Peter L. Berger's Blog, page 76

Mohamed bin Salman Unhinged? Maybe Not

No Saudi official has been more applauded and vilified at the same time than Mohamed bin Salman, the Crown Prince and de facto ruler of Saudi Arabia. That is not surprising, given the transformational nature of the project he’s leading at home, which is bound to create both winners—those who wish to open up the kingdom—and losers—those who wish more or less to preserve the status quo.

However, in foreign policy, no such polarization in world opinion about Crown Prince Mohamed seems to exist. The consensus—not shared by the Trump Administration as per usual—is that the young Saudi leader’s behavior abroad is impulsive, reckless, and outright dangerous. The only uncertainty about Crown Prince Mohamed in foreign affairs, it seems, pertains to what the 33-year old whirlwind will do next, or, to be more precise, what new crisis he will create.

In a little over a year since his appointment as second-in-command, “MbS,” as he is known for short, has raised many eyebrows and caused much consternation. He has instigated a disastrous and so far ineffective military intervention in Yemen’s civil war, freeing a host of demons from historical captivity and imposing massive humanitarian suffering on Yemen’s civilian population. He has imposed a sea and land blockade on Qatar. He has also detained Lebanese Prime Minister Saad Hariri in Riyadh, started a feud with Canada, and recalled the German Ambassador while forbidding the Saudi government from doing business with German companies.

Crown Prince Mohamed’s supporters claim that he has had legitimate reasons for all these actions. They blame media bias and general misinformation about Saudi Arabia for MbS’s bad international press. But the world remains skeptical, and policy elites are plainly worried about the Crown Prince’s next foreign policy move.

Some concern about Saudi foreign policy under the current leadership dispensation is justified. MbS lacks experience in the complex affairs of the world, seems unable to learn from his mistakes, has taken too much onto his plate too fast, and has surrounded himself with yes-men. He also believes he has the unconditional backing of President Trump, a presumption of constancy in a man with a marked tendency to boomerang on his erstwhile “friends” if he senses a slight or so much as a scintilla of disloyalty. All of this makes for, at best, a risky formula for the conduct of Saudi foreign policy. At worst it is a prelude to calamity.

All that said, there are limits to the harm his statecraft is likely to cause. The reason has to do with the difference between diplomacy and statecraft—words that many otherwise intelligent people assume to be synonyms, but are not.

Diplomacy concerns relations among states. Statecraft concerns the concert of a leader’s assets, domestic and foreign, into a unified operating strategy. And here is the rub: Crown Prince Mohamed’s top priorities are domestic. This suggests that he is and will continue to be more restrained in foreign policy than many think, on behalf of his domestic reform vision. This might not sound credible or reassuring in light of all the trouble he has caused already, but if one thinks his second year will give rise to something as stability-shattering as, say, a war with Iran, then this is a good time to stow the panic button.

The success of MbS’s grand reformist project, dubbed Saudi Vision 2030, requires utmost stability and control at home. This partly explains his aggressive consolidation of power: sidelining would-be political competitors, silencing critics, and jailing activists. MbS took major risks in this attempted consolidation, breaking two structural pillars of the regime simultaneously: the Al-Saud/Al-Wahab conjunction that has defined the temporal-religious authority balance within the Saudi polity from the outset; and the family consensus model (ijma’) that preserves elite unity amid the royal family. Arguably, taking such risks was necessary to jump-start the reform process, but the reverberations of having done so are not yet quieted. A major foreign policy crisis such as a war with Iran would profoundly jeopardize the entire reform process because it would re-empower the actor most capable of undoing everything Crown Prince Mohamed has been trying to accomplish: the Saudi clergy.

Any kind of war with Iran—whether short or long, deliberate or accidental—will enable Saudi religious leaders, who have been deeply unhappy with MbS’s cultural and economic reforms, to regain their influence in Saudi society. That would doom Saudi Vision 2030, which is a social as well as a narrowly economic program, because its realization necessitates the curbing of the sheikhs’ powers. The risk is not that the kingdom’s clerics would unseat Crown Prince Mohamed and his father King Salman in the event of a holy war with Iran, although in league with disgruntled members of the Saud elite that is not out of the question. The threat is rather that the clergy’s role and authority would catapult upward, for national mobilization in Saudi Arabia is impossible without religious sanction. That would undermine all that the Crown Prince has promised, stood for, and worked to fulfill. His sense of statecraft compels him to avoid regression in the crucial matter of clerical power, and he knows that a major war would produce exactly that regression.

So long as the struggle for influence between Crown Prince Mohamed and the Saudi clergy continues, the Crown Prince will keep talking tough about Iran but most probably refrain from engaging in any overt acts of war. That said, MbS might still resort to various options up to but not beyond the threshold of direct warfare. The Iranian leadership might think the same way too, and hence in a scenario of mutual brinkmanship the possibility of accidents cannot be ruled out. The famed British diplomat Robert S. Vansittart once wrote of Kaiser Wilhelm II, the German emperor: “He did not like war, but he liked doing all the things that led to war.” The same could prove true of MbS.

The moment a clear winner in the ongoing Saudi domestic power contest emerges is when we should start worrying about an unhinged Mohamed bin Salman. But since that emergence won’t happen very soon, if it ever does, we should heavily discount the likelihood of Saudi Arabia turning into a genuine “crazy state,” defined by the Israeli scholar Yehezkel Dror as one that exhibits high levels of irrationality and whose behavior deviates from “what is considered normal behavior within the international context.” By that standard, the Saudi leadership is no crazier than the leadership of the United States seems to be these days. There now: You’re calmer already, right?

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The New Landowners

During the French Revolution, in the days before the Terror, the Constituent Assembly was shaped like a horseshoe, with radicals sitting on the left and monarchists and the nobility sitting on the right. The layout shaped the colloquial language of Western politics for nearly two centuries, as observers generically called workers “the Left” and capitalists “the Right.” The utility of this Left-Right paradigm declined over time, as “culture war” issues displaced those of political economy. But now it is all but meaningless when self-proclaimed socialist Alexandria Ocasio-Cortez allies with the Koch Brothers and the Cato Institute to push for open borders, when the socialist Bernie Sanders joins with the capitalist Warren Buffett in calling for single-payer health insurance, and when Black Lives Matter finds common cause with Silicon Valley billionaires and the libertarian Charles Murray in support of Universal Basic Income. Even free college now has both hefty Democratic and some Republican support. The old Left-Right continuum not only fails to predict how rich and poor might vote today, but also how rich and poor might forge actual alliances.

Failure to take culture into account was always the biggest failing of the Left-Right model of politics. People vote more than just their pocketbooks. There are “values” voters; there are also single-issue voters in which the single issue is not economic—for example, ethnic identity or national pride. Still, economics is important, and there may be some value in stripping the world of everything but its economic motivations, as the old Left-Right model did, at least as a thought experiment.

A new model might start with trying to account for Alexandria Ocasio-Cortez’s political platform, along with some of her press statements. She calls for Medicare for All, housing as a human right, tuition-free higher education, a Federal jobs guarantee, a $15 dollar Federal minimum wage, open borders (euphemistically described as “safe passage” for all people wanting to enter the country), and the abolition of the Immigration and Customs Enforcement agency (ICE). On the surface this appears to be a grab bag of leftist causes, yet there is a pattern here. For example, the health care, housing, and higher education fields that she emphasizes also happen to be the three biggest economic bubbles in the American economy. The housing bubble burst in 2007, but has since re-inflated. Health care and higher education remain bubbles in the sense that they are the last two major economic sectors to be shielded, more or less, from market forces that enable consumers to strongly influence price. For this reason, health care, higher education, and housing are expensive relative to what average people can pay.

Ocasio-Cortez’s open borders position is more curious. One might expect socialists to push for more immigration—to satisfy their allies in the identity politics movement—but not to emphasize it, given mass immigration’s risk to American workers and its undermining of trade union power to the benefit of corporations. Yet she places it front and center. Assuming she is not a shill for global capitalism, or a “useful idiot,” there must be an underlying logic to this new socialist position as well.

An alternative perspective on these events can be found in the 19th century. In between Adam Smith, who predicted a harmonious world where capitalism would benefit everyone, and Karl Marx, who predicted violence and revolution, the British economist David Ricardo offered a third view of the economy.

Ricardo divided society into three groups: workers, capitalists, and landowners. He felt sorry for the workers, who, he said, lacked self-restraint, and who would produce a flock of children whenever their wages went up, creating more workers to compete their wages back down. He was less sympathetic to the capitalists, although he did acknowledge the risks they faced from competition, disruptive technologies, and low profit margins stemming from their workers’ constant demand for higher wages. But he hated the landowners. Not only was their income unaffected by population growth or intense competition, he said, but they also gained at everyone else’s expense.

In his Principles of Political Economy, Ricardo explained how the tragedy played out in light of the Corn Laws, which were tariffs placed on grain in 1815 to protect British landowners from the falling price of wheat. Take a well-situated British landowner who grows wheat on fertile land, and a second landowner whose land is the same size but less fertile. Both sell their wheat for the same price, but the well-situated landowner enjoys a larger profit. Now let’s say the capitalists in the city expand their businesses, leading to an increased demand for workers. The demand pushes up wages, but the workers procreate more, adding more workers and depressing wages. Still, the new workers must eat, increasing the demand for wheat, which leads to more land being cultivated. Since the well-situated landowners already work the most fertile land, any new land farmed will be less fertile and have higher unit costs relative to output, causing the price of wheat to rise—especially when the Corn Laws have closed the market to imported grain. When this happens, and wages remain stagnant, workers go hungry. Eventually capitalists must pay their workers higher wages to keep them alive, causing their profits to fall. Yet well-situated landowners benefit by doing nothing, because the difference between the new price of wheat and their low unit costs grows even larger.

An analogous situation exists today, except that instead of workers, capitalists, and landowners, we have workers, capitalists, and a consortium of colleges, health care institutions, and smug homeowners. Capitalists expand their businesses, increasing the demand for workers, which boosts wages. This time workers are smarter and procreate less, especially workers at high-income levels. Nevertheless, new workers keep being added through mass immigration, which depresses wages. Although wheat is no longer a problem, as technology has made food production cheap, housing, health care, and higher education care are problems. They are essential to life, or at least to livelihoods in advanced economies, yet they have been shielded from market pressures—almost as if they had a tariff wall around them—causing these industries to remain inefficient.

To continue with the analogy, our expanding population increases demand for college educations, health care delivery, and housing, which are produced inefficiently and expensively, much the same way that using less fertile land to grow more wheat drove up costs under the Corn Laws. Workers then demand wage increases from capitalists to pay the new costs, threatening the capitalists’ bottom line. Both parties are miserable, while those working or living inside the three bubbles make out like bandits. 

In the case of higher education, colleges must add new classrooms, dorms, labs, and staff to meet increased demand, especially in the less selective and poorly situated “mass” colleges that bear the brunt of that demand. This costs money. Shielded from market pressure, they do so inefficiently—for example, most colleges suffer from administrative bloat—which costs more money. The result is increased tuition levels. Despite new spaces having been created for students, tuition has risen at four times the rate of inflation since the demand for college increased 50 years ago, analogous to how the price of wheat rose in 19th-century Great Britain despite more land being put into production, as Ricardo predicted.

It gets worse. The poorly situated colleges should have difficulty passing on the increased costs to the children of workers, just as the poorly situated landowners profited much less from increased wheat prices because of their higher production costs. But government covers their inefficiency through student loan programs, which lets tuition rise even higher. The students themselves—meaning future workers—absorb the new high costs by going into debt. It’s as if the British government in the 19th century had loaned workers money to buy wheat at some inflated price, and then expected them to pay it back. Some professors get government grants that colleges then siphon off to varying degrees to pay for the new facilities; in essence, they are servants who come with their own salaries, part of which is then kicked back to the masters who employ them. If students default, workers and capitalists everywhere must pay higher taxes to reimburse them. If professors fail to renew their grants, they are kicked out and replaced with more productive ones. The poorly situated colleges do reasonably well in this environment, certainly better than Ricardo’s poorly situated landowners.

Meanwhile, well-situated colleges such as the Ivy League schools need not expand at all, since they become even more selective and prestigious by doing little or nothing different. With a fixed number of student spaces amid increased demand, or with a small, albeit inefficient, expansion, they can raise their tuition far above the new prevailing tuition charged by the poorly situated colleges, and choose from among thousands of applicants who will gladly pay the extra money.

Indeed, just as Ricardo noted that well-situated farmers prefer inefficiency among poorly situated farmers, so do elite schools prefer inefficiency among poorly situated colleges, for if college tuition rises among the “mass” colleges, the tuition that elite colleges can charge rises even higher, since many people will pay a premium for prestige. To use Ricardo’s language, the difference between tuition at elite colleges and their actual production costs grows wider, as evidenced by the widening gap between the cost of public universities and elite private ones. Adjusted for inflation, between 1975 and 2018 the average cost of a four-year public college (in-state) increased 240 percent, although if state subsidies had not declined during these years the increase would have been closer to 230 percent. During this same period, the average cost of a four-year private college increased 260 percent. Meanwhile, at the top of the tree, the cost of a Harvard education increased 286 percent. Like the well-situated landowners of old, the well-situated colleges can benefit by doing nothing new or different.

In the case of health care, hospitals, physicians, insurance companies, and drug companies must add more rooms, facilities, services, and products to meet the increased demand for medical care from an expanding population, and from the increased number of Medicaid patients within that expanded population because of the Affordable Care Act (ACA). This costs money. Shielded from market pressure, they do so inefficiently, analogous to the inefficiency inherent in farming marginal land. Not surprisingly, the inflation-adjusted cost of health care per capita, similar to the cost of college tuition, has increased five-fold over the past 50 years, just as Ricardo’s theory predicts, with almost half of that increase due to administrative costs, price increases, and the rise of third-party payers.

But again, it gets worse. The poorly situated health care operators might be expected to have difficulty passing on the increased costs to workers in the same way poorly situated farmers had difficulty passing on the increased cost of wheat. But government credits, tax deductions, and ACA subsidies buoy them. It’s as if the British government had matched every shilling a worker paid for the high price of wheat with another shilling. Yet today’s workers must still bear the brunt of the new health care costs in the form of higher deductibles and co-pays, and longer wait times for access. In addition, a tariff functions in drug pricing, with drug prices higher in the United States than in those countries that have cut deals with the drug companies, analogous to how the Corn Laws raised the price of wheat in Great Britain relative to Prussia.

Meanwhile, the well-situated health care operators—for example, hospitals and surgery centers that serve private insurance patients, or concierge doctors who treat cash-only patients—do very well, since they add more space and services at their convenience, while their affluent clientele can easily pay the higher prices. In addition, they get the same subsidies that the poorly situated health care operators get. Even their unit costs are sometimes lower, since patient health status rises with income, so their clients on average may not be as sick. They also benefit from the high production costs in the poorly situated health care sector, since, like the well-situated colleges, they can charge a premium over and above the cost of services in the poorly situated sector—for example, because they have prettier office space, or easier parking, or because their doctors on staff have better reputations. They benefit from the inefficiency that raises costs in the poorly situated sector by gaining a higher floor to work off.

In the meantime, workers with stagnant wages face real hardship, while workers who fail to qualify for health insurance subsidies get hit even harder. The capitalists who employ them worry about rising insurance premiums that threaten their bottom lines. Even if they don’t offer insurance they must still fight against the wage increases that workers demand to pay the new costs. Also, nearly all workers and capitalists alike must pay for health care’s inefficiency through higher taxes.

In the case of housing, the housing industry must add more units to meet increased demand, especially on land that builders ignored in the past, often for good reason. This costs money, especially when the labor market in construction is tight.

Worse, the housing industry is far more shielded from market pressure than most Americans realize. Building restrictions such as zoning and other regulations prevent new units from going up, especially in major cities such as Los Angeles, San Francisco, New York, and Boston. Home construction per household nationally remains near its lowest level in 60 years of record keeping, pushing up home prices dramatically. In 2017 alone, the increase was 6.3 percent, or twice the rate of wage growth and three times the rate of inflation. Like college tuition, the average cost of a house has increased four times the rate of inflation since the mid-20th century.

Many underemployed workers would like to move from regions in economic decline to dynamic cities, but they find themselves unable to do so because housing is unaffordable around productive areas. Workers already living in these areas find themselves putting more of their paychecks toward housing. For their part, capitalists in dynamic cities worry about a potential labor shortage, since without affordable housing they can’t get the additional new workers they need. In addition, their current employees demand higher wages to pay for their expensive housing, which threatens to cut into the capitalists’ profits. In no state does working 40 hours a week for minimum wage enable someone to rent a median two-bedroom apartment.

Meanwhile, homeowners, especially well-situated homeowners, see their home values skyrocket. They have a vested interest in restricting the number of houses that can be built, just as Ricardo’s landowners had a vested interest in the Corn Laws. Even poorly situated homeowners do well, since, as Ricardo noted, one’s situation is relative. The owner of a house near a park in Palo Alto is well situated. The owner of a similar house near a noisy highway in Palo Alto is poorly situated. A third person might want to build a similar house in a different part of town. But if the only land available for development requires an expensive permit, bulldozing a mountain, or draining a swamp, and sits next to the city’s garbage dump, then this third house’s production costs are going to be very high. Indeed, economists have shown that land constraints as well as local government regulations contribute to the current housing shortage, particularly in major metropolitan areas.

The result fits with Ricardo’s theory. The third house’s high price and bad location raises the value of the second house by the noisy highway, even though the latter’s production costs were small. The value of the first house by the park increases even more. In this way, established homeowners enjoy a financial benefit from land shortages and restrictions without doing anything.

With the inner workings of our economy now exposed, the logic behind Alexandria Ocasio-Cortez’s platform becomes clear, as does the logic behind the nascent alliance between socialists and some capitalists on key issues. The two groups are joining forces against the landowners of our day who have been advantaged by the Corn Laws of our day.

The higher education, health care, and housing issues in Ocasio-Cortez’s platform are all analogous to the problem of wheat prices in the 19th century. They are the most pressing issues facing workers today. In 1973, American families put 50 percent of their discretionary income toward education, housing, and health care; today they put 75 percent. To solve these problems, Ocasio-Cortez offers free college, Medicare-for-All, and housing as a right. On some of these issues major capitalists have climbed on board, since they also want these problems solved, preferably at someone else’s expense, mainly because of the upward pressure they put on wages. For example, the new J.P. Morgan-Berkshire Hathaway-Amazon venture to lower health care costs recently appointed Dr. Atul Gawande, a supporter of single-payer health care, as its CEO. Facebook CEO Mark Zuckerberg and Virgin Atlantic founder Richard Branson have pushed for Universal Basic Income, which would give workers more money to pay for services.

Some activity has also begun on the housing and college fronts. Google has jumped on the “housing as a right” issue, starting a large home-building project for its employees, while companies such as Starbucks, Wells Fargo, and Walmart have started to pay college tuition for their employees. At present, these ventures are private, similar to how health insurance began as a private company benefit in the 1940s; however, as costs continue to rise, putting pressure on wages, some employers will inevitably start to agitate for government assistance, as many of them now call for in health care.

Even today’s politics have begun to resemble the politics of British urban industrialists of old allying with the working class to repeal the Corn Laws. Even some of the complications are similar. First, not all British industrialists were on board the pro-repeal movement. Indeed, many manufacturers opposed repeal. Yet certain key industries, especially the wealthy cotton industry, pushed for repeal and funded the first large political action committee in British history: the Anti-Corn Law League. Something similar is happening today. Few employers support socialist ideas—indeed, most of them still reject socialism—yet important ones do support them at least selectively, and they are building organizations to push them.

Second, the working class in Great Britain strongly supported repeal of the Corn Laws—for example, the Chartist movement. Yet while manufacturers in the Anti-Corn Law League eagerly associated themselves with the Chartists, and took pride in the connection, the Chartists despised the Anti-Corn Law League, kept its distance, and even defaced or destroyed the latter’s property, for they saw into the manufacturers’ ulterior motives. Today’s socialist movement presents a similar double-face. On the one hand it embraces rich capitalists who support its social causes. On the other hand, it despises the “one percenters,” decries income inequality, and, in the form of Occupy Wall Street, destroys corporate property.

Third, today’s capitalists do have ulterior motives. The industrialists in the Anti-Corn League wanted lower wheat prices to help their workers—but mainly to relieve pressure on themselves. They also wanted lower duties on imported cotton, less regulation on business, and a reversal of the Factory Act, which limited the workday to ten hours. The Chartists knew all this and resented it. In the same way, today’s socialists know that some corporations want to help workers on health care, housing, and higher education, but that they do so primarily to benefit themselves. Their paths quickly diverge, for example, when business calls for less regulation. Socialists think the policy anti-worker.

Many of today’s capitalists also want more immigration. Ocasio-Cortez also supports more immigration, which is confusing. According to Ricardo’s economic theory, expanding the population in the current environment will increase the cost of housing, health care, and higher education, just as it increased the price of wheat in the 19th century. This would hurt workers. It may be why Ocasio-Cortez demands a Federal minimum wage and the right to a Federal job along with her call for open borders: These policies, along with Universal Basic Income, would give workers an economic floor to help them cope with the rising cost of housing, health care, and college stemming from mass immigration. Another explanation, of course, may be that more immigrants simply means more Democrats, who will vote for the socialist programs on housing, health care, and college, thereby solving the problem altogether—assuming that money can be extracted from somewhere to pay for all of this. Still, until such legislation is actually passed, workers facing population growth while the three economic bubbles remain intact will be very uncomfortable.

This suggests a major difference between how our politics are unfolding as compared to the 19th-century version. In 19th-century Britain, landowners faced a gradual destruction of their favorable tariff, starting with a “sliding scale” that lowered the tariff when wheat climbed in price. Our “landowners,” on the other hand, remain as insulated as ever. Rather than cut into the profits enjoyed in the housing, health care, and higher education bubbles, today’s worker-capitalist alliance demands more government assistance, which simply sustains the bubbles, buoys the position of those working or living inside them, and ensures that today’s “landowners” still get much of the reward, despite their inefficiency. It’s as if instead of gradually exposing wheat farmers to the free market, the British government had increasingly subsidized them.

Unlike in the 19th century, today’s workers and capitalists imagine that through government assistance all parties can benefit, including our “landowners.” This is impossible. There is not enough money to pay for Ocasio-Cortez’s social programs given the current level of government debt and the growing demands on entitlement programs. At best, government-run health care or free college will inevitably lead to a two-tiered system. High-income people will exit the cash-strapped government-run system and leave workers without the help of those who might pressure bureaucracies to maintain good services. In the case of health care, for example, the Sanders Medicare-for-All plan bans private health insurance to avoid this problem, but it doesn’t prevent high-income people from paying cash, which they already do in the form of high deductibles and concierge care. Thus, high-income people will be able to exit the system, creating the two tiers. Similarly, in the college system, free tuition through government subsidies will do nothing to control costs. In fact, as noted above, they will raise prices further. This will put elite colleges even more beyond the reach of average workers and reinforce the class divide.

The big government solution will not work. On the contrary, it will simply condemn workers to the margins and frustrate capitalists who find their profit margins under constant attack. All the while, those working in or living inside the three bubbles will sit back and get richer.

The only way to solve the problem is to pop the bubbles, or at least to help people circumvent them. In higher education, that means tying a college’s receipt of government money to greater efficiency, or by letting workers circumvent college altogether. There is, for example, Walter Russell Mead’s idea of a National Baccalaureate Exam, which would let young workers who pass the exam bypass college and still get jobs. There is also the option of greatly increasing apprenticeship programs in tradecraft skills, which we now do to a large but still inadequate extent through the community college vocational track.

In housing, popping the bubble means loosening restrictions on building. An even better practice would be for companies to create more branches in unpopular regions where housing costs are still low, yet the trend has been in the opposite direction as companies forsake the suburbs, exurbs, and rural areas for urban downtowns to compete for millennial talent. This practice worsens the class divide while also being a symptom of it. Advantaged young people who grow up in the well-situated housing sector, who receive medical care in the well-situated health care sector, and who attend college in the well-situated higher education sector have coalesced to form a closed caste with its own culture, including a desire for urban amenities. Since the high-tech information economy values these employees most of all, companies chase after them and pay them enough to live and propagate the next generation of well-situated lives in an urban setting. Meanwhile, the great mass of workers who grow up and receive their education in the poorly situated sector are less prized by companies, and less well-paid, and they find themselves unable to follow their well-situated counterparts into the cities. Their best chance for housing in the cities would come from a loosening of building restrictions.

In health care, popping the bubble means handing the now-existing institutions a fixed sum of money, telling them to “take care of the problem,” and if they can’t, then telling them that new institutions that can will be permitted to come into being through market forces. One example would be in-state health insurance markets being opened up to out-of-state competitors. Another example would be the easing of state certificate-of-need regulations that currently prevent health care entrepreneurs from competing for customers. A third approach would be trimming down the supervisory health care bureaucracies, including accreditation organizations, that increasingly issue well-intended regulations that actually compromise patient safety while also raising the cost of health care.

Almost 30 years passed between Ricardo’s book on economics and the repeal of the Corn Laws in 1846. The alliance of workers and capitalists finally broke the power of the landowners and gained the importation of cheap food. But it took time. So will today’s struggle.

Unlike the old Left-Right model, Ricardo’s model is not a continuum with only two points but a triangle with three. Desperate workers sit in one corner, many of them accomplishing little more than subsistence. In the second corner sit the capitalists who feel cheated by their efforts, as they save and invest, but then find their profits shrunk by wage increases. In the third corner sits a consortium of colleges, health care institutions, and homeowners content with their ever-growing spoils. Given that our workers and capitalists have yet to fully grasp the nature of their problem, and therefore usually keep pushing the wrong solution—more government—and given that our “landowners” will not surrender easily once our workers and capitalists do push for the right solution, Ricardo’s model will likely explain our predicament and our politics for some time.

The old Left-Right continuum stripped an important aspect of the world to its essentials and laid things open for everyone to examine. It was unreal in the sense that it failed to take into account non-economic motives such as culture. But by simplifying the world it did elucidate vital questions about fights over money.

Ricardo’s triangle also involves much simplification, as all thought experiments must. Like the old Left-Right continuum, it fails to take culture into account. For example, Alexandria Ocasio-Cortez’s support for open borders may be based simply on ethnic affinity and with no deeper rationale. “Values” voters exist whether workers and capitalists relate to each other as opposite sides of a continuum or as two points of a triangle.

Nor does Ricardo’s triangle take into account the qualitative improvements in health care, housing, or higher education over the past forty years that might substantiate the new high prices. Yet this point poses less of a challenge to the integrity of Ricardo’s triangle than the cultural argument does. After all, better health care, housing, and higher education are useless if they have grown so expensive that workers can’t access them.

In addition (and speaking from experience), the notion that health care and higher education are four times more valuable than they were in the 1980s, and therefore worth the price rise, is very suspect. In health care, the period between 1980 and 2018 cannot match the dramatic pace of medical discovery that occurred between 1940 and 1980, although health care costs increased at roughly the same 4 percent rate during both periods. The practice of anesthesiology, my own specialty, for example, hardly differs from its practice when I finished my residency in 1989. In higher education, standards have actually declined compared to 1980, as many colleges now offer what was once considered a high school education.

Ricardo’s triangle does essentially the same thing as the Left-Right continuum of old did, but as a triangle it arguably does a better job for our time in piercing through the distractions of everyday life and explaining the current array of forces. Like most economic models, it is basic, bare, and unadorned. It views people as two-dimensional characters. Yet it offers a powerful tool of abstraction to our politics and gives us a new way to plot the direction of their current.

1 I am using the term “bubble” in a way that most economists would describe rentier behavior—gaining from a positional advantage. I am not using “bubble” to mean sharply fluctuating price levels caused by commodity speculation, as in the famous 17th-century Dutch tulip crisis.

2 For a discussion of this point as it relates to 19th-century grain production, see Conway Lackman, “The Classical Base of Modern Rent Theory,” American Journal of Economics and Sociology (July 1976).

3 Revised number based on 18 percent drop in state subsidies of tuition during this period. Estimated from data found Center on Budget and Police Priorities and COLLEGEdata.

4 All college data derived from the National Center for Education Statistics and Student Debt Relief. Harvard data from the Harvard Crimson and Harvard University. Numbers adjusted for inflation.

5 For health care cost increase see Rabah Kamal and Cynthia Fox, “How Has U.S. Healthcare Spending Changed Over Time?” Peterson Kaiser Health System Tracker, December 20, 2017. For breakdown of costs see Peter Orszag, “Growth in Health Care Costs,” CBO Testimony, January 31, 2008.

6 Paul Sharp, “1846 and All That,” Agricultural History Review, vol. 58, no. 1 (2010).

7 Gary Anderson and Robert Tollison, “Ideology, Interest Groups, and the Repeal of the Corn Laws,” Journal of Institutional and Theoretical Economics (June 1985).

8 Albert Hirschman, Exit, Voice, and Loyalty (1970).

9 For the 4 percent number, see David Cutler, et. al., “What Has Increased Medical-Care Spending Bought?” American Economic Review (May 1998).

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America, the Forever Has-Been

It’s decline time in America. Again. Here is the up-to-date generic version. “In the years following the global financial crisis, the United States has increasingly ceded its leadership in the world, while China has rushed in to fill the gap left behind.” Under Trump, “this trend is poised to accelerate.” A bit farther back, a declinist orated: “Obama is not merely the presiding instrument of American decline, he is the architect of American decline.” In fact, Donald Trump’s shibboleth “Make America Great Again” is declinism pure, implying that the country was on the way to hell before he bestrode the stage as the country’s savior.

D&D, decline and decadence, is nothing new under the sun; “hasbeenism” is as American as apple pie, and we are now in Decline 6.0. Doom has been sounded ever since the United States emerged from World War II as the one and only global power. The wave has crested about once every decade, and usually during a presidential campaign. 

1.0 hit the nation in the late 1950s when John F. Kennedy launched his bid for the White House. These were the years of the “Sputnik Shock,” when the Soviets were first to launch a satellite into space, when high schooler “Johnny” could not “read above fifth-grade level,” while “Ivan” had already mastered calculus. These were also the years of the “missile gap,” which never existed, but helped to propel JFK into the presidency. To fib was to win.

In the late 1960s, with the Vietnam War in full swing, America was doomed again. 2.0 unfolded while Robert F. Kennedy primed himself for the White House with a message of decline echoing his brother’s rhetoric.  “Today, the Soviet Union may be ahead of us in megaton capacity.” Worse: “Twenty years ago, we were respected throughout the world. Today, hardly a day goes by when our flag is not spit upon, [our] embassies stoned. . .” Richard Nixon, running in 1968, recalled the fate of Greece and Rome. Having become wealthy, “they lost their will to live, to improve.” The United States was now reaching that period of “decadence.” But fate could be stopped if the nation were to elect Nixon, the savior it did.

3.0 was the decade of Jimmy Carter’s “malaise,” the years of skyrocketing oil prices and galloping inflation that cut the value of the dollar in half. Add the humiliation of the Tehran embassy takeover and the Soviet plunge into Afghanistan. Carter decried a “crisis of confidence. . . that strikes at the very heart and soul and spirit of our national will.”

The United States was finished again, and Ronald Reagan picked up where the Kennedy brothers had left off. “America’s defense strength,” Reagan remonstrated, “is at its lowest ebb in a generation, and the Soviet Union is vastly outspending us in both strategic and conventional arms.” It was not, but Reagan won in a landslide. As a fabled campaign slogan intoned four years later, it was “morning again in America.” But not for long.

4.0 engulfed the nation in the 1980s. This time, Japan would inherit the earth. In language foreshadowing the China hype two decades later, Japan was touted as the wunderkind of the world. Its economy was soaring, now and forever more. Where it had failed militarily in the 1940s, it would now conquer with its industrial might. Alas, Japan’s growth, as fantastic as it had been in the 1960s and 1970s, peaked in the great real estate crash of 1988. The country did not recover from stagnation until the teens of the 21st century. In the United States, by contrast, 1992 marked the beginning of the longest peacetime expansion ever.

Recall Paul Kennedy’s academic blockbuster, The Rise and Decline of the Great Powers (1987). The 700-page tome predicted that “imperial overstretch” would lay low the United States. He got the analysis right, but not the name of the victim. Imperial overstretch did in the Soviet Union, which committed suicide on Christmas Day 1991. Its meager means had way exceeded its great power ambitions.

Decline & Decadence took a break in the 1990s because the United States was now the undisputed No. 1, the “last remaining superpower,” and then with a relentlessly growing economy. The Soviet Union, Europe, and Japan, allegedly destined to dethrone the “indispensable nation,” were either down or out. But with America’s singular power, flung around in the Iraq and Afghanistan wars, 5.0 was already lurking in the wings. Now, in the early 21st century, angst centered on China, forging ahead at growth rates hitting up to 15 percent during the beginning of its rise in the 1980s.

Project double-digit growth forward, and for sure China will overtake the U.S. economy. But you can’t predict that tomorrow will be like yesterday. Take the Asian dragons and tigers of the 1960s and 1970s—Japan, Taiwan, South Korea—who wrote the book on the Chinese growth model: exports first, then under-consumption, overinvestment and an artificially cheapened currency. Invariably, this model runs out of steam, as wages rise, displacing production to cheaper countries like Vietnam. The law of diminishing returns kicks in, with each unit of investment generating less output and fewer jobs. Where double-digit growth once reigned in China, it is now down to 6-7 percent. Also, China is rapidly aging, looking at 350 million pensioners by mid-century. Retired folks don’t produce but consume, detracting resources from the Chinese military.

Nonetheless, we are now in the midst of 6.0, with China destined to displace the United States as No. 1, as predicted by the current crop of declinists. Just refer to all those pundits who are again proclaiming the “end of the American century.” Rote repetition does not strengthen their case, but against the backdrop of Decline 1.0 through 5.0, there is something new under the sun: Donald Trump, who is laying the axe to the global architecture built and maintained by all his postwar predecessors.

That architecture, also known as the “liberal international order,” was the stage where American power and authority unfolded for the last 70 years. Trump’s rap sheet is now familiar enough to need no retelling. Nor do we need to dwell on 20 months of crudeness and imperial contempt poured on friends and allies, nor regurgitate Trump’s bizarre fondness for the strongmen of the day. The new take is a wretched tale of “deconstruction” that does not serve America’s well-considered interests.

But look again—coldly, even cynically. Does Trumpism mark the foreordained fall from the penthouse of global primacy? As nasty as Trump’s antics are, they do not mark America’s impending demise. Au contraire. This rogue elephant actually generates lots of power, and he is forging ahead.

Trump’s America has gotten the attention of China, Europe, Mexico, and Canada in matters of trade. By beating up on the Europeans, he has pushed them to increase defense spending. He is realigning the strategic map of the Middle East by pushing Israel and the Sunni states into an alliance of convenience against Iran. He may well gouge a better nuclear deal out of Tehran, one that will lengthen its path to the bomb, perhaps even cut it off. He is beefing up U.S. military strength in the Western Pacific. He is exploiting U.S. economic and financial might for political as well as commercial gain.

To score a rhetorical point: If the United States is declining, how come allies and adversaries shrug off his uncouth ways,  staring at him like the proverbial deer in the headlights? Weak powers normally provoke push-back. Yet though universally disliked, Trump seems to be getting his way, plus what he craves most: attention. Countries on the way down are either ignored or pushed around.

From Clinton to Obama, the United States used to fete itself as the “indispensable power” at the center of world politics. For all his brutality, Trump dominates the stage—and the headlines—as Barack Obama, the “good American,” never could. So vice is its own reward, and this “ugly American” gets what he does not deserve, given his obsessive defiance of the rules of decent conduct.

Messrs. Putin and Xi, as self-serving and cynical as they are, score as well. But neither will soon push Trump offstage. Why not? Because this American “has-been” plays with the biggest pile of chips: the mightiest military, the richest economy, its technological edge, its sway over the world’s finance and trade. A morality tale, where the good are rewarded and the bad punished, this saga is not. But as an effective strategy, Trumpism is hard to beat.

Bad guys are not supposed to win, and we are just in the first inning. Which is a good moment to recall Letitia, Napoleon’s mother, who cautioned her son at the height of his conquests: “Pourvu que ça dure”—let’s hope this will last. In the end, the laws of international politics will kick in. Ganging up and counter-coalitions will be organized by the lesser powers. The question is only “when?” Meanwhile, this rogue elephant will continue to demolish the global order the United States built and nourished. Guardianship had its costs, but they were dwarfed by a system that amplified and legitimized American power.

If Trump gets a second term, he will complete the demolition job. Amidst the ruins of the magnificent architecture Made in U.S.A., Decline 7.0 will rear its ugly head. This time, it may be the real thing. For power unleavened by responsibility invariably provokes counter-power against Mr. Big. 

1 For the history of declinism, see my The Myth of America’s Decline (W.W. Norton, 2014) as well as my “Declinism’s Fifth Wave,” The American Interest (January/February 2012) and “The Canard of Decline,” The American Interest (November/December 2013).

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What Must Catholic Laypeople Do? “Run Toward Holiness”

In 1976, a Guinean priest named Robert Sarah was made rector of John XXIII Minor Seminary in Conakry, Guinea. The previous leadership of the seminary had been lax, and so when Sarah instituted stricter rules the young men of the seminary rebelled in dramatic fashion, setting fire to its chapel. Fr. Sarah demanded the guilty parties come forward, but no one was willing to confess to the arson or reveal the perpetrators. Sarah (now Cardinal Sarah) said in his book-length biographical interview, God Or Nothing, “if this abominable act had targeted my own room I could have forgiven it. But the chapel was the house of the Lord.” Sarah expelled the whole class and shut down the seminary for a year. Government officials demanded he reverse his decision, but Sarah held out. “How could we allow future priests, men of God, to indulge in acts of sacrilege?” Sarah reopened the seminary the next year and accepted a smaller student body, with every seminarian vouched for with a certificate of good conduct.

The measures Sarah took were drastic, but they speak to how seriously he took the vocation of priesthood and the priest’s duties to God and man. This summer, thanks to the Pennsylvania grand jury report and other revelations, we’ve learned more and more about the evil actions perpetrated against the faithful by abusive priests and craven, enabling bishops. The sexual abuse of children and seminarians, and the cover-ups associated with them, are an act of arson against Christ’s Church. It is not only an awful crime in earthly terms, but also sacrilege against God and his command that priests be shepherds to his people. Catholics in the pews are filled with grief, confusion, and righteous anger. In the face of this evil, what can we do?

I know there’s a temptation to wash our hands of the matter, to say, “You call this salvation? I’m out of here.” And so, I want to address fellow Catholics who may be facing this temptation and discuss how we can and should respond to the scandal and sin that’s been revealed. Abandoning the Church is not truly an option if we believe Christ’s words about his Church being one flock with one shepherd.1 If we are to bind up the wounds of the victims and see that wrongdoers face justice, then our task is to remain within the Church while we prayerfully and persistently seek truth. Like the unrelenting widow in the parable of Jesus, knocking again and again at the door of the unjust judge, we should keep demanding real answers and real reform from the hierarchy.

Bishops have responded to the current wave of revelations with varying degrees of humility and humanity. Bishop Robert C. Morlino penned a sobering letter about the moral rot and doctrinal failures that allowed abuse to flourish within seminaries. Among other promises, Morlino said, “I promise to put any victim and their sufferings before that of the personal and professional reputation of a priest, or any Church employee, guilty of abuse.” This is important because the reverse priority (privileging the reputation of a priest, even one known to be guilty of abuse, over justice for victims) has led to much shady and sordid hushing-up of crimes. Morlino doesn’t mince words: “More than anything else, we as a Church must cease our acceptance of sin and evil. We must cast out sin from our own lives and run toward holiness. We must refuse to be silent in the face of sin and evil in our families and communities and we must demand from our pastors—myself included—that they themselves are striving day in and day out for holiness.”

This was a much better reaction than the blame-dodging antics of Donald Wuerl, Cardinal of the archdiocese of Washington, who responded to public revelations about his predecessor, Cardinal Theodore McCarrick, with a prepared website defending his own record on child abuse. When this oily move was met with widespread incredulity, he quietly took the website down. Arguably worse was Cardinal Joseph Tobin’s immediate crackdown where he instructed priests in his charge to refuse to speak to the press after allegations of sexual misconduct surfaced in his diocese.

Pope Francis’s initial letter about the Pennsylvania grand jury reports and its abuse revelations was also disheartening, because while it spoke in general terms about “a penitential exercise of prayer and fasting,” it did not impose any particular penance on clergy or suggest any specific prayer practice for the laity. Moreover, the Pope said nothing concrete about further investigations to be pursued or restrictions to be imposed on ordained malefactors. The Pope’s response was even worse in the wake of former papal nuncio Archbishop Viganò’s dramatic allegations that Francis knowingly lifted restrictions Pope Benedict had imposed on the serial abuser Cardinal McCarrick. Francis made a very strange non-denial, saying “Read the statement carefully and make your own judgment. I will not say a single word about this.” If Francis means that Viganò’s accusations are false, he should say so. And, of course, if there is any truth to them, even elements of truth mixed with exaggerations, Francis should admit what is true. His flock deserves the truth, and we also deserve clarity rather than the perpetual cloud of obfuscation amidst this scandal. Christ brings truth and light—anything that keeps us in rumor and darkness is not from him.

What can the laity do in this time of trial? Though there is a great deal of evil, error, and suffering to confront, our hands are not tied. We are the Church too, for as Lumen Gentium affirmed: “Every layman, in virtue of the very gifts bestowed upon him, is at the same time a witness and a living instrument of the mission of the Church itself.”2 So we are not trespassing on someone else’s domain by working for compassion and justice. We are doing our job.

We should begin in penance and prayer. God is our refuge and our strength, so our efforts should have their source and final end in him. Many lay Catholics are turning to the riches of the Church’s tradition to pray for her renewal. For example, there is a Facebook group dedicated to observing St. Michael’s Lent while praying every day for justice. Other lay initiatives include prayer and penance on the traditional autumn Ember days and the feast of Our Lady of Sorrows. And, to recover the Church’s corporate solidarity with the suffering and hungry everywhere, we might take on the Friday abstinence from meat and ask the whole body of believers to fast again.

We must also listen to victims—people sexually preyed on in seminaries and silenced by the system. As difficult as it is to read accounts documenting the victimization of the young, we owe our attention to people who have the courage to speak out. For those who have been victims themselves, reading these accounts may be too wrenching—though it also might be a kind of comfort to hear from other survivors. And for all of us listening to these stories, we can begin to learn how we can be of use and comfort to our brothers whose relationships with the Church, with their vocations, and with God have been betrayed and wounded by those who should have been their teachers and pastors.

And we should demand real reform, including resignations, from bishops. We need to know who knew what and when. The conspiracy of silence must be broken. Events like the synod on young people should be postponed rather than held while grave doubts are in the air about the character and competence of bishops in attendance. To that end, the Church must empower a competent lay-led body to investigate allegations of abuse and cover-ups. (If the bishops are going to act like corporate overlords caught countenancing sexual misbehavior, they should at least hire one of the clean-sweeping firms that investigate secular institutions for malefactors.) And I tend to think the Holy See should commit in the strongest language beforehand to follow this body’s suggestions. That way the result of the investigation will not be toothless recommendations but a real verdict on whose resignations the Holy See should demand, or, as the case may be, accept, if the U.S. bishops follow Chile’s forceful example and offer resignations en masse.

One problem we face, as J. D. Flynn points out, is that there is not currently a canonical criminal process to respond to sex between a cleric and an adult. Allegations of sexual predation perpetrated against seminarians have been handled in a wide variety of ways, some definitely too lax, but all hampered by the lack of an established norm. Clear procedures must be established—a corrupt clericalism thrives when everything runs on ambiguities and case-by-case decisions. We need procedures that are as stringent, uniform, and clear as the ones that now exist for allegations of clerical sexual abuse of minors. And the procedures should be promulgated widely so we can all keep an eye out that they are being followed.

There’s much more we can do, individually and as a body. I would favor the Pope calling for a year of penance, inviting all the faithful to particular prayer practices and requiring a stricter penitential observance from all clerics. Our tradition offers a treasury of repentance: penitential psalms, Mary’s seven sorrows, sackcloth and ashes. The Roman Missal includes, among its Masses for various needs and occasions, Masses for the forgiveness of sins. The rubrics give priests pretty wide latitude to use such Masses in the face of grave pastoral need, and I would argue the present crisis constitutes precisely that. A collect from one of the Masses for the forgiveness of sins reads: “Almighty and most gentle God,/ who brought forth water from the rock/ a fountain of living water for your thirsty people,/ bring forth, we pray,/ from the hardness of our heart, tears of sorrow,/ that we may lament our sins/ and merit forgiveness from your mercy.” A collect from a Mass the priest may offer for himself is similarly apropos: “O God, who have willed that I preside over your family/ not by any merit of mine/ but out of the abundance of your untold grace alone,/ grant that I may carry out worthily the ministry/ of the priestly office/ and, under your governance in all things,/ may direct the people entrusted to my care.”

I am aware that one proposed solution to our ills is the abolition of the norm of priestly celibacy. I see this as somewhat of a distraction. I know holy married priests who entered through the Anglican Ordinariate and serve the Church with zeal. But I also think we should not underestimate the prophetic witness of celibacy, a sign of the union of the soul with God in the world to come. What we need are priests who are committed to living holy lives and not giving wickedness a foothold in the Church. Having more married priests will not be a panacea. However, all unmarried Catholic laymen committed to chastity should think carefully and prayerfully about pursuing a priestly vocation. Some of the needed reform will have to come from priests, and it couldn’t hurt to have a generation of priests specifically committed to combating the twin evils of sexual abuse and endless bureaucratic smokescreens. That could start in seminary, with young men keeping communication open with spiritual advisors and accountability partners outside of the seminary itself, to whom they could report any unchaste behavior, especially by their formators.

In other eras of spiritual disarray and moral disaster, God has raised up great saints to reform his Church and inspire his faithful: Benedict of Norcia, Francis of Assisi, Catherine of Siena. None of us would choose to live in such a challenging time. But the solution is not to close our eyes to the failures of our shepherds and the way they have grievously wronged some of the most vulnerable of God’s children. We must have faith in God, our help in ages past, and strive to serve him by comforting the afflicted and demanding their afflictors face justice—and, we pray, experience true repentance. Our trust cannot be in princes, even princes of the Church, but in the God who says: “Woe to the shepherds who destroy and scatter the flock of my pasture. . . You have scattered my sheep and driven them away. You have not cared for them, but I will take care to punish your evil deeds. I myself will gather the remnant of my flock. . . and bring them back to their folds; there they shall be fruitful and multiply.”

[1] John 10:16

[2] Lumen Gentium, 33

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Reining in Medicaid Spending

There is growing support in the United States, especially among left-of-center constituencies, for universal government-managed health care coverage achieved by expanding Medicare down the age scale and expanding Medicaid up the income scale. Many supporters of this double-creep approach, which, once achieved, would displace both Medicare and Medicaid as separate programs, simply assume that both of these programs work well and would continue to work well if expanded and then merged. That may or may not be true of Medicare, but it is certainly not true of Medicaid.

Most people seem to think that Medicaid just provides medical care for indigent adults and children. In fact, that accounts for only a small part of the billions of dollars Medicaid hands out every year. It’s so vast and complex a program that even the most astute politician or scholar has difficulty grasping it whole, and it is certainly vastly larger and more complex than anyone contemplated when Medicaid became law in July 1965.

Consider Medicaid’s current size and program diversity. It enrolled 68.5 million people as of July 2017, a 16.4 million increase in enrollment since the inception of the Affordable Care Act in 2010—which is precisely where the ACA intended its main impact to be. CHIP (Children’s Health Insurance Program), which is basically a separate Medicaid program for children, enrolled an additional 5.8 million children. Medicaid and CHIP facilitated treatment for 48 percent of all children, 23 percent of the population of the United States, and 60 percent (2.9 million) of children with special health needs (disabilities). As of July 2017, Medicaid also enrolled 8.8 million disabled adults, one million expectant mothers, 25 million non-elderly adults, and four million senior citizens in nursing homes and community care facilities. Eldercare used 21 percent of the total Medicaid budget to cover 64 percent of all nursing home and community care expenses in the country.

What these numbers mean, among other things, is that most Medicaid enrollees are healthy children and adults, but most of the money goes for the disabled and the retired. Indeed, so much of the money goes to the disabled and the elderly that medical outcomes for everyone else, when they need care, are mostly substandard. There are only two ways to explain such outcomes: Either poor people make poor patients—because they are sicker for having avoided medical care for too long, or because for one reason or another they are less likely to follow doctors’ instructions—or something is lacking in the quality of the care they receive. Or some combination of the two.

It is essential to understand what Medicaid is and how it functions—and how the Centers for Medicare & Medicaid Services (CMS) tries to manage all this—because we need to make it work more efficiently and effectively both for the sake of its beneficiaries and to avoid busting the Federal budget. Further expansion of Medicaid or folding Medicaid into Medicare, as some have suggested, are simply not viable options without significant reform of the program. Indeed, combining Medicaid with Medicare might well compound Medicaid’s current problems and destroy Medicare in the process.

The biggest problem with Medicaid is cost. Eliminating fraud, abuse, and waste, minimizing rent-seeking behavior among stakeholders, and controlling budget gaming by the states, could reduce Medicaid costs by 20-40 percent. But that’s still suboptimal. Medicaid has grown too large and complex and should be divided into three parts. Eldercare should be moved to the Social Security Administration and reformed in the process of gaining new management. Disability programs should be combined with Veterans Affairs disability and rehabilitation programs to form a separate agency. That would leave Medicaid to handle medical care for poor people, which is what it was supposed to be about from the start.

This new, slimmer Medicaid needs to be driven through the gauntlet of the Federally Qualified Health Center (FQHC) movement, which combines scientific medical care with social outreach and support. Most health problems suffered by the poor are often not strictly medical (or at least they don’t begin that way); they are consequences of lifestyle choices, with a large social, mental health, addiction, and subcultural dimension. The FQHC movement is ideally constituted to help such people get and stay healthy.

Let’s now look under the hood of Medicaid’s assembly of interlocking government bureaucracies. Since budgetary allotments are the life-blood of bureaucracies, I refer often in the following discussion to budgetary categories, amounts, and percentages because these numbers display the relative importance and magnitude of Medicaid’s program. I am well aware that budgetary analysis such as the one below makes some people’s eyes glaze over. It simply cannot be helped; to understand the real problems with Medicaid requires learning some facts. Take a deep breath if you think it might help.

Medicaid spent $574 billion and CHIP spent $14.5 billion in FY2016 (compared to $116 billion in 1978, in constant 2016 dollars). For perspective, the U.S. economy spent an estimated $3.4 trillion on healthcare from all sources. Medicaid/CHIP spent 17 percent of the total expenditure on 23 percent of the population, which indicates some budgetary virtuosity. But it is still a lot of money and it’s growing bigger.

The Federal government must reimburse the states for the pre-expansion beneficiaries according to the Federal medical assistance percentage (FMAP), which is larger for poorer states but is on average 57 percent. Individual states pick up the balance. The states are then responsible for selecting the actual delivery of care arising in significant budgetary disparities among the states. New York spent $63 billion on Medicaid, while Florida, a more populous state, only spent $22 billion.

Who are the patients and other beneficiaries of Medicaid? Medicaid spent the largest percentage (40 percent) of its budget on the disabled in FY2014, although that group compromised only 14 percent of its enrollees. In 2017 alone Medicaid and /CHIP enrolled 2.9 million children with disabilities and enrolled 8.8 million adults with disabilities such as autism, brain injury, Alzheimer’s disease, and mental illness.

For children with disability there is variability among the states as to income qualification. Tennessee requires income less than 200 percent of the Federal Poverty level (FPL) while all the other states have some version of the Katie-Beckett-option. The Katie-Beckett-option places no limits on parental income or assets, but merely limits the child’s income to around $220/month and assets to less than $2,000. In other words, Jimmy Kimmel, a wealthy man (estimated net worth $35 million) could have his son’s disability covered by Medicaid. Of course, Medicaid requires a disability such as mental disease, intellectual disability, or developmental disability. States enroll disabled adults with SSI (federal Supplemental Security Income) in Medicaid. In summary, disabled children up to the age of 19 get Medicaid relatively easily, resulting in Medicaid coverage of 60 percent of all children with disabilities. Disabled adults only get Medicaid if they are already receiving SSI benefits.

Medicaid spent the second largest amount of its budget (21 percent) on nursing home and community care of the elderly. The actual medical care of these beneficiaries isn’t specified in this amount since it is covered in the Medicare budget as a subset of the overall nursing home cost. To qualify for Medicaid long-term care (LTC) a patient must meet income and asset limits that vary by state. There is a look-back period of five years for assets to make sure that applicants have not unloaded assets to relatives just prior to the need for nursing home care. Despite the apparently stringent criteria, individual state waivers and gaming of the system (“retirement home planning”), allowing an amazing 64 percent of all eldercare patients to qualify for Medicaid nursing home and community care payment. That is a shocking percentage considering that 64 percent of elders are not poor—not even close. But 68 percent of households headed by persons over 55 were in debt in 2016. Since these people were working for most of their life, funding through a social security income deduction makes more sense than treating the beneficiaries as outright indigents.

Non-elderly adults consume about 19 percent of Medicaid’s budget and constitute 34 percent of the enrollees. Families of three or more with income levels less than 138 percent of the FPL qualify for admission in most states, but the limit varies from 18 percent to 100 percent of the FPL in 18 states. Single individuals qualify for Medicaid in most states with FPL’s of 138 percent, but 16 states require an FPL of zero percent, which means they don’t cover them. These extreme variations of the qualifying Federal poverty levels (FPL) among the states and among the programs further complicate an already complex situation.

Pregnant women qualify for Medicaid if their income is below 138 percent to 324 percent of FPL. Medicaid covers the pregnancy and extends for sixty days postpartum. Medicaid is the largest payer for patients with HIV. The 16 States with zero percent FPL won’t cover HIV patients until they become disabled, usually by getting full-blown AIDS, and then getting SSI that then qualifies them for Medicaid. Medicaid pays for 40 percent of those receiving HIV care.

Non-disabled children consume about 19 percent of the Medicaid budget and are 43 percent of the enrollees. Healthy children qualify for Medicaid as part of their family who must meet income levels less than 138 percent in Medicaid expansion states. More stringent limits of 18 percent to 100 percent apply in 18 other States. The CHIP program enrolls children in families that don’t qualify for Medicaid and whose family income varies from 138 percent to 300 percent of FPL depending on the state of residence.

Politicians often debate about more generous care for children. Non-disabled children and non-elderly adults comprise 77 percent of Medicaid enrollees, but only consume 38 percent of the Medicaid budget. The reality is, as already noted, that most Medicaid money is spent on the disabled and retirees. Why is this?

The huge variation and complexity of who qualifies for the various target groups within Medicaid, and how they do so, are the result of a half century worth of negotiations and tradeoffs among special interest groups, bureaucrats, politicians, state governments, and lobbyists. As a result, Medicaid has grown into a dysfunctional, internally inconsistent, and unfair hodgepodge.

Now that we have seen who Medicaid covers, let’s see where they are treated by again using budget data, but slicing it along a different dimension. The broad budgetary divisions are fee-for-service acute care (26 percent), fee-for-service long-term care (21 percent), managed care and health plans (46 percent), payments to Medicare (3 percent), and disproportionate share hospital (DSH) payments (4 percent).

Acute fee-for-services further breaks down into these five categories: inpatient hospital (39 percent); physician, lab, and x-ray (8 percent); outpatient services (18 percent); prescribed drugs (6 percent); and other services (30 percent).

The first group, inpatient hospital services, accounts for the largest share ($57 billion) of the fee-for-service Medicaid budget. Medicaid pays hospitals in a very complicated way. In summary, there are three major components. First is the base payment, which is collected from fee-for-service Medicaid and Medicaid HMO contracts and which amounted to $50 billion (56 percent) in 2014. Second comes DSH supplemental payments, which are meant for safety-net hospitals that see a large proportion of Medicaid patients. The third component is non-DSH supplements (NDSH), which may come from upper payment limits (UPL) or intergovernmental transfers (IGT), which are provider taxes.

UPL payments are made by the state, which is permitted to pay the hospitals the difference between Medicaid and Medicare reimbursement rates. IGT’s are generated by taxing counties, nursing homes, or other providers and then paying the money back to them. Why is this so complicated? The good reason is that states use DSH payments to keep safety-net hospitals solvent. The bad reason is that states have used the supplemental system to game the Federal government.

By statute, the Federal government must reimburse the states a fixed percentage of Medicaid expenses averaging 57 percent. States thus use the supplemental payments to get the Federal payments as high as possible. The Federal government has naturally responded by placing limits on supplemental payments—for example, IGT payments are limited to 60 percent of state contributions. After all payments are made, hospitals receive amounts varying by specific hospital from 81 percent to 130 percent of Medicare equivalent reimbursement. The national average is difficult to determine but was estimated to vary between 93 percent and 107 percent in 2014.

A national study in 2008 showed that Medicaid beneficiaries received quality hospital care 73 percent to 88 percent of the time for various measures, but this was 1 percent to 3 percent less than the case for privately insured patients. This difference is small but significant at the p < 0.05 level. In summary, some hospitals are reimbursed well for Medicaid patients and give Medicaid patients good quality care. Other hospitals, not so much.

The CMS fraud and abuse report highlights for 2017 cites multimillion-dollar recoveries from five major hospitals for embezzlement, kickbacks to physicians, false claims, and charging for more complex procedures than those actually performed. Rent seeking is excess profit gained through political leverage. Rent seeking in the form of certificates of need (CON) is an even bigger story. Combining CON with mergers of remaining local competitors has enabled many hospital groups to charge from 6 percent to 18 percent economic rent. Those are heavy fingers on the scale.

The second category—physician, lab, and x-ray—collected $11 billion (8 percent) of the acute care Medicaid budget in 2016. In 2013 a CDC analysis showed 69 percent of physicians would accept a new Medicaid patient while 85 percent would accept a new Medicare patient. Subsequent surveys showed wide variation by state going from 97 percent in Nebraska to 39 percent in New Jersey. The strongest factor correlating with patient acceptance rate is the state’s physician payment rate.

In nearly all cases, physicians complain of slow payment, difficult billing, frequent no-show appointments, poor compliance, and generally sicker and more difficult patients requiring more resources even though reimbursement for care is usually much less. Acceptance of Medicaid also varies by specialty, from 63 percent for cardiologists to only 27 percent for dermatologists. Specialty physicians are even harder to find in states with lower payment rates. Nevertheless, roughly 85 percent of Medicaid patients do see a physician at least once a year.

The third category, consuming $26 billion annually, is outpatient services received from federally qualified community health centers (FQHC), rural health centers, hospital emergency rooms (ER), and hospital clinics. Instead of going to a physician’s office, one in six Medicaid patients goes to a community health center. Once again, usage varies by state from 6 percent of beneficiaries in Georgia to 35 percent in the District of Columbia. Medicaid payment only reimburses about 80 percent of their costs.

Recognizing the shortfall, the Health Center Consolidation Act of 1996, section 330, allows CMS to make up the difference if a community health clinic meets the standards of a FQHC. For CMS to certify a FQHC, three conditions must obtain: The governing board must be more than 50 percent patients of the center; it must serve a medically underserved population; and it must offer a sliding fee schedule to patients earning less than 200 percent of the Federal poverty level. Although physicians provide services, nurse practitioners, physician assistants, nurse-midwives, clinical psychologists, clinical social workers, visiting nurses, self-management trainers, and medical nutrition therapists provide much of the care. One 2016 study indicated that the health centers save $2,400 per patient per year, or 24 percent, compared to other providers. Medicaid and FQHC’s seem to be a great match, and they have received bipartisan support.

Emergency room (ER) visits are another option for Medicaid patients. Half of the states charge a co-pay in the ER for Medicaid patients to discourage unnecessary visits. Medicaid ER visits consumed 4 percent of the Medicaid budget in 2011. Surveys have shown that although Medicaid patients are twice as likely as other patients to seek ER care, it is not mainly because they are sicker: About 8 percent of non-Medicaid visits are typically classified non-urgent while 9.8 percent of Medicaid visits were thus classified. The difference is probably owed to the fact that poorer patients have more difficulty accessing other kinds of outpatient care.

Prescription drugs were $8.4 billion (6 percent) of the acute care Medicaid budget in 2016. Medicaid gets pharmaceuticals at a 23 percent discount compared to Medicare. Medicare is prevented from negotiating drug prices, but Medicaid is required by law to get the lowest price negotiated by anyone for drugs. This demonstrates rent seeking by the pharmaceutical sector. I purchased antibiotic eyedrops in Germany for $18 for which my patients were paying over $180 for in Tampa. Assuming that the $18 is close to the economic marginal cost of production of the eyedrops, the other $162 represents 90 percent economic rent. So, the 23 percent discount that Medicaid receives is probably just the tip of the rent-seeking iceberg.

“Other services” account for $43 billion (30 percent) of the acute care Medicaid budget. Other services include dentists, physical therapy, nurse midwives, case managers, eyeglasses, prosthetic devices, rehabilitation, free-standing birthing centers, and a host of other services. States may choose not to provide many of these services.

So much for reviewing the acute fee-for-service budget; on now to the fee-for-service long-term care (LTC) budget. A large part of the Medicaid service budget goes for LTC: $118.4 billion (21.4 percent of the total) in 2016. The LTC budget can be divided into nursing home facilities (37 percent), intermediate care facilities for the intellectually disabled (8 percent), mental health facilities (3 percent), and home health and personal care (52 percent).

More than half (52.1 percent) of the LTC budget actually goes to home and community-based care for 3.2 million functionally disabled elderly. The Omnibus Reconciliation Act of 1981 under the Reagan Administration enabled funding through 1915(c) waiver programs known as the home and community-based services waiver (HCBS). Since waiver programs are not entitlements, states can set limits on enrollment in the HCBS programs by setting quotas. The goal was to save money by decreasing the use of the more expensive nursing home entitlement. However, the new benefit was so popular and generous that it became Medicaid’s biggest expense.

The specific services covered vary by state. Medicaid can pay for an assisted-living facility stay, home-care services, homemaker, adult day care, and skilled nursing care. HCBS has resisted quality assessment because the public has regarded it as “intrinsically good.” There is no standardization or explicit standards for services because of diversity among the states, diverse settings, and dispersed delivery. A matched pair study from Alabama in 2016 showed that Medicaid home health patients cost a significant (p < 0.001) $4,600/year less than Medicaid nursing home patients. Medicaid waivers for home health care will probably never be challenged because of their cost savings and popularity.

The CMS fraud and abuse report for 2017 cites fines of $9 to $268 million for fraudulent certifications of eligibility for patients, money laundering, and kickbacks and bribes for patient referrals to home health agencies.

Nursing homes constituted the second-largest part, $43.8 billion (37 percent) of the LTC budget for 832,000 patients in FY2016. Nursing homes make 10 percent on private pay patients but lose 2 percent on Medicaid patients. Medicaid patients are still desirable, however, for filling empty beds. Ratings by Federal inspectors show that the more Medicaid patients that are mixed with self-paying patients, the greater the reduction in quality of care for everyone in a nursing home.

The CMS fraud and abuse highlights report for 2017 cites nursing home recoveries ranging from $8 to $145 million for fraudulent billing for unnecessary services. In a 2015 academic paper describing the five largest nursing home chains, four had many quality violations and all five had low nursing staffing and government legal action against them. In 2008 real estate investment trusts and private equity firms discovered that good cash flow from government subsidized nursing home patients could turn a great profit if the staffing and overhead costs were cut to the bone or lower. Lawyers have found it increasingly harder to successfully sue for these abuses.

Intermediate care for the intellectually disabled is a relatively small part of the total LTC budget, running 8.2 percent but still totaling $9.8 billion. Many patients have multiple disabilities. Patients eligible for Supplemental Social Security Income due to intellectual disability qualify for this program. In 2013 there were only 120,470 children in this program, which is not very many of the Medicaid total. The individual states do most of the monitoring of quality and abuse for this highly vulnerable population.

Mental health facilities comprise the final 2.6 percent ($3 billion) of the LTC budget. This covers inpatient psychiatric care for children up to 21 years of age and other mental health facilities for those 65 and older. Medicaid covers stand-alone mental hospitals as well acute care hospital psychiatric units. Inpatient substance use disorder (SUD) programs are covered for Medicaid eligible adults of all ages for stays up to 15 days. Follow-up day-treatment centers are also funded through Medicaid.

So far we’ve covered fee-for-service acute care, fee-for-service long-term care, and DSH payments. Another, smaller area is payments to Medicare from Medicaid, which amounts to 2.6 percent of Medicare resources ($17 billion).

Here Medicaid pays the Medicare premiums for dual-eligible patients who are over 65 or under 65 and disabled. This is a relative bargain for Medicaid because the 9.2 million dual-eligible patients in 2011 were sicker than average. They constituted 20 percent of Medicare enrollment but used 31 percent ($148 billion) of the budget. This is a form of cost-shifting from Medicaid to Medicare. Patients are automatically shifted to Part D Medicare, getting more restrictive pharmacy benefits.

Medicare and Medicaid are two different systems that “don’t talk to each other.” CMS has recently established the Federal Coordinated Health Care Office to integrate the two programs more closely. This shows that some active work is already being done on the “Medicaid-for-all” concept by merging budgets and coordinating benefits between Medicare and Medicaid. This tendency to merge might solve many coherency problems in the system, but it also adds further to the burden of centralized management—thus pushing in exactly the opposite direction from where we should want to go.

The final and largest part of the Medicaid services budget is the Managed Care segment. The penetration by managed care, constituting 46 percent ($253 billion in 2016), is striking. Management fees alone subtract at least 15 percent ($38 billion) before a cent is spent on patient care. This budget covers the same services discussed above as fee-for-service items but is contracted out to insurance-style corporations that manage the patients in HMOs (Health Management Organizations) or other similar settings such as Prepaid Health Plans (PHPs) and Primary Care Case Management (PCCM). As a group they are called Medicaid Managed Care Organizations (MCOs).

In 2016, CMS published a massive 1,425-page new set of regulations called The Final Rule on Medicaid Managed Care. It represented a kind of CMS power grab from individual states, presumably to limit the states’ gaming of the Federal budget. Many of the regulations are essentially mandates regarding the delivery of long-term care. CMS ordered the states to adjust rates so that at least 85 percent of the money paid to the managed-care firms would be spent on patient care, although they did not require repayment of any overage as for the Medicare program.

The rule requires states to implement a value-based system and demands that quality of care and program integrity measures be implemented and reported: Federal payment is conditioned upon them. Obviously, CMS is trying to introduce accountability where there is little to none by molding Medicaid to be more congruent with Medicare. Though an understandable impulse, the move toward more centralized management is still a mistake. This can be seen in the nature of the added reporting obligations demanded by the new regulations, which constitute a massive diseconomy in the health care system.

Physicians who have worked in this system complain that the new rules focus on management and create a huge and costly bureaucracy dedicated to preserving the status quo rather than to improving delivery of effective medical care. Doctors complain specifically that Medicaid HMOs provide narrow and irrational formularies, unresponsive specialty networks, and difficult care coordination.

Washington is setting-up Medicaid to be a group of MCOs managed by CMS that in turn mandates financial contributions from the states, but with ever less “local” control over Medicaid delivery. HMOs and MCOs are disliked by the public and are regarded by most physicians as second-rate care providers. They potentially could save money by limiting the prompt availability of medical care and, hence, quality.

The CMS fraud and abuse highlights report for 2017 cites $31 million and $45 million MCO-related fines for failing to screen pre-certifications for insurance companies, falsely representing an inadequate network, illegal schemes to maximize payments from the government, and inflating expenditure information. Heavy insurance regulation in combination with heavy insurance lobbying make rent seeking through regulatory capture likely. The ACA mandates patients to pay for more and more required services, which explains why so many of these MCOs keep popping up. This kind of rent seeking is making them very profitable.

Here is a startling fact that hasn’t been much discussed so far. People with mental illnesses and drug and alcohol addiction—jointly termed behavioral health conditions (BHC)—consume 48 percent of the entire Medicaid budget but make up only 20 percent of Medicaid enrollees. Only about 10 percent of the total Medicaid budget is spent on treatment of BHCs themselves. The other 28 percent of the total Medicaid budget is spent on over-usage of regular health care. The average yearly expenditure per patient with a BHC was $13,303, but only $3,564 for patient’s without a BHC in 2011. Members of this group do not take care of themselves well due to psychiatric problems. There is an opportunity to improve the general health of the BHC group by offering more aggressive and effective treatment of their psychiatric problems. There is some hope. The Oregon Healthcare Trial showed evidence of significant improvements for patients with depression.

Although I have alluded above to the ACA, most of Medicaid policy evolved over the past 50 years, long before the ACA came into being, so it’s a mistake to attribute Medicaid’s problems to that law. Nevertheless, let’s look at the ACA’s impact on Medicaid, for its effect has not been trivial.

The most important impact of the ACA has been the expansion of Medicaid to non-elderly adults with incomes up to 138 percent of the Federal poverty level, which was $16,243 for one person or $33,465 for a family of four in 2016. Medicaid expansion under the ACA successfully increased enrollment by 11.5 million beneficiaries at a cost of $68 billion, which was 62 percent higher than the initially projected $42 billion. Studies have shown improved results for life-improving treatments. But self-reported health status showed no improvement. As per the Supreme Court ruling of 2012, 18 states opted out of the expansion despite 100 percent Federal reimbursement for the first two years, tapering to 90 percent Federal reimbursement by 2020 and for subsequent years.

Why would any state opt-out? The Federal government reimburses the pre-expansion group according to the Federal medical assistance percentage (FMAP), which is on average 57 percent of state expenditure. In some states enrollment of the pre-expansion group was below 50 percent of the eligible, but enrollees cost the states on average 43 cents of every dollar spent. If this group expanded its participation rate because of the more streamlined enrollment process of ACA exchanges, budgets would be devastated in states like Florida and Texas. The states also feared that future Administrations would eventually reduce the Federal share from 90 percent, leaving states with entitled recipients but inadequate funds.

Both sides of the aisle in Congress are aware of Medicaid’s cost problems. Nevertheless, the Democrats, in the words of Chuck Schumer, believe “we are a rich country, we can afford it.” The Democratic solution focuses on increasing coverage, inclusiveness, and equality of care. Their Medicare-for-All bills had 16 co-sponsors in the Senate and 122 sponsors in the House. It merges Medicare and Medicaid coverage, eliminates private insurance, and creates numerous new taxes, especially for the wealthiest 5 percent.

Republicans point out that, at projected rates of growth, Medicaid, Social Security, and Medicare will crowd out everything but debt payments on continued and mounting annual deficits. The Republican solution keeps the present Medicaid and Medicare programs, seeks to eliminate waste and gaming with block grants to the states, and frees states to include abortion restrictions.

Neither approach to the ACA-era Medicaid problem is adequate, in part because neither addresses the fundamental problem of management chaos due to the scale of the program. The Democratic approach would break the bank faster, but the Republican one would break the bank too. What we need is an approach that accomplishes real reform of Medicaid in three respects: cost, size, and quality control.

Out-of-control costs arise mainly from fraud, abuse, rent seeking by stakeholders, and gaming by the states. DHHS has estimated that 12 percent ($139 billion) of total budget expenditure was for improper payments. The Medicaid Fraud Control Unit recovered $1.9 billion in 2016, which is less than 2 percent of the $139 billion. Outright fraud like money laundering or billing fraud by criminal syndicates are clear-cut and easier to identify than abuse in the form of inflated billing and billing for marginally necessary or unnecessary services and goods. Better fraud prevention and recovery would help solve this problem, but that would require our spending more on this capacity. No such plans are in prospect.

The greatest contribution to out-of-control costs is good old-fashioned rent-seeking by the “Medicaid-medical-industrial complex.” For private companies that means excess profits enabled by political manipulation. The principal rent seekers are nursing homes, hospitals, pharmaceutical companies, pharmacies, insurance companies, MCOs, and, to a lesser extent, professional practitioners. Lobbyists for these stakeholders love a mammoth, overly complex program like Medicaid because it is a black box to the public and therefore “easy pickins.”

Rent-seeking mechanisms are not always easy to see, but here are a few more examples. CVS has recently been shown to use a pharmaceutical benefit manager (PBM) to pocket money as an intermediary between pharmaceutical companies, pharmacies, and MCOs. They have also used PBMs as an anticompetitive weapon against individually owned pharmacies. The MCOs took no notice of the PBM rip off because it didn’t affect them: Stakeholders have no incentive to control rent seeking or corruption by other stakeholders. But now that PBMs have attracted public notice, the Office of Management and budget is reviewing them.

In another example, lobbyists for the pharmaceutical industry convinced Medicaid to fund excessively large and expensive prescriptions of dangerous opioid drugs for low-income workers, as recently pointed out by Senator Ron Johnson (R-WI). Joseph Schumpeter once estimated rent-seeking costs at 4 percent of an economy. Posted profits for biological drug companies range from 21 percent to 41 percent, but rent seeking by drug companies could be as high as 90 percent.

Then there is the fact that over 80 percent of hospitals are not-for-profit or government-owned. These institutions nevertheless have their own version of rent seeking, characterized by excessive executive salaries and benefits, oligopolistic price setting, and an “edifice complex,” involving excessive investments in physical plant, from which one can extract kickbacks as well as actual rents. There is nothing illegal about a hospital investing in commercial real estate, essentially renting offices to others, as part of a business model. Almost all major urban-based universities do the same thing. But it does almost invariably distort the function of the institution. The only solution to rent seeking, aside from making it illegal, which is unlikely, is to increase transparency so as to create political pressure through public awareness.

Another contribution to out-of-control costs is the gaming of Medicaid Federal funding by the states. The Federal government must match state funding at a fixed rate determined by formula as discussed above. By using waivers for DSH, IGT, and UPL and, in some fairly outrageous cases, reclassifying county and city mental institutions, nursing homes, and hospitals as state medical institutions, they have been able to shift state costs back on to the Federal government, resulting in the states effectively paying significantly less than their agreed share.

The use of block grants to the states could be an effective long-term solution, with amounts determined by a per-capita formula adjusting for population growth, for inflation, and for states having a higher proportion of elderly or disabled beneficiaries. The states could be given waivers to determine eligibility, service delivery, benefits, and patient incentive programs—like Indiana’s proven HSA-like program—in spending their block grants. The HSA-like program gives Medicaid beneficiaries $2,500 to purchase health care using their own judgment and discretion. After meeting a $2,500 deductible, Medicaid picks up the rest of the tab. Eliminating DSH payments with block grants could save about 4 percent of the total Medicaid budget.

Above all the mammoth size and overly complex program of Medicaid makes it difficult to administer, opaque to the public, and exposes it to all of the mechanisms of out-of-control costs. Businesses reorganize or go bankrupt when they get too complicated to be profitable. Contrariwise, overgrown failures like Medicaid just keep getting bigger. They prey on all the vulnerabilities of big government, including rent seeking by stakeholders, bureaucratic empire building, the public opiate of entitlements, and intellectual and moral laziness in the service of ideology. The best available solution is to break up the present Medicaid into three separate programs: one for healthy children and adults below certain income levels—the original program concept; a second for nursing homes and community care for the elderly; and a third for disabled children and elderly.

Certainly, the eldercare component could be split into a separate agency. Although nursing homes were part of original Medicaid, the popular HCBS was not, but it has come to be seen as a middle-class entitlement and has very broad support. The eldercare program is more clearly aligned with goals of the Social Security Administration and its mainly non-medical expenses could readily be managed like social security payments.

The disability and rehabilitation programs in the Veterans Administration are close in mission to Medicaid disability program. Combining the two programs into a separate agency for management of the disabled would benefit both programs.

Divesting Medicaid of eldercare and care for the disabled should let the program concentrate better on what it was created to do: provide adequate medical care for those who cannot afford it out of pocket. The quality of care delivered by Medicaid has always been controversial and hard to measure. But on balance, most experienced people have come to conclude that Medicaid outcomes are not as good as outcomes for those who can afford private insurance, but vastly better than what they would be without Medicaid.

They can get significantly better, however, thanks to the advent of the federally qualified health center (FQHC), which dates from 1989 and started small. The FQHC team approach delivers education, nutrition, social support, and psychological counseling in addition to science-based medical care, all at a lower cost. Many low-income beneficiaries are poorly educated, not least about nutrition, and come from significantly different subcultures that benefit disproportionately from the multifaceted FQHC approach.

One measure of quality is the availability of different treatment options. A solution is preserving the fee-for-service option. This allows Medicaid to adapt to future changes, gives beneficiaries more options, and applies needed competitive pressure to the MCOs. Although it is easier for the states to contract with a small number of MCOs, the MCOs don’t typically provide higher-quality or lower-cost care than fee-for-service, and they have demonstrated a lack of interest in policing other stakeholders. So another fix would be to create objective measures of quality and effectiveness for every Medicaid program remaining once eldercare and care for the disabled are hived off. An outside agency or private contractors should perform the evaluations to ensure objectivity.

Without thoughtful reform, Medicaid will ultimately be forced to decrease the number of its beneficiaries, decrease services covered, and shift more costs to enrollees and the private sector. In desperation the Trump Administration has already begun doing many of these things to the extent permitted by administrative discretion. It won’t be enough.

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John McCain: The Enemy of Evil

The memorial service at Washington’s National Cathedral was a fitting tribute to Senator John McCain. The huge audience was there to salute a man who believed in serving his country, for which he had made enormous sacrifices. McCain was a fighter in the best sense of the word, for his country, for what he believed was right, for the oppressed and defenseless. He was a man of action who wanted to get things done for the good and sake of his country and for others around the globe. He believed in bipartisanship to get things done.

That bipartisanship was on display in the turnout for his memorial service. The crowd consisted of many Democrats as well as Republicans. In the first row were Presidents Barack Obama and Bill Clinton, along with Vice President Al Gore, sitting with President George W. Bush and Vice President Dick Cheney. Vice President Joe Biden was one of the pallbearers. The numerous members of Congress in attendance came from both sides of the aisle. In death, as in life, McCain had an uncanny ability to bring people together. Even Ivanka Trump and Jared Kushner were there, though President Donald Trump, of course, was not invited and went golfing instead.

Those who paid tribute to McCain during the service and in other ceremonies during the past week consistently cited his stand against autocrats, dictators, and demagogues. “Perhaps above all, John detested the abuse of power,” Bush said. “He could not abide bigots and swaggering despots. There was something inside of him that made him stand up for the little guy. To speak for forgotten people and forgotten places.”

McCain’s choice of the courageous Russian activist Vladimir Kara-Murza, who miraculously survived two poisoning episodes in Russia, to serve as a pallbearer was a clear parting shot at a favorite McCain target of scorn, Vladimir Putin. From Burma to Belarus, Egypt to Venezuela, countless others have been boosted by McCain’s concern for their welfare, his willingness to call leaders out for their abuses, and his support for universal human rights, democracy and freedom.

As Daniel Twining, president of the International Republican Institute which McCain chaired for 25 years, put it in a beautiful tribute, “McCain’s experiences as a POW meant that he knew what it’s like to be deprived of freedom.

McCain traveled around the world to learn about complicated situations and war zones first-hand, to show solidarity with our troops, to stand with dissidents and activists, and to speak truth to power. He spent many an American holiday away from home and with the brave men and women in our Armed Forces serving overseas. He represented the best in American ideals and leadership. Even if you disagreed with him on specific policies, you had to admire that he was a determined and principled man of action.

In his farewell address, McCain wrote, “Do not despair of our present difficulties but believe always in the promise and greatness of America, because nothing is inevitable here. Americans never quit. We never surrender. We never hide from history. We make history.”

The 18th-century British statesman Edmund Burke once famously said, “The only thing necessary for the success of evil is for good men to do nothing.” McCain believed in confronting the forces of evil wherever they existed, wherever they posed a threat to American interests, to our allies, and to basic human rights. McCain was determined never to let evil in any guise succeed. Few can rival his service to his country and his contributions to freedom, decency, and resolve to do right at home and abroad.

Former Secretary of State Henry Kissinger stated it well on Saturday in his eulogy. “The world will be lonelier without John McCain, his faith in America and his instinctive sense of moral duty,” Kissinger said. “None of us will ever forget how even in his parting John has bestowed on us a much-needed moment of unity and renewed faith in the possibilities of America. Henceforth, the country’s honor is ours to sustain.”

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The U.S.-Turkish Unraveling and the Arabs

Relations between the United States and Turkey have been poor for most of the past decade, at least as measured by the common understanding of how treaty allies behave toward one another. But over the past few weeks the bilateral relationship has reached new and potentially fatal lows.

As I outlined in an essay in these pages a week ago, part of the reason has to do with the personalities involved. For all their many differences of background and viewpoint, Presidents Donald Trump and Recep Tayyip Erdoğan are too much alike as political men: prideful narcissists who elevate personal loyalty over law, “fact” fabricators who often speak before they think, and whose exotic minds do not think well much of the time anyway.

But while the public nature of the recent spat, and the personalities therefore thrust into the limelight, explain much of the tone to the distemper, make no mistake: Serious differences of perception and interest are at the bottom of this, some of them ephemeral and temporary, perhaps, but others structural and unlikely to change quickly. This is not an evanescent mutual tantrum that will fade away like morning dew.

It is all quite complicated, with many kinds of moving parts all swirled around together—American citizens and former Turkish nationals employed at U.S. Embassy-Ankara under arrest; fighter aircraft construction and delivery suspended; economic weaknesses, pressures, and fears of failed bank contagion into parts of Europe; disagreement flowing from the civil war in Syria, not to exclude perspectives on the Russian role there and beyond; and more. All true: But most of the analysis of the current situation has failed to plumb, let alone understand, the deeper ramifications of a more or less permanent break between the United States and Turkey that may be in the offing. These concern European security and weapons-of-mass-destruction proliferation. It is this latter matter, which casts a tenebrous shadow over the Arab world, that constitutes the main focus of this discussion.

Many American experts on Turkey and the U.S.-Turkish relationship have come to the conclusion this time around that there is very little, if anything, left to lose in terms of American equities in Turkey. Erdoğan has gone off the deep end, they aver, and he’s not coming back. They therefore favor robust ripostes to what they consider to be Turkish misbehavior, and some have even praised the Trump Administration above its predecessors for getting this right at last. Indeed, one commentator recently suggested threatening to remove U.S. nuclear weapons from Turkey as a way to incentivize the Turkish government to be more reasonable.

This marks a change. Until the recent worsening of relations between the United States and Turkey, most serious observers argued for strategic patience as the touchstone of U.S. policy. Erdoğan would not be there forever, and while Turkey would not return to the kind of secular republic it was before the AK Party era, its other political parties are more moderate and more oriented toward Europe, opening the possibility of a still decent functioning relationship in the future. And while the glue of common interests from the Cold War no longer applies in full, experts have tended to agree that Turkey remains an important partner in a critical position. Hence, no one with any sense of strategy or responsibility in government would have proposed undoing the extended deterrence arrangements that bind Turkey to NATO and the United States.

Unfortunately, most country and regional experts do not think in strategic military terms, and most people who do think in strategic military terms either cannot or do not think like country or regional experts. So there is a disconnection here, which, again, explains why most of the recent acerbic American commentary on U.S.-Turkish troubles never even mentions nuclear weapons or their larger ramifications for European security.

I sympathize with the experts’ frustration, but it is a mistake to conclude that there is nothing left to lose; and as I laid out in my most recent piece in these pages, I shudder particularly at the implications of threatening to remove U.S. nuclear weapons in Turkey at a time like this. Those weapons still bind Turkey to both NATO and United States in a major strategic relationship, if clingingly at this point on account of the bad political blood flowing all about. This kind of relationship is traditionally called extended deterrence, which means that the United States pledges to protect ultimate Turkish security interests with its own weapons—in this case based on Turkish soil—so that Turkey need not deploy such weapons of its own. Aside from being considered necessary to protect NATO and other allies during the Cold War, the U.S. provision of extended deterrence has been, since the early years of the nuclear age, a key element in its grand strategy, which has included the imperative to suppress security competitions in key regions of the world.

The reasons for wanting to suppress such regional security competitions have been several. First, competitions between and among allies—Turkey and Greece, for example, over Cyprus—were thought to provide opportunities for adversaries to divide alliances and complicate alliance management. Second, competitions could breed local arms races, and thus invite ambient insecurity and raise the costs of any crises gotten out of hand. Third, some arms races could lead to weapons-of-mass-destruction proliferation, threatening the global security commons in general and generating a more dangerous world overall for the United States, as webmaster of the system, to manage. From the U.S. point of view, minimizing the number and size of wars and minimizing WMD proliferation constituted an act of doing good and doing well simultaneously: It was valuable for most others even as it was also valuable for the United States at the pinnacle of the postwar pecking order.

The Cold War is over, but the imperative to limit WMD proliferation remains—and so back to the Turkish situation we must go. Consider that Turkey sits in a regional environment in which states armed with nuclear weapons, or prospectively armed with nuclear weapons, are abundant. If a statesman or military planner sits in a swivel chair in Ankara and rotates 360° around, he can barely catch his breath between identifying actors capable of targeting Turkey with nuclear weapons: Russia, Pakistan, India, Israel, France, the United Kingdom, the United States both from its homeland and from other points in Europe, and of course prospectively Iran.

Now, the logic of the security dilemma is such that in the absence of the credible U.S. provision of extended deterrence, Turkey would feel pressure to develop its own nuclear weapons. That it has not exerted itself in that direction, despite its formidable engineering and scientific capacities, illustrates the stability of Turkish trust in U.S. protection—until recently—and the ability of both sides to bracket the core security relationship away from various disagreements. As with other nuclear-armed states, should Turkey go its own way it would do so with no active intention of actually using such weapons, but rather as a kind of insurance policy against diplomatic extortion at the hands of other nuclear-armed powers.

But of course if Turkey, no longer tethered to U.S. security protection in one way or another, developed nuclear weapons for such a purpose, other regional states would probably feel obliged to develop or otherwise acquire their own weapons, if they could, as an insurance policy against nuclear extortion by Turkey. They have already practiced that way of thinking in reaction to the possibility of an Iranian nuclear breakout, of course.

Indeed, that kind of hedging behavior is exactly what analysts have discussed for many years now as the so-called N+ danger inherent in the development of Iranian nuclear weapons. It is not just the danger posed by Iranian nuclear weapons, bad enough as that would be, but the mousetrap effect of proliferation that would likely drive other states to want such an insurance policy: Saudi Arabia, the UAE, Egypt, Algeria, and so on.

Now, some observers have argued that nuclear weapons are really not very important after all. If the United States and the Soviet Union, as well as China, France, and the United Kingdom, survived the Cold War without any nuclear use, it must be because deterrence is easy and hence stable, since all rational people know that the weapons are unusable save for the since-become-impossible exception of a state holding a monopoly over them. One well-known scholar, Kenneth Waltz, argued persistently that the more nuclear the weapons the better—because they would sober everyone up and lead to more stability and fewer wars. Happily, those with actual government responsibility did not agree.

It is unspeakably lazy thinking to glibly superimpose the U.S.-Soviet Cold War deterrence experience onto places like the Middle East. It is, after all, one thing to maintain stable deterrence when there are only two, or a small number of, nuclear powers, and quite another to maintain stable deterrence when the number of nuclear actors gets larger and becomes somewhat open-ended as more states lean that way. Under such conditions it becomes much more difficult to calculate what a sufficient deterrent is, and so efforts to make sure of having “enough” can touch off a multilateral arms competition in which sufficiency becomes an ever-moving target, almost impossible to hit. At the same time it becomes much more difficult to imagine crisis stability if one or more states resort to launch-on-warning deployment postures, which are more likely when young arsenals are small and unprotectable against preemptive attack.

Other important potential differences between U.S.-Soviet Cold War deterrence and potential multiparty deterrence in the Middle East exist, too. Let us note just three.

First, U.S. and Soviet arsenals displayed clear lines of civil-military authority in highly institutionalized state systems, but many Middle Eastern countries lack both such clear lines of authority and highly institutionalized arrangements, being instead looser and more personalized by nature.

Second, it was taken for granted that both U.S. and Soviet leaderships cared about the safety of their populations, a necessary assumption for effective deterrence. But in some heterogeneous and authoritarian Middle Eastern countries this premise may not so surely apply—think both Iraq and Syria under minoritarian (and coincidentally Ba‘athi) leadership, both of which committed mass murder against its own citizens.

And third, U.S.-Soviet deterrence operations became inextricably bound up in the minds of observers with intercontinental ballistic missile delivery systems. The result is that some people today think that if missiles can be limited in one way or another, then the dangers of nuclear weapons, even if they come to exist, would be much mitigated. This is delusional because it is technologically obtuse. You need intercontinental ballistic missiles if you’re trying to shoot a warhead across an ocean. But if your enemy target is not across an ocean, but, as in the Middle East, quite nearby, airplanes are immensely less expensive and more reliable as delivery systems.

The basic point is that in both theory and practice, there is little difference between the proliferation stimulating effects of a Turkish nuclear weapons breakout and an Iranian one. So if the U.S.-Turkish strategic partnership unravels, logic does indeed suggest a Turkish effort to develop its own nuclear capabilities. (Of course, the same kinds of pressures pertain to other key countries were they to lose, one way or another, their U.S. nuclear umbrellas, including Germany, Japan, South Korea, and others.)

If that happens, the Turkish government could probably develop deliverable nuclear warheads at least on its side of the ocean within two to three years. If the Iranian government had thought for its own good reasons to avoid overt testing and breakout postures once the nuclear deal expires by calendar or “is expired” by volition, a Turkish bomb would make that posture far more difficult to justify. One could therefore imagine a situation of twinned or near-simultaneous breakouts of Turkish and Iranian nuclear weapons even a mere three, four, or five years from now. The shock to the region would be profound, and possibly very dangerous.

I t almost goes without saying that these larger strategic implications of the current U.S.-Turkish disagreement bear significantly on the security of U.S. allies, friends, and associates in the Arab world.

First of all, any significant weakening of the structure of the U.S. alliance system diminishes the reputation and effective power of the U.S. government, and hence its ability to protect its friends and associates even outside the core of that alliance system. The United States does not have explicit defense treaty obligations, as ratified by the U.S. Senate according to the U.S. Constitution, with any Arab state on a par with its obligations within NATO, ANZUS, and its bilateral obligations to Japan and South Korea in Asia. Nevertheless, its longstanding ties to Jordan and Saudi Arabia, its special arrangements with Egypt since 1973, its more recent ties with Bahrain, the United Arab Emirates, Kuwait, Oman, and Qatar, and its looser but still friendly arrangements with Morocco and Tunisia, are all affected by both America’s reputation as a reliable and sympathetic partner and its willingness to affirm consistently its interests in those relationships. In a sense, America’s associated Arab governments (whatever one thinks of them) have been indirect but still real beneficiaries of a strong NATO, not much less so than European “neutral” countries such as Sweden, Finland, and Austria, or Israel for that matter.

This is why the fact that some Arab leaders rejoiced at the coming of the Trump Administration now looks so maladroit. They rejoiced because the new President clearly took a far less benign view of the potential for a major amelioration of U.S. relations with Iran. Some of these leaders had previously urged the Obama Administration to “cut off the head of the snake,” not to cozy up in bed with the snake, so to them, Trump seemed a huge improvement.

This, however, was a narrow and shortsighted judgment. It has since become clear that the Trump Administration is busy with an historically unprecedented act of great power self-abnegation. The President does not believe in any but zero-sum relationships. He thinks of inherited alliance ties on an entirely transactional basis, and the thinking—such as it is—proceeds almost exclusively in the literal “coin” of trade dollar numbers. Trump is not just a protectionist in trade; he is a mercantilist in terms of overall statecraft—an approach that had heretofore been obsolete for nearly two centuries, and for good reason.

Trump’s reticence to think of the United Stated as a provider of global common security goods has expressed itself in his manifest desire to have nothing to do with Syria; his instinct to leave, and let the Russians have their way with it, has been restrained only by dint of great and subtle effort by key advisers. This instinct shows even more clearly in the President’s dour attitude toward the Article 5 pledge that is the very foundation of NATO, and toward the European Union which, however troubled at present, has been a major postwar project of every U.S. administration—again, for good reason. In short, this Administration’s admittedly tougher attitude toward Iran does not presume any willingness to take significant risks on behalf of Arab associates who may find themselves in some sort of trouble.

In this context, Turkey has been and remains special as a link between NATO-Europe and the Near East. During the Cold War the U.S. government explicitly guaranteed Turkey’s borders with the Soviet Union and Bulgaria, as a Warsaw Pact Soviet ally. It managed Turkey’s border with Greece as an intra-NATO affair, again in the interest of suppressing regional security competitions among allies. Successive U.S. administrations did not formally guarantee Turkey’s borders with Iran, Iraq, and Syria. Informally, however, those countries aligned with the Soviet Union and possessing a Soviet-supplied order of battle (Iraq and Syria) were considered threats and were addressed accordingly. For example, the Soviet government used its position in Syria, largely via Syria’s Kurdish community, to build up and support the PKK inside Turkey. Arguably, that was a factor in stimulating a 1980 Turkish military coup—a development that clearly concerned the U.S. government and complicated the bilateral relationship.

So Turkey had a dual status as a U.S. ally—formal with respect to its NATO-facing flanks, informal but still real with respect to its Near Eastern flanks. Of course, things have changed: There is no more Soviet Union and Iraq is no longer a Russian client; but Russia’s role in Syria, with Iran and for a time ISIS playing roles in the context of the revenant Kurdish question, is if anything more important to Turkey than ever. The Russian position in Syria gives it considerable leverage over Turkey, so much so that in the current declined state of U.S.-Turkish relations, the U.S. government is at a loss to offset it at reasonable cost or risk. The United States and Turkey have had, at best, sometimes overlapping and sometimes incongruent interests in all of these shifting sands of events, which in the absence of a dominant Soviet threat has vastly complicated the bilateral relationship.

Suffice it to say that if Turkey were indeed to fall away from its core strategic relationship with the United States it would have different effects on the strategic environment in Europe and in the Near East. For one thing, as to the Near East, one needs to think of the U.S. military and intelligence footprint in the region as an integrated whole: Assets at Incirlik cover the Gulf as well as the Levant, just as al-Odeid in Qatar, as a command-and-control facility for air power, covers Afghanistan as well as the Gulf. The same can be said, more or perhaps less, about the basing of the Fifth Fleet in Bahrain and the concentration of U.S. intelligence assets in Jordan: These assets radiate generally, their reputational clout transcending the specific countries in which they are located.

When it comes to the Near East, the end of the U.S.-Turkish strategic relationship would basically come down to this: Instead of Turkey being part of a coherent, stabilizing, and protective U.S.-led power in the region, it would play a more independent and divisive role. One case in point is already manifest: When the Saudi/UAE-Qatari spat broke out in June of this past year, the Turkish leadership sent troops to Qatar as a symbol of its support; and just recently, in the face of punitive U.S. tariffs slapped on Turkey, Qatar pledged $15 billion in investment to ease the impact. Were the U.S.-Turkish strategic partnership to fully end, the political and geostrategic landscape of the Levant and the Gulf would be transformed on account of a truly independent, unfettered Turkish policy—in ways we can study, but cannot possibly know for sure.

Some of the scenarios one can imagine are fairly stunning. For example, there was an extended time, before the United States even existed, when Turks and Persians tried to kill one another in large numbers. The Ottoman-Safavid wars raged for much of the 16th century, their enmity reshaping the sectarian bounds within dar al-Islam. But as much tragedy as those wars caused back then, it pales in comparison to the destruction that an Iranian-Turkish nuclear war would cause in the 21st century for all the peoples of the region. Of course there is nothing inevitable about Turkish-Iranian enmity in the years ahead; but given the sectarian, cultural, and strategic cleavages between the two, only a fool would rule it out completely.

It therefore behooves everyone, each according to their own capacities, to do everything possible to prevent the development of additional independent nuclear weapons capabilities in or near the Middle East. For the moment, everything possible certainly includes not threatening to remove U.S. nuclear weapons from Turkey, let alone actually doing it, for that would be the single most powerful motivating force behind a Turkish decision to build its own nuclear weapons arsenal.

The U.S. government must not allow its pique at President Erdoğan to displace its good and common sense—whatever remains of it—despite what some experts may now be saying. For note well: It would be much harder, and perhaps impossible, to reknit the strategic relationship in the post-Erdoğan era if the core military-strategic understanding upon which it has been based were no longer in existence. A decision of this kind, whether sparked by a judgment on the U.S. or the Turkish side, is not a toggle switch that one can throw this way or that with equal ease. It would produce something more like a Humpty Dumpty scenario.

As one current head of state likes to say, “Not good.”

Note: An earlier version of this essay ran at Al-Mesbar (Dubai), September 2, 2018.

A current lesser-included case of the same problem, although not among formal U.S. treaty allies, is the current Saudi-Qatari rift—of which more below. American policymakers don’t like it when allies and associates try to harm one another.

Technically, China and North Korea may both be capable of targeting Turkey, but it is hard to imagine them doing so when so many other target destinations are higher priorities for them.

The NATO treaty has no provisions for expelling a member, but Turkey could withdraw from it. Likewise, while a sober U.S. policy would not remove its nuclear weapons from Turkish soil, the Turkish government could and might expel the United States from Incirlik Air Base, its 60-70 nuclear weapons with it.

That sounds like a lot of money, but Turkey is “short” at least $210 billion these days; so the Qatari pledge will not solve Turkey’s problem in the longer run and it will not help Turkey’s straightened banks much in the short run either unless it arrives soon in a lump sum. See here for more.

The post The U.S.-Turkish Unraveling and the Arabs appeared first on The American Interest.

Clash of Civilizations—or Clash Within Civilizations?

Samuel Huntington’s “The Clash of Civilizations” caused a stir when Foreign Affairs published it in the summer of 1993. Grand theoretical views by eminent thinkers deserve to cause stirs, whether they are right in the main or not—for being wrong grandly can start ultimately useful conversations in ways that being right trivially cannot. But Huntington’s “Clash” caused a stir for a special reason: He flew against prevailing zeitgeist, which had room for only a globalist versus nationalist conception, by proposing the concept of culture, and by extension civilization, as the organizing principle for global politics in the post-Cold War era. His attempt to determine where we, as a species, are in terms of political and social development arguably represents the pinnacle of Huntington’s work as a political thinker.

Some quarter century later, understanding what Huntington got right, and where he may have missed the mark, is worth the effort. Global politics at its great power weight class has returned to a state of competition; not that competition at any level entirely ceased between 1993 and today. Understanding the strengths and weaknesses of the Clash thesis can help leaders, particularly Western ones, navigate a turbulent international environment increasingly primed for conflict.

The Civilizational Argument

Huntington’s essay, followed by a similarly titled 1996 book, The Clash of Civilizations and the Remaking of World Order, directly challenged both globalist and nationalist predictions with its claim that differences among civilizations would become the core source of future global conflict. Unlike the former, Huntington denied that values were universal or likely would be universalizing. Increasing complexity and interconnectedness, he said, would not usher in a period of secular messianic calm, but instead prepare the way for a return to independent identities. Rather than deriving identity from ideological systems with global appeal, Huntington foresaw the enduring role of religion and culture in shaping individual and state identity.

At the same time, however, Huntington did not believe the nation-state would continue to serve as the fundamental unit of geopolitical conflict, as it had done for much of the 20th century. Instead, global interconnectedness would intensify political competition, forcing individual states to look upward and outward for protection. This combination of increasingly polarized identities and growing political competition would lead, in Huntington’s view, to an international system defined by civilizational rather than interstate competition. Civilizations would still organize themselves around certain “core states” that combined hard and soft power resources to lead their cultural groupings, while torn states would be internally split between major civilizational poles. Huntington sought to reshape our idea of post-Cold War politics emphasizing culture as a significant divider between friends and enemies, but not to the absolute exclusion of other traditional causes of enmity.

Huntington’s predictions were divided between grand theoretical pronouncements and what he took to be their specific corollaries. Certain broad insights—in particular, the endurance of value differences between the West and non-West and how it would shape politics going forward—were accurate. Moreover, several of his discrete predictions, such as, for example, the shifting military balance toward non-Western civilizations and the dynamics of fault-line conflicts, have enjoyed resounding vindication over the past two decades.

Yet for all that, one of Huntington’s broader assumptions—that political units, pressured by international competition, would work with their affiliates to create a “civilization-based world order”1—now seems mistaken. Civilizations have not cohered into unified political entities as Huntington predicted they would, each working to advance its own agenda vis a vis the others. Instead, cultural divisions within civilizations have become the dominant feature of 21st century world order, with West and East alike confronting their own peculiar identity crises. The result has not been cultural clash so much as cultural implosion—and how it ends is anyone’s guess.

The West and The Rest

The most significant and enduring of Huntington’s predictions are the deepening, persistent value differences between Western civilization and its competitors. He not only foresaw that civilizations would come into conflict, but specifically that the West would find itself engaged with multiple non-Western challengers.

Huntington divided the world into nine distinct civilizational zones. Western civilization spans the Atlantic, encompassing the United States and Canada, Western Europe, parts of Central Europe, the Baltic States, Poland, and Australia. Both Japanese and Latin American civilization can be considered loose affiliates of the West, although in Latin America cultural differences make that linkage highly variable. Slavic-Orthodox, Central Asian, Islamic, Buddhist, Hindu, Sinic, and African civilizations encompass the rest of the world’s nations, generally breaking down along ethno-religious lines.

It has become increasingly clear that major differences in values do exist between Western civilization, including its Latin American and Japanese affiliates, and nearly every other civilizational group, with the potential exception of Hindu civilization on the Indian subcontinent. Despite structural variations, every Western country is defined by an elective political system and a constitution that broadly guarantees personal, political, and religious freedom. The past 25 years of political development demonstrate that these systems, however fragile they become from time to time, rest on shared Western social and cultural values.

Huntington identifies religion as a critical differentiating factor. Western Judeo-Christian values, derived from centuries of political and social development, buttress and facilitate representative governance in a way that other religious systems do not. Regardless of this judgment’s accuracy, different cultural units do not share the same idea of legitimate political order. Most Slavic-Orthodox populations live under dominant-party anocratic regimes, such as Vladimir Putin’s Russia, which despite public elections is controlled by a politico-economic oligarchy. Alexander Lukashenko is now in his fifth term as president of Belarus having defeated the opposition by lop-sided margins since 1994.

Chinese integration into the international economic system did little to modify its underlying domestic structure. At present, China under Xi Jinping’s “Paramount Leadership” is more politically centralized and internally controlled than at any time since Mao. Chinese political institutions today resemble the imperial traditions of its past more than they do any more modern alternative.

States in the Islamic civilizational group are increasingly theocratic, authoritarian, and violent, particularly in the aftermath of the so-called Arab Spring. Tehran’s leaders and the House of Saud show no signs of relaxing their grips on power, while Turkey is morphing from a relatively liberal, secular, multiparty democracy into a religious, populist authoritarian state.

Dissent exists in authoritarian Russia and China. Much of both regimes’ perceived legitimacy is derived from the threat of government violence. Particularly in China, the regime’s insecurity, partially manifested in an obsession with Taiwan’s democratic existence, demonstrates its leaders’ anxiety over their claim to rule. Similarly, the Islamic World retains its democrats and dissidents, while a new generation of leadership in Saudi Arabia may lead to a less theocratic regime. Regardless, a high enough proportion of the population in these non-Western civilizations look askance at democracy, reject toleration of different ideological and religious positions, or actively embrace an alternative social framework grounded on different forms of legitimacy, all of them inherited to one degree or another from parochial experiences of the historical-cultural dialectic common to all civilizational zones—including the Western one.

Huntington correctly identified these differences as the inchoate drivers of non-Western opposition to the West. Russia’s growing cooperation with China is one example how distinct civilizations might enter into an alliance against a perceived hegemonic threat. Others include Russia’s active intervention on Iran’s behalf in the Syrian civil war and China’s growing economic cooperation with Orthodox and Islamic Central Asian States, Pakistan, and Iran.

The sharpening antipathy that the West faces today is in part due to the high level of underlying consistency, in certain respects at least, between Russian oligarchy, Chinese state capitalism, and Islamic authoritarianism. In their educational systems, Moscow, Beijing and Tehran encourage at least skepticism about the West and its values.  They use such appurtenances as elections to mask tyranny. All three states are as consistent in their embrace of kleptocratic rule as they are contemptuous of the freedom to speak, assemble, and pray. As competition continues, this axis shows no signs of weakening: Deeper links between Islamic states and Russia should be expected. 

The Civilizational Balance and Western Decline

Despite his criticisms of great power theory, Huntington understood that military and economic prowess play a critical role in shaping civilizational conflict. That is, while differences in values may produce and reinforce anti-Western sentiment, shifts in the major civilizations’ balance of power are what enabled the particular challenges we face today. Non-Western states have narrowed the technological gap with the West, developing the means to contest Western hegemony. China, for example, is well along in developing military applications of quantum computing, directed energy weapons, maneuverable re-entry vehicles, artificial intelligence and hypersonic weapons. More importantly, Huntington’s emphasis on the shifting nuclear balance of power retains its merit 25 years later. There was a time when the  West’s nuclear supremacy established its unassailable power.  Now, however, that supremacy is eroding as more and more non-Western states get their  hands on nuclear weapons. Out of the world’s nine nuclear-armed states, only four are Western: the United States, United Kingdom, France, and Israel. Sinic civilization comes in second place, with two nuclear powers, while Hindu, Islamic, and Slavic-Orthodox civilization each have one nuclear weapons state. Iran needs only to wait until the mid-2020s until the nuclear deal practically permits its nuclear weapons production; or it may break out sooner, depending on circumstances, to become the second Islamic nuclear power. These states do not necessarily have the same strategic culture as the West, which means the logic governing Western military policy may be outdated or even obsolete.

The problem isn’t just that more non-Western states have nuclear weapons; it’s that the nuclear weapons they have are growing increasingly dangerous. The North Korean situation demonstrates how non-Western nuclear states have refined their capabilities. Until now, such mid-level nuclear challengers as Iran, North Korea, and Pakistan lacked the missile capabilities to threaten the U.S. mainland directly. The U.S. military could therefore extend its deterrence umbrella to allies as well as a few lucky bystander nations without truly exposing its population to a nuclear strike. But Iranian and North Korean missile technologies, combined with insufficient American and allied defense systems, expose the United States to a level of risk it has not faced since the end of the Cold War. Thus, mid-level non-Western powers can effectively “decouple” the United States from its allies, or reasonably hope to do so in the absence of effective Western countermeasures. The point is that as the nuclear balance continues to shift, Western freedom of military action will narrow.

The tilting nuclear balance is not the only indicator of the growing anti-Western challenge. Non-Western states have developed both asymmetric and even some equivalent conventional capabilities, representing a further challenge to Western power. Chinese long-range missiles are designed to force American naval assets out of the striking range required to deter China or defend U.S. allies. Russian and Iranian anti-aircraft systems, combined with irregular grey zone assets, sharply curtail the U.S. ability to build up land forces near relevant conflict areas. The West’s rivals control conflict escalation in flashpoints ranging from Ukraine to Syria to the Scarborough Shoal. Meanwhile, powerful Western conventional capabilities are matched to a type of conflict that may never come.

The West’s rivals have also begun to field progressively more advanced conventional military technologies and have innovatively adapted them to the tactical-level. This is an underrated yet highly problematic trend in the balance of power between the West and non-West. Despite advances in precision-guided munitions and air forces, urban operational environments remain congested and confusing for offensive forces, nullifying the effects of Western armor and airpower. Absent the total air superiority and geographical propinquity featured in operations like Desert Storm, Western forces will find themselves operating in urban environments without the benefit of sustained interdiction campaigns beforehand. The West can no longer assume its infantry forces will prevail. We have already seen evidence of situations in which they might not: insurgent success in the Second Battle of Fallujah (against Western and Western-trained forces); Hezbollah’s effectiveness against Israel in the 2006 Lebanon War; and the tenacity of ISIS in Mosul and Raqqa.

Not only are non-Western forces becoming more adept at nullifying or matching Western technological advantages. They have also demonstrated an increasing ability to challenge Western forces in close combat. As Huntington foresaw, the West’s military decline, nuclear and otherwise, has created the conditions for a non-Western challenge.

Huntington also accurately identified how a changing military balance allows cultural power to spill across civilizational borders. Proponents of “soft power” theory in the 1990s and early 2000s argued that the utility of military force in international politics was declining, hence the supposed primacy of attractive cultural and political values. By embodying these values in foreign policy, Western states could attract allies and partners without offering concrete military incentives—or so it was thought.

For Huntington, though, “soft power,” was more an intra-civilizational phenomenon rather than an extra-civilizational one. Russian relations with Belarus, the majority of Central Asia, and parts of the former Yugoslavia benefit from historical, cultural, religious, and linguistic affiliations, just as China actively cultivates links with Sinic immigrant and expatriate communities, especially in the Asia-Pacific. But the strength of shared values weakens across civilizational borders. Western unpopularity in Islamic, Sinic, and Slavic-Orthodox civilization cannot be attributed simply to the inability of Western policymakers to articulate their professed values of tolerance and universal acceptance. Indeed, ample evidence exists that many of these norms repel states outside the West’s cultural orbit. It’s not that they don’t like us; they just don’t like what they’re hearing.

Yes, it is true that, aside from in the most reactionary sections of Islamic civilization, Western media, entertainment products and fashion remain popular throughout the world. Three of the top ten and seven of the top 20 highest-grossing films of all time in China are American made. English-language songs are routinely at the top of Russian music charts. On a casual stroll through the souk of any large Near Eastern city, the popularity of denim jeans among all age groups is undeniable. But the embrace of Western culture does not ipso facto entail the Levis-wearers’ acceptance of Western political values. Putin remains extremely popular throughout Russia, particularly among young voters. Despite the underlying brutality of his regime, the current Kleptocrat-in-Chief need not fear a pro-Western revolt, even among those most susceptible to Western influence.

Chinese youth today are less nationalistic than their parents and more exposed to Western political and philosophical culture than previous generations. Yet the Chinese Communist Party remains effective in its indoctrination efforts, and the shadow of the government’s brutality at Tiananmen Square, combined with controls over internet access, still stifles political debate. As Xi Jinping further consolidates power and Beijing cuts deals with significant non-state parties like the Vatican, the possibility that China will embrace Western values remains very distant.

Iran remains a curious case. Protests in December 2017 and January 2018 show that there is significant dissatisfaction with the clerical regime. But it is difficult to translate regime opposition into support for Western political values even in Iran, a country with a deeper proto-democratic tradition than any Near Eastern state apart from Turkey. And there is no indication that regime opponents in Iran are any less eager to acquire the global status that comes with being a nuclear-weapons state.

Technological advances and economic success go hand-in-hand with military power, so it is natural that weaker states look to stronger ones for models and aid for their own development. That process has caused a mixing of cultural and political institutions, starting arguably with 19thcentury Meiji Japan and continuing today in many dozens of states.

But when cultures and political systems do cross borders, the transmission patterns tend to track pretty closely with the civilizational balance of power at the time. In the mid-20thcentury, for instance, independent states within every civilizational zone adopted either Western capitalism or Soviet communism. And once the Cold War was over, the former Soviet states attempted, with varying degrees of success, to emulate the Western model. Western civilization had won out because its political culture allowed strong civil liberties to coexist with rapid economic growth. As a result, some in the West succumbed to a triumphalist narrative, imagining that liberal democratic capitalism was the only feasible path toward modernization.

Here Huntington disagreed. In his view, other, more authoritarian models could prove every bit as potent and enduring as Western ones, and indeed recent evidence seems to vindicate Huntington on this point. To take just one example, the Chinese system, which has now been emulated by several nations with strong Western roots, undermines the End-of-History idea that was so popular at the turn of the millennium. Ensuring the maintenance and potential growth of the West thus requires repairing our international economic and military positions, for we are no longer a cultural hegemon, a civilization without challengers. We cannot, that is, take our role in the world for granted.

Core State and Fault-Line Wars

Although Huntington’s Clash of Civilizations thesis is an exercise in grand theorizing, his approach includes what is known in the military as the “theater level”—that is, a specification of the geographic area in which conflict occurs. Huntington’s “fault line wars” thesis demonstrates the practical results of meaningful value differences between political communities. When civilizations do clash, the results can be particularly damaging.

Fault line wars are clashes between rival ethnic groups. They are different from conflicts between members of the same civilization, or between great powers that represent different civilizations. States that lie along the “fault line” between two major civilizations are particularly vulnerable largely because geographical propinquity and resource scarcity combine with identity differences to supercharge confrontations. Wars become symbolic, like the struggle between the Achaeans, who honored the rules of host-guest relations, and their Trojan adversaries, whose kidnap of Helen showed that they did not. The Thucydidean concept of “honor” as a fundamental casus belli linked to cultural pride and supremacy prevented the resolution of conflicts despite shifts in the balance of power. The victorious side in fault line conflicts, between governments or non-state actors, is liable to inflict harsh punishments upon its adversary. The Balkan wars of the 1990s and early 2000s were fault line wars between and among ethno-religious groups. Multiple flashpoints created constant potential for conflict between Catholic Croats, Orthodox Serbs, and Muslim Bosnians. Friction amid ethnic enclaves, combined with assertions of religious and cultural supremacy, led to genocide.

However, fault line conflicts can also occur in the absence of ethnic fragmentation, when deep cultural differences separate populations. Eastern Europe’s current political situation is a sustained fault line conflict, especially with regards to Ukraine, whose polarized population is split along two civilizational lines: The Russophile East gravitates toward its Slavic roots, while the Europhile West retains its Western affiliation.

Tension between political cultures can develop sua sponte, but often human intervention magnifies the tremors. Vladimir Putin took full advantage of the schism in Ukraine to isolate the east from the rest of the country and draw it back into Russia’s orbit. Similarly, in the “frozen conflicts” of Georgia and Moldova, Russia manipulated the ethnic and religious affiliations of the population for their own objectives.

Much of Eastern Europe is frozen between Slavic and Western civilization. The zone of friction runs almost exactly down Huntington’s identified fault line:

This line dates back to the division of the Roman Empire in the fourth century and to the creation of the Holy Roman Empire in the tenth century. It has been in roughly its current place for at least five hundred years. Beginning in the north, it runs along what are now the borders between Finland and Russia and the Baltic states (Estonia, Latvia, Lithuania) and Russia, through western Belarus, through Ukraine separating the Uniate west from the Orthodox east, through Romania between Transylvania with its Catholic Hungarian population and the rest of the country, and through the former Yugoslavia along the border separating Slovenia and Croatia from the other republics. In the Balkans, of course, this line coincides with the historical division between the Austro-Hungarian and Ottoman empires. It is the cultural border of Europe, and in the post-Cold War world it is also the political and economic border of Europe and the West.2

Multiple signs of stress exist along this fault line today. In the North, the Baltics remain solidly Western and anti-Russian, while Finland and Sweden refuse to be drawn into Russia’s orbit, instead maintaining independent and tacitly pro-Western foreign policies. However, Poland’s current government exhibits increasingly authoritarian tendencies, while Hungary and the Balkans are consistently more ambivalent in their allegiance to the West. Further into Mitteleuropa, fault line stresses still show.

Major Russian-speaking and former Eastern Bloc populations have retained their affinity for Slavic-Orthodox civilization—a fact demonstrated even in the heart of the West by the rise of Germany’s Alternative für Deutschland, a  right-wing German party hiding behind a nationalist veneer. The majority of the party’s voters are found in what was formerly East Germany, and a third of that base is Russian-speaking Slavic or Volga German. Russian-sponsored media outlets routinely support AfD candidates in an attempt to galvanize Slavic-Orthodox minority groups in the heart of Europe and use them against established parties in the European political system.

Western policymakers would do well to heed Huntington’s fault line analysis. It identifies the roots of many of today’s geopolitical issues and helps us predict what future conflicts might look like. It also hints at policy directions likely to be adopted by other states, which are increasingly motivated by a widespread sense of cultural precariousness.

The Clash’s Blind-Spot

Huntington’s Clash thesis has significant merit, but contemporary events undermine its argument that civilizations will naturally cohere as inter-civilizational competition intensifies. If anything, increased competition has fractured civilizational zones, particularly the Western one.

Huntington’s theory rests upon a major assumption: Political units will only evolve upward, as more and more states would integrate into their respective civilizations. Information technology and more efficient transport methods would “shrink” the world, according to Huntington, making interactions within civilizations more frequent and differences between them much starker. Economic growth would eliminate traditional subcultures, leading populations to turn to religion to find meaning and purpose. Economic regionalism would reinforce these twin motions, creating transnational cohesion and reinforcing religious bonds across borders within civilizational zones.

Finally, Huntington thought that as the West’s power declined, competition between the West and non-West, and among non-Western alternative civilizations, would spike. States would be forced to choose between ceding sovereignty for survival or risking destruction at the hands of more powerful transnational units.

There remains much to this. Value differences have certainly persisted between the West and non-West, and the military decline of Western states parallels a concerted armed challenged from states in non-Western civilizations. The world has “shrunk” with the increase in communications and transportation technologies. Yet for all that, most civilizations have refused to cohere.

Huntington was right to identify civilizations as basic units of political interaction. He erred, however, in underestimating the degree to which intra-civilizational competition would persist: Taiwan remains stubbornly independent despite China’s diplomatic and political efforts to isolate it; tensions on the Korean peninsula remain high; Vietnam, the other critical component of Huntington’s Sinic civilization, not only remains outside of China’s grasp but has explicitly attempted to build links with the United States; and although China holds the preponderance of power in Sinic civilization, the traditional rule of political competition—that power repels power—still applies in the face of cultural consanguinity.

Africa and Latin America also remain fundamentally divided. South of the Sahel, most of Africa’s states have stagnated. Potential regional leaders either refuse to exert their influence and build a clear political sphere, such as in the case of South Africa, or are plagued by internal issues, as with Nigeria. Africa remains too internally fragmented to cohere, which has allowed external powers to influence regional affairs. China now targets the continent, attempting to secure its natural resources, but the United States and France are also major players. French involvement especially indicates Africa’s lack of political coherence: Despite its economic and military fragility, France still dominates many of its former colonies.

Latin America is stronger and more developed than Africa. The civilizational group’s states demonstrate a growing collective industrial capacity, produce significant portions of the world’s energy and food supplies, and have robust demographics. Cooperation rather than competition now defines Latin American regional politics as Brazil, Argentina, and Chile seem to have largely overcome the rivalries that defined their earlier relationships. However, decolonization created multiple and distinct political traditions within Latin America. The connections with the West remain, but as Huntington recognized, Latin civilization as a whole remains distinct with its largely Catholic tradition and Hispano-Portuguese languages. Despite having significance as a broader unit, the unity of Latin civilization remains elusive, and integration between Latin American and the Anglophone parts of the New World, tenuous.

Islamic civilization, meanwhile, has done anything but cohere. In addition to the persistent presence of external powers within its domain—the West, Russia, and India—Islamic civilization is beset by a growing internal battle for political leadership. Several potential core states exist, but out of the six that Huntington identified in 1996 (Iran, Saudi Arabia, Turkey, Pakistan, Indonesia, and Egypt), only three remain as possible leaders of the Islamic world.3And those three—Iran, Saudi Arabia, and Turkey—belong to their own distinct sub-civilizations that harbor deep-seated enmities toward one another.

A religious divide also splits these competitors. Shi‘a Iran opposes Sunni Saudi Arabia and Turkey. The differences within Islamic civilization are also highlighted by each state’s choice of allies. Saudi Arabia and Turkey, two states with starkly different political systems, have historically gravitated toward the West. As Western power declines, authoritarian Saudi Arabia remains solidly within the Western orbit while still more liberal Turkey hedges its bets, albeit possibly for very time-limited reasons having to do with the ongoing Syrian civil war. Iran, meanwhile, has turned to Slavic-Orthodox civilization as a potential ally. Over time, Islamic civilization’s wars may burn out and its states might cohere into a functional international unit. But without the very unlikely ultimate triumph of one challenger for leadership over the other two, Islamic civilization is very unlikely to emerge as a united, independent force. 

Western Collapse

Most dramatically, the West has refused to obey Huntington’s model. Rather than entering a new period of competition for civilizational leadership, the West’s core states seem to be increasingly ambivalent about the ideals that have defined Western culture. The threats to Western leadership have multiplied since the Cold War’s end as revisionist challengers rise from Slavic-Orthodox, Sinic, and Islamic civilizations.

This international competition has highlighted fissures among Western subgroups. The core, comprised of the Anglosphere and Western Continental Europe (particularly Germany and France), maintained a united front throughout the Cold War, despite frequent Gallic squirming. But since the Soviet collapse, the Anglosphere and the Continent have drifted apart. Two models, not one, exist in the West: the market-focused Anglosphere approach and the socially democratic Continental method. A period of civilizational fracture could be consistent with Huntington’s thesis, but signs in both the Anglosphere and the Continent point not to competition between partners but to increasing Western frailty overall.

The problem began in Europe. Germany, a state until 1945 that embraced its own identity, erased nationalism from its (Western German) political consciousness to atone for World War II and the Holocaust. Angela Merkel’s decision to allow significant Islamic populations to enter Germany, and by extension Europe, grew out of this ideology. Merkel’s migration policies provoked a predictable reaction that, at its darkest, reflects the illiberal side of traditional nationalism.

In the Anglosphere, the United States is reconsidering its position as the standard bearer of the liberal international order, as well as its principled attachment to free trade. Meanwhile U.S. trade and immigration policy threatens to alienate all countries to south of the border with Mexico. Britain’s political leadership is inept and has been for a while. The Brexit plebiscite bordered on insane and should never have been allowed, let alone encouraged, and the current Prime Minister nearly permitted a committed leftist and avowed friend of terrorist groups to win the election. She cannot control her own party as Brexit negotiations have all but imploded. Canada, under ineffective “centrist” leadership, is faring little better.

Perhaps more important, the political climate has degenerated since the 1990s. The United States, and the West more broadly, is increasingly divided between political extremes. Shades of collectivist authoritarianism haunt much of the contemporary Left, for example in efforts to manipulate language, curtail free speech, and airbrush alleged malefactors and their works from our common cultural history. Meanwhile the Right is rife with modern versions of the interwar isolationists who lob xenophobic and nativist ideas into the public square. The result on all sides has been a growing affinity for executive action, disregard for the legitimacy of differing opinions, the evanescence of moderate politics, and a coarsening of political discourse that encourages the manipulation of the electorate.

It is therefore not particularly surprisingly that some Western states are turning away from the hard work of consolidating liberal democratic models of governance. Hungary, Poland, and even Austria have all become more authoritarian, with their ruling right-wing parties feeding off the failure of the European Left to articulate a political vision that does not demean the Western experience and its constituent national traditions. Italy and Spain do not appear to be far behind. Tolerance, mixed governance, individual liberty, and open civic cultures, among many other things, made the West great. Whether from intolerance, self-doubt, or some mixture of these debilities, the West now seems to be rejecting its own heritage. Huntington offers few assurances for declining civilizations. The West is no exception.

As we look to an uncertain future, Samuel Huntington, who passed away almost ten years ago, still teaches us one clear lesson. Man will not return to bypassed forms of political organization. Old alliance structures, regime types, and social norms will not succeed when the intellectual and moral frameworks underpinning them have been uprooted. The stakes in the fracturing of non-Western civilizations are large and unknowable. But the consequences of the splintering of the West’s ideas of liberty, the decay of political institutions, the abandonment of market-based economics, and the subduction of its military dominance are larger but knowable. As parlous as the clash of civilizations might be, the implosion of our own is much more to be feared.

1Samuel Huntington, The Clash of Civilizations and the Remaking of the World Order (1996), pp. 20.

2Huntington, Clash, pp. 158

3Huntington, Clash, pp. 177–8

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The Ox-Bow Incident at 75

Born in the late 19th century in Brookline, Massachusetts, and capable of tracing his ancestry back to the Puritans, William Wellman starred as a fighter pilot in World War I. He might thereafter have been a different kind of star, just because Douglas Fairbanks, whom he had met accidentally after landing a small plane on Fairbanks’s polo field, told him he was handsome. Fairbanks ought to have known.

Stationed in San Diego after the war, Wellman, dubbed “Wild Bill” by his mates, was teaching flight tactics to initiates and zipping down to Hollywood on weekends at Fairbanks’s prompting. The latter said that Wild Bill should take up acting, which is what Wild Bill proceeded to do. But he didn’t take to it; he concluded before very long that the acting profession was too “unmanly” for his liking. He decided that he would rather direct films than act in them.

Wellman’s judgments about the manliness of acting, or lack thereof, should not be misread. Wellman’s sense of masculinity transcended mere macho chest-thumping à la Hemingway or Mailer, the kind of two-dimensional notion that tends to produce art that one soon grows tired of, lacks nuance, does not age well, and does not incorporate a wide spectrum of viewpoints. Wellman’s sense of masculinity had more to do with leadership and taking responsibility.

It did not, however, imply anything anodyne, or too well behaved. Wellman earned his nickname both in the skies over France and in the bars below. As an assistant director, having successfully departed the actors’ studio, he broke a “no associating with femme fatales” bylaw laid down by his director-boss, which led to a thrashing. Still, his time in the director’s chair came, and with his first mature work, 1927’s Wings, Wellman proved that he was not an artist bound by simple notions of what was masculine and what was feminine. Of all the great American silent pictures, the camera moves in no other quite like it does in Wings. The sequences of planes in combat must have hit viewers at the time with that same wallop of authenticity that much later made the battles in Saving Private Ryan so searing. Other masterpieces and mini-masterpieces followed: The Public Enemy (1931), Beau Geste (1939), and The Story of G.I. Joe (1945).

Yet there is no Wellman picture like 1943’s The Ox-Box Incident, which marks its 75th anniversary this year. Even in Hollywood’s rich history of Westerns, and even the rich indie history of Westerns, there is no Western like this one.

The film stars Henry Fonda, who would always remark that it was among his favorite pictures. His character Gil Carter is friends with Harry Morgan’s Art Croft. They have been traveling a long time on the trail when they ride into a saloon in a town that has experienced a spate of cattle-rustling. This is a deeply grim saloon—perhaps the most depressing such establishment in all of the cinematic Old West. Even by small town frontier standards it is so shabby that you can scarcely imagine anyone willingly going there. The place has the vibe of a charnel house, as if boxes of bones might be tucked off to the side.

These two men have a history with this town, but an oblique one. They are not townies returning to home base. They kind of know the people there in a vague way, and Fonda’s Gil Carter is looking for his girl. But it’s obvious that this romance dates to some distant past, and his girl could simply be a prostitute with whom he once had a side-alley five-minute dalliance. We are not sure, exactly, which is unsettling, and Wellman is in no rush to provide us with any kind of peace, which is one of the movie’s themes.

A contretemps between Croft and a patron—which seems a generous term—occurs, with a chair being busted over Croft’s head, just to show how close to the surface tensions are in this desolate place. A report arrives that a rancher and top cattle seller named Larry Kinkaid has been murdered, and now a hanging party is about to be assembled. It is at this point that we meet the dramatic personae of a group who will function in relation to each other much like the group in another Fonda picture, 1957’s 12 Angry Men.

There is Major Tetley, played by Conroy, and his son Gerald (William Eythe), whom he deems too effeminate. Tetley is an invented Major, as becomes known later, a man not unlike those people we read about in our current society who invent stories about being Marines or Special Forces. His son is not effeminate; he simply does not want to make some strange bodies dangle in the trees, which is what this picture is starting to become about. But what it is even more centrally about is people lying to themselves about who and what they are, and lying, in turn, to the people around them. Reality, of course, can only be evaded for so long before it comes marching upon us, holding out a mirror with that reflection of our true selves, which we cannot avoid.

Watching this film recently during a revival showing on the big screen, I was struck by how uncomfortable fellow watchers seemed to be. It was as though they were projecting themselves into the film, where people, without a proper dispensary of facts, seek to destroy other people. Harry Davenport plays Mr. Arthur Davies, a respected senior member of the town who begs the departing posse not to do this. They haven’t done anything yet, but what they will do already seems inexorable. Carter and Croft don’t want to be there, because they know they won’t be able to stop anything out in the open. Maybe they can gum up some works behind the scenes, but when we all get to where we are going, that’s clearly, as we see, not an option.

Along the trail of the alleged murderers, the group, which is outfitted with more townsfolk, for whom this is akin to a turkey shoot, encounters a barreling stagecoach. The driver thinks this is a hold-up and fires, hitting Croft, who is more lucky than harmed, left with just a bad flesh wound.

Wellman shoots this scene on a manufactured ridge, as if there were a chasm a hundred meters below, a veritable bottomless pit in an inky night. The lighting is that of the film noir genre that had started to make inroads in Hollywood, though no one was calling it noir at the time, and no one, certainly, associated it with a Western.

People are packed in this film like the ship’s cabin scene in the Marx Brothers’ A Night at the Opera, only Ox-Bow isn’t the least bit funny. As it happens, Carter’s ex (Mary Beth Hughes) is on this stagecoach, newly married. She moves to tend to Croft, exchanging some looks with Carter, before her husband intercedes. He does so by launching into a priggish, ignorant speech of the kind often given by one whose entire self-worth has always been built around the things they were given—money, privilege, elite education. Carter stands there listening to this torrent of drivel about how he may or may not have known this woman in the past, yes, but her life is different now, and someday, after enough time has passed—which is to say, never—he might be welcome to visit their home and meet their family.

The scene plays out, and we never see Carter’s ex or her new husband again. This was just something that happened, like things in life just happen. They don’t knit up all neatly, tied with a bow, as in so many Hollywood films. So many daydreams, so many lies to self. We are not dealing in any of that in The Ox-Box Incident. What we do deal with is a series of individuals who judge but will not be judged, people who show us what they are, and by so showing reveal what they can do to the fabric of society when they act from anger and emotion rather than with equanimity and thought. The storyline detaches and reknits, or not; but the underlying theme never abates.

The posse catches up with the alleged murders, which is pretty easy, considering these three men—the articulate Donald Martin (excellently played by Dana Andrews), Juan Martinez (Anthony Quinn), and an old man, Alva Hardwicke (Francis Ford, John’s brother)—think they’ve done nothing wrong and are fast asleep in their bedrolls. It feels like 80 percent of the film plays out around this campfire, but that is on account of its emotional intensity. Wellman hung a cyclorama for a backdrop. This is a Hollywood set, not the great outdoors, but it’s done up in such a stylized way as to feel like its on loan from German Expressionist horror. Is Doctor Caligari hiding behind one of those dead acacias? Is Nosferatu perched somewhere overhead? The stench of death fills your nostrils even as you sit in the theater, but that death focuses as much on the soon-to-be-murders as the three men who are swiftly realizing that there is no way out of their predicament.

Martin has a family. He asks to write a letter to them about what is going to happen, but he wants no one to read it, trusting the letter to Mr. Davies. But Davies betrays this confidence in trying to do everything he can to help these men. The Major, though, wants no part of reality. So it goes with people whose agenda is based on moving themselves ever further away from having to confront, deal with—and possibly even rectify—what it is that they really are. Reality can be a nuisance; better, then, to judge others in lieu of confronting oneself. If we still hunted people down and hanged them with regularity, reality being as much discounted nowadays as it is, you would not be able to drive down a street anymore without seeing swaying bodies. Instead, some amorphous equivalent pollutes social media, where avoiding oneself by snap judging others is the norm.

Juan Martinez certainly has a sketchy past, and certain things the men have done raise doubts as to their innocence, but we don’t know for sure, and there is more reasonable doubt than facts. Martin’s letter ends up with Carter, who believes his story and promises he will ride out to his wife and let her know what has happened. A vote is taken, with people who believe the trio innocent stepping away from those who do not, forming two sides. On the non-hanging side, seven people stand, including the Major’s son—which makes the Major wish to kill the suspects even more. But seven is not enough. We sit and watch these three men, who had been sleeping hours before, die at the end of ropes, in a brilliantly staged chiaroscuro shot of shadows, silhouettes, and rippling cyclorama with stars painted upon it, shot from down low, angled up, as though we are on the ground, unable to reach, morally, any higher level.

What follows is predictable, perhaps, but how it unfolds is not. The men of the posse ride back to town. It is daylight, the noir-ish and horror film elements of the evening have lifted, and they meet the sheriff, now returned. He brings them news that Kinkaid is still alive and his true assailants have been arrested. Someone had lied, and a rumor had ricocheted out of control.

Learning what happened at the campground, the sheriff demands to know who is responsible. Silence can be so potent in art, as in life. Think of Orson Welles using a few seconds of dead air with his War of the Worlds broadcast, which was the most disturbing passage in the whole thing. There is a pause before the answer is given, and in that pause you are afraid that someone is going to try to cover for what happened—to avoid reality and judgment both. There is enough time for you to think it through. But then comes the answer, one of the great lines in all of cinema: “All but seven.”

Wellman was a master of sound when he wished to be. The Major and son return to a lavish house, the boy remaining outside, because the Major has locked the door. Their final exchange plays out with the two never sharing a frame in a one-sided conversation, the boy renouncing the father, and then the Major shooting himself off-screen, the shot ringing out when we were not expecting it. The sound of it may be the most powerful line in the film.

Cut to the bar, where the men have gathered. Remarkably, the place is somehow even more depressing than when the film opened. Carter asks Croft, who is angering him over not being sensitive enough to what just went down—which perhaps is not fair, given the state of their nerves—if he wants to read Martin’s letter to his wife. Croft is illiterate, so Carter says he’ll read it for everyone.

It was at that point, in a lifetime of screenings, that I never saw a theater audience more uncomfortable. Martin’s letter speaks to our rush to judge, because of our rush to avoid the suspected or known realities within ourselves, and that letter smacked damn near everyone in that movie house in the face—because it might as well have been addressed to them, with a posting date of 2018. And in this envelope was a mirror, and this mirror knew that in that darkness, in that seat, you had absolutely nowhere to go, and for a few seconds, at least, you were going to look at what you were, if you were culpable in your own version of these events.

Louis B. Meyer once responded to media accusations that 75 percent of what Hollywood made in those days was junk with the rejoinder that, “well, 75 percent of everything is junk.” The Ox-Bow Incident was not, is not, junk.

Perhaps that’s why the studio, Fox, had no idea what to do with the picture. Instead, they let it sit on the shelves for months without releasing it. We are a country of great cinematic Westerns, just as we are a country of the greatest in jazz, but there had never been a Western like this one, if you even wish to call it a Western. Fonda, who normally was not a fan of the movies he was in, cited the picture as one he was deeply proud of. Darryl Zanuck, the head of Fox, couldn’t understand what was going on, when the studio could have simply released one of their regular Laurel and Hardy pictures and done better with it at the box office. What he failed to take into account, of course, is that the soul has a box office as well, only it is the kind of box office that shakes you down and makes you look at everything that comes out—that shows you what you are.

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John McCain Speaks to the Ages

John McCain’s moving farewell statement to the American people should become required reading in schools and places of worship, alongside Abraham Lincoln’s address at Gettysburg. Both are powerful encapsulations of the value of lives lived in service, as McCain put it, to “good causes bigger than ourselves.” Each is exquisitely crafted and brief, like a good prayer or a poem, evoking the enduring quest of purposeful Americans to live up to our country’s stated ideals. They should henceforth be read aloud together at Thanksgiving dinners and Independence Day celebrations.

McCain’s serene joyousness in celebrating those around him brought to mind Lou Gehrig’s famous farewell, delivered at Yankee Stadium on July 4, 1939, two weeks after he learned he had been diagnosed with amyotrophic lateral sclerosis (ALS), the disease that would soon take his life and be ever after known as “Lou Gehrig’s disease.” Gehrig’s short speech is remembered best for his matter-of-fact statement, in the face of imminent death in his mid-30s, “today I consider myself the luckiest man on the face of the earth.”

McCain, too, said on his deathbed, “I am the luckiest person on earth.” He went on to say he had enjoyed “experiences, adventures and friendships enough for ten satisfying lives.” Like Gehrig, he spoke of the love of his family as a major reason for that satisfaction. McCain then he went on to say how much his satisfaction derived from his gratitude to and love for his country:

To be connected to America’s causes—liberty, equal justice, respect for the dignity of all people—brings happiness more sublime than life’s fleeting pleasures. Our identities and sense of worth are not circumscribed but enlarged by serving good causes larger than ourselves.

In this, McCain echoed what is perhaps the most famous speech in antiquity, Pericles’s funeral oration, delivered in 430 B.C.E. to commemorate the war dead after the first year of the Peloponnesian War. The historian Thucydides described Pericles as “the first citizen of Athens” for his leadership in battle, as patron of art and literature and architecture—and for articulating the ideas of democratic citizenship that distinguished Athens from its neighbors and rivals. Rather than speak only of the bravery of his fallen comrades, Pericles chose to speak of the ideas which they had fought and died to defend.

As he put it, he wanted to talk of “the road by which we reached our position, the form of government under which our greatness grew, and the national habits out of which it sprang.”

“If we look to the laws, they afford equal justice to all in their private differences,” Thucydides reports Pericles said. “The freedom we enjoy in our government extends also to our ordinary life.”

These lines form the roots of the famous phrase “equal justice under law”—which is engraved over the entrance to the United States Supreme Court building across the street from the Capitol, where John McCain served in Congress for 35 years, and which he invoked so powerfully in his parting tribute to America.

The passing of prominent American leaders can often be a moment for coming together and reminding us all of our better inclinations—as McCain so aptly put it, that

we are citizens of the world’s greatest republic, a nation of ideals, not blood and soil. We are blessed and are a blessing to humanity when we uphold and advance those ideals at home and in the world.

Funerals of course are times of sadness for those who miss the departed, but they can also be occasions for reinvigorating one’s own sense of purpose, and resolving to live a good and worthwhile life. The best memorial services are uplifting and invigorating in unexpected ways.

Having been fortunate enough to be present, I remember well the sweltering day in September 1983, at the National Presbyterian Cathedral in Washington, when the memorial service was held for Senator Henry S. (“Scoop”) Jackson. Jackson was a true lion of the Senate on par with John McCain, who in later years cited the elder Democratic Senator as his role model. More than a thousand people crammed the place and listened to eulogies from Ted Kennedy, Pat Moynihan, and other giants of the Senate, who spoke mainly of Jackson’s role as mentor and model, as a teacher of other Senators. I recall, too, the 1999 memorial for Lane Kirkland, in Georgetown University’s ornate Gaston Hall, when the revered labor leader was eulogized by, among others, Lech Walesa, Henry Kissinger, and then-President Bill Clinton—though the most memorable reminiscence was offered by Kirkland’s daughter, Lucy Kirkland Schoenfeld, who repeated his admonitions “to never kiss ass” and “to never cross the picket line.”

In Pericles’s oration there is a harbinger of what McCain referred to as “our present difficulties.” Pericles spoke of how a strong Athens should approach other societies, even those who do not yet share our ideals: “We throw open our city to the world, and never by alien acts exclude foreigners from any opportunity of learning or observing, although the eyes of an enemy may occasionally profit by our liberality.”

As John McCain put it, we “weaken our greatness. . . .when we hide behind walls, rather than tear them down, when we doubt the power of our ideals, rather than trust them to be the great force for change they have always been.”

Words for all of us to live by.

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