymyr Zelensky as the frontrunner in the March 31 Ukrainian Presidential election has been greeted with derision, defamation, and skepticism. He’s been labelled variously as a “clown,” a “joke without experience,” and “Ukraine’s Donald Trump.”

But Zelensky is no “clown,” nor is he the Slavic version of Donald Trump. He is a lawyer who has made millions as a producer and performer with theatrical productions and a hit television series called Servant of the People. Now on Netflix, the series stars him as a naive history teacher whose classroom rant about the rampant corruption in Ukraine is videoed by a student and placed online where it goes viral, propelling him to the presidency. The race in Ukraine is about art preempting life.

Zelensky is the antithesis of Trump, who never had a policy thought before he ran for public office. Zelensky’s scripts are manifestos on the country’s problems and possible solutions, and his character has so successfully skewered Ukraine’s political and oligarch classes for years that he has become a de facto opposition leader. Thus, his name recognition and his political credibility as a reformer are established.

But his lack of day-to-day experience running a country is a valid concern, even though this is hardly unique. Any first-term leader must undergo on-the-job training. In Ukraine, President Petro Poroshenko ran chocolate factories before he took office, and his arch-rival, former Prime Minister Yulia Tymoshenko, profiteered in the country’s murky gas business years ago before embarking on an arguably unsuccessful political career as a reformer. Both opponents have made allegations about Zelensky’s motives, and Poroshenko has accused him of being backed by an odious oligarch in exile, Igor Kolomoisky, whose network airs Zelensky’s television shows. But Oleksandr Danylyuk, the former Finance Minister who aggressively took on Kolomoisky over his corrupt bank, believes this is a smear without substance and has joined Zelensky’s preliminary team.

Frankly, in the moral vacuum that exists in Ukrainian politics and society, voting for Zelensky is a “rational” choice, not a throwaway vote.

He may lack hands-on experience, but has a body of work and a platform that aligns with the peoples’ aspirations. He has also attracted an experienced reform team. So far, his includes Danylyuk; Aivaras Abromavicius, former Economic Development Minister; People’s Deputy Sergiy Leshchenko; and successful businessman Vyacheslav Klimov, co-owner of Ukraine’s largest express delivery company, Novaya Pochta.

Zelensky’s reform platform includes a pledge to serve only one term, to hold national referendums on key issues, to lift immunity from prosecution for lawmakers, judges, and the President himself, and to undertake judicial, health care, energy, and fiscal reforms.

By contrast, Poroshenko has not upheld the rule of law by removing corrupt judges, police, or prosecutors and replacing them with bullet-proof law enforcement institutions. There has not been one high-profile conviction in Ukraine, nor charges laid against Victor Yanukovych and his henchmen who fled with at least $70 billon. He has failed to create and protect a free and unfettered press by forcing oligarchs, criminals, and powerful vested interests to divest their media assets. And he has failed to overturn immunity for the 450 members of the parliament, or Verkhovna Rada, most of whom “sell” their seats and votes to oligarchs, which is the basis of political corruption in the country.

“Promises ended with a deception because the incumbent president came to power to enrich himself,” said Leshchenko in an interview with a prominent investigative journalist who, along with others, joined Poroshenko’s party in 2014 to help reform the country and is now part of Zelensky’s team.

Despite an abysmal track record, Poroshenko is supported by some concerned that a rookie could mishandle the war effort against Russia or reverse the direction of the country toward Europe and the West. But Poroshenko’s own Finance Minister Oksana Markarova recently challenged this argument, writing that because Ukraine has enshrined European Union and NATO accession, “whoever comes to power, Ukraine’s pro-western economic development and orientation cannot be reversed.”

Besides, Zelensky has, like the others, pledged support for EU membership but called NATO membership a “guarantee of Ukraine’s security” that should be put to a referendum. As for Russia, he has stated that while Donbass and Crimea belong to Ukraine, he wants to negotiate peace with Russia. His caveat is that the United States and Britain must also be at the table.

That’s where he comes across naively. The Kremlin has refused to give the United States or Britain a seat at the table since the invasion in 2014 and will continue to do so. And negotiations are impossible because Russia holds all the cards: The conflict with Russia will remain a stalemate unless Ukraine dramatically increases its military power. Reports are that Russia has moved 2,500 pieces of heavy equipment into the region of late, while Ukraine lacks the reciprocal firepower. Without equivalence, President Vladimir Putin will continue to have no reason to enter into talks and continue to control the situation at relatively lost cost in blood or treasure.

Perhaps Zelensky will learn fast enough and make lobbying the United States and allies for “Lend-Lease” war equipment a priority to match the Russians. Until then, all that Zelensky can assuredly deliver is hope the country will win its war against grinding corruption at home. And he’s set the table in more ways than most realize. Last year, before his presidential bid, he quietly registered “Servant of the People” as an official political party. Also shocking, this party leads the polls in this fall’s Verkhovna Rada election. This means that, whether he becomes President or not, he may have successfully launched a movement reminiscent of what politically incorrect comedian Beppe Grillo of Italy accomplished in 2009 with the influential Five Star Movement. Last year, Grillo’s anti-establishment party swept aside the country’s corrupt parties in the national elections by promising to expunge corruption, prioritize the environment, and provide a universal basic income for poor Italians.

The significance of a new party winning the largest percentage of seats in the Rada cannot be underestimated and is dramatically more important than winning the presidency. That’s because, in addition to the President, the country’s parliament is its biggest scourge. Its members break laws with impunity, take bribes, and impede reforms of any kind. Zelensky’s two-pronged election strategy is brilliant and represents the best hope yet of transforming the country.

This recognition has catapulted Zelensky and his new party to the top, albeit with some bumps along the road. He has had to, on at least one occasion, disassociate his fictitious character’s televised actions from what he would do if elected. For instance, one sequence features his meltdown with IMF officials over paying any interest rates on debts. While funny in a sitcom, tongue-lashing the IMF, which props up Ukraine’s economy and reform efforts, is not the least bit humorous in reality. Zelensky addressed this in an interview, saying that, as President, he wouldn’t hurl an obscenity at the IMF as his character does because “in life, we don’t have the right to.”

But normally, his comedy crosshairs are trained on all the correct targets and he hits the mark. In one segment, for instance, he visits a fancy cathedral in the country and asks the priest who paid for it. A millionaire, the priest replies, to which Zelensky asks whether he was a businessman. “No,” says the priest, “a judge.”

In the second season, he reluctantly decides to meet with oligarchs to see if they will relent. But after one hands him a folder with a photo of their suggested candidate for Prime Minister, he abruptly leaves. That’s because their chosen candidate is a race horse. The oligarchs all laugh at this suggestion and at the discomfort of the new President. So it is hardly surprising that Zelensky has repeatedly stressed the importance of bridling the country’s craven and contemptuous oligarchs.

If Zelensky wins, Ukraine will dominate headlines around the world and so will he. This will afford him, and his team, a honeymoon period to get their feet under the desk and begin enacting the type of major reforms that Ukrainians have waited for since their Euromaidan revolution five years ago. There will be sabotage, brinkmanship, and other maneuvers, but all leavened with Zelensky’s trademark humor.

Last month, he asked an audience why Poroshenko wanted a second term.

“So, he doesn’t get a [prison] term,” said the impish candidate.

At a recent press meeting, Zelensky was asked how nervous he would be to meet with President Trump. “It would be no problem. We are both from the same industry, after all,” he said.

As for meeting Putin, the five-foot, six-inch Zelensky joked that the two, who are the same height, would simply see eye-to-eye.

The post Volodymyr Zelensky Is Ukraine’s Anti-Trump appeared first on The American Interest.

The King, the Junta, and the Juggernaut: Thailand and Counter-Democratization

Democratization, once vaunted as a historical process sweeping the globe, is today hardly a trend. Samuel Huntington’s “third wave” of democratization has given way to a “global democratic recession.” The trappings that make a liberal democracy—elections and parliaments, laws and courts, a free press—have time and again been subverted to support illiberal governments. And as the performance of alternative regime types is catching up, scholars worry that democracy itself is losing appeal.

Thailand embodies all those dynamics: sincere attempts to establish democracy failing for structural reasons; democratic institutions subverted by competing elites; all leading to the progressive stabilization of a system that is non-democratic despite an outward show of democracy. As Thais go through their democratic motions on Sunday, in the first election since 2014’s coup, it is worth asking how this state of affairs came to be. 

The modern Thai regime is a singular one: a military monarchy in command of a constitutional democracy. The United States played a role in this arrangement. When the Korean War started in 1950, Thailand became, in U.S. eyes, a domino that could never fall. Washington and Bangkok thus formed an alliance to contain the Soviet Union, which has endured in looser form to this day.

From the U.S. perspective, Thailand’s strategic raison d’être was its non-Communist character. This identity grew along three dimensions during the Cold War. First, the appeal of Communist ideology was crowded out by an exceptional ruler, King Bhumibol Adulyadej, who took on spiritual significance as a quasi-deity. Known as Rama IX, the monarch-turned-divinity would prove the perfect antidote to Mao and Ho Chi Minh.

Second, the threat of a communist rebellion—from within Thailand or from neighboring Laos and Cambodia—was contained by an expanding military armed with American weapons. This intimacy would have legacies big and small: the Thai army still trains regularly with the U.S. military, Thailand served as a rear base for U.S. troops in Vietnam, and the town of Pattaya, close to the main naval base, has remained a global sex tourism destination since war’s end.

Third, Communist economics were kept at bay. Thailand’s few state-owned enterprises (energy and utilities) left the economic space largely in the hands of private entrepreneurs. Many of them were of Chinese ancestry, which set them apart from the Siamese aristocratic and military elite.

The upper crust of the business class learned to build political connections with this elite, via gifts and the occasional strategic marriage. Officers came to be hired as consultants, retiring into comfortable corporate assignments. But the army never meddled directly with business. Thai industry was drafted into the supply chain of Japanese manufacturing and proved efficient, competitive, and profitable.

King, soldiers, and businessmen worked side by side to make Thailand a Cold War success story. Codependency did not prevent festering tensions within elite domains: palace intrigues between siblings or spouses, commercial rivalries between business leaders, and, most visibly, quarrels for the premiership between ambitious officers. But the system was robust, the domino never fell, and Thailand solidly established itself as a middle-income country.

The rapidly growing population was not completely on the sidelines. During the late 1960s, students took demands for democratization to the streets, a movement that culminated in an October 1973 uprising that was silenced by the troops. Public calls for democracy came back in the early 1990s, this time instrumentalized in a leadership quarrel between former officers that brought violence back to the streets of Bangkok. The King singlehandedly put an end to the pandemonium by summoning the bickering rivals to his palace on the evening of May 20, 1992. They were duly chastised, and peace was restored.

The events of May 1992 showed that the legitimacy of the Thai system rested in the hands of the monarch. This was neither tradition nor a foregone conclusion. A military coup in 1932 had put an end to absolute monarchy, and the junta’s leader had flirted with fascism until the late 1940s. When the young, Boston-born King ascended the throne in 1946 after his brother’s assassination, the monarchy was a weak institution on the edge of obsolescence. But a combination of personal austerity, piety, and public empathy toward the plight of the rural Thai turned him into a popular icon.

Beginning in the late 1950s, the King travelled all around the country, using the Crown’s ample financial assets to set up thousands of Royal Projects—idealized ventures that gave peasants access to modern technology, infrastructure, and markets, all under Buddhist principles of harmony with nature and self-sufficiency. Constitutionally, the King had no power. Empirically, he had struck a deep chord into the Buddhist ethos of the still-agrarian nation to become its soul and keystone.

The political crisis of 1992 not only cemented the moral authority of the monarch, it also ushered in what appeared to be real democracy. Following in the footsteps of Taiwan, South Korea, and the Philippines, Thailand promulgated in 1997 a new constitution celebrated for its genuinely liberal provisions. Yet democracy became a mere entry point for economic elites into a hitherto restricted circle of power. In a middle-income country with rapidly growing inequality, devastated by the 1998 Asian financial crisis, votes were easy to buy.

Thaksin Shinawatra, a telecom tycoon of Chinese origins, set his sights on the rural and poorest northeastern section of Thailand. He recruited local political bosses to rally the voters and, borrowing a page from the Royal narrative, presented himself as a rich, powerful, caring leader who would improve the condition of the rural poor. He promised microloans and subsidized health care, and became Prime Minister in February 2001.

Electorally savvy but politically imprudent, he quickly crossed lines and made enemies. Extrajudicial killings against drug dealers horrified liberals. The redeployment of a counterinsurgency unit away from the South reignited a long-raging civil war with local Muslims. Shocking conflicts of interest arose; when he resolved to divest of his economic empire, he boldly exempted himself from paying taxes.

Preempting the promotion of Thaksin-friendly officers to high positions, the disgusted military took him down in September 2006. He has been in exile ever since, dodging extradition requests for tax fraud. But he left behind a political machine that, for two decades thereafter, could not be beat—a “juggernaut,” as every single analyst in Thailand likes to call it.

Thai politics have been caught in a dysfunctional cycle ever since Thaksin’s ouster. The military seizes power temporarily, then promulgates a constitution crafted to block Thaksin’s party, which nonetheless carries the vote. A Thaksin proxy has a go at running the country, until terminated by either a judicial motion or a coup, and it is back to an interlude of direct military rule.

Those machinations have polarized the country into two camps, identified by the color of their polo shirts. The red shirts are Thaksin’s supporters; the yellow shirts his adversaries. In the latest round, Thaksin’s younger sister, Yingluck, a political novice appointed Prime Minister in 2011, was ousted by the military three years later on the grounds that a public scheme to stabilize rice prices had become, under her watch, a major source of fraud. When the Yingluck crisis unraveled in 2014, protesters manned barricades in Bangkok, taking fire from unknown snipers and throwing grenades at the police. In earlier clashes over the years, the yellow shirts had blockaded the airport, and the red shirts had occupied luxury malls in downtown Bangkok, setting them ablaze as the army cleared them out.

While the yellow/red division is often explained by foreign media as a class war between the urban middle class and rural poor, local experts see a more complex battleground where the masses are pawns in a power game played by competing elites. The poor are as likely to be yellow as red, depending on where they live, or, if in Bangkok, where they come from. The educated middle class tends to be yellow, but there are fervent Thaksin supporters in its ranks as well. Military officers are more likely to be yellow, but red sympathy is more apparent within the police.

Ideologically, the yellows stand for defending the monarchy against Thaksin, accused of being a crypto-republican. Republican voices, to the extent that they dare speak, can indeed be found on Thaksin’s side. Thaksin himself has remained ambiguous on the matter, and has been the object of multiple conflicting conspiracies—simultaneously suspected of being an anti-royalist and of colluding with the Crown Prince.

Amidst all those confusing cleavages, the economic elites, the great wealth behind the large corporations, are publicly neutral. It is not mere prudence that dictates their attitude. Thaksin’s generous policies toward investors, including bailouts, have earned him loyalties within their circle. His populism has consisted of highly visible but fiscally affordable gifts to the poor that have done little to redistribute concentrated wealth. Indeed, Thaksin’s populism has helped some of the very rich get richer; it is the junta that is attempting to incrementally raise the fiscal burden on wealth and speculation.

The paradox of Thaksin is that, inasmuch as he represented the emergent democratization of Thailand, he was also the spearhead of a political takeover by an up-and-coming business elite. If there is a class conflict in Thailand, it is not an attempt by better-off urbanites to disenfranchise the rural poor. The military’s reluctance to give up its political role represents the resistance of the upper-middle class to its own marginalization.

Over the decades, Thailand’s hypertrophied military has produced tens of thousands of high-ranking officers, and a uniform-bearing civil service that has grown in parallel. Higher education was the ticket to those prestigious but not especially lucrative positions. This vast social caste has now grown over three or four generations to form the core of Bangkok’s middle to upper-middle class. This group welcomes democracy in theory, but honors it mainly in the breach—and not if it means losing control to corrupt billionaires riding a populist wave.

To cover the sin of holding power through coups, the junta positioned itself as the defender of all things royal, with the troops and the yellow shirts united in undying support for the monarchy. The King was thus drafted in the military effort, although he did not and could not lead it. The war between red and yellow festered at a time when the ailing ruler had withdrawn from public life. Rama IX was too ill to be a mediator, and his inevitable succession opened opportunities to whichever camp wielded power at the time.

The transition was fraught with danger, first because, after a 70-year reign, there was no precedent for such a transfer of power, and secondly because the male heir’s lifestyle differed from that of his much-revered father. The alternative was a beloved Princess—pious, discrete, and temperamentally her father’s daughter—but second in line in a country whose succession law privileges seniority.

In this volatile environment, the junta implemented lèse-majesté laws to the extreme. Books, articles, or tweets that hinted at criticism of the monarchy could land their author in jail. Foreigners were at risk of being deported or denied entry. Such heavy-handed tactics were intended to control the media, and to intimidate the red shirt camp.

Tensions were running high when the passing of Rama IX, in October 2016, brought a reprieve to the country. The trauma of loss was so pervasive and intense that political life was suspended for several years. The Crown Prince was ushered in without objection, helped by the aura of humility and respect he showed to his late father throughout the protracted funeral ceremonies. His coronation was pushed back to a later date, allowing the nation to grieve undistracted.

This truce was Rama IX’s last gift to his country. But underneath the mournful facade, the military was preparing for the future. A new constitution had to be written, one which, it was hoped, would finally break Thaksin’s “juggernaut.” The junta appointed senators who, along with members of the House of Representative to be elected through universal suffrage, would select the Prime Minister. Those moves, combined with an electoral law biased toward small parties, were designed to ensure that the junta would maintain ultimate control.

Small parties have proliferated in the lead-up to the elections. This is no accident—constitutional monarchies have long sought to foster political fragmentation among their opponents to dilute vote shares. (The Moroccan court is particularly expert at this trick). The red camp has responded to the challenge by running secondary and tertiary lists, to rake in as many seats as possible. But this diffusion of red shirt candidates among separate party lists only makes their voters that much harder to coordinate.

The campaign has also seen the emergence of a Thaksin 2.0: another billionaire of Chinese ancestry, the scion of an automotive empire that contracts for Tesla, and a large stakeholder in a major media conglomerate. At 40 years of age, Thanathorn Jungrungreangkit has drawn comparisons to France’s Emanuel Macron and Canada’s Justin Trudeau, and represents a generational rupture from the yellow/red dichotomy. His Future Forward party opposes military interference in politics and is running on a platform of progressive redistribution. Charisma notwithstanding, he is expected only to split the anti-military vote.

The military is gingerly going to the polls with the junta’s leader, retired general Prayut Chan-o-cha, atop the list of a party created for the occasion. Despite all the constitutional tinkering, the junta showed its insecurity by repeatedly postponing the elections, ultimately hitting the hard deadline they had previously imposed on themselves: March 24, 2019.

Whether victorious or lame ducks, the junta will still be in office for the Coronation on May 4-6, which will celebrate the anniversary of Rama IX’s own 1950 accession to the throne. In the lead-up to that ceremony, the monarch has begun to assertively uphold traditional prerogatives. As nominal head of the armed forces, he has issued Royal decrees to promote loyal units and officers into his entourage. He has redesigned army uniforms and replaced his father’s likeness with his own on the life-sized murals that adorn Thai cities. The Palace has also claimed direct control over the assets of the monarchy—estimated at over $30 billion—which had traditionally been managed by a public institution, the Crown Property Bureau. Slowly but surely, the transition has been taking place, with the younger King assuming the full mantle of royal authority from his father.

In early February 2019, the monarch’s eldest sister suddenly declared she would lead Thaksin’s party list in the upcoming elections, feeding persistent suspicions of the Palace’s collusion with Thaksin. The announcement sent shockwaves through the ranks of royalists and republicans alike, who both felt betrayed by this unnatural alliance. For the junta, which already fears Thaksin’s formidable political machine, it would have been impossible to run a campaign against a royal assumed to have implicit support from the King.

It took less than 24 hours for her brother to kill her candidacy and end the speculation. Although she had relinquished her position in the Royal lineage decades before to marry a foreigner, the monarch deemed it “inappropriate” for her to get involved in politics. In a bizarre, fraternal drama, the symbiosis between King and Army had been renewed. The election would no longer simply be about selecting a government, but also a test of the nature of the regime. Even if the junta wins the popular vote on the merits, its legitimacy will remain anchored in the institution of the monarchy.

Thailand’s efforts to establish democracy since 1997 have been sincere. But moving from oligarchic to democratic rule has only delivered a nasty and occasionally violent game of cat-and-mouse between rival factions. Democracy is about more than mere institutions and constitutions; more, too, than free elections or media. Democracy is intangible and fickle.

The counter-democratization push across the East is reaching a critical mass. It is not an outright rejection of democratic practices of governance so much as a subtle subversion of them, by regimes who share best practices for so doing. Everywhere, anti-corruption campaigns are used to eliminate political rivals, the way Thailand has used tax evasion to indict Thaksin. Thai prosecution of lèse-majesté takes a page from Turkey’s infamous law to punish “insults against Turkishness,” used and abused to silence critics and opponents.

Lee Kwan Yu long ago demonstrated what an enlightened despot could accomplish in terms of economic development, but Singapore is small and uniquely located. Yet many contemporary leaders seemed determined to follow in his stride: paying lip service to some aspects of democracy, pursuing accountability and efficiency, sometimes holding elections to legitimize their rule, all the while concentrating power in their hands. The fading of factional collegiality within the Chinese Communist Party to the benefit of one-man rule, the transfer of power in Saudi Arabia from a cluster of royal siblings to a single Crown Prince, the persistence of monarchies across the Arabian Gulf, and the backsliding of Sisi’s Egypt, Erdogan’s Turkey, and Putin’s Russia all prefigure a deeper despotic trend.

In this landscape, it is no wonder that constitutional monarchies are proving resiliently monarchal. If anything, it is Thailand’s efforts at sustaining some form of democracy that now seem almost anachronistic.

The post The King, the Junta, and the Juggernaut: Thailand and Counter-Democratization appeared first on The American Interest.

What Macron Got Wrong

I met Emmanuel Macron in March 2017, at the conclusion of writing a profile for the Sunday Times, on a train to Bordeaux. I remember I was impressed by his ability to explain complex things. But I did not leave entirely dazzled. I felt like I was interviewing a jukebox. Or, perhaps, that I had met a man who was the French embodiment of The Economist.

Macron spoke like the serene unsigned editorial itself: “Europe,” “NATO,” “the rules-based international order.” I nodded along. There was only one growth model and what France needed to do was get closer to it. Tax cuts, privatizations, supply-side reforms—they were painful, yes, but they all had to be done. Only growth, faster growth, would end the French malaise.

I was struck by his memory, by his ability to summon up so many facts and briefing papers. It took me a few minutes after I’d met him to remember that what he was saying was not in fact as complex and sophisticated as he made it sound. Again, that Economist trick.

When the final results came in I was happy. A strong, sound pro-European had won the highest office in one of the big economies. Spooked by Trump and Brexit, I exhaled a sigh of relief. France would be under a steady, if not transformative, hand. The European order would be safe from the worst kinds of French populists for five more years.

What had I got wrong? As I wandered the streets of Paris in January, I recalled how I had expected riots to accompany a “no deal” Brexit in 2019. I had never imagined France would get there first. I had not expected that the man on the train would find himself leading such a chipped regime so soon after a landslide victory.

Or for the populist threat to actually have gotten worse.

The 39-year-old Macron, so young and full of energy, had confused the meaning of his own election, mistaking an accidental victory for a policy mandate. Covering the run-up, neither I nor the friends and colleagues of Macron I interviewed had any illusions about why he was going to win. A freak occurrence—a “dossier” of leaks— had sunk François Fillon, the center-right candidate who might have otherwise cruised to victory. Nobody spoke in terms of a “mandate” for Macron. France overwhelmingly knew what it did not want—François Fillon’s dirty dealings, Marine Le Pen’s National Front—but was much more ambivalent about what it did.

It didn’t vote, overwhelmingly, for the Economist growth model.

But this was exactly how Macron interpreted his election, and the implosion of the Socialists and Les Républicains in the legislative elections that followed. What aides dubbed the “Jupiterian” presidency was the manifestation of this mistaken thinking.

Macron pitched left and right during the campaign, but afterwards only delivered Economist politics. Instead of courting left-wing voters with identity politics and egalitarian rhetoric, or offering right-wing voters some anti-immigration and Euroskepticism to leaven the medicine, he did neither. Like many a French revolutionary before him, he became a purist.

The key mistake behind the “Jupiterian” presidency was not with regards to the identitarian Right, however; this rump had never been folded into the En Marche coalition. Rather, he misjudged the Left. He thought that Socialist voters had somehow been transformed, perhaps by the power of his rhetoric, into pro-European liberals when they voted En Marche in 2017.

But the eruption of the “Gilets Jaunes”—the Yellow Vests—laid the errors of Macron’s thinking bare. It wasn’t the emergence of populist, violent, and often quite anti-Semitic protest groups itself that did it. Rather, it was that despite their apparent extremism and violent tendencies, a solid majority of the population sympathized with them. French egalitarian politics had not died in the summer 2017.

But this had not been his only mistake.

Mounting failures of personal judgment had damaged his credibility. From the Benalla affair to his prickly and curt manner: lashing out at discourteous questioners, be they workers, pensioners, or even school children, never thinking how this was calcifying his reputation as “the President of the Rich.” The fact that he built himself an echo chamber in the Élysée did not help. Nor the fact that he sought refuge in the idea the French “always” turn on their leaders out of a psychological lust for regicide.

Worse still, Macron’s errors of judgment further undermined him as a crisis manager—he veered clumsily between the shrill and the panicked at the worst of the protests. And he accumulated many failures as a diplomat, such as his crass attempts to seduce President Trump—as if international diplomacy was just a matter of pulling the flattery that worked on older, vainer men in Paris.

How had I missed all this profiling Macron in 2017?

I had made the mistake with him I often made in real life: the guy with the best memory is never actually the smartest guy in the room.

Only when I left the Paris of the Gilets Jaunes did it strike me there was something more. Because, I realized, it would be a mistake to think Macron’s failure was simply his own.

What if, more unnervingly for centrist pro-Europeans, the failure of Mr. Economist was a verdict not just on a man and his foibles but on the ideas themselves? When a policy package fails yet again to be seen as genuinely legitimate, maybe it is not only the fault of the practitioner but also the practice.

A certain strand of modern folk liberalism takes it on faith that “win-win” solutions always exist, and that they are best arrived at through rational deliberation. Over time, what was a theory of politics atrophied into a theory of best practices. It forgot the reality that when it comes to resources, especially in the immediate term, there will be winners and losers. This is the fundamental truth of politics, even politics in modern liberal democracies.

For much of the 20th century, however, the discontent of the losers has been mitigated by the understanding that sustained growth would continue. A kind of “win-win” logic existed as long as growth could be counted on. Politics was boiled down to disputes about apportioning the growing pie. But now, with well-distributed growth elusive, and technocratic fixes failing to bring it back, politics as struggle is back.

Macron is nothing if not a convinced modern liberal. He embraces politics, but only as a struggle between those who favor rational “win-win” solutions and those who, irrationally, do not. This failure of judgment is most apparent on the Champs-Élysées. It should come as no surprise that with inequality burning, supposedly “pro-growth” policies that are seen to favor the rich result in class animosities that liberals thought had been consigned to history. What triggered the explosion of rioting in France was white working class anger that the costs of climate change—and indeed, the costs of globalization in general—were being placed on them.

Macron’s failures with Germany on European reform stem from similar sources. Like on the Champs-Élysées, the problem in Berlin was that the costs of Macron’s Eurozone reform program were not seen as a “win-win” pooling of German power, but as a redistribution of German power away from Germans.

The Gilets Jaunes do not believe that ceding labor protections or disposable income now will benefit them in the long run, just as they do not believe Macron will expand the French economy. Meanwhile, the Germans do not believe that ceding their privileges built into the euro will benefit them, just as they do not believe that Macron will expand European power.

Indeed, Macron’s approach to populism might be making things worse. By disdaining the way French populists posit a “corrupt elite” abusing a “true people,” the President is pretending that class conflict is not there. By pushing beyond the pale the idea that a “selfish Germany” is abusing a “subjugated France,” the Élysée is also pretending that Berlin is waiting to be seduced rather than being rational.

And by making the gulf between fact and reality bigger, by insisting these conflicts are an illusion, the President is handing vast chunks of the working class to the worst kinds of populists.   

To be sure, Macron is no fool. He understands that liberal politicians need to confront populists in a battle of ideas. But by failing to interrogate the fundamentals of those ideas he has turned himself from Jupiter into an Achilles.

This is the lesson Macron holds for English-speaking centrists. They need to embrace distributional conflict, not deny it: recognize it exists, between classes, between generations, and between nations. They must accept that sometimes conflict may even be necessary, and that positions can be irreconcilable. At minimum, they must start from this position, and from there proceed on their own terms. They can propose policies they think can generate growth, but without reliance on the happy illusion that there will be no victims. They should call out both nationalist dead ends and flawed “socialism in one country” experiments, but with the knowledge that their preferred alternative, too, is not “win-win.”

This is where Macron is better than The Economist. At moments, he has admitted there is “a crisis in contemporary capitalism”—in the interlinked problems of tax, tech giants, and finance. There have been flashes where, unlike The Economist’s recent “manifesto,” which seeks to reform the venerable tradition but in fact offers only surface fixes, Macron seems to grasp that the Western order is in a process of internal decay: that the rising costs the winners are placing on the losers is cracking it.

But he has failed to grab the nettle.

You can see it in his attempt to persuade the billionaires at Davos to pay their taxes. You can see it in the mission he has set his Finance Minister, to parlay his way to world minimum taxation. And you can see this in his failed vision for the euro.

The plans are good. Some of them are actually redistributive. But the way he has chosen to approach the problems—by kicking them up to Brussels—is telling. For Macron, Brussels is the only solution to the flaws of liberal regimes. By focusing on persuasion there, his own government kicks away distributional conflict at home.

Like his postwar heroes, Macron could accept that social peace can only be assured with serious redistribution of wealth—to the banlieues and to the roundabouts across rural France still occupied by the Gilets Jaunes. He could accept that the French working class needs to be rewarded by the status quo to fully support it, and that France cannot “seduce” but must confront Germany to redistribute power and outcomes within the Eurozone. He could accept that this means abandoning the cherished illusion Paris is an equal to Berlin, that it really is a state with much in common with Italy—in need of new, less decorous continental alliances.

But all that would mean rethinking the contemporary Western growth model—demanding not just a series of technical or constitutional fixes to Brussels but a fundamental break in how the ECB operates in Frankfurt. A change, when it comes to the billionaires, in the balance of power. A willingness to return marginal tax rates to what they were in “les trentes glorieuses.” And breaking with The Economist mindset.

This is the revolution which Macron’s failure of liberalism is hinting at, and it is one that the social forces he represents can either lead or continue to repress. Should they choose the latter, the Champs-Élysées is likely the future of French politics.

The post What Macron Got Wrong appeared first on The American Interest.

Farming and Agriculture in the Age of Trump

The agricultural and food component of the U.S. economy is large and dynamic by most economic measures. While farming accounts for just over 1 percent of GDP and employment, the full economic significance of farming is much larger because agricultural products are used in value-added activities such as food manufacturing, services, and food stores. A broader definition of food and agriculture implies a 6 percent share of GDP and an 11 percent share of employment. More than half of the nation’s 2.3 billion acres is in farm and ranch-land uses. These lands also provide environmental and recreational services to an ever-increasing urban population and an important tax base to surrounding rural communities. Because of this varied footprint, the food and agricultural sector encompasses many contemporary issues that Americans care about, sometimes passionately and in highly charged political environments.

U.S. agriculture has historically been one of the most productive in the world, owing to its rich land base, advanced technologies, and consistent investments in land grant universities and extension systems since the middle of the 19th century. Modern agriculture has also evolved into efficient international agribusiness supply chains connecting agricultural input suppliers to farmers, processing plants, and wholesale and retail outlets. High levels of U.S. agricultural productivity have translated into a large commodities-export business. While the U.S. economy, in general, has a trade deficit, agriculture consistently has a positive trade balance.

There are about 2.1 million farms in the United States, but owing to the high rates of productivity for some, most production occurs on a small share of those farms. The latest Census of Agriculture showed that in 2012 two-thirds of all agricultural products were produced on 3.6 percent of the farms. This is somewhat misleading and understated, however, because approximately one-quarter of all farms, by the very liberal official definition of a farm, have no sales in recent census years. These are largely the rural places where people prefer to live for lifestyle reasons and the generous tax breaks provided to farmers and landowners. Recently, a growing share of domestic consumers are demanding local foods or foods with nonconventional attributes, such as organic production. This is a small but growing segment of the industry. By definition, local foods will be produced on smaller farms near urban markets along with some organic production, but organic foods are increasingly produced by larger farms owing to the same market efficiencies experienced by conventional large-scale production.

Agriculture is often used as the Economics 101 textbook example of an industry closest to meeting the characteristics of a theoretically competitive industry, such as the presence of many sellers. This is highly ironic given that it is an increasingly consolidated and integrated industry, and also the focus of many domestic policies and concomitant politics. Subsidies to farmers are nothing new—they’ve been going on in their modern form since the New Deal—and are often justified by national food security interests. The argument is straightforward: We would not want to rely on our trading partners for basic essentials of life in a turbulent world.

Alliances in the Making of Farm and Nutrition Legislation Have Prevailed

Many U.S. farm and food policies follow a five-year legislative cycle to produce a “Farm Bill.” This is an expansive piece of legislation composed of a dozen Titles that covers the traditional crop commodity programs, crop insurance, dairy and livestock programs, specialty crops, organic agriculture, conservation, credit, research, trade, rural development, nutrition, local foods, and beginning-farmer programs. The latest Farm Bill, formally entitled the Agricultural Improvement Act of 2018, was signed into law on December 20, 2018. This law replaced the 2014 Act, which was in effect from 2014 to 2018.

The 2014 legislation was two years late in passage because, spurred on by House Tea Party members, there was a somewhat successful effort to cut food assistance provided in the Supplemental Nutrition Assistance Program, or SNAP (and still sometimes referred to as the Food Stamps Program, though the name was officially changed in 2008). Despite tumultuous political times on Capitol Hill over the 2017-18 period, the bottom-line is that the 2018 Act is generally considered a status quo piece of legislation with veto-proof majorities in both Houses.

So, how did our lawmakers manage to pass the 2018 Farm Bill in a timely manner in contrast to the struggles of 2014? One short answer is the blue wave that rolled over the House in the November 2018 elections. Conservative Republican lawmakers in the House, encouraged by the Trump Administration, were fighting for more stringent work requirements for SNAP eligibility prior to the 2018 elections. This was a nonstarter for House and Senate Democrats. After the elections, the Republicans recognized that if they didn’t pass the legislation during the 115th Congress, the Democrats would pass the legislation in the 116th. Failure to pass the legislation in the 115th also meant the Democrats would get the credit for delivering the commodity programs to the farm sector at a time when farm prices were low and aggregate farm income had dropped from historically high levels. Secretary of Agriculture Sonny Perdue—former Governor of Georgia, cousin to Senator David Perdue (R-GA), with strong commercial agriculture interests—placated the Republicans by promising to issue a rule to curtail state waivers of the current work requirements for the 36 states that currently have waivers for their SNAP populations.

The long-term, status quo policies of resisting reforms to subsidy payment limits for the largest farms also prevailed in the 2018 legislation. Only about 40 percent of farms receive any subsidies and subsidies are highly concentrated among the nation’s largest farms. The Environmental Working Group, using data they obtained through a FOIA request of USDA, reports that from 1995 to 2017, the largest 10 percent of subsidy recipients received 54 percent of all subsidies averaging more than $1 million over the period. Despite Senator Charles Grassley’s efforts, the 2018 legislation failed to require that farm subsidy recipients even be working on farms—this at a time when Republicans were strenuously arguing that work requirements for SNAP recipients should be significantly tightened. Instead, the farm subsidy requirement is that additional recipients of farm payments be involved in “active personal management,” something vaguely defined and unenforceable. The General Accountability Office (GAO) estimated that in a recent year the 50 farm entities with the largest farm subsidies had nearly 200 additional persons receiving farm subsidies through this loophole. The GAO also estimated that, in 2015, payments through this loophole amounted to $259 million of taxpayer money.

The rare bipartisanship that has fostered passage of the Farm Bill legislation for decades lies in the collaboration of two strange bedfellows, the farm-state legislatures and an urban coalition focused on the importance of SNAP to their constituents. More recently, the legislation has also included farm programs more appealing to urban lawmakers, such as support for local farmer markets and beginning-farmer programs. In exchange for the support of nutrition programs, farm-State legislatures are able to maintain and even strengthen farm subsidies. This coalition was solidified in the 1970s as farm-State legislators realized that to many in the general population agriculture had lost its historical uniqueness and possessed a dwindling voter base, with the farm population reduced to 1-2 percent of the population. This led to a concerted strategy to build what is today the Farm Bill coalition.

Small-government conservatives disdain both farm subsidies and nutritional assistance programs. In 2014 in the House, the Heritage Foundation and other conservative think tanks led an unsuccessful effort to diminish the power of this political coalition by breaking apart the farm Titles of the legislation from the nutrition Titles. Given the strength and successful record of the coalition, it is unlikely that such an effort to split the Titles of the Farm Bill will prevail in the foreseeable future. Indeed, in recent years the coalition has only been strengthened by the addition of environmental groups advocating for conservation issues and lawmakers from urban areas advocating for a more inclusive agenda of issues such as food safety and local foods.

U-Turns on Rules Under Trump

Unlike the largely status quo policies written into legislation under the 2018 Farm Bill, several politically charged rules related to agriculture and food processing are being reversed under the current Administration. It is clearly a case of “the devil is in the details,” but special interests are well aware of critical rules affecting their goals, which usually sum to their bottom lines. In many cases, the issues are longstanding and are altered repeatedly as administrations change. It is worth highlighting a few of the recent changes.

One change concerns the Federal rules governing line speed at the nation’s 174 chicken processing plants. Americans eat more chicken than any other meat. America also exports more than seven billion pounds of chicken, accounting for 17 percent of total U.S. production. The median salary of a worker in a chicken slaughterhouse is about $27,000 annually—and at least one-quarter of them are undocumented. Before the current Administration’s new USDA guidelines on the speed at which chickens could be processed the maximum speed was 140 birds per minute. In September 2017, the National Chicken Council, which represents the poultry industry, asked the USDA’s Food Safety Inspection Service to eliminate any restriction on line speeds. While the USDA did not totally eliminate line speed restrictions, it changed the guidelines to allow companies to apply for waivers to allow processing speeds of 175 birds per minute.

This matters because line speeds affect worker safety and the risk to consumers of foodborne illnesses, in particular, salmonella. Consumer groups oppose the waiver allowance because the pathogens in the salmonella group are one of the most common causes of foodborne illness in the United States, and the FDA has found them becoming more resistant to antibiotics. This is in contrast to some European countries, like Sweden and Denmark, that require the industry to adopt strict salmonella control strategies on-farm and in processing, adding about 1 cent per pound to growers’ costs of producing chicken.

Approximately 100 workers die annually in chicken processing in the United States. The Labor Department’s own data shows that worker injury rates at chicken processing plants are already more than 1.5 times higher than in other private industries. As a follow-up to this rule change, the Trump Administration is now seeking to eliminate any line speed restrictions at pork processing plants.

The Trump Administration also delayed and eventually rescinded a set of rules proposed under the Obama Administration known as the Farmer Fair Practices Rule. These rules made it possible for poultry and livestock farmers to take legal action against the highly concentrated processing companies that engaged in unfair practices. Concerns about the relationship between farmers and meat processors they sell to has a very long history, going back at least to the Wilson Administration. The debate initially resulted in the 1921 Packers and Stockyards Act to place a check on the market power of meat packers; legislation and rules governing this stage of the market have evolved continuously over this period.

While the economic analysis is mixed on whether, or how much, anti-competitive behavior exists, the processing companies continue to consolidate, providing farmers in any single region with few or even a single processor to whom to sell their production. The 2008 Farm Bill directed USDA to issue updated rules for the 1921 legislation to protect the rights of poultry growers in their relationships with the concentrated processing industry. The proposed Obama-era rules, with Democrats controlling both Houses of Congress, included provisions like lowering the standards that a producer needed to make a legal claim against a packer and a rule to make it more difficult for packers to price fix and avoid pricing transparency.

The big meat and poultry companies, preferring the status quo minimal regulatory marketplace, urged Congress not to finalize the proposed rules in defiance of the 2008 legislation. With the 2010 elections returning control of the House back to the Republicans, the rules were never finalized; instead the livestock companies successfully lobbied the Republican-controlled House Agriculture Appropriations Committee to reverse the intent of the 2008 Law through its funding authority by attaching a so-called “GIPSA rider” to appropriations. Congress used this process to annually defund these rules through 2015. Then, following an exposé by political comedian John Oliver, and his pleas to viewers to call their congressional representatives, the annual rider was unsuccessful in 2016. With the election of Donald Trump, the hard-fought, 10-year struggle to finalize the proposed interim Farmer Fair Practices Rule was rescinded in October 2017 and the Trump Administration indicated that it would take no further action.

Of special concern to environmental groups are changes initiated by the Trump Administration to the Waters of the United States, or WOTUS, which is an effort, according to Administration spokesmen, to “clarify” Federal authority under the Clean Water Act. The clarifications will supposedly establish rules for determining which waterways are subject to regulations requiring a Federal permit for any alterations.

The proposed rules introduced during the Obama Administration—under the leadership of the EPA and Army Corps of Engineers—elicited strong opposition from the farm community, most notably the largest and most politically effective farm group, the American Farm Bureau Federation. The reason is very simple: Agriculture is the number one source of pollution for rivers and streams, the number two source of wetland pollution, and the third largest source of pollution of lakes in the United States. Agriculture is also a major source of the expanding dead zone occurring every summer in the Gulf of Mexico as excess nutrients flow from the Corn Belt to the Mississippi River.

When then-candidate Trump stated that he would “eliminate all needless and job killing regulations on the books,” he specifically pointed to WOTUS. In December 2018, the Trump Administration replaced the 2015 Obama Administration’s proposed WOTUS rule. The new rule is based on the assumption that landowners should be able to determine for themselves whether they have a waterway subject to Federal regulations, without any need to consult with experts.

The 60-day comment period for the new rule will close on April 15, 2019. Some of the waterways excluded from protection by the Trump Administration would have been protected under both the George W. Bush and Obama Administrations. In contrast to the Trump rules, the rules proposed under these previous administrations would have protected wetlands with surface or shallow subsurface water connection to navigable waterways and some additional wetlands that were not directly connected by water to larger waterways.

Collateral Damage

One of Donald Trump’s signature issues is fairer trade deals for the United States, especially for the steel and aluminum industries. An early move on trade was to pull the United States out of the Trans-Pacific Partnership, which promised to have significant benefits to agriculture. The rhetoric of fairer trade deals appealed strongly to voters in parts of the country had suffered declining job opportunities for decades as these important industrial products were increasingly produced abroad. Trump’s major tool for accomplishing a rebalance of trade is tariffs—indeed, he often states that tariffs are the “greatest.”

Trump’s first imposition of tariffs affected solar panels and washing machines. This was later followed by the steel and aluminum tariffs; the only countries exempted were Argentina and Australia because they agreed to reduce their production capacity for these products. Tariffs on China were imposed in July 2018 on 818 categories of goods and the two countries are still in the process of negotiating fairer terms of trade. China’s unfair trading practices, including theft of intellectual property, are well-documented. There is now a strong possibility that trade tensions will be escalating with the European Union over agricultural issues, which the Europeans have argued have never been on the table.

From an economist’s viewpoint, however, tariffs are an undesirable policy tool because they reduce the efficiency of marketplace signals by distorting prices and reducing the productivity of at least one and likely more than one economy. Increased productivity is the driver of higher standards of living. Moreover, tariffs often result in collateral damage as targeted countries retaliate.

A major cost of the Trump trade wars has been borne by agricultural producers and major farm input suppliers. The United States has had a positive trade balance in agricultural commodities for decades. For example, in 2015, the agricultural trade surplus was $25.5 billion. For 2019, that trade surplus is forecast to be nearly cut in half to $13.5 billion largely as a result of Trump’s trade policies. On June 4, 2018, Trump tweeted that “Farmers have not been doing well for 15 years” and he stated that his trade talks would change that. The most common indicator of the extent to which the farm sector is “doing well” is USDA’s estimate of net farm income. In fact, until the trade wars, net farm income had been at historically high levels. In the aftermath of the trade wars, 2018 net farm income dropped precipitously; with the exception of 2016, net farm income had not been so low since 2002 (in real dollars). The latest 2019 forecast has real income increasing by 8 percent from the 2018 levels, but still below the average of real levels between 2000 and 2017. While high levels of farm bankruptcy have not been reported nationally, debt levels are rising and bankers are reporting lower levels of debt repayment.

The impacts of the trade war are not felt equally across agricultural producers, varying by the previously established commodity export market channels and the specific retaliatory measures taken by our trading partners. In recent years, Canada, Mexico, and China have been the major importers of U.S. agricultural commodities. Combined, the three countries represent about 40 percent of all U.S. agricultural exports. The largest declines in U.S. exports have been for soybeans and soybean products, with a 7 percent decline expected for 2019. China is the world’s largest soybean consumer and the United States is the world’s leading soybean producer. In a normal year, about half of U.S. soybean exports would go to China. In response to the U.S.-declared tariffs, China increased its purchase of soybeans from Brazil and other countries by about 50 percent. The two countries are attempting to resume high-level trade talks, but to date no progress has been reported. The long-run concern is that American soybean producers will be shut out of the important Chinese market that was developed through years of private and governmental efforts. Even before the trade wars, Argentina, Brazil, and Ukraine were capturing greater shares of Chinese corn imports, and the trade wars are only accelerating this trend.To cushion the blow to farmers, a favored part of Trump’s base, the Trump Administration’s USDA has provided two rounds of “trade mitigation payments” to farmers. But the bureaucratic delays and inconsistencies in the granting of mitigating waivers have negated most of the value of the payments, especially to smaller producers who lack the buffer to wait out the bureaucracy.

Agriculture, or at least large farms and producers of labor-intensive commodities, have also been adversely affected by the Administration’s historic efforts to deter migrants from entering the United States along our Southern border. While difficult to estimate, roughly 25-50 percent of hired workers in agriculture are undocumented. They have shown a greater willingness to do the grueling work involved in farm production tasks for relatively low wages, in contrast to legal U.S. residents. Without requirements that employers use e-Verify, undocumented workers were relatively safely employed in the agricultural sector. Current enforcement conditions are leading to more capitalization and shifting of commodity mixes on farms, and in the short run, sometimes, fruits and vegetables rotting in the fields unharvested.

The horticultural crop producers—of vegetables, fruits, nuts, greenhouse and nursery products—have the highest share of operating expenses for labor (25 percent or more). These are the specialties that have been hurt the most by the failure of lawmakers to address the country’s immigration policies. The current administration’s immigration policies have only worsened an already tight supply of farm labor. On the other hand, horticultural crop producers have largely maintained their export markets during the trade war and most production takes place on very large farms (e.g., only 3.5 percent of horticultural farms account for half of all horticultural sales).

Dairy producers, on the other hand, have been harmed by this administration’s trade policies and, especially, the immigration policies. The value of U.S. dairy exports is forecasted to decline by 4 percent from 2018 to 2019. Milking requirements mean dairies are extremely labor-intensive operations, with about 10 percent of their operating costs from labor. Dairies are also more likely to be mid-sized farms than producers of horticultural crops, and are experiencing greater financial vulnerabilities.

Trump’s promises to reduce regulations (especially those associated with the Clean Water Act) and to eliminate the estate tax were embraced by the farm community during the campaign. Trade wars and the labor shortages were never an appealing part of the message to the general farm community, but then-candidate Trump was very clear about these priorities. Since the current Administration’s trade and immigration policies have rocked the world of agriculture, one has to wonder if the community did not really believe those policies would be implemented after the campaign.

The majority of the farm community is a generally conservative voting block—look at the Farm Bureau’s mission statement for confirmation—and they generally vote their ideology. It is an open question if that will continue in 2020. At a recent Farm Foundation policy forum, seasoned agricultural economists saw daylight developing between this Administration’s policies and the traditional farm community. Repeated visits by cabinet members to various farm conferences is perhaps evidence that the Administration recognizes that the strength of their relationship with an important part of the Trump base is at risk.

Agricultural Policy is Not Rural Policy

While the Administration is very much in tune with the large-farm agricultural community, the non-farm rural population is also a part of Trump’s base, and it has received little policy attention since the election. It is common for policy makers to equate agricultural policies with rural policies, but the vast majority of rural residents are not engaged in farming and the majority of rural economies are not dependent on agriculture. About 14 percent of the U.S. population lives in rural, i.e., non-metro, areas.

The disadvantages of rural areas are well documented, including fewer employment opportunities and less access to health care. While farm families have had average incomes greater than the average U.S. family income for decades, rural areas in general have experienced lower incomes and a higher incidence of poverty. The rural South, in particular, has a significant number of counties classified as persistent poverty areas and a shockingly high poverty rate among children. In addition to these historical challenges, rural places are facing new challenges, such as lack of broadband access in a national economy making full use of the technology. Many rural communities are also plagued by opioid addiction.

Due to the design of the electoral college, states with large rural populations have significant influence in our national voting; and the more rural the state, the more likely residents were to vote Republican in 2016. Immediately after the election, many in rural policy circles were hoping this support would translate into a significant investment in rural non-farm economies. To date, it has not happened, nor has the campaign promise to invest in all types of national infrastructure. Instead, in an early action, the Secretary of Agriculture reorganized the USDA to remove an Undersecretary for Rural Development position to make room for a new Undersecretary focused on agriculture trade. Under the Trump Administration, the status quo approach of equating action on agricultural policies as action on rural policies appears to be continuing—while less than 6 percent of the rural population lives in areas whose economies are dependent on agriculture. 

Alternative Facts in the Agricultural Context

USDA’s annual outlays are about $140 billion, with the largest share going to nutritional programs. Besides agriculture and nutrition, the USDA’s mission is broad. Directing this mission involves a targeted research and information program with a history dating back to the establishment of USDA in 1862.

Most of the program is today housed in the mission area referred to as Research, Education, and Economics (REE). Like all government employees accustomed to transitions in presidential leadership, employees in this mission area were anxiously awaiting the appointments of the political leaders responsible for providing guidance. They got their first clue about the Administration during initial briefings, when political appointees were more interested in learning the names of the analysts working on global warming than the programs of the agencies.

The Secretary of Agriculture was confirmed in April 2017 and, in July 2017, Sam Clovis was nominated as Undersecretary of REE and USDA Chief Scientist. His appointment came as a shock to not only employees, many with Ph.D.-level training and distinguished scientific credentials, but to the Senate charged with his confirmation. Although it is required by law that the appointee for the position of Chief Scientist be distinguished in agricultural science, education, or economics, Sam Clovis admitted that he was not distinguished in any of those fields. His credentials seemed to be that he was a climate change denier, the co-chairperson for the Trump campaign, and a radio talk-show host. Only when it was revealed that he was implicated in the campaign’s efforts to broker a relationship with Russian officials was his nomination withdrawn.

The next clue that the Administration was interested in degrading the scientific capacity of USDA came in the President’s 2019 budget. The policy research arm of REE, the Economic Research Service (ERS), was targeted for a 50 percent reduction and instructed to reduce or eliminate so-called low priority research areas—like food safety and nutrition assistance, rural development, and conservation.

ERS has a storied international reputation for rigorous and objective information. Notably, some of this Administration’s policy arguments are inconsistent with objective information in ERS reports. And rarely does either party discuss an important piece of legislation affecting agriculture, food, or rural development without reference to ERS reports or data products. In light of its importance, the Republican-controlled Congress rejected the Administration’s proposal to significantly cut the ERS budget.

The Secretary of Agriculture then employed a different approach to diminish ERS: move the Washington, DC-based ERS and the extramural research granting arm, the National Institutes of Food and Agriculture, out into the hinterland. That approach, revealed in August 2018, is currently the subject of concern by Congress as expressed through the appropriations process. In spite of the strong message from the Congress, Secretary Sonny Perdue is moving ahead with the plans and has informed individual researchers whether they will be moved or be one of the minority of staff that remains in a diminished Washington, DC headquarters. The reason for the concern is that such a move is already resulting in a widespread exodus of the highly trained staff in these agencies, achieving what is, allegedly, OMB Director Mick Mulvaney’s original intention through another route.

The Secretary’s plan also includes moving ERS out of the research mission area and into the direct policy arm of the Secretary’s office. Evidently, publicly accessible and objective policy analysis is not a goal of this Administration. As it did with the Sam Clovis nomination, distinguished scientists and agricultural administrators around the country object to the plan, along with some on Capitol Hill. In his recent book, The Fifth Risk, Michael Lewis documents similar efforts to hollow out the expertise essential to informing sound policies and managing risks for the public good across the government.

Perhaps this is the true deep state some in the Administration would like to eradicate—deep in knowledge and deep in dedication to public service.

Private Sector Leaders

Large-scale agriculture in the United States has experienced high productivity levels and will make an important contribution to meeting the goals of feeding a 2050 global population of more than 9 billion. Today’s innovations contributing to higher productivity levels are especially reliant on information technologies: For example, precision agriculture technologies that monitor yields and allow for the use of variable inputs now use “big data” and sophisticated analytics techniques, developed with investments from Silicon Valley entrepreneurs and others.

Agricultural production often comes with negative externalities, like environmental pollution and soil degradation, and these “non-market” costs are not considered in standard measurement of productivity. Furthermore, it is widely understood that agriculture is experiencing and will continue to experience significant impacts from climate change. Consideration of these impacts through public R&D investments and regulation is a critical role for government, but government has been too slow to respond to these challenges—before and after the 2016 election of Donald Trump.

In spite of political gridlock, the good news is that there is evidence that consumers and private sector innovators are leading notable changes. Our agricultural system is evolving along at least two distinct pathways to offer consumers choice in the marketplace, one being the conventional path of a strong focus on efficiency and low prices. The other is what has come to be known as the new food economy where consumers are demanding other food attributes, such as how their food is produced with consideration of the food safety, nutrition, and environmental and labor impacts of production systems. While the local foods movement is part of this larger new food economy, parts of the large farm and food sectors of the corporate supply chain are also participating in this movement through various corporate sustainability, or regenerative, efforts in collaboration with consumer and environmental groups.

The post Farming and Agriculture in the Age of Trump appeared first on The American Interest.

The Virtue in Shame

Before his operation, a man bunches his surgical gown around his genitals so that no one can see them. A woman tugs a blanket over her bottom to cover herself while I put an epidural in her back. Such behavior—the normal shame response—happens all the time in my anesthesiology practice. But what underlies it?

Shame is not the desire to be moral, nor is it meant to repress sexual desire. Indeed, sexual desire is the last thing on a patient’s mind when entering a cold, sterile operating room. Nor is shame the desire to hide the ugliness of one’s body, as some beautiful patients express shame when they disrobe, while some ugly patients express no shame at all.

In my experience, shame in the operating room arises when patients take the measure of themselves as individuals at the very moment they think others are scrutinizing them. It is a protective feeling. It arises out of our desire to shield the most important parts of ourselves from general notoriety. It can be likened to a feeling of imbalance or disharmony, which is unpleasant; yet its intention is to cover or veil something of value in ourselves and to defend it against the larger world, which is praiseworthy.

But that is not how many educated Americans today view shame. They focus on the unpleasant sensation, and view shame as an unhealthy feeling. They put shame in the same category as unhappiness, anxiety, and pain. In essence, they “medicalize” shame as a malady that needs to be fixed. But unlike the first three problems, shame has no pharmaceutical antidote, which makes all the difference in how it is treated. People suffering from unhappiness, anxiety, or pain can take a pill to ease their discomfort. Without a pill for shame, it is society that has to change.

Among the various kinds of shame that our society has labeled destructive and malignant, sexual shame has become the primary target. Society, especially progressive, well-educated society, has bent over backwards to make sure no one feels any shame whatsoever about his or her sexual activities. The movement to destroy sexual shame has sometimes led to new ways of life that shock us—for example, sex education in lower school, college hook-up culture, f—k buddies and “friends with benefits,” the ubiquity of celebrity sex tapes and amateur porn, the principle of gender neutrality, the policy of letting teenage girls get an abortion (but not an aspirin) without their parents’ consent, college workshops on anal sex, and courses for credit that involve masturbation and the use of sex toys. Sometimes the changes confuse us—for example, when feminists call women consumers of sex, like the men, but also “victims,” unlike the men; or when feminists encourage women to dress sexy but then criticize the “objectification” of women.

All this confusion makes sense to an anesthesiologist, for the world of anesthesiology is a world of naked patients where shame naturally abounds. Every change associated with our half-century war on shame is derivative of one of four techniques I use every day to combat feelings of shame in the operating room.

Before describing those techniques, I need to make two points. First, in combatting shame, I appear to ally with those who view shame as something unhealthy or wrong. There can be some truth in this, but as a doctor I view a patient’s shame experience as a special situation, a needless burden borne by a sick person in an unusually stressful environment. Relieving shame’s discomfort in the operating room does not detract from shame’s larger value in everyday life, just as forgiving the absence of grit in someone with the flu doesn’t mean grit lacks value in healthier circumstances.

Second, gays, lesbians, and transgendered people seem to represent the shame-smashing movement’s leading edge, but this is wrong. It is more accurate to say that the larger population of cisgendered heterosexuals has sometimes found these groups useful, and therefore pushed their agendas in pursuit of a shame-free society on behalf of themselves.

Gays and lesbians, for example, have widened the range of acceptable sex. Yet rather than push for shame-free sex, most gays and lesbians have supported sex’s most conservative institution: marriage. By highlighting the border between marital and extra-marital sex, they actually reinforce the shame experience for married heterosexuals pursuing sex on the side. In another example, the attentiveness of some gay men to their physical looks does no work for those heterosexuals fighting against “body shaming.”

Transgendered people do more work for the anti-shame movement, which may explain why “progressive,” well-educated society jumped to their defense so quickly after “discovering” them. For example, transgendered opposition to “deadnaming,” in which a transgendered person’s original biological sex is made public against that person’s wishes, complements the larger cisgendered heterosexual goal of forgiving and forgetting—and de-judgmentalizing—peoples’ sexual pasts.

In another example, transgendered people who think cisgendered people should be more open to having sexual relationships with them work in synch with the much larger cohort of obese cisgendered heterosexuals fighting against similar prejudice, as well as against “fat shaming.” The latter want a wider population of heterosexuals to overlook their weight when considering future partners. Finally, by pushing gender neutrality, transgendered people help the larger cisgendered heterosexual world rid itself of traditional norms of femininity and masculinity, which have long been sources of shame for those who fail to somehow measure up.

Nevertheless, these smaller groups are just marginal phenomena; true reality remains the much larger population of cisgendered heterosexuals pushing for a shame-free society, using some application of the four methods I use every day in the operating room.

Fighting Shame in the Operating Room—and Beyond

The first method that anesthesiologists use to fight shame is to distract scantily clad patients from thinking of themselves as individuals. I talk to these patients as if they were “cases” rather than individuals. I greet them with a face of stone. I neither frown nor smile when I address them. I inquire into their medical histories as if they were one of many semi-naked bodies to pass before my eyes, and nothing about their personal lives—their lives as individuals—could possibly interest me.

The naked patient for me becomes like an artist’s model—a lump of flesh to puzzle over as opposed to an individual with deep personal feelings. A woman who poses nude for a male artist feels no shame; she feels herself not to be an individual but an object. If the artist starts to flirt with her, she no longer feels herself to be just an object; she suddenly experiences herself as an individual, and often blushes.

It is no different with a female patient. The more I treat her like a “case,” the less she experiences herself as an individual, and the less she feels shame. Talk to her as if she were pretty or attractive and not just another case, or tell her that she reminds me of another woman, and she will quickly blush. She will feel tension between herself as an individual and what the world thinks about her, which gives rise to the feeling of shame.

This general method accounts for many of today’s shame-smashing policies and practices. Sex education has come to lower schools to keep youngsters from stumbling into a teenage pregnancy or catching an STD. But an equally important goal is to sever sex from any sense of shame. It is why educators objectify sex. Graphs and diagrams make sex a study in the behavioral traits of whole classes rather than in the liaisons of unique individuals. It is why so much emphasis in sex education is put on the mechanics of sex, since all naked bodies function more or less similarly.

Shame often arises from deeper feelings of guilt, which itself arises from an attraction to what is supposed to be resisted. There is no attraction in sex education—on purpose. The solid wealth of information presented becomes ponderous and even a little ugly to young students; the long lines of text and paragraphic numerals at the margins grow tiresome. If anything, sex education produces in young people a curious expression of stoicism—of a certain grim acceptance of the facts of life. They feel no more shame in learning about sex than do naked patients being lectured to by a doctor on the various categories of disease.

Many young people carry this objectification of sex with them into early adulthood. In hook-up culture and among f—k buddies, sex becomes an act that the body engages in, not the self. Like the artist’s model, these people behave like objects during sex, which suppresses shame. Sexual love is practically a precondition to sexual shame, for people in love feel the urge to express their sensations physically while at the same time trying to suppress them, out of self-protection, until garnering enough evidence that one’s love is returned. None of this complex dynamic occurs during a hook-up.

Given that suppressing the sex drive seems pointless, while avoiding it seems impossible, today’s educators trying to banish shame have made the calculation that it is better for young people to meet each other halfway, to satisfy their mutual bodily desires—safely, contractually, and with mutual consent—so that afterward they will not be distracted from the more important task of discovering themselves as individuals in their careers. Thus, from their perspective, the more sex education is sanitized of love the better. The result may be more sex, assuming young people retain the interest (although recent research suggests they might not), but less shame.

This method carries complications. For example, once, while still an intern, I took care of a bashful patient who came to the emergency room with a condom trapped inside her vagina. While searching for the condom, I explained to her how she and her boyfriend might avoid this problem in the future—for example, by having her boyfriend hold on to the condom when removing it after sex. It was as if I were a doctor speaking matter-of-factly about going on a diet: Nothing fried or roasted, less salt and fat, more fiber and vitamins. The woman grew so indignant toward my air of clinical detachment that at the end of the case, instead of thanking me, she said caustically: “I think you could have been more sympathetic during the whole thing.”

For this reason I sometimes use a second method to counteract shame: I make patients think of themselves only as individuals. To keep patients out of that no-man’s land between an individualizing attitude and a generalizing attitude where shame arises, I tack in the opposite direction.

Take a hypothetical semi-naked patient with red hair named “Betty.” To keep Betty from blushing I will try and make her feel that I am comparing her with no one else; that she reminds me of no one else; and that she says things that have been said by no other patient. I do this to keep her from generalizing her situation, for as soon as I stop looking at Betty as “Betty,” the unique individual, and start looking at her as a more general type—for example, Betty, “the young naked woman with red hair”—she will turn to her self, and blush.

We see this method at work in the larger world, where thousands of people recite their sex stories or confess their sex problems on social media in ways that would have embarrassed most people a mere generation ago. The anti-shame movement encourages this. Sometimes these confessions are anonymous, but sometimes they’re not—the confessors’ voices are real and even their images on screen are real. While giving their testaments, so long as these confessors feel themselves to be unique individuals and unlike any other case (even though in reality they are very much like other cases), shame lies dormant in them. For it is not the number of people watching them that poses to their minds the risk of general publicity, but whether the audience is lumping them in with others. These confessors often delude themselves into thinking the audience is not.

Social media makes this delusion possible. For example, a Yelp restaurant reviewer sometimes imagines his or her review to be singular, and the restaurant owner to be paying special attention. To a Yelp reviewer, this turns the review into a kind of personal dialogue between owner and customer. A 2015 South Park episode parodied this inflated sense of self-importance among reviewers, who, in the episode, imagine themselves to be unique, central, and all-powerful. An analogous phenomenon occurs when people tell their sex stories on the internet. While millions of people observe them, these impassioned confessors imagine their story to be special, unlike any other case, and that to others (millions of them) they are not just “one more example of such and such,” but, instead, “John” or “Betty,” stretching out a helping hand through a personal experience, while those watching them feel for them or even shed tears for them, as one might for a friend. While describing their intimate details, the confessors seem to think they remain themselves, and are read as themselves, and are acknowledged as themselves, and that those watching them would, if they could, share with equal willingness their trend of thought, the way friends do. Because of this delusion, social media sex confessors often do not feel the danger of general publicity that incites the feeling of shame.

Obviously, the first anti-shame method and the second anti-shame method are in conflict. The first method encourages objectification; the second method discourages it. It is why my patient referenced above, with the condom trapped inside her, became angry with me. She thought I was treating her like an object when she wanted to be treated like an individual. We see the same conflict in the larger world, as, for example, when feminists encourage women to give their sexuality free reign and to dress provocatively, but then resent the “male gaze” that objectifies women who dress provocatively. Although the contradiction confuses people, it merely attests to the contradiction inherent in the two methods.

Yet both methods yield the same paradox: more sex, more discussions of sex, and more confessions of sex, but less shame. It recalls the paradox of the prostitute. The prostitute feels no shame at work, but also no shame at home with her lover. At work, the customer seeks the prostitute, not the individual, while the prostitute seeks the customer. The prostitute is purely an object. At home, both the prostitute and her lover seek the individual. In neither situation does the prostitute feel herself to be in that twilight state of indecision, part-object and part-individual, that arouses the feeling of shame.

Sometimes the second method of fighting shame fails spectacularly. I once gave anesthesia to a man who needed a penile implant for impotence. I visited him afterward, along with the surgeon (a woman, I might add). We spoke with him as if we had been friends all our lives, while the man responded in ways that made us all feel closer, even if only by joking and clowning. This was no doctor-patient relationship; this was just the three of us hanging out. We wanted the man to focus on his individuality and not to see himself as a more general case of male impotence. Then two young female nursing students entered the room. Thinking the man’s easygoing nature a license for them to say anything, one of them teased lasciviously, “Can we see how it works?” The man’s lips dried instantly. Suddenly, he was no longer a unique individual; he was now the impotent man with desires who needed a funny device to make his penis grow. His situation had been generalized before an onslaught of seeing eyes. He grew ashamed and his relaxed manner never returned.

For this reason I sometimes use a third method to fight shame. I try to keep patients from thinking that others are watching them. Shame comes when people feel a disharmony between how they see themselves and how they imagine others see them. Saint Augustine said as much when he noted how a man often feels no compunction against saying the stupidest things in public but will feel terribly ashamed if caught innocently copulating with his wife. At such a moment, the man feels himself to be compared with the general class of animals. Rid him of onlookers and his shame fades.

True, one doesn’t need to be watched to feel sexual shame. Some people feel shame when masturbating alone. Nevertheless, most people do feel less shame when they are alone.

I often enter birthing rooms where pregnant women greet me with their legs spread wide apart and their private parts open for all to see. During uterine contractions most forget themselves and think only of their pain. I have never seen a birthing mother in the middle of a contraction express shame. However, once I’ve placed an epidural and rid mothers of their pain, the potential for shame returns, and these women sometimes grow embarrassed when I return to check them.

To ease a mother’s shame, I will often look down when entering the room, and walk straight over to her chart lying on the counter. With my eyes fixed on her chart I will ask her how she’s feeling as I scribble notes. When I do look up, I will stare directly into her eyes, as if there were nothing unusual about her bottom half to distract me. Indeed, if someone were to ask me at that moment why I looked only at her eyes and not at her bottom, I would feign confusion, and declare: “Why should I look down there? Is something out of the ordinary going on down there?” Because I glance away from her private parts, the mother loses the audience needed to initiate the shame cycle.

This anti-shame method takes several forms in the larger world. Most obvious is the “right to privacy” movement supported by many liberals and conservatives, which is the right to have no onlookers. Technology makes snooping on people easy. The mining of personal data by such companies as Facebook and Google is equally troubling. People risk shame and humiliation if their information gets out. The “right to privacy” pushes back against this trend.

The method takes another form in the “right to be forgotten.” Embarrassing details of a person’s intimate encounters can live forever on the internet, resulting in the potential for eternal shame. If the details get erased, there can be no onlookers and therefore no shame.

This is where privacy rights begin to merge with the opposition to “deadnaming,” and, in the larger cisheterosexual world, with the effort to get people to forget, or at least forgive, one’s sexual past.

The notion that people can start fresh at any moment is a very American one, so much so that to think otherwise is almost un-American. At the same time, people today are so desirous that their sexual history should disappear of its own accord that they barely think how all of this should come about, other than that other people should simply deny the undeniable. They are as children who want everything to be made of chocolate. They pretend to have no past, and they expect others with meek smiles to pretend with them. Sometimes a man or a woman will have a history of hundreds of sexual partners but then expect to be accepted as someone who had always been waiting for Mr. or Ms. Right. The slate is wiped clean. “Life begins now,” declares the vulnerable party—nothing to be ashamed of here.

Gender neutrality represents another application of this anti-shame method. Just as it is easier to be anonymous in a big city than in a small town, so is it easier to rid oneself of onlookers if one’s sexuality is merged into a universal type. An eye trained to the difference between two distinct genders will not easily notice something different or unusual if all people are clustered around a single mode. What is distinct is blurred or effaced altogether. With gender neutrality, people become like the customary trunks of firs and pines in a dense forest, all so similar that no particular tree stands out. Without the stark division between masculinity and femininity to serve as a standard for comparison, no tension between the individual and a larger group standard can exist. This arrests the shame cycle.

The fourth method of controlling shame works on the principle of jujitsu, where an opponent’s strength is used against him. Some semi-naked patients cannot be rescued from their shame. It is too intense. Rather than fight it, I intensify it so that the patient grows insolent toward it. In other words, I encourage the patient to become cynical.

Here is an example: When a female patient tries repeatedly to cover her bottom while I place an epidural in her back, I sometimes say in a bitter tone, “Don’t worry, I’m not thinking about bottoms. I’m thinking about high taxes and government incompetence. Our whole system, it’s so corrupt.” I become an angry curmudgeon. The naked patient ineluctably falls into my groove of thought. Indeed, sometimes she goes from being ashamed of her nakedness to rejecting civilization altogether and becoming sufficiently exhibitionist to throw off the rest of her covers.

This method transforms a naked patient’s shame into the shame of the cynic. The cynic isn’t shameless; on the contrary, the cynic has a hypersensitive feeling of shame, which he or she rebels against by protesting defiantly against prevailing expressions of shame. The cynic still feels a kind of shame—it is why sarcastic people in particular often fear ridicule; they go from being revealers to the revealed—but shame’s expression is perverted so that it no longer discomforts. It is transformed into indifference toward anything sexual—for example, toward the fact that one’s bottom lies exposed in the operating room.

Yet there is a dark side to this method. Shame is a protective feeling, but what if the cynic believes he or she has little inside himself or herself worth protecting? In such cases, expressions of indifference may pass into a love of the obscene, while the feeling of shame itself is discredited with mockery and wit.

We see this method abound in the larger world: Celebrities eager to make sex tapes and amateurs eager to defend their appearance in porn videos; comedians who poke fun at clergymen for their celibate ways; filmmakers who stereotype all suburban parents as buttoned-down, sexually repressed prudes; spokespeople for free love; spokespeople for the “culture of irony”; and run-of-the-mill critics of traditional mores, modest attire, and conventional sex relationships—in other words, many of the people who define today’s hip cultural scene.

Their teasing defines “edgy,” but it is sometimes just a protest against prevailing conventional expressions of shame used to divert attention from their own strongly felt lack of an inner life. They attack modesty, yet they themselves have no charms for modesty to conceal. Their indifference has passed into resentment; their cynicism has passed into jokes about genitalia and the desire to shock. The jokes themselves suggest an air of self-confidence; indeed, they let the jokesters form a conception of life which allows them to think well of themselves and even take pride in their outlook. But it is really all a façade. If they were to change their shameless attitude, they would lose the feeling of superiority it accorded them, and for this reason they instinctively cling to the kind of people who look upon life in the same way they do—hence, the hip cultural scene.

The jokesters’ cheeks are white with confusion or resentment rather than red with healthy shame. Yet some self-described freethinkers have cheeks that are white with anger. These people recall the very prudes they poke fun of. Old-fashioned prudes, seen in both genders, invoke their moral code to find situations that cause shame in others, thereby giving them an opportunity to express their moral indignation. This lets them enjoy a kind of sexual gratification otherwise denied to them: The more they moralize, the more pleasure they feel. Their smugness diverts attention away from deficiencies in their own lives; they replace the feeling of healthy shame with the excitement of condemning the feeling of shame in others.

Some extreme feminists behave similarly. They ferret out all sexually significant events in their surroundings and are eager to condemn them harshly if they deviate from their moral code. Cases of sexual assault obviously deserve condemnation, but the fury expressed toward perpetrators of milder incidents, involving, say, a tasteless joke in mixed company or a brief moment of unwanted hand-holding—a fury often more intense than the sympathy shown toward the “victim”—betrays a deeper feeling of pleasure, almost as if the fury itself were providing an alternative form of sexual satisfaction. As in the case of prudes, their sadistic moralizing titillates them; their criticism accomplishes the very thing it is meant to condemn.

I knew a woman who moved out of town after her divorce. Years later, when I saw her again, I asked her why she had done so. She told me it was not to find a new job or new spouse, but because people back home kept asking her about her…situation. She didn’t want to stare into their embarrassed smiles again and explain. That’s the hardest thing about a break-up, she said: explaining. It made her feel awkward, as if she had done something dirty and shameful.

Critics of shame dislike shame because it is an uncomfortable feeling. And it is. By ridding society of shame, they imagine that they are helping people rise up and revolt against some jailer. I don’t blame my friend for wanting to leave town.

Yet some critics of shame have risen up against false expressions of shame rather than true shame, and in their war against the former they have overlooked the value in the latter. Indeed, for today’s critics, the latter has no value, for to their minds there is no difference between true shame, which is universal and healthy, and false expressions of shame arising from a particular morality they despise. Today’s critics despise a traditional morality that condemns both pre-marital sex and non-heterosexual sex, that lauds only one ideal of male or female beauty, and that forces people to hide their bodies under stupid, baggy clothes. They confuse the judgments of this old-fashioned morality with true shame, as if wearing a one-piece bathing suit to avoid the wrath of an old biddy is synonymous with blushing. It is not. The former reflects the artificial urge to conform to a particular morality; the latter reflects the natural urge to shield oneself from notoriety.

To make different kinds of sex acceptable, today’s critics have risen up against uptight scolds who narrowly define respectable sex. Yet they erroneously think such scolds speak for true shame. To encourage people to discuss their sex lives with their doctors or friends without feeling shame, they have risen up against tight-lipped puritans who suppress this legitimate desire. Yet they erroneously think such puritans speak for true shame. To help people enjoy sex without feeling ashamed, they have risen up against prudes who smugly parade traditional values. Yet they erroneously think prudes speak for true shame.

Helping people to enjoy sex or talk about sex without embarrassment are positive things, but by confusing false shame with true shame, and then opposing both, the critics’ methods have also encouraged the disjunction of sex from higher feeling. They have encouraged the delusion that one’s sexual past can easily be forgotten. They have abetted cynicism and obscenity. They have poured venomous and bitter ridicule on any act of modesty. They have enabled a new kind of prude to come into being, as vicious as the old one. They have turned masculinity and femininity into dirty words.

They have confused asceticism, prudishness, uptightness, and conformism with true modesty. They have confused distended forms of behavior with a true virtue.

To tell the difference, study the color of the person’s cheeks. The cheeks of the puritan, the prude, the scold, and the conformist are invariably white with fear or anger. The cheeks of the modest are red. Those red cheeks are like a suit of armor, shielding from the outside world what the modest person believes is valuable in himself or herself. For that person, shame is a healthy reflex.

Think of a young woman in love, blushing with shame. She is brimming over with a new kind of affection. Her eyes sparkle bashfully and mischievously, as if she has an intimate secret to tell. Nature is calling her just as time cues a tiny flower to open even during a frost. She has much to give, but it still needs nurturing and protection until she knows that it will be properly received, and so she blushes in shame. She cradles her burning cheeks in her hot palms. It is a healthy instinct that masterfully and indivisibly enters her will.

True, her shame discomforts her. But it also represents almighty, palpitant life. To call this a disease and embrace shamelessness, to rid her of that discomfort and describe doing so as progress, is to kill that life. It is akin to the twisted logic that says dead people have perfect health because they never get sick.

The post The Virtue in Shame appeared first on The American Interest.

The Rise of Unfreedom in the West

It’s time to call it: Democracies across the West are at an inflection point on free speech, and it’s not clear which way things will go on this issue in the next 20 or 30 years. In some cases, ostensibly liberal governments have already made moves to police and suppress what they deem unacceptable speech; in others, rigid political binaries have threatened to crowd out traditions of free inquiry and debate. All too often, it seems not to matter what is said in an argument but rather who says it and how it was said.

Superseding this once-proud tradition of free speech, empiricism, and free inquiry is calculating, cautious, self-censoring phraseology. And when people do express unorthodox views, it is often in hushed tones, out of fear that an overheard comment could kill their career and get them ostracized from polite society. A December 2018 Rasmussen Reports poll found that today only 26 percent of American adults believe they have true freedom of speech, while 68 percent think they have to be careful not to say something politically incorrect to avoid getting in trouble. In 1990 there were approximately 75 “hate speech” codes in place at U.S. colleges and universities; just one year later the number had swelled to more than 300 before spreading like a brushfire thereafter. According to the Foundation for Individual Rights in Education (FIRE) in 2018, 90 percent of American universities maintain at least one policy that either restricts protected speech or could easily be interpreted as doing so. Meanwhile in Europe, Germany unveiled in 2017 a new law, known locally as NetzDG, which included massive fines for social media networks that are insufficiently diligent in policing “hate speech” on their platforms. In 2018 Paris followed Berlin’s lead by toughening its laws on “hate speech” on social media. The same year a YouGov poll in the United Kingdom found that significantly more British voters (48 percent vs. 35 percent) believed that there were “many important issues these days where people are not allowed to say what they think.” Last but not least, a 2019 report to the Council of Europe concluded that European press freedom was more fragile today than at any time since the end of the Cold War, given the rise of attacks on and intimidation of journalists. In short, the abridgement of this most fundamental democratic freedom to speak one’s mind appears to have become the norm across the West, as though our elites and governments were rushing headlong down the road to a new dystopia. How did we get here?

For decades now, the freedom to speak and argue—the most fundamental right of a free people—has been under assault by neo-Marxist advocates of a “more just society.” But it is only recently that their efforts have succeeded in shutting down an ever-widening range of venues of public debate: first in academia, then in the media, and of late in politics. Today the fundamental right to free speech is under threat not just from speech codes—that is, from proscriptions on what cannot be said—but also increasingly from prescriptive rules about what one must say, as though perfunctory condemnations of Western history were the price of admission to public debate.

Why are societies in Europe and America seemingly intent on suppressing the fundamentally democratic impulses to speak freely, to err, to debate, and even to offend so that, through it all, we might come to learn what passes the common sense test and possibly arrive at a larger national consensus on policy? When did ideological allegiance (liberal vs. illiberal) become a litmus test for what constitutes appropriate public discourse? And how did we get to the point where political expressions of concern for the economic and social welfare of the nation’s own is “xenophobia,” and where the only praiseworthy use of American power is to unconditionally embrace globalization or save the planet by signing onto high-minded but ultimately unenforceable declarations of virtuous intent? Why is it that in Europe today the traditional generosity of its people is all but taken for granted, while that same citizenry’s desire to ensure its own welfare and security, and to transmit its cultural inheritance to the next generation, is often reviled as intolerance by the intelligentsia, politicians, and the media?

The roots of our growing unfreedom were planted in the late 1960s, but only today can we truly appreciate the extent to which the ideas of that era deconstructed our democratic culture. This latest neo-Marxist lurch toward unfreedom happened in the span of a single generation, the result of a cultural unmooring during which conservatives seem to have lost their sense of caution, and liberals their collective mind. Today it is not uncommon to hear that the West itself is—as I was recently told—merely a “cultural construct of the early 20th century,” and that truth requires little empirical testing but is instead dependent on the identity of the individual who expresses it.

Ironically, this latest assault against the foundational values of our democratic tradition was exacerbated by arguably the greatest ideological triumph in the history of the West—and, in hindsight, also our most dangerous moment. The year was 1990—the first post-communist government had already been formed in Poland a year before, the Hungarians had opened their borders to allow refugees from East Germany to escape, and the Czechs and Slovaks had gathered in Wenceslas Square to tell the communist mafia that it was time to leave. Then the Berlin Wall came down and the Germans held their breath, hoping against hope that the once impossible dream of reunification would actually come true. On both sides of the Atlantic we cheered the annus mirabilis, exulting in the sight of this utter and seemingly irrevocable triumph of democracy—this ultimate consummation of American leadership and the West’s expenditure of blood and treasure to stop communism and preserve and expand liberty.

Indeed, both Americans and Europeans had every reason to celebrate. The world seemed perfectly poised to surf a new tsunami of freedom. History was on our side—or at least so claimed a plethora of op-eds, scholarly articles, and talking heads on television. At the time it seemed natural to many a commentator that what was believed to be universal would soon eclipse the national. The rules and institutions of Western-style democracy had proved their ability to cross the boundaries of culture now that a heterogeneous mix of countries had cast aside the Soviet yoke to take them up. Now that all of Europe had affirmed the value of freedom, was it not obvious that it would conquer the globe? The right to national self-determination was not so much discarded as allegedly transcended.

And yet the moment of the Soviet collapse carried a hidden threat that, in less than three decades, would deepen our divisions and weaken the foundations of individual liberty. Our sense of victory contained within it the seeds of arguably the greatest peril the West has ever confronted: the ideological certitude—not just on the Left—that we had cracked the code of the human condition and could get on with the work of perfecting both the individual and society.

With the implosion of the Soviet Union we lost an enemy whose society was a living example of what projects aimed at re-engineering human nature were likely to yield: the loss of liberty, followed by repression and terror. Once the toxic Bolshevist experiment that had cost millions of lives and created unspeakable human misery was (at least in Europe) no more, the temptation of triumphalism proved too alluring. Since it seemed plausible on a basic level that liberal market capitalism had overpowered communism, it followed that there were no limits to what institutional and market reforms could achieve, especially once one discounted variables like culture and history as explanations for why liberal democracy had flourished in some societies and not others. It seemed that all the post-Cold War wave had to do to succeed was to go global. And so at its moment of triumph the West fell victim to a post-Enlightenment delusion of the perfectibility of man.

Yet the Soviet collapse also empowered neo-Marxists and fellow-progressives in the West to turn inward and focus on the “enemy within,” namely, that of the “system.” Without a tangible reminder of what efforts to re-engineer humanity had produced in Europe and elsewhere, it became possible for the ideologically committed to construct a narrative of what “true socialism” could have achieved if only the Stalinists and Maoists had not corrupted the collectivist dream. At the same time, the business community, no longer tamed by a once powerful sense of national solidarity, grew besotted with spurious claims about the “inevitable logic of the market.” Many among America’s policy and business elites argued that off-shoring the U.S. supply chain to Asia would not only make us rich but would also lead to that region’s export-driven modernization and eventual democratization. They told us that in the era of globalization, export-driven modernization would inevitably lift underdeveloped economies out of poverty, leading to the rise of an educated, empowered middle class that would demand representative government. Even today some continue to cling to this argument, against all evidence to the contrary.

Unfortunately, it is no exaggeration to say that freedom is waning across the West—not because foreign armies have defeated us in battle, or because all of our wealth has been drained by an alien economic power. Rather, the West is increasingly at risk of becoming  “post-democratic” because its most basic foundational values of free expression and the liberty and sovereignty of the individual are being banished from the public agora. Discourse at American colleges and universities today more closely resembles that of the notorious Artek indoctrination camp for young Soviet pioneer activists than the “discussion, collaboration, and enlightenment” Thomas Jefferson envisioned when he conceived of the University of Virginia. In both Europe and America those with aspirations for professional attainment in academia, the corporate world, or the media must increasingly bow to the dominant orthodoxies and purge their speech of all incorrect phrases, with the goal of ultimately cleansing their mind of impure thoughts.

Unmoored from its cultural heritage and increasingly ignorant of its history, the West is fragmenting along racial, ethnic, and ideological lines. In the United States the process is well under way of transforming “e pluribus unum” into an American Balkans in which warring groups squabble over past grievances—real and imagined—and where a sense of patriotism and the mutuality of obligation so fundamental to a nation under a republican form of government is being purged from the culture. Here America is not alone, as similar undercurrents of unfreedom are deconstructing some of the oldest political traditions in Europe.

With freedom of speech under assault, the West, both as a polity and as a distinct cultural inheritance, is in the throes of a fundamental battle for the survival of its democratic traditions. It is time for all of us to stand up for liberty. And to do so out loud.

The post The Rise of Unfreedom in the West appeared first on The American Interest.

For Unity, Community, and Responsibility: The Alliance Party of America Is Born

Editor’s Note:  The Alliance Party is a new 527 political party that recently formed as the merger of several smaller centrist parties. Those parties include the Moderate Party of Washington State, the American Party of South Carolina, and the Modern Whig Party as well as nearly a dozen others. The Alliance Party is one of several developments on the American political scene rising on the periphery of the two-party system. These include the Serve America Movement (SAM)—TAI published an essay by its leaders this past September—Better Angels, Unite America, With Honor, Stand Up Republic, the Renew Democracy Initiative, and several others. This essay is thus the second in a series that we hope will eventually include all of these new centrist forces in American politics and civil society, or as many as we can persuade to write for TAI. Full disclosure: TAI Founding Editor Adam Garfinkle is a member of the Alliance Party.

In February a new American political party was born: The Alliance Party of America, or, for short, The Alliance. The result of a merger sealed this past October among several centrist parties, we, this new Party’s national chairman and co-chairmen, beg your attention so that, beginning in a familiar traditional voice, we may explain why we have founded this party, and what we hope and expect it to achieve.

When in the course of human events it becomes necessary to alter the habits to which a democratic public has become accustomed, a decent respect for the opinions of our fellow citizens requires that we should declare the causes which impel us to this conclusion.

We declare these truths to be self evident to all sentient adult Americans, that the inalienable rights of us all—among these Life, Liberty and the pursuit of Happiness—stand jeopardized on account of the debased political conditions with which we now live. We assert that it is the Right of the People to alter such a status quo, and to institute new leadership for government, laying its foundation on principles openly declared and organizing its efforts in such form as shall be most likely to effect the best outcome for the common weal.

Prudence dictates that political stabilities long established should not be changed for light and transient causes. But when a long train of failures caused by an irresponsible, insulated, and self-absorbed political class threaten to render the nation dangerously divided, disconsolate, fearful, and unsafe, it is the people’s right to throw off such a failed political class, and to provide new guardians for their future security.

Such has been the patient sufferance of the American people; and such is now the necessity that, we believe, constrains us to alter our political circumstances. The history of the present American political class over roughly the past 40 years, composed of malefactors of both major parties, is a history dominated by inadequacies, hypocrisies, and cowardice.

So we declare the need for a new independence, not from an empire as was the case when Jefferson wrote the original Declaration, but from a political status quo that no longer serves its avowed purposes. To prove this need, let Facts be submitted to a candid nation.

The political class of the two-party monopoly has refused to allow reasonable ballot access for any party that might threaten its position. It has corrupted the Federal Election Commission and the relevant election commissions of the 50 states to erect artificial stringencies that prevent the American electorate from having a fair range of true choices from which to pick on election days.

The political class of the two-party monopoly has failed repeatedly to consummate its responsibility in the Legislative Branch to pass a budget in a timely fashion, and has failed even to enact legislation for automatic continuance resolutions, as have the legislatures of other democracies, in order to prevent harmful government shutdowns.

The political class of the two-party monopoly has consistently misled the American people as to its supposed devotion to fiscal responsibility. As a result of its short-term pandering and political cowardice, the nation is today saddled with a debt so huge—$22 trillion and counting—as to mortgage the future of generations of Americans yet unborn. The dangers of this debt to prosperity and national security alike are acute.

The political class of the two-party monopoly has repeatedly failed to solve long-gestating challenges to sound public policy, among them the need for comprehensive immigration reform, dealing effectively with the crisis of spiraling health care costs and insurance premiums, staunching the looming insolvency of the Social Security Administration, responding to the need for sensible gun control, arresting environmental degradation of several sorts, responding to the growing deficiencies of K-12 public education, and many others besides. These failures exist despite the ready availability of pragmatic solutions to all these challenges.

The political class of the two-party monopoly has failed utterly to take the measure of changes in the world economy and to adapt policies to manage those changes. Captured by corporate and financial special interests, both parties happily abetted the massive offshoring of good American jobs. Locked in an obsolete industrial-age mindset, neither party has made a remotely serious effort to understand and to adapt to the IT/AI-abetted age of automation into which we are now venturing.

The political class of the two-party monopoly has similarly misunderstood the nature of modern economic vitality. It has failed to invest in basic science, and in research and development, to the extent that its wiser forebears did. Worse, it has judged consumption a better index of economic vitality then production, resulting in a massive distortion of its own comprehension. Consequently, it has erected an array of disincentives to work, and so has harmed working families and the communities in which they live.

The political class of the two-party monopoly has unwittingly created a poverty trap for the nation’s most unfortunate citizens, locking them into barren islands of privation and virtual nutrition deserts through a combination of predictable job loss, poor education, prejudice, and but thinly veiled zoning/housing discrimination. That this poverty trap aligns with racial divisions in American society is a consequence of a tortured history of which we are all aware; but that it has been allowed to persist, now for decades, without significant further effort by government to make fair amends for that history is an affront to all that America stands for.

The political class of the two-party monopoly, in thrall to special interests, created the conditions for the economic collapse of 2008, a collapse in which large numbers of ordinary Americans lost significant equity, and from which many if not most have yet to recover. But the political class of the two-party monopoly bailed out the banks, and left the American people to their own devices. In the process they have also left a financial sector more concentrated, just as opaque and misregulated, and as bound again to collapse as the one that crashed in 2007-08.

The political class of the two-party monopoly has facilitated the complexification of the Federal tax code for the benefit of special interests, not least the upper 1 percent of the wealth pyramid, at the manifest expense of average Americans. “Carried interest” tax deferral scams are one example of many dozens.

The political class of the two-party monopoly has over time aggrandized the role of the Federal government in the American Federal system, over-centralizing it and thereby creating a crisis of democratic participation among the people. The administrative state and its voluminous bureaucracies on both the state and Federal levels have metastasized into a herd of one-size-fits-all behemoths that is neither effective nor efficient, thanks in part to the conflicting and overly specific mandates inflicted upon government functions by witless legislatures dominated by witless lawyers. Regulation is of course a necessary and natural function of government, but American society has become notoriously over-lawyered, driving out common sense, professional initiative, and civic participation—all at enormous, and mostly gratuitous, expense.

The political class of the two-party monopoly has shirked its responsibilities to make hard choices on an array of social issues, shunting off to a largely unaccountable bureaucracy and to the Courts their responsibility as elected officials to make such judgments—a role for the Judiciary that the Framers never intended.

The political class of the two-party monopoly has undermined the rule of law by failing to enforce existing immigration laws and by actually rewarding those who have broken that law with “sanctuary city” protection; by endorsing (very recently banned) asset forfeiture laws, and the hyper-militarization of the police, in contravention of the Fourth Amendment; by allowing a huge disconnect to emerge between state and Federal drug statutes; and by many and several other means as well.

The political class of the two-party monopoly has allowed the function of the Veterans Administration to deteriorate to an intolerable level, betraying those who have put themselves in harm’s way to protect our freedoms. This class has considered the VA to be so marginal to its concerns that rank patronage considerations have driven choices of leadership, to evident dismaying effect.

The political class of the two-party monopoly has been responsible for serial misjudgments and mistakes in the foreign and national security policies of the United States. In the greater Middle East alone several are familiar, but Democrats and Republicans alike also told the nation over many years that the growing wealth of China—made possible in large part both by American investments and by the U.S.-designed structures of the postwar liberal trading order—would result in a politically liberalized “stakeholder” China that posed no threat to American interests. These and other misjudgments have significantly undermined American leadership and now threaten to unleash dangerous chaos in the international system.

The political class of the two-party monopoly has reacted counterproductively to the post-9/11 threat of mass-casualty terrorism. Instead of asking the American people for courage and steadfastness, it has created a permanent bureaucratized paranoia that has undermined the pragmatic can-do spirit of the nation. And what it has done stupidly it has also done at enormous expense.

These facts represent no small failures each in their own right. But they sum to a conclusive indictment of the political class of the two-party monopoly, which has grown manifestly unrepresentative of the majority of Americans. One major party has lurched to the right and the other is far advanced toward lurching extreme left, both captured by special interests of one kind or another and both illustrating serious and growing internal fractures. Their abstract ideological manias have driven out pragmatism and any willingness to compromise on behalf of the nation, leaving our politics a toxic blood sport, and our political discourse a reproach to both decency and logic.

The rancor of our political rhetoric, egged on by a media culture fixated on clickbait, has abetted incivility, hollow political posturing, and outright falsification to an extent not seen since the decade before the onset of the Civil War. Indeed, the nation is increasingly hostage to a “cold civil war” thanks to the behavior of its political class. Unfortunately, the chill is thawing; we have already witnessed some political violence, and if we the people do not force into retirement most members of the current political class, the extent of future political violence could come to stagger our imaginations.

The failures enumerated above are ultimately behind the frustrations that led in November 2016 to the election of the current President, who has fomented in turn the crisis of American governance in whose midst we live and worry. The current President therefore must be seen as a symptom of deep dysfunction, as well as a subsequent contributor to that dysfunction since his election. Everything was not fine before November 2016, and it will not be fine in future just because the current President eventually leaves office—one way or another. It is a mistake to ascribe our problems to just one person, concentrated into just a few months of political time.

Some of us in the Alliance Party are angry, and many are frustrated. All of us feel disappointed with what our political leadership has done to our great country over the past several decades, and we tremble for our future. In essence, through their dereliction of responsibility as regards the national debt, their allowing an accident-prone financial system to get even worse, their lack of concern or action with respect to the inadequacies and inequalities of our system of public education, and their failure to understand or help adapt the nation’s labor profile to new circumstances, the political class of the two-party monopoly has declared war against America’s children, born and yet unborn. It is hard to overstate the travesty of intergenerational responsibility it has perpetrated.

We have come to the conclusion, many of us reluctantly, that hope for redemption from within the two major parties is no longer a serious possibility. The two dominant parties are locked in an increasingly obsolete pseudo-debate. Neither party’s leadership understands the new challenges afoot. Neither possesses even a vocabulary to analyze them. In consequence, neither major party offers any vision for the future—one offering a puerile nostalgia and the other a warped utopia. Both repel any hint of practical creativity within their midst.

We of The Alliance Party stand for the traditional virtues of politics as a vocation: reason, service, respect for others and their views, compromise, humility, honesty, a problem-solving focus, and the courage to make hard decisions. The members of the current two-party monopoly stand only for re-election. The process that collects money to produce an electoral win collects no input from the citizenry at large. Few of our elected officials feel any shame at putting party above nation, because they take the passivity and political fecklessness of the nation for granted. They therefore feel no compunction against trying to bypass the Constitution, distort the rule of law, and often even violate the demands of basic human decency when it suits their needs.

A time of political realignment in America is now upon us, and The Alliance means to be a leading vehicle of it. We want to be clear: The Alliance Party intends to establish a foundation within our communities for the long term. We will run candidates at all levels of government, and we mean to win many, many elections. We will not be satisfied with being a telegenic irritant or a fulcrum to drive the major parties back to their senses. We are not a “third party”—we are a new party that intends to become a major party. The American electorate must suffer no longer with choices of lesser evils.

Is this a realistic ambition? It has happened before in American history, when a major party—the Whigs, which put four Presidents in the White House—disintegrated in 1852 due to internal dissension and the modern Republican Party rose to take its place. Many leaders of the new party had been Whigs—not least Abraham Lincoln—but they switched allegiances and began anew to make a difference. It happened, too, in a different way when the Populists of William Jennings Bryan took over the moribund Democratic Party in 1896, and it happened in 1932 when Franklin Delano Roosevelt assembled the New Deal coalition that largely defined American politics for the rest of the 20th century. Something similar is about to happen again. It is time for reform and renewal. Indeed, it is past time.

Not convinced? Then recall what happened in the spring of 2017: Emmanuel Macron smashed the hollow vessel of French politics, winning the presidency and a parliamentary majority as both the Gaullists and the Socialist parties turned to dust. When a frustrated French electorate spied a chance for real change, an electoral revolution ensued. Is the American electorate today any less desirous of real change than the French one was less than two years ago?

We think not. More than 41 percent of new voters register as independents. That is no accident. Every poll shows that the American people believe, correctly, that today’s major parties do not represent their views. Every poll shows that most Americans feel a sense of futility with making their voices heard in today’s political environment. Their instincts are uncannily correct. A recent poll conducted by Triton Polling and Research found that 56 percent of New Hampshire voters would consider voting for an independent—meaning a non-two party monopoly—candidate for President. Why is that a significant number? Because if the 2020 Alliance Party presidential ticket wins 56 percent of the vote, that ticket will win the White House.

These views on the part of the American electorate align with the fact that many new centrist social and political movements have been founded in the past few years: Better Angels, Stand Up Republic, the Renew Democracy Initiative and more than a dozen others. This is a positive sign. The Alliance Party fully supports these new energies rising outside the bounds of the two-party monopoly, and looks forward to cooperating with all groups and individuals working to build the next American future. In this venture we are neither glibly optimistic nor pessimistic: We are merely very focused.

It is not enough to be against something. That is too easy and too emotionally indulgent. The Alliance Party is for an America that continues to struggle toward its high ideals, to create a more perfect union. We are in unbreakable agreement on a basic philosophy of government, which we express with just three words: unity, community, and responsibility. Let us elaborate a bit on what we mean.

Unity: The Alliance Party is dedicated inalterably to the principle of E Pluribus Unum. We will never, like current small-minded Republicans, deliberately divide Americans and sow fear and hatred by stigmatizing immigrants, blacks, Muslims, or any group. And we will never, like current Democrats, indulge in divisive “identity politics” blame-game victimization stratagems.

We reject all forms of bigotry and exclusion, which only divide us. We affirm without reservation the primacy of conscience and free speech as integral to basic human dignity.  And we believe we are all Americans first, political partisans second. The American people understand that more unites us as Americans than divides us as Republicans, Democrats, and others.

Community: We believe in the primacy of local politics—in other words, subsidiarity. As noted above, we believe the Federal system has become unbalanced toward the center, and that we need to return as appropriate resources and decision authority to the states and to localities in order to foster levels of democratic participation that can justify and fulfill the Founders’ vision.

Obviously, key functions of the Federal government remain critical to national security and well-being. We can easily name them, for they are virtually an historical constant across the globe. In the American case, six such functions stand out:

First, the Federal government must maintain full responsibility for external security—the military function—and for defining who is and can become a part of the nation within its territorial definition.

Second, the Federal government must establish and regulate the parameters of our continental-size market economy, which requires clear and actionable property rights, contract and patent law, and other legal requirements that must be constant for all 50 states. The idea that markets bear a primeval resemblance to natural selection and predate the invention of government—such that government should therefore have little or no role in their regulation—is ahistorical nonsense on stilts.

Third and related, only the Federal government can establish what money is, and manage its production and value.

Fourth, only the Federal government can enforce fairly and uniformly the highest law of the land—in our case including the Bill of Rights, an integral part of the Constitution.

Fifth, the Federal government must be responsible for major infrastructure investment and maintenance—including our burgeoning information infrastructure—since critical infrastructure far transcends the capacities of any one state or group of states to finance and manage.

And sixth, the Federal government must have the means to perpetuate itself such that roles within its main functions remain the same, but the individuals who fill them can change without undue disruption.

Beyond these six key functions, we believe that the primacy of state, county, and municipal government should prevail. The solutions to problems are usually best found nearest the problems. And after all, we live in an increasingly net-centric, distributed-system world; our over-centralized Federal system is a vestige of an industrial age now largely passed, and does us more harm than good.

Moreover, subsidiarity puts a high premium on democratic participation. It is much easier for most people to interact in smaller than in larger groups. Participation in democratic governance at the local level is also a means of building social trust and community, which we sorely need to restore after decades of erosion.

And mark well: Clawing back our overgrown administrative/bureaucratic Federal state is the only politically realistic way to get a handle on paying down our $22 trillion national debt, for neither eviscerating Medicare, Medicaid, and Social Security, nor raising taxes to levels necessary for the purpose, are even remotely feasible.

Of course, subsidiarity is not a panacea. Corruption at local levels is no scarcer than it is at the national level, and insular forms of blinkered thinking may at times be worse. Nevertheless, subsidiarity can enable populations who think “red” and populations who think “blue” to each have most of what they desire without denying the other what they desire. We do not need, nor should we seek, a one-size-fits-all solution for every public policy decision point that comes along, but rather embrace the bounded flexibility inherent in subsidiarity and in a well-balanced federal system.

Moreover, local government can function as experimental laboratories in search of new “best practices.” Winners can be scaled up across the states and, when appropriate, adapted to the national level. Waiting for all our problems to be solved at the national level is roughly akin to waiting for hell to freeze over.

Indeed, some culture war issues are so fraught with emotion and unmovable conviction on both sides that no solution to them on the national level is possible. These issues fester in endless toxic debate, poisoning the politics of everything they touch. It would be best to return such issues to local constituencies, where there is at least a chance for consensual resolutions. It helps that, in many cases, there is simply no remit in the Constitution for such issues to have ever become Federal questions in the first place.

In short, we believe government should better support what Edmund Burke called the “little platoons” of social life that form the bedrock of any decent political order. Too intrusive a central government actually undermines that bedrock, destroying the very basis of its own legitimacy over time. We believe government should strive toward the ideal of what Thomas Jefferson termed the virtues of “ward democracy,” a form of self-government that encompasses and gives voice to family, faith communities, workplaces, and, indeed, to the full array of Tocquevillian mediating institutions that are the traditional hallmarks of American democracy.

These aspirations are already built into the structure the Framers have given us; we see no need for amending the Constitution in any way to do what is best for our country.

That is why one proposal that the Alliance Party is considering concerns an expansion of the House of Representatives. The House started small: In 1789 there were only 65 members. With each census the number increased with population growth in order to maintain roughly the same ratio of representatives to constituents—until 1911, when Congress capped the size of the House at 435. But as the population continued to grow, that act meant that the original ratio shifted steadily upward. Today the number of constituents per representative is more than one per 700,000; the Founders had in mind something more like one in 30,000. No wonder most people feel de facto disenfranchised, as mere drops in an immense ocean.

Many proposals to enlarge the House have emerged since 1911, but they all ran up against a general antipathy to making government in Washington any larger than it already was. But now we can do something we could not readily do before: We can significantly enlarge the House, but not site it in Washington, DC. A new law enlarging the House could and should stipulate that Congressmen will spend only ten weeks a year in Washington, another ten in caucus with their state house colleague in their respective state capitals, and the rest of the time living in their districts and interacting with their constituents. Work would be broken down by committee assignments, and secure communications and vote casting insured by email, telephone, chat rooms, and other telecommunications venues—the same way every major business now operates.

When is the last time you heard a Republican or Democratic politician voice support for, let alone come up with, a significant constructive idea?

Last in this regard, one more important, but usually unspoken, virtue of bringing politics back to the level of communities and neighborhoods stands out: The toleration of differences—even the celebration of the dignity of difference—is far easier in the context of face-to-face interactions than it is through mediated images. It is much harder to look another person straight in the eye and despise him or her than it is to do so virtually on the internet, where anonymity is a normal if unnatural state of affairs.

Since most Americans are more tolerant in daily practice than they are in the ether of abstraction that defines virtual media, it follows that political polarization will decrease when Americans, irrespective of their political views, come again to depend on one another as neighbors—rather than on a faceless bureaucracy taking cues from a distant capital city.

People in any given community or neighborhood do not all share the same beliefs any more than on any given imaginary Main Street, USA all the houses look exactly the same. So long as it is not forced on people, diversity is certainly a great strength: It makes the nation more than the mere sum of its parts. It enriches everyone who lets it, and that would still be most of us.

Our communities are under tremendous stress at a time of massive and rapid change in the country and on the world; it is central to the Alliance Party’s mission to support, strengthen, and, as necessary, help build them anew. Strong and vibrant communities, and solid families within them, are the foundation of a strong and vibrant America. That our political class has for all practical purposes lost sight of that core truth is, we believe, the font of the dysfunction of the past quarter century.

But here we must be frank. Yes, we are critical of our two-party monopoly’s political class in recent times. But it is generally true that in a democracy people get the government they deserve. We the People have let the deal go down. We have not held our leaders’ feet to the democratic fire. In our affluence and complacency, lulled by the ceaseless temptations of a shallow entertainment culture, we have been lax in fulfilling our obligations as citizens. We have rendered ourselves too easily divided by political sharpsters who use language for its shock effect like social media uses clickbait. We have not well shouldered the civic responsibilities of self-government. So when we go pointing fingers, we need occasionally do so in front of a mirror.

Responsibility: Citizens of a democracy have a civic duty to participate in creating and maintaining a decent social and political order. We hear much talk of rights, but rights are meaningless without responsibilities. Symptomatic of the crisis of participation we face, many Americans have come to assume that the government grants rights to people as it grants financial benefits to some. But the premise of the Constitution is that sovereignty resides with the people; so it is the people who grant rights to the government, not the other way around, to create our unique form of ordered liberty.

But for ordered liberty to work in the context of limited government, citizens must engage in efforts to realize common goals outside of government—in society. So beyond voting every once in a while, citizens must work together on behalf of the common weal—whether by volunteering to mentor the young or to care for the old, being mindful stewards of the land, or investing resources in a better future.

Civic responsibility also means being an educated voter and community participant. That means getting off the couch and away from the screens that pervade our lives and into the mix of the real world—the world outside our heads. We learn with and from others, and we learn from doing as much or more than we can learn from books.

The Alliance Party’s emphases on community and responsibility are obviously related. If our communities are sound, people will be drawn to participate in them. They will embrace their agency and fulfill the civic responsibility that their liberty requires. By the same token, when people participate they build community in the process. The unraveling of both participation and community that so many Americans have experienced in recent years can be reversed only by joining the two elements together, this time in a positive direction.

That is why, for example, The Alliance supports a scaled-up voluntary National Service/Baby Bond program. Such a program can build community and social trust even as it spreads equity available to young people. We are also studying the feasibility of a New Pioneer Act—a renewal of the 1862 Homestead and Morrill Acts. As with the original, a New Pioneer Act would use selected plots of Federal land to build new communities, some based on state-of-the-art non-corporatized agriculture, others on different economic bases. The aim, again as with the original, is to spread equity, especially among young people, teach craft and touch skills, rebind people with the natural world, and experiment with a range of new best practice innovations in education, elder care, infrastructure and more. Such a program, if ultimately scaled up from pilot-scale beginnings, would also create huge numbers of good jobs as these new communities prove market-viable.

The Alliance Party places the highest value on being present and active at the local level because we are not a conventional political party: We are part social movement, as well. We correspond exactly to what David Brooks wrote in his May 14, 2018 New York Times column: “I’m a Whig. If progressives generally believe in expanding government to enhance equality, and libertarians try to reduce government to expand freedom, Whigs seek to use limited but energetic government to enhance social mobility.” (Full disclosure: One of the merging parties that has formed The Alliance Party is the Modern Whig Party.)

We have ideas about energetic but still limited and self-limiting government, and about social mobility. One of them involves getting people working together at local levels throughout the country to “Plant a Billion Trees” in a decade. (That sounds like a lot of trees, but it works out to fewer than four per person spread over ten years.) We can help ameliorate global warming by sequestering massive amounts of carbon in one of the most cost-effective ways science offers us.

We will partner with other groups to get these things done, and so knit together more social capital in the process. We can create local Planting Brigades and develop youth-based “Dig That Tree” Auxiliaries to help them. We look forward, as well, to establishing community-based stewardship associations to care for our environmental commons. If businesses and other groups can “adopt a highway,” communities led by The Alliance can adopt a forest or a park or a public playground.

It is important that Party community-building activities involve multi-generational civic participation, because age-segregated cohorts compose a significant social problem. We want sports leagues, faith communities, book clubs, and groups of all kinds to pitch in. We emphatically include able residents of retirement and even assisted living facilities, for we are largely wasting the accumulated experience and wisdom of the steadily increasing numbers of healthy and still vital retirees among us. With our youth and with our elders we will go forward together.

We have other ideas, too—on the debt problem, education, immigration, national security, healthcare, press freedoms, energy, civil rights, sustainable economic growth, climate change, gun control, and more. Read our Platform for some details.

And unlike the major parties we have also established an ongoing Alliance Party Policy Workshop in which ideas are presented and discussed among Party members, and the general public beyond, on an ongoing basis. We relish open debate and welcome an environment in which argument is conducted in the spirit of reaching a common goal, and through it a better future for all Americans. The Alliance Party invites a spirit of constructive engagement within its ranks and between Party members and the wider American public.

Why? Because the nation needs ideas, small- and medium-sized ones but also big ones. America is at its best when it conceives and pursues a pioneering project, a collective striving with a purpose. That is partly because we share but marginally the sort of bloodline nationalism characteristic of other Western nations. Hence, we have always had a smaller social idea than that of our European allies, which helps to explain their greater affinity for social democratic welfare states. Our creedal founding as a child of the Enlightenment has bequeathed a more abstract national ethos, which has meant that America’s national unity has tended to inhere more in a sense of common purpose than in a static “creed” or DNA base: As a nation we have always been more verb than noun, so to speak; but that has made our unity more fragile and so, as our history illustrates, more vulnerable to disruption.

Now it is, once again, painfully disrupted. We live in a relatively rare moment in our history when no clear common pioneering vocation exists to unite us, even as the stories we tell about ourselves have lost traction. Indeed, the pessimism stalking the land arises mostly from a pervasive sense of collective purposelessness. And so the nation seems to be disintegrating into identity groups defined partly by class, partly by educational levels, partly by ethno-racial criteria, and partly by ideology—all reinforced by the now-well-understood echo-chamber effects of designer media.

Worse, our routine political dynamics now exacerbate instead of ameliorate this disintegrative tendency. Political entrepreneurs both Left and Right, preying on economic insecurity and fear of ethnic and subcultural differences, seek to create partisan enclaves defined by contending us-versus-them atavisms. “We the People” are shrinking among what some call the “tribalization” of our society and politics.

For reasons already laid out, we cannot now expect social/institutional innovation from the Federal government in its current state of disrepair, as we have experienced in our history with a variety of projects—the Homestead and Morrill Acts, the Civilian Conservation Corps, the GI Bill, and others. Reform dynamism must therefore start from outside government, and it must renovate government as it moves toward success. That is why the social movement aspect of The Alliance is so critical.

The story Americans must tell each other in the onrushing future is a story about work and dignity, about mastering technology before it masters us, and about finding new unity in a new purpose that wrestles with both—and that will ultimately defrost our government from its present immobility.

We are under no illusion that all of our problems are political in any simple sense. The strains we all sense run deep in the culture. Many disquieting trends have been decades in the making. Some we recognize; others, like the striking decline of deep literacy, we have barely noticed. Passing this or that law cannot vanquish all the challenges we face, but working together we can ease the pains of this difficult era. That is the least we can do, and it is what we must do.

We must wrestle with the deeper challenges we face together, in the great noisy swirl of American democracy as it rises above the inert funk into which we, together with our failed political class, have cast it. We will bring solutions to government. The people will solve their problems, as only the people can. As always, democratic government reflects us; it does not, for it cannot, fashion us.

There is a peaceful revolution in our future. The pioneers of the next America are rising among us now, and The Alliance is the vanguard of that peaceful revolution. We need you to be successful, so please join us. Can you, especially those of you with children and grandchildren, afford not to?

For one version of this proposal, see Michael Brown, AnnMaura Connolly, Alan Khazei, Wendy Kopp, Michelle Nunn, Gregg Petersmeyer, Shirley Sagawa, and Harris Wofford, “A Call to National Service,” The American Interest (January-February 2008).

The post For Unity, Community, and Responsibility: The Alliance Party of America Is Born appeared first on The American Interest.

When “Profit” Is Just Another Word for “Waste”

More Than Medicine: The Broken Promise of American Health

Robert M. Kaplan

Harvard University Press, 2019, 240 pp., $29.95

The reader of Robert M. Kaplan’s new book is confronted in its early pages with two startling observations:

The state of health in the United States is already worse than in peer countries, and we are losing ground. . . .

If U.S. health care spending were in line with that of our peers, we would save some $1.1 trillion per year, enough to fund all sorts of public goods such as education, infrastructure, industrial policy, social insurance, and defense. We could retire the national debt in about fifteen years.

Many Americans are already aware of the extraordinary cost of health care in the United States. This fact is frequently explained away by asserting that such is the price to be paid for the best health care system in the world. Kaplan’s book shatters that comforting myth and exposes the American health care system for what it is: below average in quality and therefore way above average in cost. And he makes a dire prediction:

Failing to get to average means that more and more resources will be confiscated on behalf of a health care system that produces only mediocre outcomes. Preventable health conditions will continue to limit our workforce, making the economy less competitive. Reform always comes with difficulty, but, in the U.S. case, maintaining the status quo is the riskiest strategy of all.

To back up his main premise that Americans are vastly overspending on health care, Kaplan hits a number of important points. He marshals data about the overall poor quality of the American health care system. He documents the very common application of clinically inappropriate care in the United States, while at the same time noting the American failure to apply best-practice clinical science consistently. He also challenges the commonly held point of view that the pathway to optimum health treks through biomedical intervention. But perhaps his harshest criticism is directed at the poor safety record of hospitals:

Over the past few decades, it has become increasingly clear that medical care is a source of considerable harm. . . . A recent analysis of studies published between 2008 and 2011 finds that preventable medical errors account for between 210,000 and 400,000 deaths nationwide each year. . . . If the higher estimate is right, that means about five people die of complications from medical care for each one who dies of diabetes or Alzheimer’s.

Kaplan has a prescription for improving American health system performance.

The United States would benefit from new research exploring the health effects of quality improvement, social conditions, and behavior. Existing evidence suggests that a health system designed on the basis of this research will improve health by attending to a broader range of health determinants. Happily, other wealthy countries already demonstrate that such a system is also less expensive than our own. But even if reform saves money in the long run, it will cost a lot in the short term. Where will the funds come from? One possible source is money we could be saving by reducing waste in the health care system. In 2013, the Institute of Medicine estimated that inefficiencies cost us about $750 billion per year in that sector. This suggests that roughly a quarter of health care expenditures yield no benefit.

Kaplan makes a persuasive argument that we Americans are not getting a good return for our investment in biomedicine, which he characterizes as health care devoted predominantly to biological mechanisms to the relative exclusion of social and behavioral determinants such as violence, poverty, racism, workplace policy and stress, and poor education.

Kaplan is particularly effective in outlining the enormous cost of poor-quality care. “Per capita, the United Kingdom spends about $0.40 for each dollar spent in the United States,” Kaplan writes, “Belgium and Denmark spend about $0.50 for each dollar spent in the United States; Spain spends about $0.33.” Kaplan begins the book by speculating that Americans must find the pursuit of good health to be more important than any other objective, because they are willing to spend so much in search of it.

Health care now accounts for the biggest sector in the biggest economy in the history of the world. In 2017, the United States spent $3.2 trillion, or about 18 percent of the gross domestic product (GDP), on health services. Most countries that Americans consider our economic competitors spend less than 11 percent of their GDP on health care. If the U.S. health care system were an independent country, it would have the fifth-largest economy in the world, behind only China, Japan, Germany, and the United States itself.

This high price for biomedicine comes at the expense of opportunity costs for American government at all levels, but it is also pinching the economic status of individual Americans.

Few households can avoid the pinch. On average, American families now pay 23 percent of their income for health insurance premiums. In 1999 that figure was 11 percent. We are getting less in return, as deductibles and copayments increase. These costs also come out of wages and job opportunities. Faced with the high price of insurance, employers are less able to expand workforces and raise employees’ pay.

Kaplan notes that excess health care spending in the United States is not buying Americans better health when compared to that enjoyed in other developed nations; quite the opposite is true. But Kaplan’s strongest observations about the disconnect between health spending and health status are about the variations in health care delivery among the regions within the United States itself. Referring to data published by researchers at Dartmouth University, known collectively as the Dartmouth Atlas, Kaplan writes:

The Dartmouth Atlas, breaking down health care use geographically, makes for stark reading. The maps show that the amount spent on health care and the number of services delivered differs greatly across geographic regions, with no relation to age, race, or sex distributions, or to diagnostic profiles of given communities. . . Evaluations of the Dartmouth data find essentially no relationship between per capita spending and health outcomes across the United States. . . Indeed, a variety of evidence links greater use of care with bad outcomes. Several analyses show that people are slightly more likely to die in communities where more acute hospital care is used.

In a final damning observation about the massive variation in clinical practice in the United States, Kaplan concludes that high utilization is a direct consequence of supplier-induced demand. After noting that discharge rates for high-variation conditions are low where hospital bed space is more restricted, Kaplan offers the following observation:

The correlation between admissions and supply of beds suggests that, where care is available, it tends to be used—that oversupply is inducing high demand and not that supply is growing to keep up with demand that would otherwise be there. . .it is clear that providers create demand for their services by diagnosing more illnesses. . .the level of variation in health care services remains high today. . .That variation doesn’t seem to result in great differences in outcomes, suggesting that greater expenditures aren’t buying us better health.

Kaplan leads us to the point of understanding that the high variation in health care utilization across regions in the United States must document massive use of clinically inappropriate care, meaning care that is rendered without there being any significant chance that the patient’s condition will benefit thereby. Kaplan, therefore, is forcing us to recognize that in the American health care system, business as usual would rather make a sale than really care for a patient.

But that is not even the worst of the American health care system, according to Kaplan. Both the clinical science that provides the foundation of American biomedicine, and the hospital bedside, where biomedicine is practiced upon the patient, are failing to focus on what the ill and injured really need, or more importantly what we all need in order to live well.

Noting that the cutting edge of biomedical research is often dull, Kaplan provides the reader with a brief history of Federal funding for clinical science research, specifically highlighting the growth and development of the National Institutes of Health (NIH). Writes Kaplan: “For all our genius, our research process is beset by systemic flaws that undermine the quality and usefulness of scientific findings.” In essence, he argues that American biomedicine research has not realized anything like the hype surrounding it.

For instance, the Human Genome Project, costing billions, was predicted to “revolutionize the diagnosis, prevention, and treatment of most, if not all, human diseases,” leading to the “complete transformation” of clinical medicine. Now, 20 years later, none of these transformations have taken place. According to Kaplan, genetic research has provided scant incremental value over an old-fashioned medical interview with a family history, taken, in time-honored tradition, by a physician at the patient’s bedside.

The problem is not just unrealized hype, but what Kaplan calls research malpractice. Poor methods, publication bias, research not applicable to clinical settings, inadequate basic science supplies, and overuse of animal models all have a role in creating a clinical science community that has a research product that is incorrect about half the time. As evidence of the failure of the biomedical science community, Kaplan notes that new pharmaceutical innovations are not appearing, which he blames not only on the poor practice of clinical science research, but also on the drug industry:

Its priority is to make money, not to provide better health. Thus companies spend literally billions of dollars tweaking older, effective drugs in order to re-release them before patent monopolies run out. With minor modifications to their products, firms can wrest drugs from the generic market, securing their bottom lines.

Even when effective treatments are available, American health care providers as often as not fail to deliver these treatments to their patients. Kaplan illustrates this conundrum using heart attack, stroke, high blood pressure, and other clinical problems as examples.

In the case of high blood pressure, it has been known for 50 years that untreated high blood pressure leads to cardiovascular disease (heart attack and stroke). Effective treatment for high blood pressure is available. But, as a nation, we still fail to deliver this needed care consistently. Kaplan notes that one-fourth of American patients with high blood pressure do not know they have it, and 40 percent of those aware of their high blood pressure are not being treated. But at Kaiser Permanente, 87 percent of high blood pressure patients are treated and controlled. How is this accomplished? Here’s what Kaplan found:

Kaiser’s approach upends traditional models of medical care. Instead of waiting for a person to make an appointment with her doctor, Kaiser is proactive. Kaiser’s physicians measure blood pressure during every encounter. Patients diagnosed with hypertension hear from a Kaiser employee regularly. . . Kaiser initiates contact and relies on a range of providers, reducing barriers to effective care.

Kaplan effectively argues that U.S. health care business as usual fails to help patients because patients are not the reason health corporations are in the health business; profits are the reason. Distracted by the bottom line, American health care businesses cannot realize the optimum value of our health care dollars. Non-profit organizations, like Kaiser, seem best suited to take on quality improvement in health care delivery, thus saving lives and dollars.

One of Kaplan’s more interesting observations is contained in the book’s chapter about the social determinants of health. Noting that there is good reason to “believe that social forces are not only associated with ill health but are also sources of it—sources we can try to address,” Kaplan argues that higher social spending in European countries is the explanation for Europe’s advantage in life expectancy over the United States, because “this spending helps reduce poverty, improve school performance, mitigate the handicaps of discrimination, and promote healthful behaviors such as eating well, exercising, and refraining from smoking.”

Pre-eminent among these social determinants of health, according to Kaplan, is educational attainment:

Education is more important to health than are other social effects. If we could eliminate homicide there would be about 12,000 fewer deaths in the United States per year. Eliminating fatalities from automobile collisions would reduce deaths by about  30,000 per year. Eliminating diabetes, itself powerfully influenced by social factors affecting diet and exercise, would reduce the number of deaths by about 80,000 per year. But ensuring that everyone gets a high school education could prevent an estimated 240,000 deaths per year.

Kaplan backs this startling observation by citing multiple studies of large populations of Americans which find that “there is in fact a systematic relationship between educational attainment and life expectancy” which is not accounted for by income or other demographic differences, not is it due to medical and behavioral risk factors. He acknowledges that there is no unifying hypothesis which would explain this robust relationship.

This observation brought to my mind a study conducted by McKinsey and Company ten years ago entitled “The Economic Cost of the U.S. Education Gap,” by Auguste, Hancock, and Laboissiere. Noting that deficits in American education were identified in a landmark national report in 1983 (“A Nation At Risk”), the McKinsey authors asked how the failure to close the gap between American education and high performing nations by 1998 affected the economy. Their answer? The 2008 GDP was $1.3 to $2.3 trillion smaller that year due to the poor educational performance of U.S. schools. Why did our nation fail to close the international education gap by 1998, 15 years after the first President Bush declared himself to be the education President? Could it be that Kaplan is correct, one of the opportunity costs of spending $1.1 trillion too much on health care each year in the United States is that we are failing to improve the education of our children? Apparently that opportunity cost is twofold because it both leads to 240,000 premature deaths each year and costs us $2 trillion in annual lost productivity.

Kaplan is a scholar, and so takes a very measured tone. Given his startling findings about the failure of American health care delivery, a more determined look at the business factors affecting how we Americans do health care might have been useful. It’s simply not true that the problems in cost and quality that Kaplan identifies are due merely to a misapplication of biomedicine. This is not just a philosophical problem. There are hints sprinkled throughout the book that he sees the business issues as the issues.

In the final chapter of the book, entitled “A Way Forward,” Kaplan discusses six systemic pathologies responsible for waste in American health care, based upon the work of Donald Berwick and Andrew Hackbarth. These six pathologies are failures in health care delivery, poor care coordination, overtreatment, administrative bloat, pricing, and fraud and abuse. Between the lines written about these six pathologies is, I believe, what has to be understood as a criticism of the core business model of American health care corporations. With the exception of fraud and abuse, these pathologies all come about because the focus of health business in the United States is not on what the patient really needs, but how best to exploit a patient’s pathology for profit. What Berwick and Hackbarth (and by extension Kaplan) call waste, American health care business calls profit.

Kaplan’s reticence to push hard on the U.S. health care business model leads to one truly regrettable sentence, found on page 3: “That same faith (in biomedicine) fuels runaway prescription drug prices: only because we believe we need them are we willing to pay so much for them.” Here Kaplan ignores an obvious reality. People with diabetes, for instance, don’t believe they need insulin, they know it. But the pharmaceutical firms also know they need insulin, which is why they can increase insulin prices by orders of magnitude. Unlike a market, demand for health care goods and services doesn’t change with price. No one ever had an appendectomy because it was on sale. And no insulin-dependent diabetic ever stopped trying to buy insulin because the price was too high.

Kaplan is correct that the time for radical change in American health care delivery has come. Personally, I have long since preferred single-payer health system reform. If we already had such a system in the United States, Kaplan’s preference for a greater emphasis on the social determinants of health would be more likely to occur, because we would already be saving the hundreds of billions of dollars now annually wasted on the inefficiencies of health insurance. Reduced public spending on health care would create the opportunity to increase social spending, for instance on education. For readers not yet ready to embrace radical reform like single-payer, More Than Medicine: The Broken Promise of American Health will offer a genteel, scholarly view about the dumpster fire that is the American health care system. That would be a good place to start.

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