For many people, the prospect of what might happen if Donald Trump wins a second term is too awful to contemplate. But, as we are witnessing with the coronavirus, not contemplating scenarios that have at least some chance of happening is a grave mistake. Indeed, it’s a mistake that helped elect Trump in the first place.

Ideally, the press corps would be hard at work exploring this question. Alas, it is not. In the thousands of presidential campaign stories that have been published this year, you will be hard pressed to find much reporting or informed speculation about what policies Trump might pursue if he’s reelected, or what the consequences might be if he were successful in enacting them. That’s not because such things aren’t knowable in advance. If that were the problem, political reporters wouldn’t have spent the last six months gaming out which candidates were, say, likely to win which primaries. The real reason campaign journalists don’t do this kind of work is that it’s not what they’re trained to do—and, perhaps, it’s not what most people want to read. 

We think our readers are different. So we gathered a distinguished group of area experts and beat reporters. We told them to imagine that, come November of 2020, Trump wins the Electoral College and the balance of power in Congress remains unchanged; Republicans hold the Senate and Democrats hold the House. Then, we asked them to think through the hitherto unthinkable: What will Trump aim to do, and what could he realistically get away with, if given another four years in power? —The Editors

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This essay is part of a package imagining the policy consequences of a second Trump term. Read the rest of the essays here. And, if you enjoy what you’re reading, please consider making a donation—we’re a nonprofit media organization and rely on the support of our readers. In return for a contribution of $50 or more, you’ll receive a complimentary one-year subscription to our print edition.

Donald Trump’s critics have often charged him with ignorance and a lack of a strategic approach to foreign policy. This is a profound misunderstanding of the president. In fact, Trump has always had a certain strategy, based on his “gut” and his experience with international business and business personalities. It is a strategy built on old-style U.S. isolationism and an appreciation of the new realities of international business. His reelection will confirm a profound realignment in U.S. security policies and U.S. military priorities. This strategy will be based on transactional values and uninhibited by history and experience.

For more than 70 years the United States has maintained its powerful grip on western Europe, an outgrowth of World War II and the subsequent Cold War challenge of the Soviet Union. The principal instrument of U.S. influence has been NATO, in which the U.S. provided the dominant military component while the Europeans provided the geography, and a lesser degree of financial commitment and defense resources. It was a matter of mutual using—we used the Europeans’ diplomatic and financial clout to serve what we believed were vital U.S. interests, not only in Europe but also beyond, and they got a powerful security umbrella, under which they could devote proportionately greater resources to social welfare without fear of renewed intra-European conflict. With more than 500 million people, a GDP that rivals our own, and a culture that largely shares our own values, Europe was our natural partner—and the transatlantic partnership has been hugely successful in promoting peace and prosperity.

After his reelection, President Trump is likely to gut NATO of its significance. Expect policy changes by tweet. Russia will no longer be seen as a threat. NATO enlargement will cease, and support for Ukraine and Georgia will be curtailed. Countries will be expected to spend more than 2 percent of their GDP on defense, and they will pay more for U.S. troop presence and exercises. Article 5—collective defense—will be conditioned. Security arrangements will be created with the United Kingdom outside NATO, and NATO will be held hostage to more favorable U.S. trade terms. Should the European Union resist U.S. economic pressures, the president will bring leverage through diminished American support for NATO.

The consequence will be an opening for Russia to exploit the particular weaknesses of each of these countries, politically, economically, or informationally, further weakening not only NATO but also the EU. Europe, including western Europe, will be open for deeper penetration by Russia and China.

In the Mideast, the U.S. will anchor a U.S.-Israeli-Saudi alliance directed against Iran. American forces will leave Iraq and Syria. Russia will be viewed increasingly as a sometime partner, sometime collaborator, and sometime adversary as it consolidates its control over Syrian and Libyan oil and stabilizes Turkey’s expansionist tendencies. ISIS will become a weapon used primarily against Iran and the Kurds, reducing parts of Iran to a failed state. But U.S. military efforts, largely directed against ISIS, will be curtailed.

In Africa, U.S. investment efforts to increase its influence under an enhanced U.S. International Development Finance Corporation will be too little, too late. An expanding Russian military and contract military footprint will further grow Russian influence over not just Europe and the country’s own oil and gas needs, but also its investment flows into Africa. Continuing large Chinese investments in resource-rich southern African countries will enable China to find the resource security it seeks.

In both the Mideast and Africa the consequence will be continuing low-level conflict and a loss of broader American influence.

The U.S. military needed to pursue the America First strategy will be subtly transformed with higher technology and smaller forces, even as the defense budget grows. The emphasis will be on defense, not intervention, and where there is intervention, it will be a quick strike and then withdrawal. Forward forces will be largely withdrawn, including, at last, from Afghanistan. Active, multiple lines of defense along our southern border will be established, with the U.S. Border Patrol increasingly supplemented by deep intelligence and backstopped by mobilized National Guard forces.

The Army will likely face the greatest cutbacks, with withdrawals of forward forces from Korea and Europe enabling major units to be cut. Special Operations Forces will be protected, even as some forces are withdrawn from Africa. The National Guard can expect to be well funded and to receive expanded missions in fields such as cyber-defense and border reinforcements. High-tech projects like directed energy weapons, hypersonic missiles, glide aircraft, and space-directed efforts will continue.

The Navy will be sustained with a focus on its missions in the Mideast and the Indo-Pacific, but it will be seen as particularly valuable as leverage in securing the right trade arrangements with China. In the end, it will sustain deep cutbacks in ships, and especially aircraft carrier battle groups, as the U.S. pulls away from its extended overseas commitments.

In Asia, the U.S. will look increasingly to the financial consequences of its alignments and alliances. Temporarily, Japan and South Korea will be able to maintain a U.S. presence and commitment by substantially raising their “host nation support” payments. But in order to move forward with a resolution of U.S. trade issues with China, the president is likely to trade off U.S. forward presence in the western Pacific; the key issue will be the price. These military commitments will be viewed in transactional terms—how and how much will China pay for the U.S. to depart the region?

The consequence in Asia will be to avoid an armed conflict with China over Taiwan and the South China Sea—the so-called Thucydides trap—but it will also trade U.S. alliances for an economic purchase of American withdrawal, greatly increased Chinese power in the area, and reduced U.S. influence.

In Latin America, the president’s principal aim will be to drive back immigration, including illegal immigration. Foreign assistance will be directed to those countries and activities that can best preclude immigration. A secondary aim will be to ensure that U.S. companies can exploit any particular resource opportunities, for example the massive oil find off the coast of Guyana, and to maintain the current trade balances under the newly agreed United States-Mexico-Canada Agreement.

History and experience would teach us that these policies are unwise. In two world wars in the twentieth century, the United States determined that it could not allow a hostile power to dominate Europe. Three generations of American leaders faithfully sustained that lesson, maintained peace, and ensured that the United States—and American values—maintained their dominance through the Cold War and post–Cold War period across the globe. But that lesson, and the alliances and forces that enabled it, and the world that was built with American values and American blood, will be left behind with the 2020 reelection of President Donald Trump. Long-term security will be negotiated away for short-term gains, both economic and political. In the world left to our children, America will be more isolated and less secure. Hardly America First.

The post Can The Liberal World Order Survive Another Four Years of Trump? appeared first on Washington Monthly.

This essay is part of a package imagining the policy consequences of a second Trump term. Read the rest of the essays here. And, if you enjoy what you’re reading, please consider making a donation—we’re a nonprofit media organization and rely on the support of our readers. In return for a contribution of $50 or more, you’ll receive a complimentary one-year subscription to our print edition.

It has never been easy to be a public official in the United States. In contrast to other rich democracies in Europe and Asia, bureaucrats are not held in high esteem. In Germany, Japan, France, or Britain, the country’s best and brightest aspire to public service, whereas in the U.S. they go to the private sector or, if they are public spirited, into the NGO world rather than government service. Conservatives in particular have long derided “pointy-headed bureaucrats” who today have morphed into a “deep state” that is seeking to subvert the personification of the people’s will, President Donald Trump.

As a result, American public service is under grave threat. It has been heavily politicized during the first Trump term, and in a second may deteriorate rapidly as cronyism, corruption, and incompetence become the new norms.

This is immensely concerning. American government—indeed, all governments everywhere—depends on the efforts of competent officials who are loyal not to the politician who appointed them but to a broader public interest. This loyalty is encapsulated in the United States by the oath that higher-ranking officials take to defend the U.S. Constitution, rather than to serve the president who appointed them. While public officials do have political preferences—how could they not?—vast numbers of them go to work every day believing that they are neutrally serving the public interest rather than a particular political party. Consider NASA, the Centers for Disease Control and Prevention, the Federal Reserve, the Forest Service, the Social Security Administration, or the uniformed military, all integral parts of the federal government.

But under Trump, no department or agency appears secure. In his first term, Trump has criticized his own intelligence community, the FBI, the Justice Department, the National Security Council, and the State Department for seeking to undermine him. The Federal Reserve and its chairman, Jerome Powell, have been constant targets of a president wanting the Fed to inflate the money supply to help his reelection chances. Trump has intervened to overturn the military’s punishment of Navy SEAL Edward Gallagher, and tried to influence a Defense Department decision to award a multibillion-dollar contract to Microsoft rather than the target of his ire, Amazon. Even a local outpost of the National Oceanic and Atmospheric Administration came under attack for disputing the president’s false assertion that Hurricane Dorian was threatening Alabama. Trump’s disdain for public service is reflected in the huge number of senior positions, including ones like secretary of defense, that have been left unfilled for extended periods of time.

Perhaps the most dangerous of Trump’s interventions concern the actions he has taken toward the Department of Justice. Trump seems not to have the slightest understanding of the rule of law, believing that the law should serve his interests rather than the reverse. During the 2016 campaign he urged criminal prosecution of his political rival Hillary Clinton, and later pushed his loyal attorney general, William Barr, to investigate his own department over the Mueller investigation. Barr has questioned the U.S. Attorney for the Southern District of New York for looking into the activities of Trump’s friend Rudy Giuliani and the Trump Organization. Most recently, the president tweeted criticisms of the sentencing guidelines handed down after the conviction of his friend Roger Stone, leading to the resignations of four prosecutors involved in the case. The deference of the senior leadership of the Justice Department to his wishes has sent shivers down the spine of every federal prosecutor in the country.

The rule of law is not some physical mechanism that limits the authority of powerful officials. It ultimately depends on the political power of other institutions in our complex constitutional system. When Republicans in the U.S. Senate acquitted Trump in his impeachment trial without hearing further witnesses, they were, in effect, telling him that it was okay to use the power of the U.S. government to promote his own election chances. Since his acquittal, he has behaved more overtly like a mafia boss, using his authority to punish enemies and reward friends. If he is reelected and the Republicans continue to hold on to the Senate, the hunt for disloyal officials will escalate. The president will truly feel that he has the mandate to do whatever he wishes, like having his attorney general initiate criminal prosecutions against his Democratic opponents. He will be safe in the knowledge that the Senate will not object.

It is not as if the federal government was a competent, finely tuned machine prior to Trump’s election. The Progressive Era project of professionalizing public service, begun at the turn of the 20th century, got only so far before the antistatism of American politics halted and reversed it. Today, a change in administrations, even within the same party, leads to the turnover of roughly 4,000 political appointees, compared to the mere handful that change in European and Asian parliamentary democracies. In the State Department, it is hard for a foreign service officer to rise to the rank of assistant secretary or ambassador given the number of political appointees claiming these positions.

Politicization of the government today takes many forms. Over the past decade, nearly one-third of the new hires in the federal government have been military veterans, due to the congressionally mandated Veterans’ Preference program. This policy is understandable in light of America’s wars in the Mideast, but it does not necessarily provide the best pool of applicants. Federal contracting is subject to myriad rules requiring minority, female, Native American, and small-business preferences. One of House Minority Leader Kevin McCarthy’s relatives, for example, was the beneficiary of a Native American preference, despite his extremely tangential relationship to that group.

While many Americans believe that the size of the U.S. government has expanded relentlessly over the decades, we have no more full-time federal employees than we did in the 1960s, and today the government is no larger than it was 60 years ago. Both Republicans and Democrats have participated in the charade that they are holding back the government’s size by replacing civil servants with legions of contractors, whose activities are far less transparent and accountable, and more costly.

The long-term consequence has been the erosion of the prestige of public service and an accompanying decline in the numbers of young people willing to enter it. Paul Volcker, whose lifetime passion was promotion of public service, led two commissions (in 1990 and 2002) that documented the aging and declining morale of the federal workforce. In the time since the second Volcker Commission, the problem has only grown worse. What idealistic young person today would want to join the State Department or the EPA and find themselves working for a political operative who didn’t believe in the central mission of the agency, and was unwilling to back employees who did?

In How Democracies Die, Steven Levitsky and Daniel Ziblatt note that democratic regression today does not take the form of a military coup but, rather, unfolds as the piecemeal erosion of democratic norms over an extended period of time. Donald Trump did not likely start out wanting to be an authoritarian leader; instead, he expected that he could run the country like a large family business. Since then he has come up against the Constitution’s checks and balances and has fought relentlessly to get around them. One of these checks is the existence of a neutral civil service.

Americans do not need to look far to see what Trump might do to this institution during a second term. In recent days, Trump has put in place as director of national intelligence a political supporter with no background in intelligence because he didn’t like the IC’s conclusion that Russia was interfering in the 2020 election. His newest national security adviser has also publicly claimed not to have seen any information supporting this view. If Trump wins reelection, we may see an EPA chief who asserts that global warming is a hoax, a CDC head who claims that the novel coronavirus was a Chinese plot, or a surgeon general who says the anti-vaxxers have a point.

The U.S. federal bureaucracy has weaknesses: It is too rigid and too rule bound, and it fails to attract the best talent. In an ideal world we would undertake a major reform of U.S. public administration and implement a 21st-century version of the 1883 Pendleton Act, which mandated, among other things, that federal jobs be allocated by merit. But under the current circumstances, it will be enough to fight a rearguard action in defense of classic public service as it exists today, warts and all.

The post What Would a Second Trump Term Do to the Federal Bureaucracy? appeared first on Washington Monthly.

This essay is part of a package imagining the policy consequences of a second Trump term. Read the rest of the essays here. And, if you enjoy what you’re reading, please consider making a donation—we’re a nonprofit media organization and rely on the support of our readers. In return for a contribution of $50 or more, you’ll receive a complimentary one-year subscription to our print edition.

In January 2018, the Centers for Medicare & Medicaid Services announced that it would support states that wanted to add work requirements to Medicaid. Six months later, Arkansas became the first state to put that guidance into practice.

The results were disastrous. More than 18,000 people lost health coverage. It turns out, however, that most of those people had met the requirement or qualified for an exemption. So why did they lose their health care? The new regulations required recipients to log their hours online—something that was almost impossible for those who had no internet access or who tried accessing the website during its nightly shutdowns. Meanwhile, administrative mistakes meant lost coverage for thousands.

A district court halted Arkansas’s work requirements, concluding that states cannot “refashion the program Congress designed in any way they choose.” The rule has since bounced around in the court system, as more states have attempted to add work requirements, and more judges have struck them down. The Trump administration will likely take their case to the Supreme Court, and there is no telling how the Court might rule on it.

Medicaid work requirements are just a glimpse into the Trump administration’s unified, coherent, and intentional assault on the safety net. It has also targeted food stamps, public housing, health care, and immigrant services with changes that would make benefits harder to access. These attacks ignore the broad public support of government programs, and reams of social-science research, putting millions of Americans at risk.

But unlike the GOP playbook of yore, where changes or cuts to safety net programs played out through the legislative process, Trump’s approach takes place almost exclusively behind the scenes—through executive actions and administrative rule making, and in the federal courts. While some of the administration’s proposals have proceeded, the courts have, until now, served as an important bulwark against these initiatives. If Trump wins a second term, that’s likely to change.

Republican efforts to cut safety net programs are not new. When Ronald Reagan came to power in the early 1980s, he launched an aggressive campaign against the welfare state, arguing that Lyndon Johnson’s Great Society project was “the central political error of our time.” The Reagan administration reduced funding for a range of safety net programs and restructured them to shift authority to the states.

Republicans accomplished much of their agenda in that era by working with moderate and conservative Democrats. But that bipartisanship—as well as public support for many antipoverty policies—limited their efforts to dismantle the programs.

Trump differs from his conservative predecessors in that he has made no such effort to work with Democrats. His first attempt to repeal the Affordable Care Act was profoundly unpopular, with support for the effort polling in the teens and 20s, the lowest ratings for any major piece of legislation in at least a generation. Republicans nonetheless tried to ram through several bills, which generated widespread protest and outrage, and eventually failed. Congressional efforts to cut the Supplemental Nutrition Assistance Program (SNAP), otherwise known as food stamps, were also unsuccessful.

And so, the Trump administration has shifted its attention away from Congress and to the rule-making process. Last year, in the span of nine months, the Agriculture Department proposed a bevy of changes to SNAP. For example, they proposed tightening work requirements and raising the income and asset limits that determine eligibility. Court decisions have stopped work requirements for now, and the asset rule has yet to go into effect. But if it does, about three million people will lose benefits.

Other agencies have been busy changing rules, too. Under dispute in the courts now is a proposal from the Health and Human Services Department that would allow health care providers to withhold medical services, medications, and information if they have moral or religious objections.

The Department of Housing and Urban Development proposed a rule forbidding people who qualify for public housing from living with an undocumented family member. For some, loss of housing or family separation would become the only options.

In many instances the courts have blocked these changes. But there are ominous signs on the horizon—specifically from the Supreme Court. In January, it overturned a lower court’s injunction and allowed the Department of Homeland Security’s “public charge” rule to move forward. The rule allows the federal government to deny green cards to immigrants who use Medicaid, food stamps, housing vouchers, or other forms of public assistance. In late February, the administration began implementing that change.

The lower courts’ resistance to the administration’s proposals has come to frustrate many prominent conservatives, including at least one on the Supreme Court. Justice Neil Gorsuch has criticized this “increasingly common” use of nationwide injunctions by district court judges to halt government policies, and has vigorously urged the Court to confront the issue.

If given four more years, Trump will continue to work with Republicans in the Senate to reshape the judicial system to accommodate conservatives’ decades-long goal of dismantling the welfare state. He has, at breakneck speed, already appointed more than a quarter of the active judges on the U.S. Court of Appeals. His judicial appointees are also comparatively younger than his predecessors’, extending their long-term power. Trump’s judicial legacy will entrench conservative governance for the foreseeable future.

IThe U.S. safety net is not easily understood. More than 80 interwoven and interdependent programs are spread across several departments and agencies. Nearly every program has different application procedures, eligibility criteria, and benefit levels. For millions of underemployed workers, children needing free lunch, families with exorbitant health care bills, people who cannot work because of a disability or chronic illness, and others, these programs may be the only reason they get by. But the vastness of the safety net makes it difficult to protect.

The programs do, however, have one unifying element: Nearly all of them use the federal poverty line to determine eligibility. Changing that line would hit all the programs at once, upending the lives of millions.

In 2019, the Trump administration proposed redefining the poverty line formula and changing how inflation is factored in. While it is not clear which inflation index the administration would use, it seems likely they would choose one that grows slowly. In other words, as the cost of living increases for everyone, the federal poverty line would stay comparatively low.

This change would ripple across the dozens of federal programs that use the poverty line in some way. More than 250,000 low-income seniors and people with disabilities would receive less help from Medicare, or lose it altogether; over 300,000 children would lose comprehensive health coverage, as would some pregnant women; at least 250,000 adults would lose health care coverage that they gained through the ACA’s Medicaid expansion; around 40,000 infants and young children would lose nutritional supplements; and more than 200,000 people, most of them in working households, would lose food stamps.

It is unclear whether the administration even has the authority to make this change on its own, but that has not stopped them before. For now, the rule is under review and hasn’t been finalized. If it is, it will almost certainly be challenged in court. But if that case comes before a judge who is sympathetic to the administration’s argument, millions of Americans could lose access to health care, food assistance, prescription drug benefits, heating assistance, or housing subsidies.

Government antipoverty programs work. Census data shows the massive economic impact these programs have on low-wage workers: In 2018, income from these programs kept more than 47 million people out of poverty. During economic downturns, they play a critical role in helping low-income families meet basic needs and act as a stimulus for the economy. Studies of the Great Recession suggest that the effects of unemployment spikes and poverty increases were buffered by safety net programs that acted as a counterforce. The changes proposed by the Trump administration will likely obliterate this cushion in the next recession.

Incomes are soaring and poverty is plummeting, Donald Trump said during the State of the Union address in February. “Our economy,” he said, “is the best it has ever been.” The facts reveal a different reality. A 2017 study showed that nearly 40 percent of Americans cannot pay for a $400 emergency expense. Income inequality is worsening, and the racial wealth gap is widening. Real wages have stagnated. Inflation and rising prices are creating new economic burdens for low-income families. A third of Americans struggle to afford food, shelter, or medical care. Social mobility has plummeted.

The 2021 budget proposal confirms Trump’s intent to cut social programs. Billions of dollars in spending on programs that provide economic stability and health care for families could be slashed. Student loan assistance, Medicaid, children’s health insurance, food stamps, housing assistance, disability insurance, heating assistance, and Medicare all face major reductions.

If Trump wins a second term, the emergence of a stingier, more punitive, and increasingly burdensome safety net would be a high priority for the administration. The federal court system—not Congress—would become the primary battlefield where social policy is contested. The judicial system, ripe with appointments of like-minded judges and perhaps another justice to the Supreme Court, would wage the administration’s war on the safety net. The damage to the policy infrastructure would not be easily undone. In the meantime, millions of already sidelined Americans would become hungrier, sicker, and more vulnerable, eradicating any shot at the American dream—or even just plain survival.

The post How Trump Would Gut the Social Safety Net With a Second Term appeared first on Washington Monthly.

This essay is part of a package imagining the policy consequences of a second Trump term. Read the rest of the essays here. And, if you enjoy what you’re reading, please consider making a donation—we’re a nonprofit media organization and rely on the support of our readers. In return for a contribution of $50 or more, you’ll receive a complimentary one-year subscription to our print edition.

“If I were Trump, I’m not sure I’d really want health care to be my headline legislative battle,” said Harold Pollack, a professor at the University of Chicago and an expert on health policy. Health care is the one issue where Democrats have a huge polling advantage, he continued. “Why foreground that if you can do other things?”

Which is not to say that nothing will happen, he was quick to add.

Health policy experts from across the political spectrum agree that if Trump wins a second term in the White House, health care may not be a legislative priority. Particularly if Democrats retain a majority in the House of Representatives.

There’s always the possibility that an external factor will spur action. A new disease threat—either the new coronavirus or some other highly contagious disease—could force the White House and Congress to work together to improve the nation’s public health infrastructure. Also looming is the insolvency of the Medicare trust fund, currently estimated to take place in 2026. The last two times Medicare was close to not being able to pay all its bills—in 1983 and 1997—Congress and the president (Ronald Reagan and Bill Clinton, respectively) stepped in to shore up the program’s finances.

Then there are a handful of issues so important to the public that addressing them has gained bipartisan support in Congress. Finding a way to bring down drug prices has been a priority for both Congress and Trump, as has fixing the problem of “surprise” medical bills that show up when an insured patient receives health care outside of his or her insurance network. If these issues aren’t dealt with before the 2020 election, they will likely get rolled over onto the next Congress’s to-do list.

If he’s unable to make much progress through legislation, Trump is likely to turn to a strategy Obama embraced in his second term: Use executive authority. “I’ve got a pen, I’ve got a phone,” Obama famously said. Since congressional Republicans and the Trump administration have failed to repeal and replace Obama’s signature health law, they’ve already adopted this approach.

“Obamacare won’t be repealed, it will just rust away,” Pollack said. For example, the Trump administration has hobbled the state marketplaces where individuals can buy insurance, with a variety of small-scale policy changes. The administration cut nearly all the funding for staff to help people sign up for coverage through the marketplaces, and made it easier for consumers to buy cheaper plans elsewhere that may not cover preexisting conditions, one of the core requirements of the Affordable Care Act. “The president and Republicans see it as politically advantageous to have the marketplaces function poorly,” Pollack told me.

The administration may have other rule changes teed up. A second-term Trump administration might try even harder to make changes to Medicaid that would allow states to functionally shrink the program. In exchange for decreased federal funding, states would be allowed to side-step some current federal rules on who and what must be covered. The proposal is almost certain to be challenged by opponents in court. But if it goes into effect, people in states that take the deal could see Medicaid co-pays increase and benefits decrease, or could lose coverage entirely.

Trump has already put forward a number of far-reaching executive initiatives only to have them halted by the courts. Proposals that would let states require Medicaid recipients to prove that they work or perform community service in order to keep their health insurance have been struck down in three states. In a recent ruling overturning the new requirements, judges noted that when Arkansas added work requirements, some 18,000 people lost health coverage. In most cases, people lost coverage not because they failed to meet the work requirements, but because the process for reporting their hours to the state was too cumbersome. In addition, the courts blocked a Trump order that would make it easier for health care workers to decline to perform or even help with abortions or other procedures that violate their conscience. A rule that required drug companies to include prices in their television ads was also struck down.

If Trump wins a second term, this trend might reverse. The Senate spent most of 2019 not passing legislation, but approving new judges—at twice the typical annual rate. In 2019 alone, according to the National Review, the Republican-majority Senate filled the seats of nearly 12 percent of the American judiciary. With a simple majority vote, Mitch McConnell sped up confirmations by changing Senate rules. And on average, Trump-appointed judges are more conservative than those chosen by past Republican presidents.

The White House is wearing this as a badge of honor. “President Trump’s historic appointments have already tipped the balance of numerous Federal courts to a Republican appointed majority,” read a White House press release, adding, “Approximately 1 out of every 4 active judges on United States Courts of Appeals has been appointed by President Trump.”

There is also the possibility that another seat will open up on the Supreme Court. If Democrats don’t win the presidency in 2020, it’s hard to see how some of the aging liberals on the Court could hold on for another four years. Ruth Bader Ginsburg is 87, and in poor health. Stephen Breyer will turn 82 in August. A third pick for Trump would cement the conservative majority that’s already in place, perhaps for a generation.

The headline-grabbing issue for a change at the Court is abortion. There are already five nominally anti-abortion justices, and the first major abortion case since Brett Kavanaugh joined the bench will be decided later this year. Most observers think it unlikely that the Court will expressly overturn Roe v. Wade, the landmark 1973 case that legalized abortion nationwide. More likely is that it will simply approve more and more drastic restrictions until abortion is only available in the bluest of states. A sixth anti-abortion justice would make that all but certain.

And far more than abortion is at stake. Many of the president’s blocked proposals could eventually get a stamp of approval from a 6–3 conservative majority. The administration is supporting a lawsuit, currently making its way to the Court, that would declare the ACA unconstitutional in its entirety. Lawyers across the ideological spectrum consider the case legally dubious. But if the Trump administration wins another Supreme Court seat, the ACA could be struck down, and, with it, protections for preexisting conditions and other popular provisions.

One potential bright spot, Pollack predicts, is that Trump may not have the patience to enact other sweeping changes to the health care system. “I think this requires too much work,” he said, “and I think he’s bored by the level of detail.”

The post How Trump Could Take Away Obamacare With a Second Term appeared first on Washington Monthly.

This essay is part of a package imagining the policy consequences of a second Trump term. Read the rest of the essays here. And, if you enjoy what you’re reading, please consider making a donation—we’re a nonprofit media organization and rely on the support of our readers. In return for a contribution of $50 or more, you’ll receive a complimentary one-year subscription to our print edition.

From the perspective of the liberal policy establishment, Donald Trump has launched an aggressive and unprecedented assault on workers’ rights and the labor movement. From the perspective of the right, Trump has governed on labor almost exactly as any other Republican president might have.

“When he was first elected, I ventured his administration might be different from traditional Republicans in a few ways, including in its relations with unions,” Walter Olson, a labor policy expert at the libertarian Cato Institute, said. One of the president’s first meetings in 2017 was with leaders of the building trades, Olson noted. “But in the end, they have been very much in line with what you would have expected from, say, Carly Fiorina.”

In many respects, Trump’s administration has followed in the footsteps of Ronald Reagan and his acolytes, who pioneered the Republican playbook on weakening unions. From stacking his administration with anti-union ideologues to firing more than 11,000 striking air traffic controllers during his first year in office, Reagan set in motion a pro-corporate agenda that Trump has continued to push forward. In case there was any doubt about how the Trump administration regarded the conservative icon’s labor record, in August 2017 then Labor Secretary Alexander Acosta announced that Reagan would be inducted into his agency’s Hall of Honor.

One way Trump has taken aim at unions is through the National Labor Relations Board, or NLRB, which is the federal agency tasked with protecting the rights of private-sector workers and encouraging collective bargaining. Private-sector workers are barred from bringing workplace grievances through the courts themselves, so filing complaints with the NLRB—which has more than two dozen regional offices spread across the country—is how employees can seek redress if they feel their rights have been violated. If an issue can’t get settled at the regional level, it gets kicked up to the agency’s five-person panel in D.C., which issues a decision.

Trump’s NLRB has kept busy, handing down a spate of decisions that align with employer interests and overturn Obama-era decisions. In early 2017 the Chamber of Commerce, a powerful business lobby, published a wish list of 10 policies it wanted to see changed under the Trump administration. In less than three years, the NLRB addressed all 10 items on the list, even going beyond what the lobby requested in some instances. For example, new NLRB decisions make it harder for workers and union representatives to discuss issues on employer property, and give employers more power to unilaterally change collective bargaining agreements. Decisions like these tend to have modest immediate impact but become far more consequential as they have more time to take effect.

“Unfortunately, how the three Republicans on the NLRB seem to view their job is to weaken the law as it pertains to workers’ rights, but also amp up scrutiny of unions and penalties against them,” Lynn Rhinehart, a senior fellow at the left-leaning Economic Policy Institute (EPI), said.

Republicans say the flurry of Trump administration actions is a natural response to what they viewed as aggressive rule making by the Obama administration. “The perception on the Republican side is that Obama hit so many balls across the net, so [the administration] is responding by swatting balls back now,” Olson, the Cato Institute expert, said. “Generally, I think the business community just wanted to get some relief from all the new rules imposed by the prior administration.”

But beyond playing ping-pong with Obama-era dictates, the Trump administration has also been working to hollow out the NLRB. According to an EPI analysis, the number of full-time employees working in the agency dropped by 10 percent during Trump’s first two years in office, including 17 percent fewer regional field staff. Given that the nation’s roughly 129 million private-sector workers can’t bring their grievances through the courts, the fewer NLRB staff available to process their complaints, the fewer opportunities workers ultimately have to get justice.

Perhaps the clearest example of the Trump administration’s attitude toward unions is its treatment of federal workers. Over the past three years, with the strong encouragement of the president, agencies have taken steps to strip federal workers of their union rights and undermine their negotiated contracts.

“I have to admit federal workers have suffered,” Everett Kelley, the national president of the American Federation of Government Employees, said. “We’ve seen federal worker contracts just ripped up and replaced with contracts written by management that had no negotiations at all,” he said. Civil servants have been forced out, Kelley continued, while staff vacancies have been left unfilled.

Last October, the Trump administration instructed agencies to move as fast as possible to restrict unions in federal workplaces. One of the first, practical consequences was that many union reps, who for years had access to government agencies, were no longer welcome inside. In late January, the president took another step, issuing a memo that gave Defense Secretary Mark Esper the power to end collective bargaining for the Pentagon’s civilian workforce of roughly 750,000 people, more than half of whom are in unions. It’s not yet clear what Esper will do with that power.

A second term for Trump would likely bring more of the same, said Donald Kettl, a professor of public policy at University of Texas at Austin and an expert on the federal government. While past Republican presidents have tried to diminish federal unions, he said, few presidents have been as successful as Trump. “He’s skillfully found a way to use these issues to energize the [Republican] base,” Kettl continued, and he’s pursued tactics that don’t require legislative action. Trump has latched on to recurring conservative themes—his “deep state” attacks on bureaucrats are not radically different from Nixon’s “enemies list”—but his push has been “a more focused, concerted, and successful effort than the anti-bureaucracy campaigners have been able to muster in the past,” Kettl said.

If Trump’s first term was focused on making it tougher for workers to unionize, both conservatives and liberal policy wonks agree that a second term would likely mean more attention directed toward regulating gig workers. Generally, gig workers—like Uber drivers—aren’t afforded the protections of traditional employees, like minimum wage, overtime, unemployment insurance, and the right to join a union. Increasingly, though, labor advocates are building a case that many of these workers have been shortchanged; they’re functionally employees and should be protected as such.

It’s clear that the Trump administration disagrees. In one 2019 decision, the NLRB reversed an Obama-era ruling to find that SuperShuttle drivers were independent contractors, not employees. The agency’s general counsel, Peter Robb, another Trump appointee, reinforced that decision, issuing a memorandum declaring the same thing about Uber drivers. That sends a strong message to gig workers to not bother bringing any new cases to the NLRB on this topic.

Meanwhile, blue states have been pushing in the opposite direction. At the start of 2020, a sweeping new law known as AB5 went into effect in California, taking aim at the problem of misclassifying employees as independent contractors. Other states, like New York and New Jersey, are now following suit with their own versions of the law, and the Democrat-controlled House of Representatives passed its own bill in February that similarly would make it harder for employers to classify their workers as contractors. Other states, like Washington, are considering bills to allow for so-called “portable benefits”—where workers, regardless of whether they are employees or contractors, could accrue benefits on a per-hour basis, and these would be fully portable, like Social Security. (The Washington Monthly has championed this idea.)

Rachel Greszler, a labor policy expert at the conservative Heritage Foundation, said that while Republicans are interested in addressing some of the concerns faced by contractors and gig workers, their proposed reforms differ from laws like AB5. She suggested policies making it easier for contractors to pool together to finance their health insurance, using what are known as “association health plans.” Greszler also pointed to universal savings accounts, which would function similarly to employer-administered 401(k) accounts. The Trump administration supports both of these policies and has already taken steps to make association health plans available more broadly.

The decisions already issued by Trump’s NLRB could weaken the impact of California’s new labor law by confusing workers and deterring other states from moving forward with their own solutions. “I think it is probably very confusing to hear that you are not an employee and don’t have a right to collectively bargain under federal law, but that you are an employee for the purposes of California law,” said Sharon Block, an Obama Labor Department official and now a labor expert at Harvard Law School. “When labor rights are more complicated it makes it less likely that they will be invoked. It’s good lawmakers are moving forward in California, but this counter-signal from the federal government could have a chilling effect on workers who might otherwise assert their rights.”

Another four years of Trump, said Shaun Richman, a labor expert at SUNY Empire State College, would mean an even greater effort by the NLRB to try to stop federal labor law from adapting to “the modern workplace.”

“They are closing their minds to the ways that business models actually work, they don’t want the National Labor Relations Act to adapt to the fissured workplace,” he said. “It’s not an exaggeration to say four more years is an existential threat.”

The post How Trump Could Dismantle Workers’ Rights with Another Four Years appeared first on Washington Monthly.

This essay is part of a package imagining the policy consequences of a second Trump term. Read the rest of the essays here. And, if you enjoy what you’re reading, please consider making a donation—we’re a nonprofit media organization and rely on the support of our readers. In return for a contribution of $50 or more, you’ll receive a complimentary one-year subscription to our print edition.

On the campaign trail in 2016, Donald Trump vowed to make sweeping changes to the U.S. immigration system. If elected president, Trump said, he would build a wall spanning the entirety of the U.S.-Mexico border, ban all Muslims from entering the country, completely eliminate the resettlement of Syrian refugees, and deport millions of undocumented immigrants who have lived in the interior of the United States for years.

As his first term comes to an end, Trump has made serious progress on many of these promises. The administration has spent billions of dollars replacing chain link fences along the border with  100 miles of steel barriers, with new barriers under construction. He has banned nationals of certain Muslim-majority countries from obtaining visas. The U.S. still takes in refugees, but admissions have hit an all-time low: The resettlement cap for the 2020 fiscal year was just 18,000, a 79 percent drop from Barack Obama’s last year in office. Immigration and Customs Enforcement (ICE) has carried out massive raids and opened more than a dozen new immigrant detention facilities. The administration has implemented a number of measures meant to deter asylum seekers from even trying to come—including separating migrant children from their families, a practice that continues in some cases.

Unable to pass major immigration legislation, the administration has accomplished all of this through executive action, spurring lawsuits from activists. Sometimes, the litigation has been a success. In 2019, a federal judge blocked a Trump executive order that would have barred immigration by those who could not quickly purchase U.S. health insurance, ruling that it was beyond the president’s powers. Several district court judges issued an injunction against the wall, arguing that Trump was unconstitutionally violating the will of Congress.

But the Supreme Court has allowed many of the president’s policies to take effect while courts consider their legality, including construction of the border wall. In a recent concurring opinion about immigration, Justices Neil Gorsuch and Clarence Thomas rebuked circuit judges who issue nationwide injunctions against the administration’s policies, claiming that they are largely acting out of turn. The Court has also given Trump more decisive victories, including signing off on a modified version of his travel ban.

Should Trump win a second term, he will likely nominate at least one additional Supreme Court justice and add to the nearly 200 federal judges he has appointed so far (a quarter of all federal judges). The legal firewall that has held back the most radical of his executive orders could crumble. He will continue to target not just undocumented immigrants and asylum seekers, but legal immigrants as well.

“I don’t think there’s an end in sight,” said David Bier, an immigration policy analyst at the Cato Institute, a libertarian pro-immigration think tank. “As soon as they get these different measures approved by the courts fully, they’ll move on to the next step of expanding them. That’s what we’ve seen every step of the way with this administration.”

The president’s war on immigration is being waged on two fronts: at the border and in the interior. In both domains, he’s just getting started. In late 2019, the president created two pilot programs—the Prompt Asylum Claim Review (PACR) and the Humanitarian Asylum Review Process (HARP)—that fast-track asylum cases for Mexican and Central American migrants at the southern border. Although the ACLU and other organizations have sued the administration over these programs, which they say deny migrants a fair day in court, it’s likely they’ll be expanded further if Trump is reelected, even before courts decide their legality.

The expansion of PACR and HARP could echo the administration’s rollout of the Remain in Mexico policy, which began as a pilot program at a single port of entry in California in January 2019. It has since been expanded along the entire border, forcing roughly 60,000 migrants to wait in Mexico while an immigration judge in the United States decides their case. Originally, the policy was only applied to migrants from Spanish-speaking countries. But in January, the administration began sending Brazilian nationals seeking asylum to Mexico.

If Trump is reelected, it’s only a matter of time before the administration decides to further expand this program too. It may start with Indian nationals: According to federal data analyzed by the Migration Policy Institute, 72 percent of all extra-continental migrants apprehended at the border during the fiscal 2018 hailed from India. Migrants from Cameroon, the Democratic Republic of the Congo, and Eritrea—the most prevalent African nationalities at the border, according to the same data—could be added to the administration’s list as well.

During a second term, it is also likely that Trump would expand the border wall. With the blessing of the Supreme Court, the administration already reallocated nearly $10 billion in military funds to pay for construction of the wall. The administration diverted another $3.8 billion in funds from the Pentagon in February. Unless legislators explicitly forbid the administration from reprogramming funds, Trump will likely continue to use military money to fortify the border during his second term.

The wall may be a Trump original, but some of the president’s toughest policies were first proposed by influential conservative think tanks. To get a sense of what a second term might bring, it is worth looking at what those institutions are proposing. The Heritage Foundation has urged the administration to unilaterally give immigration judges the ability to decide all status cases without listening to immigrants’ testimonies, not just those of the undocumented at the border (as PACR and HARP already do). The influential right-wing think tank also wants immigration judges to have the power to rule against different forms of protection, including asylum, without hearing a full trial.

This agenda, of course, would likely encounter massive resistance by liberal municipalities. Hundreds of cities across the country, including New York City and Washington, D.C., have declared themselves “sanctuaries” for undocumented immigrants. Though there’s no legal definition of a sanctuary city, these jurisdictions typically limit their cooperation with federal immigration authorities. But this could make them a target under a second Trump term. The Department of Homeland Security is deploying 100 officers from the U.S. Border Patrol’s elite tactical unit to the interior of the country, where they’ll help ICE carry out arrests in these places.

In its official capacity, the Trump administration claims that it isn’t against immigration per se, just illegal immigration and immigration by people who are supposedly a drain on the economy. The administration says that it actually wants legal migrants, so long as they are educated or possess economic talent. The president’s signature legislative proposal, for example, wouldn’t necessarily cut immigration levels. Instead, it would largely replace family-based green cards with employment-based ones.

His actions, however, suggest that immigration at large is the target, and it’s likely that a second Trump term would enable federal immigration agencies to make life harder for documented immigrants, too. Even in sanctuary cities, ICE sometimes arrests and tries to deport green card holders who have come into contact with the criminal justice system. The administration has also signaled a desire to begin targeting naturalized citizens, creating a new denaturalization “task force” under the Department of Justice in February.

This shouldn’t come as a surprise. The think tanks and advisers who surround Trump have made it clear that they view legal immigration on the whole as an ill. Former Trump chief strategist Steve Bannon and current Trump adviser Stephen Miller agreed in a 2016 conversation that legal immigration is the “beating heart” of America’s migration “problem.” Miller has pushed repeatedly to slash green card levels.

Miller may succeed even if Democrats hold the House—and not only through the president’s executive actions. The Supreme Court is expected to rule soon on the fate of the Deferred Action for Childhood Arrivals program. If the Court lets the program end, Trump may go to Democrats in Congress and promise protection for Dreamers, but only in exchange for broader immigration cuts. The party shut down the government for several days in January 2018 to try to make sure Dreamers wouldn’t be deported, and failed. Though the party’s progressive wing would likely refuse to fall in line, it isn’t hard to imagine that to protect them, come 2021, Democrats would give Trump what he wants.

The post Trump’s Second Term Immigration Agenda appeared first on Washington Monthly.

This essay is part of a package imagining the policy consequences of a second Trump term. Read the rest of the essays here. And, if you enjoy what you’re reading, please consider making a donation—we’re a nonprofit media organization and rely on the support of our readers. In return for a contribution of $50 or more, you’ll receive a complimentary one-year subscription to our print edition.

Can civil rights and civil liberties withstand a second term of President Donald Trump? They have already taken a major hit. Playing to his base, Trump has unremittingly targeted the most vulnerable among us. His anti-immigrant measures began with the Muslim ban, which he recently expanded to bar immigrants from three more predominantly Muslim countries and three countries with large Muslim minorities. He has separated families, detained individuals who posed no threat to others or risk of flight, sought to deny asylum on grounds that were directly contrary to statute, and attempted to rescind protected status for the Dreamers.

On reproductive freedom, he promised to overturn Roe v. Wade, and has appointed judges with that goal in mind. He barred federally funded Title X family planning clinics from advising pregnant women about their rights to abortion, blocked undocumented teens in federal custody from accessing abortion, and gave a green light for employers to deny insurance coverage for contraception to their female employees.

He has sought to reverse nearly every advance that the LGBTQ community made under President Obama. He barred transgender individuals from serving in the military. He rescinded guidance requiring schools that receive federal funding to allow transgender students to use facilities that correspond to their gender identity. And his administration argued in the Supreme Court that a bakery had a First Amendment right to discriminate against a gay couple who sought to purchase a wedding cake, and that federal law does not bar employers from firing their workers for being gay or transgender.

He praised white supremacists in Charlottesville as “very fine people,” and referred to African countries as “shitholes.” His Justice Department sought to back off from consent decrees requiring police to treat their citizens with equal respect and dignity. And he reversed a rule requiring local governments to avoid housing plans that have a disparate impact on minority communities.

At the same time, he has appointed an unprecedented number of federal judges, most of them handpicked by the Federalist Society for their conservative ideological commitments.

You get the point.

But there’s hope. With the exception of his judicial appointments, most of what Trump has done can be undone. All of his initiatives targeting immigrants, restricting reproductive freedom, and countering racial and LGBTQ equality were accomplished through unilateral executive action. As a result, they can all be reversed through unilateral executive action. This doesn’t diminish the harms these actions have already inflicted on hundreds of thousands of people, but it does mean that the damage can be cut short. If he is defeated.

But if Trump manages to win, then what? The next president will almost certainly have the opportunity to appoint one or more Supreme Court justices. The Court is already more conservative than it has been in nearly a century. If Trump gets to replace a liberal justice and create a 6–3 conservative-liberal split, the number of 5–4 decisions splitting in a liberal way, already relatively rare, will likely be erased altogether. We would then need not one but two “swing” justices to swing in the progressive direction for the liberal view to prevail.

What might this mean? Roe v. Wade overturned, the end of affirmative action, and very little chance that
LGBTQ equality could be advanced through the courts. The Court would be even more solidly pro-business,
anti-labor, and anti-consumer than it currently is. And we would likely see a radical expansion of gun rights, property rights, and religious rights—including the right to invoke religion to discriminate against others. Criminal defendants and immigrants, who haven’t fared well in the Court for decades, would do even worse, and government officials would be given a green light to further strip them of meaningful constitutional protections.

The Justice Department’s Civil Rights Division would remain moribund for another four years, further enabling voter suppression and police abuse across the country. An AWOL Civil Rights Division would have political repercussions far beyond 2024. The 2020 census results will kick off nationwide redistricting, and without a vigilant Justice Department overseeing the process and intervening where appropriate, the Republicans will seek to build in ten-year advantages in the district maps they draw.

More generally, if Trump wins reelection he’s likely to believe that xenophobia worked, and that will then prompt him to try to implement even more virulent and aggressive measures against immigrants, especially those of color. Particularly if there is a terrorist attack that implicates ISIS or al-Qaeda, the Trump administration’s response will likely make George W. Bush’s brutal “war on terror” tactics look humane.

So what can be done?

If Trump wins, it will become all the more essential that “we the people” exercise our First Amendment rights to resist. Trump acts in many ways like a populist autocrat. But unlike some of his counterparts in eastern Europe, he has to operate in an environment with a robust civil society and a strong free speech tradition. The First Amendment empowers citizens to check their government by protecting the right to criticize their leaders; the right to associate with like-minded others to amplify their concerns; the right of the press to report on government abuse; and the right of the citizenry to assemble and to petition their government for change. This is why autocrats in other countries often target the press, the nonprofit sector, and the academy—that’s where resistance to autocracy resides. Suppressing or silencing civil society is a lot harder to get away with in the United States.

Our system of divided government also facilitates resistance. Federalism means that blue states will continue to be able to push back against federal policies that hurt their citizens, as many states have already done by suing Trump in his first term. State courts, legislatures, and town councils can provide protections to their residents that the federal government takes away, including protections for LGBTQ individuals, immigrants, and the poor.

If the House remains in Democratic control, it will be able to play a checking role, through oversight, appropriations, and refusing to pass laws that erode our rights. And even though Trump has appointed nearly 200 judges, the federal courts will remain an important backstop. The courts’ legitimacy rests on the rule of law, a principle and norm that Trump routinely flouts. This is why he has lost more legal challenges than perhaps any prior president, before judges appointed by Democratic and Republican presidents alike. Even his own appointees have ruled against him, as when D.C. District Judge Timothy Kelly ordered the White House to restore press privileges to CNN’s Jim Acosta after the president revoked them.

That may change if he wins reelection and appoints another major portion of the federal judiciary. But this possibility only underscores why we must hold the courts to their most solemn responsibility—of protecting those whose interests the majoritarian process sacrifices. Checks and balances do not run of their own accord. We the people are the ultimate guardians of our liberties.

But if you believe that a second Trump term would create a civil liberties dystopia, the single best thing to do is stop it from happening. In the words of the ACLU’s 2018 midterm campaign, “Vote like your rights depend on it.” (The ACLU is nonpartisan, and does not endorse or oppose candidates, but we educate voters and urge them to make their votes count.) It’s not enough to vote; you need to amplify your voice by encouraging others to vote like their rights depend on it, too. After all, Trump won in 2016 not because he earned a larger share of the vote than Mitt Romney did in 2012. His share was, in fact, smaller. The reason Trump won is that Hillary Clinton’s vote share was less than Barack Obama’s. It was low Democratic turnout that made the difference. If that changes because people vote for civil rights, Donald Trump will lose. It’s as simple as that.

The post Can Civil Rights and Civil Liberties Survive a Second Trump Term? appeared first on Washington Monthly.

This essay is part of a package imagining the policy consequences of a second Trump term. Read the rest of the essays here. And, if you enjoy what you’re reading, please consider making a donation—we’re a nonprofit media organization and rely on the support of our readers. In return for a contribution of $50 or more, you’ll receive a complimentary one-year subscription to our print edition.

I’m a big fan of violent suspense movies: The Bourne Identity, Fight Club, Winter’s Bone. But horror films? Not so much. The reason, I think, is that horror movies are all about experiencing the feeling of helpless terror, which isn’t my thing. The whole point of a thriller, by contrast, is to identify with protagonists who have enough agency and wit to assert some measure of control over the situation, no matter how dreadful. 

To many people, the Trump presidency has felt like one long horror movie. To me, it’s been more like a thriller: disorienting, appalling, emotionally wrenching, but not disempowering. Almost every insane or diabolical decision the president has made has been met with countermoves—by the courts, civil servants, voters, Nancy Pelosi—that have frequently lessened the impact and fortified my faith that all is not lost. 

The novel coronavirus is the latest case in point. Trump’s willful dismissal of the crisis in its early weeks will almost certainly result in many unnecessary deaths. But the wise words and prudent actions of others, from the National Institutes of Health’s Anthony Fauci to ordinary citizens, give me hope that we can “flatten the curve.” 

Similarly, the possibility that Trump could be reelected is, for many people, like a horror flick too frightening to watch. The essays in our cover package certainly provide evidence for maximum alarm.

But there are reasons to think that a second Trump term would not be as apocalyptic as we might imagine. One reason is that the direst scenarios our essayists lay out—the end of Obamacare, a slashing of the safety net—are likely to happen only if Trump is able to continue to pack the courts with conservatives. But that presumes that the GOP holds the Senate. This has not been a sure bet since vulnerable Republican senators like Maine’s Susan Collins supported him in the impeachment trial. It is even less so now that the presumptive Democrat presidential nominee is moderate Joe Biden—and not Bernie Sanders, who down-ballot Democrats rightly see as a potential drag on their chances. 

Another reason is that second-term presidents almost always find themselves in a weakened position. Sometimes it’s because foolish decisions they made in their first terms catch up to them in the second term—think George W. Bush putting the singularly unqualified Michael Brown in charge of FEMA two years ahead of Hurricane Katrina. Sometimes it’s because they let their reelections go to their heads and then act carelessly—as Bush did with his push to privatize Social Security, Bill Clinton did with Monica Lewinsky, and Ronald Reagan did with the
Iranian arms-for-hostages deal. Even presidents who appear invincible can suffer irreparable damage. Nixon won the 1972 election in an overwhelming landslide. He was gone in less than two years.

Of course, Trump has created more scandals in his first three years than any other president did in eight. What’s protected him so far, and what gives him a decent chance of winning reelection, is the rock-solid approval of Republican voters. Even in the wake of his mismanagement of the pandemic, that support remains (as of this writing) undiminished. 

Will his base continue to back him unqualifiedly for four more years regardless of conditions on the ground? I doubt it. Recall that George W. Bush was also beloved by conservatives in his first term. But then, after being re-inaugurated, he tried (and failed) to privatize Social Security. Then Katrina hit. Then Harriet Miers had to withdraw her Supreme Court nomination. Between January and November 2005, Bush’s approval rating among Republican voters fell by 22 points.

Sure, Trump benefits from a hermetically sealed right-wing media ecosystem that recycles his self-serving nonsense. But that system was already a BFD during the Bush years—Fox News drew more viewers during the 2004 Republican National Convention than any other TV network. In the end, it could not save Bush from the real-world consequences of his own actions. 

The parties are even more ideologically sorted today, and Trump plays to the racism and xenophobia of his base, which Bush mostly did not. So it’s possible that he will retain the loyalty of his supporters regardless of what happens in a second term—continuing mass deaths from the coronavirus, a brutal recession with few fiscal tools to fight it, and so on. 

But if his numbers do begin to slip, it will be huge news. GOP lawmakers with their eyes on the 2022 elections will start to defy him. He will lash out and do more foolish, counterproductive, unconstitutional things. His base of support will shrink further. His party will get wiped out in the midterms. The House will impeach him again, and this time the votes will be there in the Senate to convict him. He’ll helicopter to Mar-a-Lago, where federal agents will be waiting with subpoenas. After a lengthy trial over crimes committed before and during his presidency for which he no longer enjoys immunity, he will live out his final days in prison.

Hey, it’s my movie.

The post Why a Second Trump Term Will Not Be a Horror Movie appeared first on Washington Monthly.

On a warm spring day in 2019, Sonji Wilkes appeared before a House Energy and Commerce subcommittee to explain how an unexpected medical bill had upended her life. Soon after her son was born, doctors discovered that he had hemophilia. He was taken to the neonatal intensive care unit (NICU) after he wouldn’t stop bleeding. The hospital was unfamiliar with his condition and lacked the drugs it needed to get his blood to clot. It called in an outside hematologist, who brought medication to staunch the flow. After pumping drugs through an IV line in the newborn’s scalp, the bleeding stopped.

Wilkes spent the following few weeks processing the diagnosis. “It’s quite a shock to find out that your almost-10-pound, healthy-looking baby boy has a lifelong disorder,” she said. But a few weeks later, she received a second shock: a $50,000 bill for his treatment—not from the outside hematologist, but from the hospital NICU.

“My husband and I were dumbfounded,” Wilkes told Congress. “We had been in an in-network facility. How could we possibly be responsible for that amount?” As it turned out, the hospital had contracted its NICU out to a physicians’ group that didn’t accept their insurance. Indeed, the group accepted no company’s insurance. They were rogue.

The family refused to pay. They had been careful to pick a hospital that took their insurance. They had checked to make sure that their specific doctor took it as well. “We felt we had made a good-faith effort to stay in network,” Wilkes, now 44, said.

It didn’t matter. Their insurer refused to cover the cost, and the physicians refused to knock it down. The doctors’ group went to collection. Wilkes’s credit tumbled. Years later, after a class-action lawsuit, her bill was dismissed. But it was too late for her score to recover, and it has caused her financial headaches ever since. “My family incurred a devastating surprise bill,” she told the subcommittee. “Failing to pass meaningful legislation means you are letting millions more families experience the fear and pain my family faced. Please get this done.”

Surprise medical bills occur when insured individuals, like Wilkes and her son, are treated by out-of-network health care providers whom they cannot choose. This can happen in a wide range of situations, from emergency room procedures to biopsy reports. At least two Americans who returned recently from China, developed coughs, and were required to get coronavirus tests received surprise bills topping $1,000. (Congress has since passed legislation seeking to make coronavirus tests free.)

Considered obviously unfair, the practice is opposed by both parties in Congress. After Wilkes finished her opening remarks, every congressperson in attendance expressed sympathy. They told her that surprise billing was a problem they wanted to solve. Wilkes found testifying empowering. “I left feeling quite optimistic,” she told me. “I remember sitting there and thinking, ‘Wow, the system really works.’”

At the time, her positivity was well founded. When Wilkes spoke before Congress, Democratic and Republican members of the House Energy and Commerce Committee were working together to craft legislation that would stamp out surprise billing. On the Senate side, members of the Health, Education, Labor, and Pensions (HELP) Committee were drafting a similar bipartisan solution.

The two committees soon reconciled their legislation. The subsequent agreement would have fixed the amount doctors could charge for surprise bills, subject to appeal, and required that insurers cover the resulting costs. Within each committee, this approach commanded near-unanimous support. “I do not think it is possible to write a bill that has broader agreement than this,” said Lamar Alexander, the Republican chairman of the Senate HELP Committee. Frank Pallone, his Democratic counterpart in the House, agreed. “I’m hopeful that this bipartisan, bicameral agreement can be voted on quickly.”

The committees announced the deal on December 8. The insurance industry endorsed it. So did consumer advocates. The White House quickly signaled support and pushed for its inclusion in a must-pass December 20 spending package. Activists held their breaths. In an era of extreme polarization, where health care is a leading political issue, the government was on the verge of passing an important medical reform.

But over the next 48 hours, hospitals and doctors’ groups came out against the proposal. The American Medical Association criticized the agreement. The American Hospital Association wrote that it would “jeopardize patient access to hospital care.” In the Senate, Minority Leader Chuck Schumer reportedly signaled that he was uncomfortable pushing forward with the fix. Three days after the deal was released, Richard Neal and Kevin Brady, the top Democrat and Republican on the powerful House Ways and Means Committee, put out their own surprise billing proposal. It was a single page of bullet points that contradicted what Pallone and Alexander had set forth. It was a classic legislative maneuver designed to derail progress.

It succeeded. Congress did nothing. The December 20 deadline came and went.

The failure prompted broad outcry. “It’s a plague on both our houses,” said Zach Cooper, a professor of health policy and economics at Yale. He denounced Washington’s inability to act despite “bipartisan agreement and support from the president.” In an editorial, USA Today blasted a feckless Congress for leaving “the surprise medical bill plague untreated.” Since the legislation failed, representatives have continued to work on the issue. But the timeline for hashing out or passing a final fix is currently unclear.

The stakes are high in this fight not only because surprise bills are so unjust, but also because it engages the most important long-term issue in health care: rising and unsustainable costs. Nearly 18 percent of U.S. GDP goes to health care today, up from less than 5 percent in 1960. Since 2009, average premiums have increased more than twice as fast as wages. Deductibles have nearly doubled. Health care spending per person in the United States is now roughly twice that of other wealthy nations, with no appreciable differences in outcomes. The main reason for those higher costs is, quite simply, that Americans pay higher prices, for everything from knee surgeries to medicines, than anyone else.

Eliminating surprise billing entirely would save people with employer-provided health insurance approximately $40 billion annually. Compared to the $3.6 trillion the U.S. now collectively spends each year on health care, that is not a large amount. What makes the legislative battle over surprise billing so important is less the savings it could produce than what the fight itself represents: a dry run for broader reform. If Washington cannot deal with a problem so obviously egregious, it is difficult to envision how it could address rising costs more broadly. But if it does eventually pass something like the Pallone-Alexander bill, Congress will have for the first time set prices for private health care. In doing so, it will have created a launch pad for much bigger reforms.

Hospitals and doctors are well aware of this. They know it could reduce their profits and their pay. That’s why they have pulled out all the stops to make sure that the only surprise-billing legislation that passes is legislation without robust controls on cost. They have many stops to pull. Hospitals and doctors’ groups are some of the largest employers in congressional districts, with ready access to elected officials. They are backed by deep-pocketed Wall Street investors who are not afraid to spend on their behalf. They perform critical services—many are on the front lines in the current fight against COVID-19—and in doing so have earned positive public reputations. And many members of Congress are doctors themselves. These representatives were typically opponents of the Pallone-Alexander bill.

I spoke to one of those representatives, Dr. Phil Roe of Tennessee’s First District, in early February. I asked what role physicians were playing in Congress’s attempts to stop surprise billing. “Well, Daniel, as human beings, we all look after our own vested self-interest,” he told me. “That’s why when one of the Washington Nats fouls the ball, line drive off, I’m ducking, because I’m looking after my own vested self-interest. It’s no different in this. We’re all doing that.”

In early 1917, the California state government proposed giving all its residents health insurance. It was one of the first attempts in the United States to provide an entire population—from the rich to the poor—with medical coverage.

Almost immediately, a group of doctors established the California League for the Conservation of Public Health to campaign against the proposal. The organization distributed public pamphlets that seized on World War I anti-German hysteria; the state’s proposed system, one of them read, “is a dangerous device, invented in Germany, announced by the German Emperor from the throne.” (Otto von Bismarck had established a system of near-universal health coverage in Germany several decades before.) In its communication with doctors, the group conveyed a different message. What the state proposed, they said, was “wholesaling medical services at bargain counter prices.” Reformers overwhelmingly lost.

For the next four and a half decades, every other attempt at establishing a broad system of health insurance met a similar end. While crafting Social Security programs, many of Franklin Delano Roosevelt’s advisers pushed for provisions that would broaden access to health care. Almost all of these incited protest from the American Medical Association, the main professional organization for physicians, and Roosevelt made only halfhearted attempts to see them through. His successor, Harry Truman, made a more serious effort—proposing and campaigning for a single-payer national health insurance plan. This provoked even stauncher physician opposition. The AMA wrote that Truman’s plan would turn doctors into “slaves,” and it spent $1.5 million in a marketing campaign to fight the legislation. At the time, it was the most expensive lobbying effort in U.S. history. After three years, the president gave up.

Liberals finally broke through in 1965 with the passage of Medicare and Medicaid, which provided health insurance to the elderly and the very poor. But their success was circumscribed to get doctors on board. They never sought coverage for other groups, remembering past fights with the AMA. They created a generous system for reimbursing hospitals and physicians. For years after its passage, Medicare proved to be a jackpot for health care providers.

When Bill Clinton won the presidency, Democrats tried to pass legislation that would cut costs and further extend coverage, but they were beaten back by a coalition of doctors’ groups, hospital groups, and insurers. After Democrats swept into power in November 2008, they again began negotiating over a health insurance bill they hoped would give nearly all Americans access to health care. But this time, they quickly moved to get doctors and hospitals on board, promising not to reduce their revenues in exchange for support. Politically, the strategy was a success. Despite extreme partisan opposition, the legislation passed.

The resulting Affordable Care Act has been very effective in its goal of giving health insurance to more Americans. Since its passage, close to 20 million people have gained coverage. This has helped change the discourse around America’s medical system. With more people insured and with insurers more strictly controlled, activists and journalists have been able to increase their focus on other flaws in American health care.

That includes surprise medical billing, which has long been a feature of American medicine. Decades ago, hospitals started contracting out the management of certain parts of their operations, like emergency rooms, to independent doctors’ practices and staffing companies because it was cheaper than hiring physicians outright. Doctors have more than made up that difference by accepting fewer insurance plans than the hospitals and charging patients out-of-network fees. This angle works best for certain kinds of physicians—specifically, the ones patients don’t choose themselves. Not coincidentally, surprise bills come far more often from ER doctors, anesthesiologists, radiologists, and pathologists than from cardiologists.

Like health care costs in general, surprise medical billing rates have been climbing. According to a study by Stanford University, the number of ER trips that resulted in a surprise bill increased by 32.5 percent from 2010 to 2016. Over the same time period, surprise bills related to in-patient hospital stays increased by 60 percent. Today, the majority of ambulance services result in some kind of surprise charge.

Health economists point to several reasons for the increase. One is that rates of hospital outsourcing are on the rise, a trend driven in part by the widespread application of digital medical records. A second is hospital mergers. Between 2006 and 2018, the United States has seen 1,095 announced hospital consolidations. In 2017, approximately two-thirds of all hospitals were part of chains, up from roughly half in 2002. Meanwhile, the physicians’ practices that staff hospitals have also merged. It’s easy to see why this would result in more surprise bills, as well as higher costs overall. Doctors’ groups have less of an incentive to cut deals with insurers if they know that patients will have to see them. Hospitals don’t need to worry as much about antagonizing customers when they are the only game in town.

Today, one-quarter of Americans say they have received a surprise bill. Even the savviest consumers haven’t been able to escape. Health policy experts told me they have been surprise billed. So did patient advocates. Roe, the physician-turned-congressman, told me that he received a surprise $3,000 bill from a pathologist after surgery to treat prostate cancer.

When Congress reconvened in the winter of 2019, surprise billing was therefore at the top of the agenda. But while all stakeholders agreed that the practice should stop, they disagreed over how. Patient advocates and insurers asked the government to benchmark prices for treatments—like X-rays or appendectomies—to the median price that insured people pay while in network. Insurers would then automatically pay the out-of-network physician that amount. Providers protested that benchmarking was an unfair government intervention in the health care marketplace. Instead, they called for surprise bills to be settled by arbitration, where a third party would decide what insurers would ultimately pay the doctor on a case-by-case basis.

Consumer advocates generally oppose arbitration. That’s because evidence suggests that arbiters tend to make physician-friendly rulings, resulting in large insurance payouts. Insurers then pass on the costs of these outsize charges to consumers in the form of higher rates, deductibles, and co-pays. Since New York State implemented an arbitration system to settle certain surprise bills in 2015, costs for New Yorkers have gone up, not down, according to a Brookings Institution analysis.

Pallone, the House Energy and Commerce Committee chairman, told a consumer advocacy conference that doctors had asked Congress to effectively “recirculate” any charges lost in a surprise billing ban “so that the individual pays it in their premium.” He balked at the request. “This isn’t about just eliminating the surprise and making you pay in monthly installments for the same amount,” Pallone told the advocates. “That’s not what we’re up to here.” In the spring, the committee released draft legislation that would benchmark all surprise billing charges.

Doctors and hospitals then went into lobbying overdrive. Their allies in Congress, including Roe, introduced alternative legislation entirely based on arbitration. In response to the pressure, the House and Senate committees rewrote the bill in mid-July. Doctors could now ask arbiters to review bills above a certain dollar threshold.

The deal still faced provider resistance. But some former skeptics signed on. Patient advocates stayed on. It was the kind of compromise that nobody loved, which is to say the kind that might just get through Congress.

The ads began in the summer. In one, emergency medical technicians wheel an unconscious trauma victim from an ambulance and into a hospital, only to find that it’s been abandoned. In others, narrators blast insurers for denying coverage and ask that listeners call on Congress to support “IDR,” or independent dispute resolution—longhand for arbitration.

At first, it wasn’t clear who, exactly, was behind these commercials. The proximate group, named Doctor Patient Unity, didn’t list its donors or members. But they were clearly well funded. They were rich enough that they could broadcast during the Democratic debates. Indeed, they were rich enough that they aired ads during the World Series. The entire campaign has cost more than $28 million.

After months of speculation about the funding source, on September 13 The New York Times unveiled the answer. The two main bankrollers were the Blackstone Group and KKR—the world’s first- and third-largest private equity companies, respectively. Blackstone and KKR own the two largest physician-staffing companies in the emergency room business, TeamHealth and Envision. Both firms are notorious for accepting far fewer insurers than the hospitals they operate in and sending out-of-network charges to those they treat. One study found that when TeamHealth set up shop in an emergency room, out-of-network billing rates increased by 32.6 percent. When Envision’s main ER subsidiary entered, out-of-network rates also shot up—sometimes to nearly 100 percent of all bills.

That private equity firms have been investing in doctors’ groups engaged in surprise billing shouldn’t come as a shock. The private equity business model is based on making above-market returns. To do so, they frequently purchase companies that have cornered their market or can do so by buying up the competition, giving them the power to raise prices. Emergency room patients are, by definition, entirely cornered.

Surprise billing allows doctors and their private equity partners not only to extract more money from patients but also to demand higher payments from insurers. “You basically piss enrollees off so much, piss patients off so much, that they then complain to their insurer or employer, who are then willing to pay even more,” said Loren Adler, a health policy expert at Brookings. Insurers then pass along higher costs to patients in the form of higher deductibles and premiums. Employers pass the cost on to workers by keeping their salaries down.

As hospitals and doctors have become increasingly involved with private equity, the line that divides them has thinned. Private equity companies now own entire hospital chains. The private equity firm Cerberus Capital Management, for example, owns Steward Health Care—the country’s largest private for-profit hospital system. Private equity has come to dominate certain specialties. Three out of the last four presidents of the American College of Emergency Physicians have worked for a company owned by private equity, including the current president, who doubles as an executive at Envision. Private equity is deeply involved in many others. The president of the American Academy of Dermatology runs a private equity–funded practice.

The scale of Doctor Patient Unity’s ad buy caught Congress’s attention. “When you’re dropping that much money, people certainly notice,” said a Democratic Senate staffer close to the negotiations. And as the commercials ran, doctors continued to meet with members of Congress. They made the same argument as private equity lobbyists: that the benchmarking bill would close hospitals and be a giveaway to insurers.

All the lobbying had an impact. In December, when Frank Pallone and Lamar Alexander released their final agreement, they expanded the number of benchmarked charges that physicians could appeal to arbiters. It still wasn’t enough for doctors and hospitals, who roundly condemned the deal. Soon, Richard Neal and Kevin Brady, the Ways and Means leaders, put out their one-page proposal. Schumer expressed unease with Pallone and Alexander’s bill. It stalled.

Both Neal and Schumer have close ties to opponents of benchmarking. Neal received roughly $30,000 in campaign contributions from the Blackstone Group during 2019. Today, Blackstone is his second-largest campaign contributor. Holyoke Medical Center, one of the major hospitals in his district, has contracted with Envision. Schumer is famously close with the Greater New York Hospital Association (GNYHA). His Senate Majority PAC has received $4.5 million in donations from the group since December 2017. According to reporting by The Washington Post, Schumer met with GNYHA representatives two days before expressing his discomfort with the Pallone-Alexander agreement.

When Neal and Brady released the full text of their legislation two months later, it was entirely based on arbitration: If providers and insurers could not agree on what to pay, a third party would decide. But it instructed arbiters to consider median in-network rates, and providers were not quite satisfied. The American Medical Association wrote that it was “appreciative” of the committee’s efforts, but it stopped short of an endorsement. The American Hospital Association was similarly lukewarm. The American College of Surgeons thanked the committee but wrote that “some areas still need to be addressed.” They were concerned that the mediation system, as designed, was not favorable enough to physicians. By requiring doctors to disclose their typical compensation, the ACS argued, the bill could “potentially driv[e] down physician payment.”

The topic of physician pay is difficult to objectively discuss. In treating the sick, doctors and hospitals offer an extraordinary service for which one can’t help but be thankful. For that reason, they retain high approval ratings. Even in the aftermath of horrific surprise medical billing stories, the families I talked to had kind words for the people who treated them.

“We’ve been really fortunate to have really good doctors, so I’m always appreciative of what they’ve done for me,” said Angela Eilers, who received a $13,000 surprise medical bill from an anesthesiologist after her infant daughter required heart surgery. She blamed insurers for the charge, and praised physicians for their work dealing with insurer requirements. “They’re just fighting the system too,” she said.

Physicians defend their compensation using similar logic. “Who is going to show up at two o’clock in the morning and see you?” Roe asked me. “It’s not going to be the insurance provider. It’s going to be the doctor.” As justification for high reimbursement, he cited the “years and years and years of training” aspiring doctors must endure. “They deserve to be fairly compensated.”

There is no doubt that American doctors must pass a grueling set of classes, exams, residencies, and rituals before they get to work something even approximating normal hours. They are highly skilled and work essential, and sometimes dangerous, jobs. They deserve compensation that is well above average.

But it’s simply a fact that American doctors make far more money than their counterparts in other high-income countries. On average, U.S. doctors make roughly twice as much as those in other wealthy democracies. There are more doctors in the 1 percent than there are members of any other profession.

Their salaries are far from the only source of high health care costs. Wall Street financiers and hospitals both make large profits by exploiting American medicine’s many market failures, including the ability to send surprise bills. These institutions jack up the cost of care and then use those excess earnings to give raises to executives and expand their reach.

Nonprofit hospitals, which receive tax exemptions in exchange for working toward the “community benefit,” are especially guilty. “They see their mission as growing and making more money,” said Shawn Gremminger, the former senior director of federal policy for Families USA and a onetime hospital lobbyist. A Politico investigation found that the nation’s top seven hospitals as ranked by U.S. News & World Report—all nonprofits—took in more than $33.9 billion in operating revenue in 2015, a 15 percent increase from two years before. These hospitals’ spending on direct charity care fell by 34 percent over the same time period. “They don’t reinvest [their money] back in the community,” Gremminger told me. “They build another patient tower, or they buy another overpriced MRI machine.”

All of this might still be justifiable if the disproportionate salaries and massive spending—the highly paid specialists and expensive new equipment—correlated with better health outcomes. But they don’t. The United States spends more of its GDP on heath care than every other state in the Organisation for Economic Co-operation and Development (OECD), and its outcomes are middling at best. America’s life expectancy, for example, is below the OECD’s median. Indeed, Americans’ life expectancy went down between 2014 and 2017, even though the country’s health care spending went up faster than inflation. One of the main reasons for the growth in early deaths was the profligate prescription and distribution of opioids: in other words, because of overspending by heath care providers.

None of this has stopped doctors’ and hospital groups from asserting in letters and ads that benchmarking would result in more deaths. Politically, this is a powerful charge. “We’ve been experiencing a period of rural hospital closure,” said a congressional aid working on the issue. “So when you start seeing ads saying things like, ‘Hospitals are going to close if you prevent surprise billing,’ that scares folks.”

But the assertion is baseless. Many of the forces behind rural hospital closures—such as depopulation, or the tendency for rural patients to seek care in urban centers rather than close to home—have nothing to do with surprise billing. Others, like consolidation and outsourcing, are actually causing surprise billing. It is difficult to see how benchmarking rates would make any of them worse.

In fact, benchmarking surprise bills would have only a tiny impact on health care financing. According to research by the Congressional Budget Office, the Pallone-Alexander agreement would reduce staffing company and hospital revenues by at most 1 percent over 10 years. The Centers for Medicare & Medicaid Services estimates that hospital and physician revenues will rise by more than 60 percent over the same period of time, or by $1.6 trillion.

The truth is that surprise billing rarely occurs, or doesn’t ever occur, in most hospitals. Only a handful of specialists, like ER physicians, widely engage in it. Yet doctors’ and hospital groups are nearly unanimous in opposing the Pallone-Alexander legislation. The question is why.

As America’s health care costs continue to mount, politicians have embraced bolder and bolder interventions. The Affordable Care Act, a bill once so progressive and momentous that its destruction became the sine qua non of the Republican Party, is now widely viewed by Democrats of all stripes as insufficient. Creating a public option, a position too liberal to pass in 2010, is now the core of moderate Joe Biden’s health care plan. Democrats on the left demand a single-payer health care system, where the government would have extraordinary leverage over medical costs.

But within the party, politicians across the board are increasingly endorsing a cost reform that’s even more blunt: setting health care rates outright. It’s something that America’s two government-run insurance plans—Medicare and Medicaid—already do. Moderate Pete Buttigieg proposed capping the cost of all out-of-network bills, surprise or otherwise, at 200 percent of what Medicare pays. Progressive Elizabeth Warren’s Medicare for All proposal would have set hospital reimbursement rates at 110 percent of what Medicare offers.

Price setting in private health care is not a new concept. Writers in this magazine have been exploring the idea of administrative pricing since 2014 (see Phillip Longman and Paul S. Hewitt’s “After Obamacare” in our January/February 2014 issue). Plenty of other high-income nations, including Germany and the United Kingdom, have long set prices for health care treatments. But it’s certainly new to see it in the health care plans of prominent presidential candidates.

This shift has hospitals and doctors anxious. In letters and advertisements denouncing the Pallone-Alexander agreement, providers and their private equity partners routinely refer to benchmarking as “government rate setting.” They warn that this will lead to doctor shortages and hospital closures. “Beware,” one advertisement starkly declared.

The ads make clear something virtually every expert and advocate told me: Providers are worried that any surprise billing legislation based on benchmarking creates a slippery slope. After all, if the state can set rates for surprise bills, why can’t it set rates for all bills?

At first glance, that fear is overblown. In politics, providers usually win. In an era of extreme partisanship, where the legislative system is laden with choke points and vetoes, where passing a solution to even the most salient patient abuse is a slog, it seems unwise to expect bold reform.

But the government has intervened in health care pricing before, despite provider opposition. In 1983, faced with ever-rising Medicare payments, Congress passed bipartisan legislation that set the rates the public program would pay for various tests and treatments. And as private health care costs continue to explode, political alliances are shifting in curious ways. Employers were once implacably opposed to a public option. Now, many are embracing it as an acceptable alternative to paying for their employees’ rising premiums. Insurers, long wary of any government intervention in health care, are now actively lobbying for price controls, if only in the context of surprise medical bills. This has led some activists and analysts to argue that price setting is a matter not of if, but of when.

“We’re up to 18 percent of the U.S. economy being spent on health care,” said Gremminger, the former hospital lobbyist. “Is the inflection point 25 percent? Is it 30 percent?” Whatever number it is, he is confident we will one day reach it. He compares the health care industry to an animal “that literally, so long as there is food in front of it, will eat it.” American health care, he said, simply can’t regulate itself.

That leaves the United States with three options. It can try to put out fires, as it is doing with surprise billing, while overall prices continue to rise. It can try to change the underlying economic incentives, as public option proponents hope their bill might. But barring that, Gremminger told me, “the only thing we have left is one of the most straightforward, which is administrative pricing.

“That would be a sea change,” he said. “But I’m not sure how far away we are.”

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