On a Monday afternoon in late July, a group of leading Democratic members of Congress, including Chuck Schumer, Nancy Pelosi, and Elizabeth Warren, gathered in small-town Berryville, Virginia, to pitch the Democrats’ “Better Deal” economic agenda.

The party’s strategy for 2018 had been a topic of obsession since the day after the 2016 election. The Democrats were finally being forced to confront a fundamental weakness: the perception, as the comedian Lewis Black once put it, that while the Republicans are the party of bad ideas, the Democrats are the party of no ideas. Shortly after the election, Schumer had admitted on national television that one reason for Hillary Clinton’s loss had been the lack of a “strong, bold economic message.” In Berryville, he told the crowd, “Too many Americans don’t know what we stand for. Not after today.”

Sort of. The agenda’s tedious branding—the subtitle was “Better Jobs, Better Wages, Better Future”—drew mostly derision, not least for its resemblance to the Papa John’s motto: “Better Ingredients. Better Pizza.” A New Yorker humor piece listed “rejected slogans,” including “Not Perfect, But Also Not Trump.”

The problem went beyond the name. If the Better Deal was treated like an overstuffed grab bag of policies designed to placate the entire Democratic caucus, that’s because it was one. Much early coverage focused on a proposed tax credit for job training, the exact kind of centrist technocracy so many liberals were afraid of—“reminiscent of what Bill Clinton was selling in the 1990s,” as Michelle Cottle put it in the Atlantic.

The Democrats’ problem, then, isn’t that no one knows what they stand for on the economy. It’s that everyone knows what they stand for: higher taxes, more spending on social welfare, and a stream of opaque, nibble-around-the-edges government programs. Hillary Clinton may as well have said she had binders full of ideas.

Many commentators did, however, notice one element of the Better Deal that was quite new—and potentially transformative. If you got past the bland subheading “Lower the costs of living for families,” you would have found something very different from what anyone was selling in the 1990s: a section on “Cracking Down on Corporate Monopolies and the Abuse of Economic and Political Power.”

This anti-monopoly plank—which Schumer and Pelosi emphasized in op-eds in the New York Times and the Washington Post, respectively—reflected a growing awareness that the economy has become dangerously concentrated. In sector after sector, from retail to beer to eyeglasses, the market is controlled by a small handful of giant companies. And mounting evidence suggests that corporate consolidation is behind some of the economy’s deepest problems: income inequality, declining innovation, and the exodus of wealth and jobs from the heartland toward the coasts.

Donald Trump’s ability to tap into these symptoms goes a long way to explaining his decisive Rust Belt appeal. He could channel a sense of decline among white voters there because, unlike Clinton, he told a story about what caused it—free trade, illegal immigration, and corrupt politicians—and how to fix it: quit NAFTA, build a wall, lock her up. That story was mostly false, and it oozed racism and sexism. But Clinton didn’t offer an alternative. If Trump was a quack doctor, peddling fake medicine, then Clinton missed the diagnosis.

That’s why including proposals in the Better Deal to address consolidation, however light on details, could end up being a turning point. It marked the party’s first unified attempt to grapple with the structural economic barriers holding so many people back. Unlike Trump’s racio-economic populism, the story of monopolization isn’t a hoax, and it doesn’t pit ethnic groups against each other.

A month after the Better Deal announcement, something happened that gave warnings about corporate consolidation more urgency. New America, a center-left think tank, fired a team of anti-monopoly researchers after the group’s director, Barry Lynn, praised European Union sanctions against Google. That was apparently the last straw for Eric Schmidt, a billionaire Google executive and, along with Google itself, one of New America’s most generous funders. A chain of emails from New America’s president, Anne-Marie Slaughter, strongly suggested that she fired Lynn and his team for angering Schmidt and imperiling the think tank’s access to future Google money. (Slaughter publicly denied that suggestion, claiming that Lynn had a pattern of bad behavior.)

It would have been hard to concoct a better anti-monopoly publicity stunt: a single plutocrat was revealed to have the power to restrict the flow of ideas into public debate. The story of the firing broke on the front page of the New York Times, and two days later Tucker Carlson, of all people, was interviewing Lynn’s colleague Matt Stoller on Fox News about whether Google is a monopoly. In September, the comedian John Oliver even devoted a long segment of his HBO show to “corporate consolidation.” Concern about monopoly was suddenly mainstream.

This is new. The Reagan administration sharply curtailed antitrust enforcement in the 1980s, and no administration, Democratic or Republican, has tried hard to revive it. Quietly green-lighting enormous mergers has been a rare area of bipartisan consensus for three decades—as Chuck Schumer, the senator of Wall Street, now freely acknowledges. “How the heck did we let Exxon and Mobil merge?” Schumer said to George Stephanopoulos while discussing the Better Deal. “And that was Democrats!”

The idea that something’s got to be done about monopolies seemed to go from fringe argument to a pillar of the Democrats’ economic plan, at least rhetorically, overnight. But it didn’t really come out of nowhere. The Better Deal announcement, the New America dust-up—these were the bubblings of a movement that had been brewing for nearly a decade. The story of the Democrats becoming—maybe—the anti-monopoly party, the party of small business, is not just a politics story. It’s a story about how ideas win and lose and then, maybe, win again. And it’s the story of how a small group of political outsiders got the party establishment to adopt an idea that was essentially left for dead in 1978.

A challenge in writing a story about monopolies, or antitrust—the body of law concerned with cracking down on monopolization—is that the terms themselves are like a foreign language to most people.

That wasn’t always the case. America used to have a robust tradition of anti-monopoly politics, as you may recall from learning about the “trust buster” Teddy Roosevelt in middle school. Farmers were held hostage to discriminatory rates imposed by the railroad monopolies that shipped their crops. Ranchers had to settle for whatever the “big five” meatpackers wanted to pay them. Shopkeepers were squeezed by national wholesale chains. (“Monopoly” is useful shorthand. Technically, when a handful of companies control a market, rather than just one, it’s called an oligopoly.)

In 1890, Congress passed the Sherman Antitrust Act, which outlawed attempts to build monopolies or restrict competition. Congress expanded the scope of illegal business activities with the Clayton Act of 1914, the same year it created the Federal Trade Commission, and it tightened the screws once more in 1936. These laws were mostly vague, but, as interpreted by the federal courts, they allowed officials in the Department of Justice and the FTC to block mergers, break up companies that had gotten too big, and make sure markets stayed competitive.

Throughout those years, it was common for leading politicians to talk about the dangers of monopolization. At the most basic level, the problem with monopolies is that, with no competition, they can charge exorbitant prices. But consolidated economic power poses dangers beyond prices. In the 1912 election, candidate Woodrow Wilson declared, “If monopoly persists, monopoly will always sit at the helm of the government.”  Franklin Roosevelt, in his speech accepting the Democratic renomination for president in 1936, blamed the Great Depression on the “economic tyranny” of a monopolized economy.

Around that time, Roosevelt and his legendary antitrust chief, Thurman Arnold, kicked off a period of especially aggressive antitrust enforcement that would last into the 1970s. Note that this period saw the country’s fastest increases in living standards, the economic halcyon days to which so many people, not least Trump voters, wish we could return. The historian Alfred Chandler Jr. later wrote that Roosevelt’s antitrust division “set the stage” for the twentieth-century information revolution by forcing companies like IBM to create room for rivals to compete and innovate.

By the 1960s, it was understood that the federal government would intervene to keep firms from getting too big, period. In the 1961 case Brown Shoe Company v. United States, the Supreme Court ruled unanimously that a merger giving one company control over 2 percent of the nation’s shoe outlets violated the Clayton Act. But, perhaps because the movement was so successful, antitrust eventually came to lose its political cachet. It became “one of the faded passions of American reform,” wrote the historian Richard Hofstadter in 1964. Historians, he wrote, had come to “ignore antitrust for the same reason the public ignores it: it has become complex, difficult, and boring.”

He might have added “vulnerable.”

Before his last name became synonymous with failed Supreme Court nominations, Robert Bork was a law professor at Yale and a disciple of the so-called Chicago School of economics. The Chicago School movement, most associated with Milton Friedman, argued for laissez-faire economic policy based on the premise of individuals as hyper-rational market participants. To the archconservative Bork, antitrust wasn’t boring; it was an outrage. Cases like Brown Shoe proved that the Supreme Court had gotten out of control. It was blocking, on touchy-feely grounds, business activity that basic economic models promised would increase efficiency.

In 1978, Bork published The Antitrust Paradox, which utterly upended the field. The Court’s doctrine, Bork argued, was incoherent: it sought both to protect consumers from high prices and to protect small businesses from being squashed. Those goals were at odds with each other—paradoxical—because protecting small businesses from monopolies would allow them to charge higher prices.

In Bork’s entertainingly snarky telling, most politicians, judges, and even economists were just too stupid to see this obvious contradiction. The truth is that antitrust law reflected a decision to balance the protection of small (or at least, non-monopoly) businesses, which leaders going back to Thomas Jefferson saw as vital to democracy and opportunity, with the economic advantages of larger enterprises. But Bork thought there was no way to make those trade-offs in a principled way.

And so Bork argued that federal judges must resolve the “paradox” by declaring that the only legitimate purpose of antitrust law was to promote “consumer welfare,” basically meaning lower prices. And the only way to promote consumer welfare was to promote efficiency, because efficiency meant more production, which meant cheaper products. Any other purpose would interfere with efficiency and must therefore be ignored.

To see how radical this was, just consider one example of something not captured by consumer welfare: employee welfare. In a town dominated by a single employer, workers may be forced to submit to poverty wages and abusive work conditions. Coal miners know this all too well—so do Walmart employees. (See Alec MacGillis, “What J. D. Vance Doesn’t Get About Appalachia.”) But to Bork, that could never justify antitrust enforcement so long as the product stayed cheap.

The Antitrust Paradox makes for remarkable reading today. Like a caricature of a Chicago School economist, Bork explicitly warned against learning from experience. Rather, all business practices should be judged based on what “simple” (his word) economic models predict. “Only theory can separate the competitive from the anticompetitive,” he wrote. And theory says consolidation is good, because it means strong firms are crushing weak ones.

But the most striking thing about Bork’s book is how up front he was about seeing the fight over antitrust as part of the culture wars of the 1960s and ’70s. The Warren Court, he wrote in the 1993 preface to the second edition, “wrecked many fields of law in its reckless and primitive egalitarianism. Antitrust was one such field.”  For Bork, an antitrust decision like Brown Shoe was the same kind of leftist judicial activism as Roe v. Wade.

He presented his method as a technical, value-neutral way to apply the law—a “science.” It was a cousin of originalism, another favorite Bork theory, which holds that judges must interpret the Constitution by figuring out the Founding Fathers’ true intentions. And, just like originalism, the consumer welfare test pretends to free the law from the grips of ideology when in fact it simply swaps in a different one.

Antitrust, Bork lamented, had been invaded “by the ideologies of statism and interventionism,” and his loathing for economic progressivism was so intense that he repeatedly tipped his hand. For instance, he berated liberal judges for usurping Congress’s authority, but also argued that if Congress tells courts to consider factors other than prices, the courts should refuse. That betrayed the phoniness of his professed concern about judicial activism. What was at stake was no less than the fate of capitalism versus socialism.

When it came to economics, Bork got almost all the important stuff wrong. “I doubt that there is any significant output restriction arising from the concentration of any industry,” he wrote, meaning there was nothing wrong with monopolies short of outright price-fixing. After all, if a monopoly raised prices, other competitors would swoop in to undercut it. The market corrects itself.

But Bork was writing for an audience of nine, and here he was devastatingly effective. Almost as soon as it was published, The Antitrust Paradox became gospel at the Supreme Court. By 1979, one year after the book came out, the Court was already citing its claim—debunked by historians—that “Congress designed the Sherman Act as a ‘consumer welfare prescription.’ ” It’s not a stretch to say that, within its field, The Antitrust Paradox had the biggest practical impact of any single work of legal scholarship, ever. “The decisive cause,” by Bork’s own account, “was a change in the composition of the Supreme Court.” As the Warren Court’s “liberal ideologues” died or retired, Richard Nixon had been able to install a conservative and corporate-friendly majority that cottoned instantly to Bork’s free-market fantasia.

The election of Ronald Reagan in 1980 meant conservative free-market economics was ascendant no matter what. But Bork provided the intellectual framework to scale back antitrust, and once his ideas caught on among the judiciary, even aggressive-minded enforcers would have a hard time winning cases. Meanwhile, generations of college students who took Econ 101—people who today run the nation’s corporations, think tanks, and government agencies—were steeped in the Chicago School dogma that monopoly can’t be a problem because the market will always fix it. The laissez-faire approach to mergers and competition ultimately became orthodoxy in both parties. “Antitrust was defined by Robert Bork,” the legal scholar Barak Orbach told the Washington Post when Bork died, in 2012. “I cannot overstate his influence.”

Bork reserved special contempt for people who worried about the economy growing too concentrated overall. “The imminent concentration of all ownership in a few giant corporations, with the concomitant demise of small business, is the standard, Mark I, all-weather antitrust hobgoblin,” he wrote. “This congealing of the economy . . . never comes to pass.”

Well, sure, but only thanks to the legal regime that he was helping to dismantle. After the Reagan administration, following Bork’s lead, kicked off the era of lax antitrust enforcement and rampant mergers, the economy would begin a steady climb to levels of concentration not seen since before the original Progressive Era. The most intense wave of mergers has taken place in the years since the 2008 financial crash. According to an analysis by the Economist last year, two-thirds of all corporate sectors grew more concentrated between 1997 and 2012. Today, for example, three chains—Walgreens, CVS, and Rite Aid—control 99 percent of the nation’s pharmacies, and two of them tried to merge last year. Four companies control 85 percent of the beef market. Waves of airline mergers have left four major carriers that account for 80 percent of domestic seats. And so on.

All this merger activity has led to the exact thing Bork promised wouldn’t happen: higher prices. In 2015, the Northeastern University economist John Kwoka published a meta-analysis of every study ever done on mergers in the U.S. since 1985. He found that more than 60 percent of studied mergers led to product price increases, of an average of nearly 9 percent. In some sectors the effects are especially jarring: other research shows that hospitals with no local competition charge 15 percent more for the same care than hospitals with three or more competitors. (See Phillip Longman, “How Big Medicine Can Ruin Medicare for All.”) In short, post-Bork antitrust policy has failed even on its own terms.

Price increases were only part of the story, however. Median wages stagnated, as more and more economic gains went to the top 1 percent of earners; rates of small business creation declined; and the biggest companies’ profits kept growing even as they invested less and less in their businesses. But for years, no one thought to ask whether the rise of a new class of monopolists and the dawn of a new Gilded Age were connected.

Barry Lynn is an unlikely foil to Robert Bork. A tall fifty-six-year-old Floridian with squinting, skeptical eyes, he is neither a lawyer nor an economist. In 1999 he was the executive editor of a small business magazine when a massive earthquake in Taiwan caused the stock prices of several U.S. tech companies to crash. It turned out that almost all the world’s semiconductors were produced there, so that the earthquake, which knocked off power to the region’s airports, had momentarily cut off an essential step in the supply chain. That was Lynn’s epiphany. At a time of widespread boosterism for the emerging global economy, the quake had revealed the danger of industrial concentration.

After the business magazine folded, in 2001, Lynn got a fellowship position at New America while he worked on a book about the frailty of the global supply chain, which came out in 2005. In his next book, Cornered, published in 2009, Lynn wrangled with the broader effects of a hyper-concentrated economy. That year, drained from writing two books back to back, he decided he needed a new strategy. Instead of spending years on another book, he would supervise a team of researchers. And instead of pumping out white papers like other think tanks, the team would produce original journalism.

Robert Bork had inaugurated the second monopoly age by convincing the legal world to ignore facts on the ground. Lynn and his team would take the opposite approach, building a case for rejecting Chicago School competition policy by showing what life really looked like in Bork’s America.

But first they needed an outlet. One was Harper’s, which had published a 2006 piece by Lynn arguing to break up Walmart. The other—and here’s where this story gets very incestuous—was the magazine you’re reading right now. Lynn’s work brought him into contact with another New America fellow named Phillip Longman, who happens to be senior editor at the Washington Monthly.

In early 2010, Paul Glastris, the magazine’s editor in chief (so, my boss), was looking for a story about the economy. Longman pitched him a piece that would take on a central riddle of the 2000s: from 1999 to 2009, the economy had added zero new jobs. Even before the real estate bubble burst, growth was historically weak. Explanations like technology and offshoring didn’t quite add up.

Longman and Lynn had a novel theory: the rise in corporate consolidation was the culprit. Small businesses drive most job creation in the U.S. A monopoly, meanwhile, has little reason to hire more workers, because it can just charge higher prices. At the very least, Longman and Lynn concluded, economists and policymakers should start asking whether monopolization was partly to blame for a decade of weak job creation.

The Monthly had published pieces on concentration in specific industries, including a 2004 cover story by Ted Turner about media consolidation. But Longman and Lynn had figured out something bigger: consolidation across sectors was driving troubling nationwide trends. The article became the first in a series that Lynn and his team would publish in the magazine over the next seven years (including Longman’s piece on health care monopolies in this very issue). In 2011, Lynn got funding to set up his Open Markets group at New America. “The idea was to get as many pieces out there under as many names—up to that point it was mostly just me, and sometimes Phil, writing about these issues,” he said. “But there were no other names. So it was like, ‘Well, Barry sees another monopoly!’ ”

His first hire was a recent Williams College grad named Lina Khan. Khan became a fixture of the Monthly table of contents in 2012, covering the plight of independent chicken farmers and collaborating with Longman and Lynn on two especially prescient pieces: one on the nasty effects of airline consolidation, which saw renewed interest during the airline scandals of the past year; and one documenting a steep decline in rates of business start-ups since 1980, which was later validated by a Brookings study inspired by the article.

The pieces hardly went viral, but they left a trail for other researchers to follow. As the smoke cleared from the 2008 recession, economists were trying to make sense of the fact that the share of income going to labor, versus capital, was going down. That could have been due to technological change—but if that were true, you’d expect to see rising investment. That wasn’t happening. Other possible theories didn’t square with the facts either. Something was pumping up corporate profits at the expense of workers.

“This is where the Barry Lynn stuff comes in,” Paul Krugman, the New York Times columnist and Nobel Prize–winning economist, told me. “Most people who do good economics do stuff partly based on statistics, on measurement, on data. But you always want a story that buys into lived experience. If you tell a story that fits the data but doesn’t sound at all like what you see in the world around you, then we’re very suspicious of that story.” The argument about consolidation both described the real world and fit the strange data economists had been observing. It had taken journalists, whose currency is reporting, not theory, to see it.

In 2012, Krugman wrote approvingly in a column about Lynn and Longman’s argument “that increasing business concentration could be an important factor in stagnating demand for labor, as corporations use their growing monopoly power to raise prices without passing the gains on to their employees.”

That shout-out from Krugman, the first of several, was essentially an invitation to other economists to do research to test the hypothesis. Over the next few years, they would begin supplying the numbers to back up Lynn and Longman’s observations. But apart from Krugman, the reaction from prominent thinkers and writers was mostly silence. The dominant liberal worldview was still better captured by a 2005 paper written by a then up-and-coming liberal economist named Jason Furman. The title was “Wal-Mart: A Progressive Success Story,” and it argued that liberals should celebrate Walmart for providing such cheap goods to poor people.

Furman would go on to chair Barack Obama’s Council of Economic Advisers. Under the Obama administration, antitrust policy continued to be permissive—2015 would be the biggest year ever for mergers. Lynn still needed to figure out how to get the attention of the political elite.

When Lina Khan showed up at the Omni Hotel in New Haven for a welcome party for the Yale Law School class of 2017, she wondered if she’d made a mistake. She had applied to law school because she was convinced that the law needed a new antitrust movement. But journalism still beckoned. As she wandered around the outskirts of the reception, she told the first person she met that she was already thinking about dropping out.

That person happened to be me. (I told you this story was incestuous.) It was late August 2014, and I was a third-year student helping run the first-year orientation program. I told Khan that journalists were indeed cooler than lawyers, but since she was already at Yale she should probably give it a shot.

Boy, was that good advice. Yale Law School, where students taking antitrust in room 120 can feel Robert Bork’s portrait smirking at the backs of their heads, is one of the most insidery institutions in America—a place where Harvard and Yale college grads outnumber those from all state schools combined, and where students begin gunning for Supreme Court clerkships before they get their first-year course schedule. Bill and Hillary Clinton met there. They had Bork as a professor.

In other words, while Barry Lynn and the Washington Monthly kept banging away from outside the political establishment, Khan had infiltrated the establishment’s finishing school.

During her first year she met a second-year student named Michael Shapiro, who had worked for the National Economic Council in the Obama White House before coming to Yale. Shapiro, like some of his former colleagues, was aware of the new monopoly critique, having read Krugman’s columns. But from Khan he got a steady dose of the most emphatic version of that argument.

Shapiro was plugged into the small world of Democratic wonks brainstorming economic policy in anticipation of the coming presidential campaign, and he passed along the monopoly stuff that he was discussing with Khan at school. (One of his contacts was an old friend, Jessica Schumer, daughter of Chuck and chief of staff to Jason Furman. Also a Yale Law grad.) When the Clinton campaign launched in spring of 2015, Shapiro joined the economic policy team.

“I think he was a key voice on this, early, as a place that we should focus,” said Jake Sullivan, the campaign’s top policy adviser (and yet another Yale Law grad). “Like, really early. The end of ’14, beginning of ’15.” The most tangible result came in October 2015, when Clinton published an op-ed in Quartz promising, if elected, to “take steps to stop corporate concentration in any industry where it’s unfairly limiting competition.”

2015 seems to be when the first tendrils of interest in bringing back antitrust started sprouting among liberal cognoscenti. Around the same time as the op-ed, Furman and his former colleague Peter Orszag delivered a paper arguing that economic “rents”—profits in excess of what companies should earn in a competitive market—were largely to blame for rising inequality. Furman, you’ll recall, is the guy who a
decade earlier was urging liberals to embrace Walmart.

The major liberal think tanks were also getting involved. New America already had Lynn and company. The Roosevelt Institute in May 2015 published a report, coauthored by Joseph Stiglitz, that focused heavily on breaking down industry concentration to foster competition. Most significantly from a political perspective, the Center for American Progress, the policy factory for the Democratic Party founded by John Podesta, would issue a paper in mid-2016 called “Reviving Antitrust.”

Even the Economist, normally a cheerleader for all things free trade and free market, published a March 2016 story picking up the argument that the super-high profits flowing to the top firms suggested a monopoly problem.

Meanwhile, in the White House, the Council of Economic Advisers was building off the Furman/Orszag paper from 2015. In April 2016 it published a brief adding the administration’s weight to the argument that consolidation was up, competition down, and American workers were suffering for it. Obama himself issued an executive order directing all agencies to identify ways to crack down on anticompetitive practices in their areas of jurisdiction.

But, even with the executive order, this was still basically the realm of white papers, conferences, and issue briefs. It was policy, not politics.

One Friday morning in March 2016, while I was in town for a story, I met Khan for breakfast at Patricia’s, a New Haven diner. Lunch wouldn’t work because she had to catch a train to D.C. She was vague about why, but eventually I pulled it out of her: she was having dinner with Elizabeth Warren. Warren’s staff occasionally organizes policy-oriented dinners for the senator, and they had reached out to Khan for help planning one focused on antitrust.

It might seem strange that a senator and former law professor would reach out to a current law student for advice on a legal topic. But there just weren’t many options. Khan was one of very few people interested in antitrust who wasn’t already an antitrust lawyer trained to look at the world in terms of Borkian efficiency.

“Effusing about one’s interest in antitrust and monopoly was not very common, or so I’m told,” Khan said. “I talked about this stuff at parties.” Her Yale pedigree didn’t hurt, either.

Warren’s office asked Khan to suggest other dinner guests. Naturally, she picked her old boss, Barry Lynn. Lynn had pitched the Democratic primary candidates (even Martin O’Malley and Jim Webb) his argument for an anti-monopoly agenda, but to little effect. Even Bernie Sanders had been lukewarm. Now, Lynn was being invited to present the argument he had been obsessing over for a decade to one of the most powerful Democrats in the Senate.

Khan and Lynn showed up with a stack of reading material for Warren, mainly their Washington Monthly stories from over the years. Warren was a natural audience. A purveyor of wonky progressive populism, she had made her name in part by inveighing against “too big to fail” and the government’s response to the financial crisis. She also was vocal about net neutrality, which is rooted in concern over how internet provider monopolies will abuse their power. A few weeks after the dinner, Warren’s staff asked Lynn to help organize an event where the senator would give a speech on consolidation and competition.

The speech Warren gave, in late June 2016, read like a synopsis of the work Lynn and his team had been doing since 2010. “I love markets!” she declared. But the markets needed help. The “too big to fail” problem, she explained, “isn’t unique to the financial sector. It’s hiding in plain sight all across the American economy.” That, she said, left consumers with fewer choices, made it harder for start-ups to enter markets, devastated local economies, and allowed the biggest players to rig the political system in their favor.

In Lynn’s view, Warren had done no less than carve out a new niche in the party—between the corporate wing, cozy with Wall Street banks and Silicon Valley tech giants, and the Bernie-ite, self-styled socialists. To my boss, Paul Glastris, the speech had “the potential to change the course of the presidential contest,” as he wrote in a breathless blog post.

That was wishful thinking. The mainstream press barely covered the speech. No one cared.

True, the Democratic platform in July included a section on “Promoting Competition by Stopping Corporate Concentration,” thanks in part to work by Lynn’s colleague Matt Stoller. According to Herbert Hovenkamp, one of the country’s foremost antitrust scholars, it was the first platform to make prominent mention of anti-monopoly policy since 1912. But no one besides party activists really pays attention to platforms. Clinton herself, despite the early op-ed in Quartz, barely returned to the topic, other than in one campaign speech a few weeks before the election.

Several people from the campaign policy team told me they wished they had pushed the competition issue harder. The fact that they did not was one symptom of a by now exhaustively documented failing: despite Bill Clinton’s panicked insistence that Hillary needed to develop a stronger economic message to win in places like Michigan, the communications team thought it knew better. The campaign would stick to talking about how vile Donald Trump was.

“This was an issue that we never got to give the lift that we wanted,” said Jake Sullivan, Clinton’s top policy adviser. A veteran of two disastrous campaigns, Sullivan doesn’t hold himself out as a political pundit. But I was curious whether he thought being louder about anti-monopoly policy would have been smart.

“I’m not sure how much weight this set of issues can carry politically, but my hunch is, quite a bit,” he said. “It tells a story that both allows you to explain why things are going on but also has some hope of being susceptible to solutions.”

So why didn’t the campaign push it harder? Sullivan acknowledged the obvious—the campaign was light on economic messages in general—but also suggested that his team never quite figured out how to talk about things like consolidation, antitrust policy, and competitive markets in a way that would get through to voters. “Some aspects of it are difficult to translate,” he said, like the threat monopolization poses to democracy. “They are more abstract.”

Voters in 2016, unlike in 1936, weren’t used to hearing and thinking about the perils of monopoly. A recent piece in the Atlantic by Stacy Mitchell showed that use of the word “monopoly” in books peaked in 1949 and has since plummeted to 1880s—pre–Sherman Act—levels. Although Harper’s and the Washington Monthly had been raising the issue for years, more prominent elite media like the Economist and the Atlantic didn’t catch on until the 2016 primaries were under way. The mainstream press—major newspapers and network TV—still hasn’t. It’s a lot to ask of a political candidate, in the midst of a campaign, to simultaneously run on an issue and teach voters what it is.

“One of the things the Chicago School stole from us is the language,” said Zephyr Teachout, a law professor and member of Lynn’s post–New America group, the Open Markets Institute. “It sounds technical, but it’s actually deeply political, deeply moral. The loss of language was a central loss.”

In 2014, Teachout ran a surprisingly strong campaign against Andrew Cuomo in the Democratic gubernatorial primary in New York, winning 34 percent of the vote despite raising less than $1 million. Lina Khan was her policy director. Teachout, who had written a book making a corruption-based argument against Citizens United, had two main policy platforms: public financing for elections, and fighting consolidation. But media coverage of her candidacy focused almost entirely on corruption and campaign finance, which the press was used to, and ignored her anti-monopoly platform, which it wasn’t. A feature on Teachout by Jill Lepore in the New Yorker didn’t mention monopoly or consolidation once.

Trump’s election forced a traumatized Democratic political class to recognize that it had no coherent vision that addressed the circumstances of the modern American economy. Chuck Schumer, the Senate minority leader, was especially vocal about the party’s need to develop a compelling agenda to have any chance at taking back Congress in 2018, though he gave no indication that he had anything specific in mind. From November through July, his office spearheaded an effort to gather ideas that could both get buy-in from the various factions of the party and appeal on a gut level to the voters the party had lost. It was a post-election Warren Commission, endlessly studying where the bullet had entered the party’s brain.

Schumer and his staff spoke with all forty-seven other Democratic senators, as well as leaders from the House, including Nancy Pelosi and the cochairs of the messaging committee. They also talked with people at the major liberal think tanks and survivors of the Clinton campaign, including Sullivan.

At many of these stops, what they found was anti-monopoly. Key Clinton and Obama policy people were on board; the top think tanks were pushing it; and Elizabeth Warren, who after Bernie Sanders is the most influential figure within the Democratic left, had gone all in with her speech last summer. A handful of other prominent senators, including Amy Klobuchar and Al Franken, were also pushing for antitrust to be part of the agenda.

Oh, and remember Michael Shapiro, from the campaign? In fall of 2015 he started dating his old friend Jessica Schumer; in 2016 they got married. Jessica had drafted the party platform in Philadelphia that contained a section on breaking up monopolies. It’s safe to say that her father was hearing about the topic from many directions.

Meanwhile, Shapiro’s old schoolmate Lina Khan had been influencing the conversation from inside the ivory tower. In January, the Yale Law Journal published her 24,000-word academic article “Amazon’s Antitrust Paradox.” The article is a direct attack on the argument Bork advanced in The Antitrust Paradox—namely, that the only thing the law should worry about when it comes to monopoly businesses is their effect on consumer prices and product quality. Khan makes a powerful case that Amazon—even though it delivers quality products at low prices with incredible service—should be seen as a major threat to competition thanks to its dominance of essential internet infrastructure.

The article has been viewed more than 80,000 times—an astounding number for any piece of legal academic writing and truly remarkable for a student author—and generated enough buzz that Khan was profiled by Steven Pearlstein in the Washington Post. In the still-small world of people who think and talk about monopoly and antitrust, Khan had become an overnight sensation. That was powerful evidence that there was pent-up demand for intellectual leadership on how to address the radical changes being wrought by tech giants like Amazon.

While a threshold number of Democratic wonks were now behind an anti-monopoly push, elected officials needed some assurance that voters would reward them for sticking their necks out on an unfamiliar topic. A slew of Washington Monthly articles had insisted that anti-monopoly policy would be good electoral politics, but there was never any evidence. That changed in April with a poll conducted by Hart Research Associates. The poll presented voters with a battery of questions and scenarios to probe their feelings on corporate consolidation.

The poll found that voters were much more worried about how the very rich use their power to benefit themselves than about excessive government regulation. Eighty-six percent agreed with the statement “Our economy is increasingly dominated by a small number of very large corporations,” and nearly 60 percent, including Rust Belt voters, said they were “extremely concerned” that “[c]orporate monopolies control too much of our economy and our political system.”

Maybe the wonks were onto something.

Let’s not exaggerate. The Democratic Party is not suddenly the anti-monopoly party in the way that Reagan’s GOP became the party of deregulation and Trump’s has become the party of nativism and white grievance (and more deregulation). The Better Deal is just an elaborate set of talking points, and the section on competition and consolidation is one of many—too many, you might say—policy items. The 2018 congressional candidates are free to pick and choose whichever elements of the agenda they want, if any. In the upcoming midterms, former Obama administration officials Lillian Salerno and Austin Frerick are running on anti-monopoly platforms in Texas and Iowa, respectively, as David Dayen reported for the Intercept. But that’s two among dozens. Doug Jones, currently running in the December special election for Jeff Sessions’s vacant Senate seat, doesn’t mention anything about consolidation, or anything else Better Deal related, on his campaign’s issues page.

It’s true that important figures in the party seem convinced that taking on monopolies is an important idea. Keith Ellison, a leader of the party’s progressive wing in the House and the second-in-command of the Democratic National Committee, has taken to anti-monopoly with gusto. Over the summer he recorded a half-hour podcast discussion with his colleague Ro Khanna, a freshman congressman from a district including Silicon Valley, on all things monopoly and competition. When I spoke with Ellison in his office in September, he was in the middle of reading Barry Lynn’s Cornered and Jonathan Taplin’s recent book, Move Fast and Break Things, about the dangers of big tech.

“I’m not into this to try to advance a political position,” he said. “I actually believe that monopolies and cartels are bad. It is truly something that I believe in. But from a political standpoint, Democrats are always trying to figure out, how do we work for the consumer and the small business person? Well, this issue opens the door to that.”

On the Senate side, in late September, Senator Amy Klobuchar—seen as a possible 2020 presidential candidate—introduced a bill into the antitrust committee, of which she’s the ranking Democrat, titled the “Merger Enforcement Improvement Act,” which would give antitrust enforcers more information on the effects of mergers. Its nine cosponsors—all Democrats—include Cory Booker and Kirsten Gillibrand, also potential 2020 candidates.

But these are baby steps. Turning anti-monopoly into winning electoral politics, as Chuck Schumer hopes, and into successful policy, if Democrats ever take back power, presents a number of challenges.

First, Democrats need to figure out how to discuss it in a way that connects with voters. “The lesson out of the election is: really detailed, well-tuned plans on a wide range of issues do not capture the public’s imagination as well as a smaller number of bold clear ideas that represent values,” said Andy Green, the managing director of economic policy at the Center for American Progress. So far, there’s no proof that Democrats can turn anti-monopoly ideas into statements of core values. Tom Perriello ran in the Virginia gubernatorial primary on a message built partly on addressing consolidation, and lost handily to über-establishment candidate Ralph Northam. Zephyr Teachout ran for Congress in a New York district that Trump won, and lost by nine points. The candidacies of Frerick and Salerno will be important test cases.

Part of the appeal of focusing on consolidation is that it’s a pocketbook issue: mergers have jacked up the prices of things that really matter to ordinary people, including medicine, airfare, and internet access. The April polling by Hart Research found that “rising prices for essentials” topped respondents’ economic concerns, and a slim majority rated “corporate monopolies are raising the prices we all pay” as an “extremely serious” concern.

But the pocketbook paradigm could be a trap. Voting is more an expression of tribal identity than a rational bet on the practical effects of policy. Promising to help voters’ bottom line only works if they trust you in the first place. And focusing just on prices ignores the issue of small business and regional competition. Cheap consumer goods can’t make up for the lost jobs and wages in the large swaths of the country denuded of local businesses by behemoths on the coasts.

Sticking to the price argument also doesn’t address what may be the most urgent front in the war over consolidation: big tech. Giants like Amazon, Google, and Facebook pose threats to our democracy that aren’t captured by prices, as recent revelations about how Russia used Facebook and Twitter to influence the election illustrate. For consumers, Google and Facebook’s products are free; Amazon, meanwhile, is beloved for its low prices and exceptional service. Building a new anti-monopoly movement that confronts the issues posed by these tech giants will require a vocabulary for how their dominance threatens not consumer prices but, rather, the existence of competitive markets, media, and freedom itself—interests that were part of the antitrust movement before the Borkian revolution.

“If you just leave it in the arena of, ‘Oh, I want to order some sneakers online and I’ll get them tomorrow and they’re a pretty decent price,’ then we’re sunk,” said Ellison. “You can hope and pray that Chipotle opens up a restaurant in your neighborhood, and hope that a Walmart comes, and hope that a monopolist blesses you with their presence. Or you can fight the monopoly, keep the markets de-concentrated, and maybe open up your own shoe store, restaurant, or whatever. Maybe . . . we could return to interesting, local culture again, which these people are destroying.”

This will require angering some of the Democrats’ most important and deep-pocketed donors, something the party has not yet revealed an appetite for. The Better Deal, like the party platform before it, didn’t say a mumbling word about the new tech giants. (Klobuchar and her colleague Mark Warner did recently propose a bill that would force Facebook to disclose more information about political ads on the site.)

“They can start infecting—some people argue they already have—the whole of Washington,” said Ellison, referring to monopolists and their lobbyists. “You can get members of Congress to be like, ‘Monopoly? What are monopolies? We like monopolies, monopolies are awesome.’ ”

Reforming competition policy will also trigger pushback from the antitrust bar. Herbert Hovenkamp, the leading antitrust scholar, agreed that enforcement has been too lax, but warned that going back to a pre-Bork approach that looked out for small businesses and workers, not just consumer prices, “would drive the economy back into the Stone Age.” In his view, the economic boom times of the New Deal and Warren Court eras happened in spite of antitrust enforcement, not because of it.

If Democrats have the skill and guts to take on these challenges, though, the rewards of an agenda that prioritizes breaking down monopolization could be big. Today the owners of America’s nearly thirty million small businesses tend to lean Republican. A movement to take small business’s side against the corporate Goliaths marauding the economy could change that dynamic. The tech industry itself is full of small and medium-sized firms that would surely support a movement to rein in the likes of Google and Amazon.

More broadly, an anti-monopoly, pro-competition agenda offers Democrats a way to make sense of what has gone so deeply wrong in our political and economic system without embracing either the revolutionary anti-capitalism of the far left or the anti-government nihilism of the right. Another way to say this is that anti-monopoly politics is a traditional American position—“the middle ground,” as Republican Senator Orrin Hatch recently put it, “between intrusive public management and corrosive private conduct.” (On the other hand, Hatch defends the Bork consumer welfare approach and has teasingly labeled those who disagree “hipster antitrust.”)

“I used to go to a lot of Tea Party rallies,” said Zephyr Teachout. “They had a satisfying story: ‘You’re out of power because of big government.’ And the Democrats’ message has been, ‘You’re not out of power.’ That denied people’s stories. The only way to counter the Tea Party is to give people another story about why they’re out of power. If there’s the Tooth Fairy and nothing, I’m going with the Tooth Fairy.”

Trump, like any salesman, understood that. He won the industrial Midwest by pretending that kicking out Mexicans and renegotiating NAFTA would bring back the good jobs. The Democrats need a better, truer story. In beginning to push back against a monopolized economy, they just might have found one.

The post The Democrats Confront Monopoly appeared first on Washington Monthly.

Many of us still remember the moment during the debate over the Affordable Care Act when a powerful Democratic senator not only blocked supporters of single-payer health care from testifying before his committee, but even had some arrested. Well, reports are that Max Baucus has been born again. “My personal view is we’ve got to start looking at single-payer,” the now-retired senator recently told a political gathering in his hometown of Bozeman, Montana. “We’re getting there. It’s going to happen.”

Not long ago, politicians advocating for single-payer health care were taken to be on the lefty fringe. But now Democrats of every stripe, including some with plausible presidential aspirations, are using the term to describe what they think America needs now. In 2013, Bernie Sanders couldn’t find a single cosponsor for his single-payer plan, which would replace private insurance with Medicare-like coverage for all Americans regardless of age or income. Today the roll call of supporters for his latest version includes Cory Booker, Kirsten Gillibrand, Kamala Harris, and Elizabeth Warren. Others embrace what they describe as alternative single-payer plans, like Senator Chris Murphy’s legislation that would allow any American to buy into Medicare instead of getting their insurance through their employers or the individual market. It’s enough to make an exasperated Dana Milbank publish a column in the Washington Post under the headline “The Democrats Have Become Socialists.”

But have they? Actually, no. Real socialized medicine, as we’ll see, might work brilliantly, as it has in some other countries. But what these folks are talking about, often without seeming to realize it, is something altogether different. And it could lead to disastrous outcomes unless we get smart about what’s really going on.

Adopting a single-payer system might have done a lot of good—twenty years ago. But since then, a massive wave of corporate consolidations has transformed the American health care delivery system in ways that make the single-payer approach highly problematic. Most Americans now live in places where there is little or no competition among medical providers. In market after market, hospitals, clinics, physician practices, labs, and other key health care infrastructure have been merged into monopolies controlling nearly all aspects of health care in the areas in which they operate.

Switching to single-payer wouldn’t, on its own, address the fact that the lack of competition leaves these Goliaths with almost no pressure to keep costs down. Since medical monopolies are becoming too big for either party to challenge, a single-payer, Medicare-for-all-type plan would likely degenerate into super-high-cost corporate welfare, rather than achieving lower prices or improved quality. The only sure way to avoid that outcome would be to simultaneously enact aggressive antitrust and pro-competition policies to bust up the monopolies and oligopolies that now dominate health care delivery in nearly every community in America.

To see what is really at stake here, we need to begin with a distinction that is typically lost in our health care debates. There is such a thing as socialized medicine, but it’s not synonymous with single-payer. In Great Britain, for example, a socialist government nationalized the health care sector after World War II, and today the British government still owns and operates most hospitals and directly employs most health care professionals.

Another example of socialized medicine is the system run by the U.S. Department of Veterans Affairs. The VA owns and operates hospitals and clinics in every state. These are staffed by government employees, most of whom belong to public employee unions. As such, the VA is double-rectified, Simon-pure socialized medicine, even if most members of the American Legion might not put it that way.

Both of these examples of socialized medicine are far from perfect, but they have demonstrable virtues. The UK’s National Health Service produces much more health per dollar than ours, largely because it doesn’t overpay specialists or waste money on therapies and technologies of dubious clinical value. Though they smoke and drink more, Britons live longer than Americans while paying 40 percent less per capita for health care. Meanwhile, a vast peer-reviewed literature shows that the VA, despite dismal press coverage and a few real lapses, actually outperforms the rest of the U.S. health care system on most key measures of health care quality, including wait times and the use of evidence-based medicine. (The health care journalist Suzanne Gordon and I recently wrote a paper for the American Legion, “VA Health Care: A System Worth Saving,” that explores how well VA coverage works.)

For better or worse, what the Democrats marching under the banner of single-payer are advocating is nothing like these examples of real socialized medicine. What they are calling for, instead, is vastly expanding eligibility for the existing Medicare program, or for a new program much like it.

So, what does Medicare do?

It doesn’t produce health care.

Rather, it pays bills submitted by private health care providers.

Thus, under a single-payer, Medicare-for-all plan, the provision of health care itself—its modes of production, if you will—would remain almost entirely in the hands of private enterprise. Meanwhile, its financing would become exclusively a burden borne by government.

The conceptual confusion about Medicare runs so deep that when conservatives call for making the VA outsource its care to private-sector health care providers, liberals generally (and rightly) label such plans “privatization.” Yet these same liberals characterize a Medicare-for-all plan that does essentially the same thing as somehow striking a blow against private control of health care. Meanwhile, many conservatives continue to assert that Medicare is “socialized medicine,” when it’s really the same thing they propose for the VA: a government subsidy for private providers.

So now that we’ve defined our terms a bit better, what can we say a single-payer system would be likely to accomplish? One clear benefit would be to reduce the excessively high administrative costs that weigh down the existing system. Automatically covering every American with a single-payer plan would free up most of the resources that providers and insurance companies currently waste on paperwork and efforts to shift costs to some other player. Patients wouldn’t have to worry about whether the doctor they want to see is “in network” and would avoid a host of other hassles, like having to change doctors every time their employer decides to switch to a cheaper plan.

Having one universal health care insurance plan would also allow the government to stop devoting so much time and money trying to figure out who does or does not meet eligibility requirements for public programs like Medicaid and VA health care. Resources currently spent on sorting out which Medicaid recipients earned too much money to qualify this month, or which of a vet’s maladies are caused by aging and which by his service in Vietnam, could instead go into the hands-on delivery of health care.

The savings could be significant. In 1991, the General Accounting Office estimated that if the U.S. adopted a
Canadian-style, universal single-payer system, the reduction in administrative costs alone would have been enough not only to finance health care coverage for every American, but to do away with all deductibles and co-payments. That’s probably not true anymore. Today, only about 7 percent of U.S. health spending goes to paperwork, largely because the prices of everything else have spiked so dramatically. Still, the U.S. spends a far larger share than other countries on administration, and we could have fixed that a generation ago by moving to single-payer.

We might also have retarded a much more fundamental factor driving health care inflation. Back in the 1990s, single-payer advocates stressed that the real savings would come by giving government “monopsony” power in health care markets. If you are the only buyer in a market with many suppliers—that is, the single payer—that makes you a monopsonist, and it gives you a lot of leverage to negotiate for lower prices. Making government the single payer in health care markets would have allowed it to jawbone doctors, hospitals, drug companies, and medical device makers into charging less and providing safer, more effective health care.

This is what Canada did when it adopted a system in the early 1970s under which each provincial government became the sole purchaser of health care within its own borders. Provincial governments used their monopsony power to negotiate fee schedules with doctors and fixed budgets with hospitals and medical suppliers that left Canadians with a far thriftier, more efficient system. The process was noisy and contentious, but it was carried out in the sunshine and resulted in much lower prices and rates of medical inflation than were occurring in the United States, even as Canadians got greater access to doctors, better health, and longer lives.

So it’s reasonable to think that following the Canadian example twenty-five years ago could have done a lot to restrain health care prices in the U.S. That, in turn, would have made a much bigger difference than most people realize in averting the unsustainably high overall costs of contemporary American health care. That’s because those costs are driven mostly by the prices we pay, rather than by our consuming more care than people in other rich countries.

This is a point worth dwelling on, because it speaks again to how mixed up the terms of debate over health care reform have become. Conservatives often assert that Americans consume too much health care because we don’t pay for it using enough of our own money. Accordingly, they argue that the way to lower costs is to force us to pay more out of pocket through higher deductibles and medical savings accounts, while submitting to narrower provider networks that limit our access to specialists and therefore our consumption of care.

But it turns out that other advanced countries can offer their citizens universal access to government-financed health care, as well as higher volumes of most forms of beneficial treatment, while still having much lower per capita costs. Canadians see more doctors per year than Americans do while spending about 50 percent less per head on health care. Similarly, the average German is seen by a doctor more than nine times a year, compared to four for the average American. Germans also receive far more hip replacement surgeries per capita and about the same number of knee surgeries, and get to stay in the hospital longer while recovering. Yet the average hospital stay in Germany costs just one-third of what it does in the U.S.

So the big reason why Americans pay more for health care than their counterparts in other rich nations is not complicated. As the health care economist Uwe Reinhardt once put it, “It’s the prices, stupid.”

Most Americans are aware that they pay far more for drugs than their peers abroad. For the thirty most commonly prescribed drugs, prices in the U.S. are roughly double the average for other rich countries. Yet drugs account for only 10 percent of total U.S. health care spending, so they are not the main reason our health costs are so high.

A much bigger factor is the price of physician and clinical services, which account for about a fifth of total U.S. health care spending. Adjusted for differences in the cost of living, the average orthopedic surgeon in the U.S. has a net income nearly three times what France’s equally well-trained orthopedic surgeons make for performing the same procedures. It’s true that many doctors are overworked and underpaid, particularly sole practitioner physicians trying to make a living in an increasingly consolidated sector. Yet the income of the highest-paid doctors, most of whom are specialists and many of whom have substantial investment and business income as well, keeps pulling away. Medical professionals now outnumber lawyers and bankers among the ranks of the 1 percent.

Even salaried doctors are doing well compared to their counterparts in other professions. In the 1980s, an American doctor on salary typically earned about 20 percent more per hour than other American professionals with comparable levels of education. But in recent years, according to a study published in Health Affairs, that income advantage has increased to nearly 50 percent. The McKinsey Global Institute found that if U.S. doctors earned the same amount as their counterparts in other advanced countries, America’s doctor bill would be roughly 35 percent lower.

A still larger factor in driving up costs are the inflated prices charged by hospitals. Hospital care accounts for about a third of total U.S. health care spending. While prices vary dramatically from one hospital to another (depending on how much competition they face), and from patient to patient (depending on their insurance plan), U.S. hospital prices overall are simply astronomical compared to what hospitals in other advanced countries charge for the same services. According to a 2012 study by the Commonwealth Fund, the average hospital visit costs nearly three times more in the U.S. than the average for other advanced countries.

All this means that if the federal government could use the monopsony power created by a single-payer system to negotiate for more reasonable health care prices, it would be a very big deal. And back in the 1970s, ’80s, and even into the ’90s, something like that just might have been possible. But today, the vast corporate consolidation of ownership in most health care markets in the U.S. makes that a dubious proposition.

Health care delivery in the United States a generation ago was still in many ways a cottage industry. As late as 1995, fully sixty independent drug companies competed in America’s pharmaceutical markets, compared to just ten today. Independent, locally owned pharmacies had not yet been displaced in most communities by giant chains like CVS and Walgreens. More significantly, most doctors still worked as independent sole practitioners or in small group practices. Most hospitals were locally owned, community-focused institutions. In most metro regions of any size, they still faced real competition from other local hospitals over insured patients.

That competition was far from perfect. Regulatory barriers to entry tightly constrained the supply of health care professionals and limited the building of new hospitals. Informal cartels and kickback arrangements between hospitals and doctors were not uncommon. But it was rare for providers to exercise full-fledged monopoly power. In fact, starting in the 1980s and continuing through the ’90s, most found themselves at the mercy of increasingly monopolistic health insurance companies. Doctors and hospitals were put on the defensive as insurers merged with one another and forced providers to make price concessions if they wanted to keep their insured patients. Insurers used their increasing monopsony power to put the screws on drug companies and everyone else in the medical supply chain. This explains why, for a brief moment in the 1990s, the nation’s overall health care bill actually declined.

But then came a counterrevolution that has proven far more consequential. Not only did sixty drug companies combine into ten, but hospitals, outpatient facilities, physician practices, labs, and other health care providers began merging vertically and horizontally into giant, integrated, corporate health care platforms that increasingly dominated the supply side of medicine in most of the country. Like Amazon or Google, these platforms extend their power by controlling the very marketplace in which customers and suppliers have to do business. Even nominally independent surgeons, for example, can’t stay in business if the only hospital in town won’t grant them admitting privileges, or if it grants “affiliated” surgical teams better terms. Many of these platforms became part of large chains operating in multiple regions; others achieved dominance in a single city, which still gave them extraordinary market power.

Local power is everything in health care. Most health care services can’t be imported from China or even from the next county over. Yes, you could drive for hours to see a doctor, or even fly to India or Costa Rica to get an operation, as some people do, but for most people with most conditions that’s not practical. Instead, no matter where you are, most health care is produced and consumed locally, meaning that if providers become organized as a local monopoly it’s a very big deal. In a local market that’s been cornered, even the largest purchasers of health care, including insurance companies and large national employers, become price takers, not price makers.

According to a study headed by Harvard economist David M. Cutler, between 2003 and 2013 the share of hospitals controlled by large holding companies increased from 7 percent to 60 percent. A full 40 percent of all hospital stays now occur in health care markets where a single entity controls all hospitals. Another 20 percent occur in regions where only two competitors remain. To use another measure, according to the standard metric used by the Federal Trade Commission to measure degrees of concentration, not a single highly competitive hospital market remains in any region of the United States, and nearly half of all markets are uncompetitive. A study recently published in Health Affairs found that hospital ownership in 90 percent of metro areas is so concentrated that it exceeds what antitrust regulators have historically regarded as the threshold for when action is needed to avoid inefficiency and collusion.

This consolidation in health care shows no sign of abetting. Just the first six months of this year saw fifty-eight major mergers among hospitals and health care systems, with six of those involving corporations boasting $1 billion or more in revenue. The absorption of IASIS Healthcare by Steward Health Care, the country’s largest private for-profit hospital operator, will leave Steward with thirty-six hospitals in ten states. This robust merger rate exceeds last year’s. And in 2015, hospital mergers and acquisitions were up by 18 percent over the prior year and 70 percent since 2010.

The effect of this massive consolidation on prices is predictable. According to a study by Yale economist Zack Cooper and others, if you stay in a hospital that faces no competition, your bill will be $1,900 higher on average than if you stay in a hospital facing four or more competitors. The CEOs on top of these chains may be the biggest winners, and it doesn’t matter whether or not the institutions have a “nonprofit” tax status. Toby Cosgrove, the cardiologist who heads the nonprofit Cleveland Clinic, pulled down some $4 million in reportable compensation in 2014.

As hospitals combine into local and regional monopolies, they can leverage their power by buying out local physician practices. Consider the anticompetitive effects of these deals. Doctors play a large role in steering patients to different hospitals, and anti-kickback laws prevent hospitals from paying doctors for these referrals. Yet those laws become inoperative when a hospital simply buys a doctor’s practice and puts him or her on its payroll. Such a deal not only allows a hospital to effectively buy referrals, it also forecloses future competition. To win the business of these referred patients, a rival hospital would generally first need to convince them to change doctors.

The absorption of physicians into monopolistic enterprises is highly inflationary. A 2014 study of physician organizations in California found that groups owned by local hospitals charge 10 percent more per patient than physician-owned groups. Meanwhile, groups owned by multi-hospital systems, which tend to be even more monopolistic, charge nearly 20 percent more per patient. A 2015 study by the National Academy of Social Insurance found that “there is growing evidence that hospital-physician integration has raised physician costs, hospital prices and per capita medical care spending.”

Americans pay for consolidation in other ways. For example, when hospitals in a community merge, one or more often ends up closing its doors, forcing many patients to travel long distances to access the last remaining hospital in their region. Hospital mergers also often result in fewer jobs for nurses and lower-skilled health care workers, in turn eroding their ability to bargain for fair wages and decent working conditions. Though consolidation can sometimes lead to economies of scale and reduce labor costs, the overwhelming consensus of health care economists is that these savings are not passed on to consumers, who instead experience higher prices and lower quality.

So what would happen today if a government program like Medicare were given responsibility for purchasing all health care in the United States? At first it might seem that giving the government that kind of concentrated purchasing power is just what we need to contain the growing monopoly power of hospitals.

But what happens when a single payer finds itself negotiating with a single provider?

If you want a hint at what that would look like, think about how well our “single-payer” Pentagon procurement system does when it comes to bargaining with sole-source defense contractors. Not a pretty picture. In theory, the government could just set the price it’s willing to pay for the next generation of fighter jets or aircraft carriers and refuse to budge. But in practice, a highly consolidated military-industrial complex has enough economic and political muscle to ensure not only that it is paid well, but also that Congress appropriates money for weapons systems the Pentagon doesn’t even want.

The dynamic would be much the same if a single-payer system started negotiating with the monopolies that control America’s health care delivery systems. Think about how members of Congress representing, say, western Pennsylvania would be likely to respond if Medicare-for-all dared to reject the terms demanded by the University of Pittsburgh Medical Center, the region’s dominant health care provider. Notwithstanding its academic name and origins, UPMC is a Goliath that controls nearly 60 percent of the inpatient medical-surgical market in the greater Pittsburgh area.

Who would blink first if the government threatened to exclude UPMC from its health care plan, which would be the only one available? There are millions of people who live in western Pennsylvania and need access to the hospitals, doctors, and other health care infrastructure UPMC controls. Without access to the system, they might have to drive hundreds of miles to find a doctor or hospital. It would be an instant health care crisis.

Moreover, UPMC is the largest single employer in the Pittsburgh area and one of the biggest in the state. And as it keeps buying more and more hospitals throughout the rest of Pennsylvania, its political power continues to grow. The commercials it would run to get what it wanted from a single-payer system almost write themselves. “The people of Pennsylvania deserve access to the health care they’ve paid for. Tell Congressman Smith to vote no on denying you access to the hospitals and doctors serving our community.”

Of course, in the vision of some single-payer supporters, the government would not negotiate with the likes of UPMC over prices; it would just dictate prices. But it’s unrealistic to expect members of Congress to stand up to corporations that, thanks to unchecked consolidation, not only control the lion’s share of medical professionals and health care infrastructure in their communities, but also are often the largest single providers of jobs and campaign contributions.

Long before consolidation reached the extreme level it’s at today, lobbies for different sectors of the health care system routinely kicked the federal government around. The American Medical Association was so strong that the federal government for years allowed it to set the prices Medicare paid surgeons and other physicians for performing different procedures. Similarly, Big Pharma made sure that the Affordable Care Act contained language forbidding the federal government from engaging in cost-benefit analysis of drugs, and has dissuaded Congress from allowing Medicare to bargain over drug prices. Similarly, hospital supply cartels have fought off government regulation despite the demonstrably high prices they were extracting from the system. It is frankly naive to expect that health care regulators won’t become even more captured than they already are if the industry they are supposed to regulate gains even more concentrated economic, and therefore political, power.

The choice before us is thus stark. True socialized medicine might work to contain prices and make the U.S. health care system sustainable. But short of flat-out nationalizing America’s health care delivery system, the only other option is to make sure that the market power of hospitals and other providers is sufficiently dispersed that it remains politically possible to regulate them.

Single-payer is therefore doomed to fail unless supporters fuse it with another reform: the aggressive use of antitrust and other competition policies not just to lower drug prices but, even more crucially, to bust up the monopolies that dominate the American health care delivery system. To that end, new legislation would be useful, but even simply leaning on regulators to enforce existing laws would ensure that at least two or three competing health care systems remain in every major metro area. Doing this is not in itself enough to fix America’s health care crisis, but it is a cause to rally around if we are ever to have a sustainable, universal health care system in America.

The post How Big Medicine Can Ruin Medicare for All appeared first on Washington Monthly.

As of late September, Donald Trump had the lowest approval rating of any president that far into his first term. Yet there has been remarkably little atrophy among Trump’s base. A Wall Street Journal/NBC News poll from the same month found that 98 percent of Trump primary voters approve of the president’s job performance. Among Americans who support Trump, 61 percent don’t envision anything that would change their favorable opinion of him. A majority of Republican voters consider themselves primarily loyal to the president rather than to the Republican Party.

It’s no wonder, then, that 2018 GOP primaries are devolving into fights about which candidate in the race is most closely aligned with the Trump agenda. Take the Arizona Senate race: Jeff Flake, the incumbent, who refused to endorse Trump and wrote a book earlier this year excoriating the president, is facing a tough primary challenger in Kelli Ward, who has positioned herself as an unwavering partner to the president. Steve Bannon, back at Breitbart after being ousted from the White House, is scheming to cultivate Trump allies to challenge establishment Republican incumbents with help from the billionaire Robert Mercer, who has already pumped $300,000 into a Super PAC affiliated with Ward’s campaign.

In the murky sea of 2018 GOP candidates, the most fascinating creatures are the ones trying to capture the secret sauce that propelled Trump from laughingstock to president. Trump’s crudeness didn’t deter as many voters as pundits anticipated and Democrats hoped; nor did his embrace of the politics of white racial resentment. Down-ballot candidates have taken notice. Elements of Trump’s brand of populism are surfacing in various configurations among two types of opportunists: longtime vulgarians emboldened to run for higher office by the president’s success, and establishment politicians eager to rebrand themselves to ride Trump’s appeal among the GOP base.

Right-wing populists existed before Trump descended the escalator in Trump Tower to announce his candidacy in 2015: Paul LePage kicked off his Maine governorship in 2011 by skipping a Martin Luther King Jr. Day breakfast and then saying the NAACP could “kiss my butt”; Iowa Congressman Steve King once called Barack Obama “very, very urban,” to pick one of the many examples of racist dog-whistles since he joined Congress in 2003; and Sarah Palin’s anti-intellectualism in 2008 laid the groundwork for Trump’s ascent. But Trump is a new breed, and the success of his impersonators in 2018 is the first major test of whether Trumpism will transcend the man in the White House. An early-warning sign that the answer is yes: in Alabama’s Senate primary in late September, establishment favorite Luther Strange, who had earned an endorsement from Trump, lost badly to Roy Moore, the former Alabama Supreme Court chief justice who was twice removed from the job for defying federal court orders, has called homosexuality “a crime against nature,” and still questions Barack Obama’s citizenship.

The era of Trumpism, in other words, may not even have begun.

So go ahead, meet the Trumpkins.

Corey Stewart (VA—Senate)

Trumpyness score: 9/10
Electability: 4/10
Notable tweet:

For any aspiring mini-Trumps who find themselves lagging in the polls, the candidacy of Corey Stewart provides a glimmer of hope. Heading into the Virginia Republican gubernatorial primary in June, Stewart was polling more than twenty points behind his rival, Ed Gillespie. Yet on election day, Stewart, a little-known county official who ran on a platform soaked with Trumpian white identity politics, came within 1.2 percentage points of defeating Gillespie—a former lobbyist and RNC chair who outspent Stewart three to one. Now, in the wake of his surprising performance in June, he’s trying to snatch away Tim Kaine’s Senate seat in 2018.

“I was Trump before Trump was Trump,” Stewart, who chairs the Prince William Board of County Supervisors, says. “I’ve always kind of been like him and his style of brutally honest, blunt talk.” In 2007, he spearheaded the passage of a law that curbed undocumented immigrants’ access to public services and ramped up immigration enforcement from local police, later bragging that the law was “probably the nation’s toughest crackdown on illegal immigration.” Today, Stewart casts himself as a defender of southern heritage. Since the Charlottesville City Council voted in February to remove a statue of Robert E. Lee, Stewart has held rallies denouncing liberals who risk “losing part of our identity here in Virginia” by tearing down Confederate monuments. “Nothing is worse than a Yankee telling a Southerner that his monuments don’t matter,” Stewart—who was born and raised in Duluth, Minnesota—tweeted in April. Following the murder of an antiracist protestor by a white supremacist in Charlottesville in August, Stewart, like the president, criticized “leftwing agitators” and questioned why “we never hear about violence on the left.”

In addition to tapping into Dixie pride, Stewart has ingratiated himself with the far-right fringe. He’s prone to retweeting figures like the right-wing conspiracy theorist Mike Cernovich, and in February he stood at a press conference alongside Jason Kessler, the white nationalist blogger who would organize the rally that turned deadly in Charlottesville. On the Reddit page r/The_Donald, Stewart disparaged his former opponent Ed Gillespie as a “cuckservative,” the popular alt-right pejorative for mainstream Republicans seen as overly sympathetic to liberal values.

Stewart, who served as Virginia chairman of Trump’s campaign until he was pushed out, oozes with Trump-like bluster. “I’m not going to hold any punches,” he said. “I’m not going to backstab anyone. I’d rather stab them right in the gut—I don’t believe in whisper campaigns.” So far, Stewart has attacked Kaine for “race baiting” by supporting DACA and accused the senator’s son Woody of being a member of Antifa after he was arrested at a counter-protest to a pro-Trump rally.

With no primary opponents, Corey Stewart has a clear shot at Tim Kaine. True, no Republican has won a statewide race in Virginia since 2009, and Kaine had a 53 percent to 36 percent edge in the first poll of the Senate race. But Stewart has outperformed the polls once already and is betting he can do it again.

Shiva Ayyadurai (MA—Senate)

Trumpyness score: 8
Electability score: 2
Notable tweet:

https://twitter.com/va_shiva/status/836010985408380930?ref_src=twsrc%5Etfw&ref_url=https%3A%2F%2Fthehornnews.com%2Fouch-elizabeth-warren-wont-like-defeat-fakeindian%2F

An immigrant entrepreneur from India with four MIT degrees who has studied under Noam Chomsky and quotes Freud’s Jokes and Their Relation to the Unconscious from memory, Shiva Ayyadurai has little in common on paper with a president who brags about his affection for the “poorly educated.” Yet Ayyadurai is waging a scorched-earth campaign in the Republican primary in Massachusetts to unseat Senator Elizabeth Warren by kindling the same dark impulses of the Breitbart and Infowars right that boosted Trump’s candidacy.

Born in Mumbai to an “untouchable” caste, Ayyadurai brands himself as a “real deplorable,” and he relishes abrasive, goading political tactics. Trump famously loves to denigrate Warren by calling her “Pocahontas,” a reference to revelations that she once listed her ethnicity as Native American in a Harvard directory in the 1990s. Ayyadurai is taking it one step further, running on the promise that “only a real Indian can defeat a fake Indian.” For Warren’s birthday, he mailed the senator a DNA test kit, baiting her to prove her indigenous ancestry. (She sent it back to him.)

A first-time candidate who, motivated by Trump, voted for the first time in 2016, Ayyadurai has been a serial entrepreneur, founding an email management software company  in 1994 now called EchoMail that has included Nike and the U.S. Senate as customers. Ayyadurai’s contempt for the establishment seems to harken back to his widely disputed claim to have invented email as a fourteen-year-old in New Jersey. It’s a claim on which Ayyadurai refuses to give any ground; his personal website is inventorofemail.com, and after Gawker wrote a brutal takedown of his “inventor of email” shtick, he sued, settling with the now-defunct publication after its coffers had already been drained by a lawsuit from Hulk Hogan.

When I caught him on his cell phone in early September, Ayyadurai punctured his stream-of-consciousness rants against Warren, the military-industrial complex, and “academic elites” with not infrequent F-bombs. Like Trump, he’s impossible to quite pin down: he laments the power of Monsanto and GMOs while, in the same breath, laying out a case against the Paris Climate Accords. The common thread of his political ideology appears to be disdain for the mainstream media, big business, and, especially, academia—the “fake news behind the fake news,” he calls it.

As a Senate candidate, Ayyadurai has cozied himself up to the fringe right, occasionally joining Alex Jones on Infowars, and partying with Mike Cernovich after CPAC earlier this year. He has referred to minorities (including himself) as “darkies” and released a YouTube video likening Trump’s proposed border wall to a cell membrane, implicitly equating Mexicans with viruses.

In reliably blue Massachusetts, Trump won under a third of the vote, and Warren remains popular, so Ayyadurai’s quest to become the state’s “real Indian” faces a series of hurdles, including a tough GOP primary. A June poll has Ayyadurai trailing Warren 61 to 25 percent, but, in his mind, that’s precisely the underestimated, outsider position that he’s overcome his entire life.

Joshua Mandel (OH—Senate)

Trumpyness score: 6
Electability score: 7
Notable tweet:

Joshua Mandel has the best electoral chances of anyone on this list. Trump won Ohio, long a quintessential swing state, by almost nine percentage points, even while losing the national popular vote. Trump’s support in the Buckeye State hasn’t been lost on Mandel, a forty-year-old making his second bid to defeat Senator Sherrod Brown.

Mandel, who looks and sounds like a high school freshman, has made a meteoric ascent through the ranks of Ohio state politics, boosted by a polished resume, a groomed persona, and, until recently, a mainstream conservative ideology. An Iraq War veteran and two-term student body president at Ohio State, Mandel married into one of the wealthiest families in Cleveland. He won a seat on the Lyndhurst City Council fresh out of law school at age twenty-six by campaigning door to door on a promise of fiscal conservatism, eventually implementing the town’s first-ever property tax cut. He has positioned himself for higher office ever since, turning a stint as a state representative into his current role as state treasurer in 2010, then narrowly losing to Brown in 2012.

In his current Senate campaign, Mandel has flirted with xenophobia and Islamophobia. In May, not long after he announced his campaign by noting his commitment to protecting “Judeo-Christian values,” he traveled to the southern border to meet with border patrol agents and write tweets assailing the “liberals & squishy repubs” who oppose Trump’s border wall. Since signaling his intention to challenge Brown again, Mandel has established himself as one of the Ohio public officials most fervently opposed to sanctuary cities, supporting an ill-fated bill in the state legislature that would have banned sanctuary cities and held local officials who violated the law liable for the crimes of undocumented immigrants.

Mandel tweeted out his support of Mike Cernovich and Jack Posobiec in July against accusations from the Anti-Defamation League that the two right-wing trolls have dabbled in white supremacy. Mandel, who is Jewish and the grandson of a Holocaust survivor, opted to align himself with provocateurs who have argued, respectively, that “date rape does not exist” and that Hillary Clinton has ties to a (nonexistent) sex cult in the basement of a D.C. pizza parlor. Mandel has embraced full-blown Islamophobia, retweeting a tweet that reads, “I am so sick and tired of PC idiots worrying about defending Islam. I stand with Israel and my Judeo-Christian culture and I find Islam offensive.”

In May, he tweeted out a local news story with the caption “Ohio Mosque chains kids to wall & beats them for not reading Quran. We must protect women & kids from these people.” He failed to mention that the article he shared was from 2013, and that the story had been widely debunked, including by the news channel that originally published it.

Mandel poses a serious threat to Brown: a prolific fund-raiser, he has already raised more than $4 million in a state that’s trending more reliably red than purple. With an endorsement from Ohio GOP heavyweight Senator Rob Portman, he lacks any competitive primary opponents.

Joe Cicero, a registered independent and the former mayor of Lyndhurst, takes a dim view of Mandel’s latest branding as Donald Trump 2.0: “He fooled everyone in the city. He was opportunistic from the start, one of the worst things that ever happened to Lyndhurst. Josh Mandel is inadequate as a human being.”

Lou Barletta (PA—Senate)

Trumpyness score: 7
Electability score: 6
Notable tweet: 

Borders not secure, laws ignored. Now a plan to relocate unaccompanied minors to Hazleton & other towns. Must stop.http://t.co/kFfTVkq64o

— Lou Barletta (@RepLouBarletta) July 1, 2014

A decade ago, Lou Barletta, then mayor of Hazleton, Pennsylvania—a working-class, post-industrial town of 25,000 tucked into the foothills of the Poconos—rammed through an ordinance aimed at ridding the town of its burgeoning undocumented population. Now a congressman, Barletta wants to take his nativism to Congress’s upper house, running a campaign to defeat incumbent Democrat Senator Bob Casey.

Latinos began to flood Hazleton in the early aughts when low-skill warehouse and meatpacking jobs arrived in town after the city promised tax-free development. After two undocumented immigrants were accused of shooting a man in Hazleton in 2006, Barletta seized on the incident by fear-mongering about a nonexistent “crime wave,” and promising to wage “a war on the illegals.” (Prosecutors eventually dropped the charges.) He drafted the so-called Illegal Immigration Relief Act, which cracked down on landlords and businesses involved with the “hiring or harboring of illegal aliens,” imposing a $1,000-per-day fine on any landlord who rents to an undocumented immigrant, and declaring English the city’s official language. Donning a bulletproof vest the day he signed the law, Barletta declared, “[To] the illegal citizens, I would recommend they leave. . . . What you see here tonight, really, is a city that wants to take back what America has given it.”

While the ACLU successfully blocked Barletta’s law in federal court, it propelled his political career, helping him win a seat in Congress amid the Tea Party wave of 2010. Barletta hasn’t toned down his anti-immigrant fervor as a congressman, introducing a law that would strip all federal funding from cities that don’t enforce federal immigration laws, and advising the Federation of American Immigration Reform, an anti-immigrant organization with white supremacist origins. (The group’s founder, John Tanton, once said that “for European-American society and culture to persist requires a European-American majority”).

Trump urged Barletta, an early supporter who served on the presidential transition team, to run for the Senate after Barletta reportedly turned down an offer to serve as labor secretary. As by far the highest-profile name in the crowded GOP primary, in a state that went for Trump, he’s got a serious shot at snatching Casey’s seat.

Jamie Longazel, a Hazleton native and professor at John Jay College of Criminal Justice, wrote a book, Undocumented Fears, about Barletta’s use of anti-immigrant paranoia toward political ends. “Part of the reason that this part of Pennsylvania—and Pennsylvania more generally—moved toward Trump is because the seeds had already been planted by Barletta,” he said.

Scott Wagner (PA—Governor)

Trumpyness score: 8
Electability score: 5
Notable Facebook post: 

A wealthy businessman who made an improbable ascent to power against the wishes of many in his own party and whose political shtick is rooted in bullying and intimidation. Sound familiar? It’s no coincidence that Scott Wagner, a freshman state senator, has been referred to as “our Donald Trump” by Pennsylvania Republican operatives. Wagner now wants to take his politics statewide, running in the GOP primary for a chance to replace Democratic Governor Tom Wolf.

Wagner, a self-described “garbage man without a college degree,” has populist credentials that Trump could only dream of. As a teenager, he shoveled horse manure on his family’s farm for $5 a week; today he’s worth a reported $20 million as the president and CEO of Penn Waste, a trash-hauling company. In 2014, Wagner became the first write-in candidate to win a race in state history, blowing away his competitors by injecting his own wealth into his campaign.

Stylistically, Wagner channels Trump’s tendency toward threatening rhetoric. After his election in 2014, Wagner warned his new colleagues in a radio interview that he’d “be sitting in the back room with a baseball bat. And leadership’s gonna start doing things [that] Pennsylvania needs done.” He’s established himself as a thorn in the side of his fellow Republicans, leading the push to oust a top Republican state senator from a leadership position for being insufficiently conservative. Of the governor, meanwhile, he has said that state Republicans had him “down on the floor with our foot on his throat and we let him up. Next time, we won’t let him up.”

Wagner’s aggression has gone beyond mere rhetoric at least once. At a campaign event at a country club in early May, he spotted a tracker from the opposition research PAC American Bridge who was quietly recording his speech. Wagner stormed to the back of the room and yanked the camera out of the tracker’s hands, bloodying his finger. “We’ve never had an incident like that before,” said Lizzy Price, a spokesperson for American Bridge. Wagner escaped criminal charges, but he never returned the memory card from the camera he confiscated.

Wagner’s climate denialism is Trump-like in its absurdity and free association. “I haven’t been in a science class in a long time, but the earth moves closer to the sun every year,” he told a reporter earlier this year. (It does not.) “We have more people. You know, humans have warm bodies. So is heat coming off? Things are changing, but I think we are, as a society, doing the best we can.” Wagner has never been a white nationalist type, but he has begun to master the art of racial dog-whistling—he has refused to apologize for a rant in which he referred to George Soros, the billionaire liberal donor and bogeyman for the right, as a “Hungarian Jew” with “a hatred for America.” Governor Tom Wolf’s poll numbers are in the 40s (though trending upward), so he’s vulnerable to a Republican opponent. So far, Scott Wagner only has one Republican opponent—a political newcomer—and with his deep pockets, don’t be shocked if this “garbage man” moves into the governor’s mansion in Harrisburg in 2019.

Jim Renacci (OH—Governor)

Trumpyness score: 5
Electability score: 3
Notable tweet:

Jim Renacci, a mild-mannered congressman representing northeast Ohio, isn’t prone to Trump-style bellicosity or hyperbole. But as the fight to replace Ohio Governor John Kasich, who is term-limited, in 2018 devolves into a civil war between the Trump and Kasich wings of the GOP, Renacci, a staunch Trump supporter, is wielding his anti-establishment credentials to imitate the president and boost his underdog candidacy.

A former mayor and city councilman now in his fourth term in Congress, Renacci was lauded as a freshman for a professed desire to wade beyond partisan lines. In 2011, he formed a bipartisan breakfast club with a Democratic counterpart to send a message to fellow House members that, as he wrote in the Washington Post, “progress is more important than politics and partisanship.”

Even though he has held elected office since the 1990s, Renacci casts himself as an outsider. “I’m not a career politician,” he told me. “I’m a career businessman.” He has distanced himself from the Kasich allies in the primary race by promoting the benefits of “a Columbus outsider and career businessman like me.” Like Trump, Renacci launched his political career following success in the business world: he is among the richest members of Congress, with a net worth reportedly north of $50 million, amassed from a handful of business ventures ranging from car dealerships to nursing homes to a stake in a minor-league baseball team. Renacci’s campaign slogan—“Ohio First”—pays homage to Trump’s “America First,” and he ends his campaign videos by urging voters to “join us as we make Ohio First again.”

Renacci’s disinclination toward Trumpian bluster may explain why, in a July poll, 70 percent of likely Ohio voters didn’t know who he was. Lately, however, he has adopted components of Trump’s pugilism, mostly directed at Secretary of State Jon Husted, a primary rival with broad name recognition in the state. Trump made a habit of denigrating opponents with epithets—“Little Marco” Rubio, “Lyin’ Ted” Cruz, “Crooked Hillary” Clinton—and Renacci has taken to referring to Husted as “Dishonest Johnny,” claiming that Husted spread misleading stories about him. “He embodies the self-serving, dishonest political establishment that will say or do anything to dupe voters into believing that they’re something that they’re really not,” Renacci told me. “He’s never run against me before, and I think he’s learned that the jig is up and I won’t let him do it any longer.”

The primary isn’t until May, but Renacci is lagging behind his better-known opponents: Mike DeWine, the attorney general and former senator, so far leads the four-way race with 42 percent versus of likely voters versus just 5 percent for Renacci. Renacci is doing all he can to show his close ties with Trump, reiterating that he was the first member of Ohio’s congressional delegation to back him and hosting a fund-raiser with Corey Lewandowski, the president’s first campaign manager. Mike Pence praised Renacci in a June visit to Ohio, applauding the congressman for being a “strong partner of this administration” and claiming, “I was for Jim Renacci before it was cool.” Renacci has also gotten endorsements from two grassroots pro-Trump groups, Bikers for Trump and Citizens for Trump. But for that to translate into electoral victory, Renacci needs to hope that the antiestablishment gusts of 2016 are once again swirling in 2018.

The post Meet the Trumpkins appeared first on Washington Monthly.

On a sunny August day, an elderly, fragile-looking black man sits slumped in a wheelchair, eyes closed, outside the doors of a DaVita Dialysis center. The business takes up the corner of a run-down strip mall in Southeast D.C., in a heavily black neighborhood across the river from the Capitol. It’s next door to a liquor store and steps away from an ACE Cash Express check-cashing outlet, a barbershop, and a takeout place. A big sign on the glass warns visitors that firearms are not allowed inside. A handicapped-accessible public bus waits in the parking lot to take other patients home.

It’s midafternoon, but the shopping center is buzzing with knots of people hanging out by the takeout and the barbershop. Everybody seems to know someone on dialysis. One man in a barber’s smock out for a cigarette break says he had a friend who died at a dialysis center. He says ambulances are a constant presence at the DaVita clinic. It’s not unusual for people to die on dialysis: nationally, about one-fourth of patients die in the first year, and six in ten will be dead within five years.

As many as thirty million Americans have chronic kidney disease. If you’re one of them, and you’re white, well educated, and middle class or higher, odds are you’ll get the kind of medical care that will save your kidneys. You likely have private health insurance and get regular checkups. You probably caught your condition early and are taking medication to slow down the disease’s progression.

But if you are poor, less educated, and black, the odds are much greater that your disease will run unchecked and your kidneys will eventually fail. According to the National Institutes of Health, black people are nearly four times as likely to suffer kidney failure as whites. Then you will likely end up on dialysis, spending three days a week, four hours at a time, at a place like this one, as your blood is pumped out of your body, filtered, and pumped back in.

Farther down the sidewalk, waiting for her daughter at the takeout, is Sharon C., a soft-spoken sixty-two-year-old black woman in a sleeveless white dress and Jackie O sunglasses who doesn’t want to give her full name. She sits in a wheelchair, her left foot and ankle grotesquely swollen, the result of poor circulation caused by the diabetes she was diagnosed with in 2005.

Sharon goes to a different DaVita center for dialysis, one near Capitol Hill, where she spends every Tuesday, Thursday, and Saturday. “You can’t miss a treatment,” she says. “You can’t go anywhere.” She says she only got on dialysis two months earlier, when her one functioning kidney finally failed. She is not on the wait list for a transplant. “I need to find a donor,” she says, echoing what patient advocates say is a common misperception among dialysis patients: that you can’t get a transplant unless you find a donor for yourself. “I don’t want to be like this.”

Of the 661,000 Americans with kidney failure, about 468,000 people—more than a third of whom are black—are on dialysis. In the District of Columbia, where the prevalence of kidney failure is the highest in the nation, according to the Centers for Disease Control, there are twenty-three dialysis centers, mostly in Northeast and Southeast Washington, the predominantly black parts of the city that are also ground zero for diabetes and high blood pressure, the two conditions most linked to kidney disease. Another 100 dialysis centers are within a twenty-five-mile radius of the city, again concentrated in the suburbs with the largest minority and low-income populations. In District Heights, Maryland, a DaVita center dominates the busy intersection of Pennsylvania Avenue and Silver Hill Road. In a strip mall just across the street is a clinic run by U.S. Renal Care.

Like check-cashing outlets and payday lenders, dialysis centers—the vast majority of which are for-profit, like DaVita and U.S. Renal Care—are now fixtures in the urban commercial landscape. “We used to say there’s a liquor store on every corner,” said Clive Callender, a transplant surgeon and professor of surgery at Howard University. “Now we say there’s a dialysis unit on every corner.”

The prevalence of dialysis centers in minority neighborhoods is a reflection of policy failures that encourage—indeed institutionalize—class and racial disparities in American health care. These failures include more than just disparate access to the primary and preventive services that could help high-risk patients stave off kidney disease. Public policy effectively steers low-income and minority patients with kidney disease toward dialysis and away from superior options, particularly transplants.

Everyone with kidney failure, also called end-stage renal disease, is covered by Medicare. And Medicare guarantees payment for every dialysis session. As a result, the treatment of kidney failure is a volume-centered business aimed at keeping dialysis centers running. “You fill up a facility with so many stations, you make sure somebody is sitting in each of those chairs around the clock,” said Dennis Cotter, president of the Medical Technology and Practice Patterns Institute. “It’s the Henry Ford production model.”

This system creates an incentive for clinics to keep patients on dialysis until they die.

That’s one reason why low-income patients have a tougher time getting transplants, which is the best treatment for kidney failure: their clinicians may not tell them it’s an option. And the longer they stay on dialysis, the poorer their health is likely to be, making them less viable as transplant candidates.

Patients may also not be able to afford long-term treatment after surgery. While Medicare pays for the transplant itself, it only pays for three years of immunosuppressant medication to prevent the transplant from being rejected by the body, despite the fact that the one-year cost of these drugs is about a third the cost of keeping someone on dialysis. People running out of coverage ration their medication, lose their transplanted kidneys—and end up back on dialysis. Patients like these are less attractive for transplant centers, which want to keep their success rates high.

This unfair system is also a major driver of U.S. health care costs. While kidney failure patients make up about 1 percent of Medicare beneficiaries, they accounted for 7.2 percent of Medicare spending in 2014 and almost 1 percent of the total federal budget. For each patient on dialysis, the government spent $87,638 in 2014. Much of that money goes to just two companies: Colorado-based DaVita Inc. and the German conglomerate Fresenius Medical Care, which together control the lives of 69 percent of dialysis patients.

As common as dialysis is today—there were 6,757 dialysis units nationwide in 2014, according to federal data—it was once a scarce medical luxury. The story of that transformation is both a triumph and a tragedy for federal policy.

Until the early 1970s, a diagnosis of kidney failure was tantamount to a death sentence. In 1962, the journalist Shana Alexander published a now-classic account in Life magazine on the workings of what she called Seattle’s “Life or Death Committee,” a group of seven anonymous citizens convened by the King County Medical Society to decide who would have access to the Seattle Swedish Hospital’s ten dialysis machines. The committee—the original “death panel” if there ever was one—looked at applicants’ income and net worth, marital status and children, occupation, education, and “past performance and future potential.” As Alexander wrote, “With no moral or ethical guidelines save their own individual consciences, they must decide, in the words of the ancient Hebrew prayer, ‘Who shall live and who shall die; who shall attain the measure of man’s days and who shall not attain it; who shall be at ease and who shall be afflicted.’”

In 1972, Congress and President Richard Nixon passed legislation extending Medicare to anyone with end-stage renal disease. It is still the only disease for which sufferers are eligible for Medicare regardless of age. According to lore, the pivotal moment for the legislation was when kidney patient Shep Glazer hooked himself up to a dialysis machine on the floor of the House Ways and Means Committee and pleaded for the money to afford his treatment. “I am forty-three years old, married for twenty years, with two children, ages fourteen and ten,” Glazer told the committee. “If your kidneys failed tomorrow, wouldn’t you want the opportunity to live? Wouldn’t you want to see your children grow up?”

In a testament to government’s power to create new markets, the legislation transformed dialysis from a treatment for the lucky few to a multibillion-dollar industry in the course of slightly more than a decade.

With a guaranteed stream of government payment for every treatment performed, dialysis clinics began springing up nationwide. Some were nonprofit, like the Nashville-based Dialysis Clinic, Inc., established in 1971. Others were for-profit and quickly came to dominate the nascent sector. Today, the two largest providers report annual revenues in excess of $27 billion. Fresenius is not only one of the world’s two largest providers of dialysis services, it’s also the world’s largest manufacturer of dialysis equipment. According to Fresenius’s 2016 annual report, more than half of the dialysis machines worldwide are made by the company. It’s the principal supplier of equipment to the world’s number-two dialysis provider, DaVita. 

Medicare currently pays dialysis clinics $231.55 per treatment. That means a clinic like the one in the Southeast D.C. strip mall, with twenty-five chairs, can make $5,788.75 every four hours if all chairs are filled. Assuming three shifts a day, six days a week, that’s $5.4 million per year.

The question today is not who shall live, but how.

“Dialysis is hell,” said David White. In the days before his kidneys failed him, White was the hard-charging IT manager at the D.C. office of a big law firm, with a lot of bad habits to cope with the stress. “I had high blood pressure. I smoked for thirty-two years, a pack and a half a day. I drank too much.” And he never had time for doctors.

When his wife finally dragged him to the emergency room, ten years after his last doctor’s visit, White collapsed on his way to triage. He had “crashed,” poisoned by his body’s own wastes. He was forty-seven years old.

Doctors administered emergency dialysis, inserting a catheter that led straight to his heart. Later, they created a fistula, which looks like a ropy bulge on White’s left bicep. It’s a place where the artery and vein have been grafted together to make it easier to hook up a dialysis machine and ensure good blood flow.

For the better part of six years after leaving the hospital, White went to a clinic in downtown D.C., three times a week, for four hours at a stretch. He couldn’t go back to work, and the sessions left him exhausted with what patients call a dialysis hangover.

“All you want to do is sleep,” White said. “You just want to rest until you feel better. And when you feel better, guess what? It’s time to go back to dialysis again. It’s a pretty strange way to live.”

Providers try to portray dialysis clinics as safe and pleasant. Here’s the for-profit company American Renal Associates, which operates 214 clinics nationally, describing its facilities in a recent quarterly report filed with the Securities and Exchange Commission:

Our clinics generally contain between 15 and 20 dialysis stations, one or more nurses’ stations, a patient waiting area, examination rooms, a supply room, a water treatment space to purify water used in hemodialysis treatments, staff work areas, offices and a staff lounge. Our clinics are also typically outfitted with amenities including heated massaging chairs, wireless internet and individual television sets.

But patients say clinics are far from luxurious. “You can’t eat without the flies coming everywhere,” said Sharon C. She’s not alone. “Dialysis facilities offer a great environment for some bugs, including roaches, flies, and gnats,” reads the “Bugs and Infestations” page on the website of the Quality Insights Mid-Atlantic Renal Coalition, one of several “ESRD Networks” established under federal law to improve the quality of end-stage renal disease care in the United States.

Amenities also can’t hide the fact that dialysis is a grim and grueling process. “Your blood is leaving your body,” said Dennis Cotter of the Medical Technology and Practice Patterns Institute. “It’s going through a filter and getting returned. That in itself is traumatic because the blood encounters a lot of foreign surfaces, and there’s a huge problem with a large variety of infections.” Especially dangerous are the chest catheters used primarily for emergency dialysis, as in the case of David White, but that remain indefinitely in some patients. They have been called the “great white tubes of death” because of their ability to send pathogens straight into a patient’s heart and bloodstream. (Studies have shown that patients with catheters are at least three times more likely to die from infections than patients with a fistula.)

Patrick Gee, who lives near Richmond, Virginia, said he remembered the first time he set foot in a dialysis clinic, after his diagnosis in April 2013. “I stood there and cried,” he said. “I was looking at amputees. I was looking at people who were brought in and out by paramedics. Nobody had a smile on their face. It looked dead.”

Patients often experience cramps, chills, fever, and crippling fatigue as their bodies attempt to cope with a process that tries to accomplish in four hours what a pair of healthy kidneys would have done over the course of two to three days. Gee said it was all he could do to keep his eyes open on the drive home after a session. “One time I got in the garage and parked the car and my wife found me asleep behind the wheel,” he said.

Part of what’s so exhausting about dialysis is that patients’ hearts must cope with the stress of pumping their blood through a machine, usually at the rate of a pint per minute. According to the U.S. Renal Data Service, 41 percent of deaths among dialysis patients are due to cardiovascular problems. “I can’t remember if the ambulance came for me once or twice,” said David White, who recalled one episode when his heart wouldn’t stop racing for thirty minutes. “I saw one person almost die. It was really gruesome. After he was gone, there was a pool of sweat around his chair. It was unbelievable. . . . I saw other people carried out. It always goes through your mind that you’ll never see that person again.”

It’s tempting simply to blame the dialysis companies for being callous and predatory in their treatment of dialysis patients. Earlier this year, HBO’s John Oliver dedicated an entire episode of Last Week Tonight to the questionable practices of dialysis companies and ridiculed the flamboyant CEO of DaVita, Kent Thiry, for riding into company meetings on horseback, dressed as a Musketeer and referring to himself as the “Man in the Iron Mask.” Oliver also aired a clip of Thiry comparing the management of his dialysis business to that of Taco Bell. “If I had 1,400 Taco Bells and 32,000 people who worked in them, I would be doing the same stuff,” Thiry tells a group of business students at UCLA. 

What Oliver didn’t say, though, is that the government’s current method of paying a set amount per dialysis treatment exactly encourages Thiry’s approach. The fee that Medicare pays dialysis providers is called a “bundled” payment, and it varies slightly from year to year depending on the costs reported to the government by providers. The current $231.55 per treatment is intended to cover all services, equipment, supplies, and drugs involved in a single session.

The point of the bundle is to keep costs low for the government by preventing providers from nickel-and-diming Medicare with separate bills for various procedures. But it also encourages providers to perform as many treatments as they can at the lowest possible cost to maximize revenues. That prompts clinics to err toward a one-size-fits-all approach. Dialysis centers are, in fact, like Taco Bells.

There are better ways to treat kidney failure than the in-center hemodialysis that most kidney failure patients endure. One is peritoneal dialysis, which can be performed at home. Patients pump dialysis fluid into their abdomen to absorb toxins, then pump it out again in what’s known as a fluid exchange. It’s a gentler process that also leads to better survival rates and quality of life, including the ability for many to continue or go back to work. But in 2014, just 9.3 percent of patients diagnosed with kidney failure began treatment this way.

“The typical center, the easiest thing to do is just put them on in-center hemo[dialysis],” said surgeon Joseph Melancon, chief of the George Washington University Transplant Institute. “That’s one set of skills [for the staff]. Everybody is the same.”

Putting someone on peritoneal dialysis would require more staff with different skills, including the ability to train patients to perform the procedure at home. As a result, the patients most likely to be on peritoneal dialysis are the ones who have the resources to demand it. In 2014, nearly 10 percent of whites and more than 12 percent of Asians with kidney failure were using peritoneal dialysis, compared to 7.8 percent of blacks.

The fee-for-treatment structure also means there’s less incentive to invest in innovation that could improve dialysis patients’ lives. Why innovate when the existing model guarantees steady and growing revenues? Add the fact that the two biggest firms have already crushed or purchased almost all the competition, and the result is that the process of dialysis has barely changed over the last forty years.

The technology of modern dialysis rests on two twentieth-century breakthroughs. In 1944, Dutch physician Willem Kolff invented the first “artificial kidney” in Nazi-occupied Holland using, among other things, sausage casings, orange juice cans, and a washing machine. After the war, Kolff sent four of his (by then refined) machines to the United States, where they were successfully used to treat soldiers suffering from kidney failure during the Korean War.

The second breakthrough was in 1960, when Belding Scribner and Wayne Quinton, working at the University of Washington in Seattle, invented the “Scribner shunt,” a U-shaped Teflon tube inserted into a patient’s arm that made it possible to connect to a machine as often as necessary. Before then, the damage done to a patient’s veins with each treatment made it impossible to administer more than a few sessions.

While the Scribner shunt has since been replaced by the fistula like the one in David White’s arm, today’s dialysis machines are not far removed from Kolff’s original invention. “It seems unimaginable that dialysis care has made so little medical and technological progress,” wrote Gary Peterson, founder of the news site RenalWEB, in a 2015 essay. Despite early expectations that “our state-of-the-art technology of 1975 would be quickly surpassed and replaced,” Peterson wrote, today’s machines are essentially no different from those developed in Europe in the 1970s. Expected breakthroughs with stem cells, portable dialysis machines, and xeno-transplantation have yet to materialize.

In its 2015 annual report, Fresenius referred to its ongoing development work into a “portable artificial kidney.” It merits one paragraph in the 215-page report, and there is no mention of when this technology might become available.

Here’s where the big companies do innovate: squeezing ever more pennies out of Medicare. With few competitors left to buy, the big companies are now entering into “joint ventures” with kidney doctors, who are offered ownership stakes in new clinics that are typically built with borrowed funds. In 2015, the private equity–owned American Renal Associates, which owns 214 clinics exclusively through this model, went public with a $100 million IPO. According to its most recent public filing, the company now operates in twenty-five states with 379 nephrologists as “partners.” 

Because dialysis is exempt from a federal law that prohibits doctors from referring patients to clinics and laboratories that they own, nephrologists are free to refer as many patients as possible to their own clinics. In fact, the dialysis companies are counting on nephrologists to keep their centers filled. “Our medical directors refer patients to our clinics,” read the 2016 annual report of American Renal Associates.

The most tragic consequence of a system that incentivizes keeping people, especially poor people and minorities, on dialysis is that it also keeps them from getting what is beyond doubt the best treatment for kidney failure: a transplant.

“A successful transplant gives you almost a normal life expectancy, particularly if you’ve never been on dialysis,” said GW transplant surgeon Joseph Melancon. Between 76 percent and 85 percent of transplant recipients survive five years after transplant, compared to just 42 percent for patients on traditional hemodialysis. In 2014, of all patients suffering from end-stage renal disease, fewer than one in five black patients with kidney failure were transplant recipients, compared to just over one-third of white patients.

Today, David White is healthier than he’s ever been, thanks to a kidney transplant he got in 2015 at George Washington University Hospital’s Transplant Institute with the help of Melancon. But he’s one of the lucky ones. The Transplant Institute happens to be in the same building as White’s former dialysis center. When the institute opened, White got on the elevator and signed up for the transplant wait list.

Getting a transplant is an uphill battle for anyone; there were just 17,914 kidney transplants performed in the United States in 2014 with 88,231 people on the wait list. But poor and minority people with kidney failure face additional systemic obstacles. Emory University researcher and associate professor Rachel Patzer has found, for instance, that black patients living in the southeastern United States have a 59 percent lower rate of transplant than whites, and that blacks living in the poorest neighborhoods are 67 percent less likely to be put on wait lists than poor whites.

One reason, mentioned before, is that Medicare doesn’t pay for long-term treatment of transplant recipients. So kidney patients who can’t afford to pay out of pocket for immunosuppressant medications after three years either take themselves out of the running for transplant or are discouraged by transplant centers from applying.

At Piedmont Healthcare in Atlanta, for example, the transplant program’s website includes a page on “Financial Considerations” for prospective transplant patients. Among other things, the page notes that “[a]ll transplant patients are advised to make long-term financial plans for transplant.” Patients “whose financial or insurance situation is uncertain,” it goes on, should “engage in fundraising efforts to establish a ‘safety net’ of funds they can access for post-transplant costs”—basically asking patients to run a Kickstarter campaign to finance the procedure.

Dialysis patients are also simply less likely to learn that transplant is an option—perhaps because each patient a center refers away means one less Medicare payment. Howard University surgeon Clive Callender said some of his black patients were told they’d be eligible for transplant “later,” after they spent some time on dialysis. “They were told, ‘We’ll dialyze you for a year or two and then after that we’ll put you on a transplant list,’ ” he said. “Of course, the longer you’re on dialysis, the poorer your outcome is, the more likely you are to reject your transplant, and the more likely you are to die.”

While federal regulations require patients to be educated about transplant, “there are really no rules or regulations about what that education should look like,” said Emory’s Rachel Patzer. “We don’t know if a patient is being asked, ‘Hey, do you want a transplant, yes or no?’ and that’s the end of the discussion.”

In fact, there’s every reason to make that education perfunctory at best. Doctors even trade anecdotes about competition among nephrologists and surgeons for the “best” patients, because the patients most likely to last the longest on dialysis—namely, those who are younger and healthier—are also the best transplant candidates. “I think there really is a financial incentive for a dialysis nephrologist—especially if they’re an ‘easy’ patient, a low-maintenance patient—to keep them on dialysis as opposed to referring them to transplant,” said Joanne Bargman, a nephrologist and professor of medicine at the University of Toronto.

Transplant surgeon Joseph Melancon is more blunt: “I’m not saying it’s typical, but I’ve definitely heard it said, ‘Wow, you took my best patients and gave them a transplant when they were doing so well on dialysis’—which is exactly the opposite of what you want.”

Among the patients never told about transplant when starting dialysis was Patrick Gee. Gee eventually got on a wait list, at the Virginia Commonwealth University’s Hume-Lee Transplant Center, but he feels he’s lost valuable time. “When I was told that my kidneys were failing, I should have been told right then and there I could have had a transplant instead of dialysis,” he said.

The Medicare entitlement for dialysis was begun with the best of intentions: to save lives and to democratize access to a treatment that was then available only to a few. But over the last forty-plus years, the system has evolved in a way that calcifies the gross racial and class disparities in our treatment of chronic kidney disease and kidney failure.

It doesn’t have to be this way. Nor would it be if kidney disease and kidney failure were problems largely confronted by the middle class. It’s because the victims of these diseases are politically invisible that we’ve come to accept substandard care as the norm and to tolerate the exploitation of their suffering for profit.

That means that an essential way to fix the problem is to end the disparities in preventive and primary care that lead to the disparate incidence of kidney disease in the first place. In a landmark report, the Institute of Medicine found that black diabetes patients were less likely than white ones to get important blood tests, eye exams, and flu shots, and more likely to use emergency rooms for their care instead of doctor visits. And despite the importance of good primary care in detecting kidney disease—which is often symptomless until a patient “crashes”—so-called health professional shortage areas are disproportionately located in poor and minority communities.

Erasing decades of institutionalized discrimination is a societal challenge that must remain a long-term priority. But there are things that can be done now to ease the suffering of kidney disease patients in the short term.

First, we should improve the lives of people currently on dialysis.

While it’s likely too late to unwind the clock on dialysis as a for-profit enterprise, there’s plenty of evidence that providers respond to financial incentives. Before 2011, for example, Medicare allowed providers to bill separately for the drug erythropoietin, or EPO, which clinics gave dialysis patients to stave off anemia. These separate payments caused its use to skyrocket, accounting for as much as 11 percent of the costs of caring for end-stage renal disease patients in 2004 while doing nothing to improve their health. Once Medicare ended separate billing for EPO, its usage immediately declined.

The EPO example shows how the right payment policy can prevent bad outcomes. It can also reward improvements in quality. To its credit, Medicare has begun to move in this direction. In response to ongoing concerns about the quality of dialysis, the Centers for Medicare and Medicaid Services (CMS) began providing “Star Ratings” of dialysis facility quality in 2014.

But the clinical outcomes tracked by the CMS are too easily gamed. In a keynote speech before the Annual Dialysis Conference in 2015, the University of Toronto’s Joanne Bargman recounted interviews in which American nephrologists told her about all the ways in which they got the lab results they wanted, such as rounding down a person’s weight or taking “strategic blood draws” at just the right time to get the best numbers.

The CMS’s current metrics also don’t include many of the measures that patient advocates say are the most meaningful to them, such as whether they can go back to work. In a survey of dialysis patients reported in the September 2016 American Journal of Kidney Diseases, patients said the outcomes they prioritized were “fatigue/energy,” survival, ability to travel, “dialysis-free time,” and impact on family.

“In the 1970s, people used to keep their jobs,” said Renal-WEB’s Gary Peterson. “That’s where we started dialysis, and I can’t believe we’ve gone backwards from that. But if you set up employment as a financial incentive, [clinics] are going to make sure that patients have gentle dialysis treatment, that they’re well rested, and that they have as few complications as possible.”

The second thing to do is to give low-income and minority patients a fairer shot at getting a kidney transplant. That means, at a minimum, making sure Medicare pays for lifetime coverage of immunosuppressant medications for transplant patients, instead of just thirty-six months. The original rationale for the current policy, established decades ago, was that transplant patients would eventually get jobs and private insurance, but the instability of work in the modern labor market and the price of coverage make this reasoning far less plausible today. A likelier explanation for the policy’s continued existence is lobbying by the dialysis industry, which benefits from keeping patients on dialysis and not “losing” them to transplant.

Switching to lifetime coverage would save both lives and money. While the initial cost of a transplant is expensive—about $250,000—the cost of immunosuppressant medicines to maintain a transplant is around one-third the annual cost of dialysis, which runs between $80,000 and $100,000. Studies conclude that, factoring in indirect costs of dialysis like increased emergency room visits, a transplant becomes cheaper than dialysis after about 2.7 years.

Finally, federal policy can help stop the predation of low-income dialysis patients by increasing the amount of screening and early treatment people receive for kidney disease so they are less likely to end up on dialysis in the first place. As always, the key is designing a payment model that rewards prevention and early treatment.

In October 2015, under the authority of the Affordable Care Act, the CMS launched an initiative to support pilot programs providing comprehensive, “person-centered” models of care for kidney disease patients. One encouraging program is REACH Kidney Care, developed by the nonprofit Dialysis Clinic Inc. (DCI). In a white paper, the organization says it intends to better “manage” patients who are not yet in kidney failure by controlling high blood pressure, diabetes, and other conditions that could hasten the disease’s progression, and referring more people for transplant. Patients who do go on dialysis receive better education on options like peritoneal dialysis and on how to avoid hospitalization and other complications. In a pilot implemented in Spartanburg, South Carolina, DCI reported that 37 percent of its dialysis patients started treatment at home (more than three times the national average) and two-thirds avoided hospitalization before their first dialysis session (versus one-third nationwide).

One important way to encourage this kind of innovation is to roll back over-consolidation in the dialysis industry. While nonprofit and smaller dialysis providers still exist, their numbers are dwindling.

“The big commercials can do things we can’t even begin to do just because of their size, such as a research project on 10,000 of their patients,” said Barry Smith, president and CEO of the nonprofit Rogosin Institute. “But we can be creative and we can change things in a short period of time.” Like DCI, Rogosin is working on ways to prevent patients from ending up on dialysis. “The other thing we want to do, which is not what DaVita or Fresenius would want to do, is put ourselves out of business in terms of dialysis,” Smith said

But if consolidation puts organizations like Rogosin and DCI out of business first, patients will suffer.

With the ultimate fate of the Affordable Care Act still uncertain under Donald Trump and a Republican Congress, it’s unclear what will happen to the experiments begun at the CMS to improve the lives of kidney patients. At the same time, as Phillip Longman argues elsewhere in this issue (“How Big Medicine Can Ruin Medicare For All,” page 29), Democrats who want to move toward single-payer or a robust public option must figure out how to lower the cost of delivery to have any chance of succeeding. Fixing how Medicare treats end-stage renal disease, which accounts for 7 percent of its budget, would be a good place to start.

Meanwhile, time is running out for patients like Patrick Gee, who is on dialysis, and David White, who will eventually face the loss of Medicare coverage for his transplant medication if Congress doesn’t act. “I’m eighteen months out, so I’ve used half my time,” said White. One thing he knows is that he doesn’t want to go back to dialysis. “I’m going to figure it out before then.”

The post The Dialysis Machine appeared first on Washington Monthly.

As the GOP-controlled Congress continues its efforts to “repeal and replace” the Affordable Care Act (ACA), the most dramatic potential impacts of repeal are what draw the most attention: the numbers of people who could be left uninsured, and the dollars that could be lost from Medicaid.

A less attention-getting—but just as important—consequence of repeal would be the loss of inventive, and often pioneering, improvements in the care given to many Medicaid patients living with the combination of serious mental illness (SMI) and chronic health conditions. These innovations, ushered in before and expanded through the ACA, have quietly rescued millions of patients from a downward spiral of declining health, and, in some cases, homelessness and premature death.

Part of a group known as the “5/50”—the 5 percent of patients who are responsible for about 50 percent of the nation’s medical costs—people with SMI face extreme health risks. They are likely to die, on average, twenty-five years earlier than the general population. For them, managing a chronic condition while living with mental issues such as severe depression, schizophrenia, or bipolar disorder can be nearly impossible. Patients like these may lack even the capacity to keep their daily lives on track, let alone handle a chronic health problem, like diabetes, that requires multiple trips to multiple doctors with multiple medications and treatments. All too often, they end up in the nation’s emergency rooms, after a chronic condition has become so severe that it may cause serious disability or even death. The resulting rise in health care costs is enormous. Ineffective care for these patients accounts for as much as $120 billion in annual health care costs. Reducing these financial and human costs and improving the lives of people battling chronic physical and mental health problems have long been priorities for public health experts, and addressing the issue became a central part of the ACA.

Pennsylvania was among the first states to test the effectiveness of coordinating care for SMI patients, so that all of a patient’s providers—physicians, nurses, psychiatrists, social workers, and others—consistently share information about the patient and, in some cases, develop a closer relationship with them. The result has been better health, as well as more compassionate, more effective—and more cost-effective—care.

For a patient who has not only a primary care doctor but also various other providers—a heart specialist, a kidney doctor, an ophthalmologist, a nutritionist, a physical therapist, a nurse practitioner, and others—in addition to mental health specialists, having someone to manage the moving parts can be lifesaving. Without the right coordination, for example, medications prescribed by one doctor for one problem could cause a reaction to other medications prescribed by someone else, putting that patient in the hospital and worse off than before.

Among the early examples of how coordinated care can improve the lives of patients with SMI and chronic health problems are two programs launched in Pennsylvania’s Allegheny, Bucks, Montgomery, and Delaware Counties in 2009. In the years following the 2007–08 financial crisis and the ensuing recession, Pennsylvania public health officials became increasingly concerned about the mounting health problems of people with coexisting mental and physical health challenges. More than one million Pennsylvanians live with mental illness, according to the University of Southern California, while the Kaiser Family Foundation found that more than 30 percent of residents report “frequent mental distress.”

To combat this problem, Pennsylvania officials added funds to a grant from the nonprofit Center for Health Care Strategies to help launch the SMI Innovations Project pilot, with the goal of dramatically improving the coordination of physical and mental health care for SMI patients. Each of the four participating counties would receive a share of the savings achieved.

Allegheny County, in southwest Pennsylvania, is the state’s second most populous county and was already a leader in the treatment of mentally ill patients, particularly with regard to their treatment by the criminal justice system. Studies by the Urban Institute estimate that a majority of state prisoners (56 percent) and jail inmates (64 percent) and nearly half of federal prisoners (45 percent) have mental health problems, and it is reasonable to assume that effective treatment could keep many of those people out of incarceration, with resulting benefits for the patient and lower costs for the state.

In Pennsylvania, the annual cost of incarceration is approximately $42,000 per inmate. Like most states, Pennsylvania addresses this challenge in part by participating in the federal mental health court programs, which tries to direct mentally ill offenders to treatment and other interventions to prevent recidivism. Despite mixed results around the country, Allegheny County’s mental health court program has been notable for its results, serving 209 people in 2016–17 and thousands since the program’s creation in 2001. In addition to a special “crisis intervention team” training program for police officers (who wear special badges indicating their expertise with mentally ill offenders) and protocols for diverting minor offenders to special units at local hospitals for treatment instead of to jails, the county also tries to ensure that appropriate mental health treatment is a regularized part of the county’s intake process. “We assess people, through questionnaires, to see if they need substance abuse treatment, primary care, or other services,” said Shannon Sommers, who coordinates resources, including health care, for the Allegheny County Department of Human Services and the court.

Given this track record, Allegheny County’s involvement in the SMI Innovations Project pilot—a care coordination effort called Connected Care—was a natural extension of its efforts to improve the lives of seriously mentally ill residents. Before Connected Care, physicians and other care providers discussed specific cases, but it was not a consistent, broad policy with specific checks and balances, according to James Schuster, vice president at Community Behavioral Health Care and the primary administrator of the Allegheny County program. What changed was expanding the reach of care managers to touch every case and to ensure that information about hospitalizations, medications, emergencies, housing status, and other details were shared with all care providers. “Health plans needed to exchange information and do it through joint treatment planning,” said Schuster, but the primary emphasis was on teaching physicians, health plan administrators, and behavioral health providers to work as a team.

Allegheny County’s model also offered lessons in achieving cost savings while working within an existing health plan structure. Unlike other counties, they did not bring on any new employees or increase direct outreach to patients or the homeless. They analyzed claims data on existing plan members to decide whom to enroll in the integrated care experiment.

“We worked to get consent to reach out to our mental health care patients’ primary care providers to let them know when a patient had been hospitalized, for example,” said Brandi Holsinger, a care manager with the Connected Care program. “If a patient had an emergency room visit, we would call their provider the next day to let them know so that they could follow up with the patient. In the past, we only did this sporadically in crisis situations.”

The results were excellent. The Allegheny County Connected Care program showed an estimated 12 percent reduction in mental health hospitalizations for patients in the pilot and a 10 percent reduction in hospital readmission rates, when compared with other Allegheny physical care plans that did not adopt the integrated care model. All three factors—ER visits, readmissions, and mental health crisis hospitalizations—are key drivers of health care costs. “The integration of health care, particularly physical health care and behavioral care, saves money,” said Estelle Richman, who was secretary of Pennsylvania’s Department of Public Welfare (now the Department of Human Services) from 2003 to 2009 and later a senior official at the Department of Housing and Urban Development under President Obama. “You treat the whole person, not just the mental illness and not just the physical body.”

On the streets of Norristown, a Philadelphia suburb along the Schuylkill River, Madelyn Pontari is a familiar sight as she ferries one of the twenty-five or so people in her care to the multitude of appointments needed to manage the chronic health problems they battle along with mental illness.

Preemptively apologizing for the bad reception on her flip phone—her clinic runs on a tight budget, and can’t afford smartphones for its employees—while negotiating the day’s plans, Pontari does a lot more than just get people to the doctor on time. “We start out reviewing profiles to figure out why these people are going to the emergency room so much,” she says. “And we ask, do they have the right type of doctor? What’s their relationship with that doctor?”

Pontari, a registered nurse, is a “wellness recovery team” (WRT) navigator, a position created by a program in Montgomery, Delaware, and Bucks Counties called HealthChoices HealthConnections. This program’s approach is slightly different from the pilot in Allegheny, but has led to equally impressive results. In Montgomery County, improvements were achieved through the creation of WRTs, an entirely new method of care that provides wraparound services to selected seriously mentally ill patients, often working with those who are homeless or in other crisis situations.

Spending a few days in the life of a WRT navigator makes it easy to see the difference between the fragmented care most of us receive and the coordinated services provided for an SMI Innovations Project patient. Once Pontari meets a patient, she concentrates on getting to know them a little better. She probes for clues that will assist her in designing a care plan that will help them recover whatever level of health and independence they can manage. “You don’t need to know what type of trauma a person has been through, just that there’s been trauma. You see those symptoms and figure out how to work with them,” she says. Being there at each appointment, sitting with patient and physician, being alert for moments that can help build a relationship between the two, making sure treatment instructions are understood and the right questions are asked and answered—these are just some of the essential elements of Pontari’s work.

No matter how complex the situation, Pontari takes a holistic approach. One of her patients is Sal Venezia, who suffered a cascade of events that left him sick and destitute, in just a little over three years, starting in 2014. “It was like a big bomb just dropped,” Venezia says. “I had everything—a home, a job. Then I sold my house to help take care of my elderly aunt and grandmother. I invested in their home and moved in with them because they were both ill and I didn’t want them to be alone. I figured I would get it back later when the house was sold, or live there.”

He did not foresee the work accident that would crush a disc in his back, eventually costing him both his job as a chef and his medical coverage. Nor did he know that he would need bypass surgery at about the time his aunt and grandmother died and he found out a reverse mortgage would take the house he’d invested everything in. He fell into a depression so deep he considered suicide. When a crisis intervention manager at the Coordinated Homeless Outreach Center of Montgomery County asked Pontari to help him, he had been in the shelter for months and his diabetes was wildly out of control. “[Madelyn] helped me get everything under control, blood pressure, diabetes, everything, but it was a hard ride,” says Venezia, who just turned fifty-three.

Many of Pontari’s patients are what she calls the “sickest of the sick.” Being homeless, the case for about 35 percent of those in her care, makes things even more challenging. “If they become homeless, they cannot take care of their health,” she says. “If you don’t have that base, you can’t do anything else.”

When things fall apart, as they did for Lea Cairns, another of Pontari’s current patients, emergency rooms often become the primary source of both physical and behavioral care. Repeated hospitalizations also pile up, as health conditions become acute because of a lack of early and regular treatment.

For those who think—as many in Washington currently seem to—that people living in poverty are somehow lazy or gaming the system, it’s worthwhile to note that the line between stable and severely depressed and on the streets can be shockingly thin. Cairns was just as surprised as Venezia was to find herself homeless. She was once a librarian and a schoolteacher, but after her husband’s death—followed by two heart attacks, a stroke, several bouts with severe depression, and other problems—her life unraveled. Pontari’s support for her includes keeping her three grown children, including one in medical school, updated on her progress. At fifty-five, Cairns is now in transitional housing. She has lost weight, her blood pressure is consistently below 130/80, and recent tests show improvement in her heart function.

The Montgomery County pilot was ultimately successful enough that all of the payers involved—Keystone First, Magellan Behavioral Health, and UPMC—are still caring for patients using the tested models and are planning to expand coverage. According to evaluations conducted by the Center for Health Care Strategies and Magellan, Montgomery experienced an 11 percent reduction in ER visits for SMI patients, while SMI patients visiting an ER spent 19 percent less time there. Overall admissions to medical facilities fell by 56 percent, and those admitted spent 37 percent less time there. Psychiatric hospital admissions also dropped by 43 percent, and the use of assisted residential environments—housing—declined as well, by 14 percent.

And in Allegheny County, the results convinced state officials that the system was a better way of caring for high-need, seriously mentally ill patients. “A few years ago, our state department of health felt so positive about it that they created a pay-for-performance model for all the behavioral health plans around the coordinated care model,” said pilot administrator James Schuster.

The benefits of the approach taken in Pennsylvania go beyond what is traditionally measured. Analyses of integrated care programs for SMI patients focus quite narrowly on the savings associated with keeping people out of hospitals. But researchers seldom include the additional savings that are likely to occur with improved physical and mental health.

The social services supports that have helped Venezia, for example, are not part of the integrated health care he received. But his improved physical health and recovery from clinical depression allowed him to take advantage of the job and housing opportunities Montgomery County’s social service agencies were able to provide.

The savings to state and federal governments incurred by keeping people out of homeless shelters and helping them return to work are an added bonus that should be considered in any evaluation of integrated care initiatives. The total cost of homelessness is calculated to be between $30,000 and $40,000 per person per year, depending on the city.

After years of research, and successful ACA-supported demonstration projects not only in Pennsylvania but also in Washington State, Missouri, New York, and others, the question is no longer whether integrated care for high-need patients saves money, but what model is the most effective.

Since all SMI integrated care programs depend on Medicaid, the other important question is whether these programs can survive in a federal climate that seems increasingly hostile to caring for mentally ill patients and is controlled by legislators determined to turn Medicaid into capped block grants.

For now, integrated care plans for people in Pennsylvania with serious mental illness should be relatively stable for the next two years, due, in part, to the success of the SMI Innovations Project. Using that evaluation data, the state applied for and was awarded a Certified Community Behavioral Health Clinic designation by the federal Substance Abuse and Mental Health Services Administration; this will supply as much as $10 million to continue to improve their integrated care models. The work began in July.

Montgomery County’s Madelyn Pontari emphasizes that it’s not just the money that makes her county’s program successful. “It’s getting people from not being able to do anything for themselves to being able to do at least some things independently,” she says. For Sal Venezia, the benefits have been clear. “Now that I’ve got my health together, I’m working a part-time job,” he says. It’s the first step into a second chance at a stable life.

The post Mind-Body Connections appeared first on Washington Monthly.

I remember, with unusual clarity, the first time I met Kukula Kapoor, the woman I would eventually marry. It was the winter of 1982. I was a grad student at Northwestern University. She was an associate producer of a talk show on the Chicago PBS affiliate. We were both twenty-four. A mutual friend brought me by her rooming house in Evanston. Kuku made us tea on a hot plate. She talked fast, with an emotional intensity that I found almost worrying, though intriguing. I also noticed her exotic good looks: big eyes, café au lait skin, hair cut short Liza Minnelli style, and short shorts, too, revealing thin, shapely legs.

Ethnically, I couldn’t quite place her. She looked Greek, like me, but while her first name sounded Greek, her last name definitely didn’t. Turkish, maybe? Arab? During the conversation, she mentioned being “born in Tibet.” Hmm, I thought, so that’s what Tibetans look like.

Not quite. Over the next year, as we got to know each other—we were dating other people at the time but saw each other socially—I got a more accurate fix on her.

She had indeed been born in Tibet, but her father was an Indian diplomat who had helped the Dalai Lama escape and then took the same route himself—on ponyback over the Himalayas—with his family, including two-year-old Kuku. (She was named for the cuckoo bird singing outside the window the morning she was born.) A series of foreign postings followed: Switzerland and Germany (where her parents had previously been posted at the end of World War II); Senegal, where Kuku attended a Baptist missionary school and developed a love of all things American; Syria, where she witnessed dogfights between Israeli and Syrian jets; and then, finally, back to New Delhi, where she happily studied at a Catholic boarding school. She then attended Indiana University, where her aunt and uncle were on the faculty. She graduated with a degree in journalism and political science, and soon landed her TV job in Chicago, waiting tables at night to make ends meet.

I found her life story impossibly romantic—certainly way more so than my own childhood in suburban St. Louis. We were different in other ways, too. She was passionate; I was cerebral. She was a strong partisan Democrat, politically engaged by predisposition as well as background: her mother, a successful entrepreneur and diplomatic hostess, was a Congress Party activist who knew Indira Gandhi. I had no real political loyalties, my vaguely leftish inclinations balanced by a streak of middle-American conservatism I got from my parents. She revered journalists and journalism; I had no particular interest in the profession. (I don’t remember ever reading a newspaper in college.)

I did have ambitions to be a writer, though, and soon learned that Kuku had a voracious appetite for fine fiction and a gift for language. I remember her once describing Norman Mailer, a guest on her TV show, as “walking like a pugilist, on the balls of his feet.”

Eventually, I made my way to D.C., interned at the Washington Monthly, and caught the journalism bug. One wintery day in 1984, on a visit to Chicago, I called Kuku up. She invited me over to her place—she now had a one-bedroom apartment, with an actual kitchen—and cooked me a dinner of beef curry. We talked and talked and talked, and eventually—well, let me just say that we didn’t leave her apartment for three days.

A year and a half later, we were married. My family fell in love with her, and as I watched them do so, I began to grasp something fundamental about Kuku: she had an immense capacity for love and empathy. She was a hugger and a hand-holder. She drew people in with kind, joyful eyes, drew them out with gentle questions, and made them feel appreciated and understood. She remembered the details of everyone’s lives, especially their children and families. She could even recall the hard-to-parse names of all my parents’ many Greek American friends. (Even I couldn’t quite do that, and I had grown up with them.)

After the wedding, we moved to D.C. I went to work as an editor under Charlie Peters at the Monthly, she as a staffer for Ralph Nader. We were doing similarly heady (if not very remunerative) work for famed Washington crusaders in the depths of the Reagan years. But we came at things differently. I preferred policy to politics; she was the opposite. She felt Reagan’s rise threatened everything she believed in; I felt it was a sign that Democrats needed new ideas. She thought liberalism needed to be defended; I thought it needed to be reformed. For the next thirty years, this would be the primary axis around which political discussion in the Glastris-Kapoor household turned.

In 1988, I took a job as Chicago bureau chief for U.S. News & World Report. Kuku went to work on Michael Dukakis’s campaign, wanting to fight the fight directly. That bittersweet experience ended around the time my part-time office manager/reporter left for law school, and Kuku took her place—after first giving birth to our daughter, Hope. For five years Kuku and I (sometimes with Hope in tow) worked together in an office overlooking Lake Michigan and traveled, separately and sometimes together, on reporting assignments around the Midwest. At night, over beers and burgers at our favorite bars, we’d talk about the writers we both loved—George Orwell, Somerset Maugham—and those we disagreed on. I admired V. S. Naipaul; she found him dreadful—“His soul is dark and shriveled,” she said. She tried to get me interested in P. G. Wodehouse, but I never quite did. She said I was “uncivilized.” She was not joking.

Mostly, though, we talked and talked and talked about politics and policy. Any friends and family members who came to our house for Kuku’s many dinner parties got sucked into this conversational vortex.

By 1994, both of us were eager for an adventure. When a posting in Berlin opened up, I grabbed it. We set up the bureau in our apartment, blocks from where the wall had recently been. While I traveled in and out of Yugoslavia covering the end of the Bosnian War, Kuku explored Berlin, learned German, cared for Hope, and hosted dinners for other journalists. She was the happiest I’d ever seen her, living a life she was bred for.

After the war ended, U.S. News shut down the Berlin bureau and offered us Moscow as consolation. Around that time, our friend Jim Fallows took over as editor of the magazine. With two young kids—our son, Adam, had just been born—we decided that living in Moscow with a newborn made less sense than helping Jim reinvent the magazine. Kuku had no love for D.C. (“Give me a real city,” she would say), but made the best of it, raising the kids and turning our little dining room in Glover Park into a dinner-and-political-debate club for friends. When Fallows was fired eighteen months later, I quit the magazine, a decision Kuku supported. I then went to work as a speechwriter for President Bill Clinton, a decision she really supported. Finally, I was fighting the fight directly.

A White House job is all consuming. I was frequently out the door at 6:30 a.m. and not home until midnight. Kuku half-jokingly called herself a single mother, and that wasn’t far from the truth. But she was extraordinarily proud of what I was doing. To her, public service was sacred. She ultimately got to serve, too, doing press advance for Clinton’s trip to India. We figured her late father was smiling down from heaven.

Kuku was too much of a liberal to be sold on Clinton’s centrist–New Democratic agenda. But she adored the president regardless, because he knew how to win. She had no illusions about the need to gain and hold power, and about what happens when that power is lost. She found Clinton’s dalliance with Monica Lewinsky disgusting, but she fumed at the liberal pearl clutchers who didn’t defend him, almost as much as the Republicans who impeached him.

Around this time, Kuku started having severe pain in her joints. Tests revealed that she had rheumatoid arthritis, an auto-immune disease in which the body slowly destroys its own connective tissue. Her bedside table soon became a mini-pharmacy. The various medications helped some, but seldom stopped the degeneration for long. Every few years for the next twenty she’d have to have a joint replaced—an ankle, a hip, a wrist, both knees. But few outside the family and our closest friends knew how much pain she was in. She simply didn’t complain. “I’m a tough Punjabi girl,” she would say. And she was.

When the administration ended, I took over editorship of the Washington Monthly from Charlie, who was retiring. Kuku, who was working as an office manager at our kids’ public school, agreed to help our new business manager, Claire Iseli, get a grip on our shaky finances. (The two of them brought in $46,000 in much-needed revenue from newsstands that hadn’t been billed for three years.) I then asked Kuku to take over the editing of our book reviews. It was a vital part of the magazine, and I knew she’d be great at it. I already relied on her editing: in all the years we were together I never published any story of significance without having her first read it and mark it up. She took the job, and my faith was borne out. She became a brilliant editor and made the book review section the place where some of the best thinking and writing in the magazine could be found.

It started with the choice of books to put out for review. As editor in chief, I had certain fixed ideas about this, which Kuku respected. But she was strong willed and had definite views of her own, and I knew when to get out of her way. She commissioned more books than I might have on foreign affairs, popular culture, the politics of religion, and American history, especially biographies—subjects she was passionate about and felt the magazine ought to weigh in on. The result was a much livelier and more interesting section.

Another secret to her success was the relationships she built with a growing stable of talented reviewers. Convincing a busy writer to read a turgid 500-page book, wrestle their thoughts into a review, and go through several rounds of often tough editing—all for 10 cents a word—takes diplomatic skill. That Kuku had in abundance. But she also genuinely cared about her writers. She remembered the names of their spouses and kids and asked about them. She got into email back-and-forths with them about politics, baseball, and pasta recipes. She sent them books we got from publishers that we weren’t going to review but she thought they might enjoy. Her writers knew she loved them, and they loved her back. Because of this bond they were more patient with our editorial demands and worked harder than they otherwise might have.

Reviewing nonfiction public affairs books is more craft than art. There are formulas for doing it right: connect the book’s subject to something in the news; tell the reader what’s in the book first before launching into your criticisms of it. And there are certain talents a good book review editor ought to have: a broad knowledge of the world; an ability to challenge or improve a reviewer’s argument; a sense of what readers know and don’t already know about a subject. Kuku had, or developed, all of these talents. She also worked hard, often reading the book in question in order to fix an especially jumbled review.

But it was her literary sensibility that most distinguished her work. She had a highly tuned sense of language: how a sentence sounded; what word would bring delight; how the entirety of a review, when you got to the end, made you feel. That’s what most gave her the ability to make a serviceable review impressive, and an impressive one beautiful.

The editing gig was part time, which suited her, because her greatest passion was being a mother to our children. And not just the ones she had given birth to. She was the second mother to scores of Hope’s and Adam’s friends, who loved to hang out at our house because they knew they would be hugged, fed, and listened to. She treated our young Monthly editors like her children, too, bringing home-cooked food in during late-night closings. (I can still see a young Josh Green rubbing his hands in glee as Kuku walked into the office with a pan of pastitsio.)

Over the last few years, Kuku struggled even more with pain, as well as debilitating fatigue. She worked mostly at home, but continued to come into the office once a week or so to participate in meetings and have lunch with writers or publishing house reps (they loved her too, of course), and then recede into her office, surrounded by a wall of books and photos of her kids. Outwardly, she looked fine—great, actually. Inwardly, two decades of pain were starting to wear down her spirits.

Then, in early July, we both caught a flu. Mine went away, but hers got worse very quickly. (The medicines taken to combat rheumatoid arthritis suppress the immune system.) We took her to the hospital, where she was diagnosed with pneumonia and put in the ICU. Her condition soon escalated to Acute Respiratory Distress Syndrome, a condition in which the lung tissue becomes inflamed and damaged. She was sedated and put on a ventilator. She stayed that way for seven hellish weeks as heroic teams of doctors and nurses tried to save her life. In the end, they could not. On August 29, Kukula Kapoor Glastris, love of my life and mother of our children, passed away. She was fifty-nine.

During those harrowing and heartbreaking weeks in the hospital, and in the difficult weeks that followed, the love and generosity Kuku radiated her whole life came back to us in the form of astonishing support—from our extended families, our friends and neighbors, and the community of current and former Washington Monthly colleagues. Because of that support—the cast on our broken limb—the kids and I are doing okay. (To get a sense of that support, go to the page for Kuku put together by our friend Steve Waldman on LifePosts.com.)

Kuku’s empathy was not just personal, but political, as well. It was a reflection of her bone-deep belief in the liberal philosophy of inclusiveness, of caring for others, especially those who are marginalized and in need, of diverse peoples and faiths being all in this together.

Empathy, like other human traits, falls on a bell curve. Kuku was on one side of that curve, and this fed into and fueled her worldview. Yet it was hard for her to fully fathom that other people did not feel the same way—that they in fact felt threatened by the breaking down of barriers that made her so happy. I spent hours with her trying to make that point, and she could grasp it, for a while. But then her understanding would disappear. Her powers of personal empathy did not extend to those who lack this broader, cross-cultural empathy.

There are tensions in any marriage. Our good fortune was to have tensions that were, mostly, productive. Our three-decade-plus political debate was basically the same one the center-left has been having all these years, and continues to have. The truth is that we agreed on most things, and where we disagreed we influenced and fortified each other—though honesty compels me to admit that she pulled me more in her direction than the other way around.

Another way to put this is that I pretty much absorbed the whole of Kuku’s worldview—political, moral, aesthetic, all of it—into my own. In that way, and many others, she helped shape the publication you are now reading—from the ideas we champion, to the character of the young people we hire, to the way we treat those young people, to the way they look at the world when they leave here. Kuku is no longer with us physically, but everyone here at the Monthly feels her presence. And so, by reading, you will, too.

The post Kuku: A Love Story appeared first on Washington Monthly.

We are, one hears, spending too much time on Appalachia. There are too many dispatches from woebegone towns, coastal reporters parachuting in to ascertain that, yes, the hard-bitten locals are still with their man Donald Trump. There are too many odes to the beleaguered coal miner, even though that entire industry now employs fewer people than Arby’s. Enough already, says the exasperated urban liberal. Frank Rich captured this sentiment in March in a New York magazine piece entitled “No Sympathy for the Hillbilly.” “Maybe,” he mused, “they’ll keep voting against their own interests until the industrial poisons left unregulated by their favored politicians finish them off altogether. Either way, the best course for Democrats may be to respect their right to choose.”

The superficial “downtrodden Trump voter” story has indeed become an unproductive cliché. And upheavals in industries with larger, more diverse workforces than coal, such as retail, deserve close attention as well.

But our decades-long fixation with Appalachia is still justified. For starters, the political transformation of the region is genuinely stunning. West Virginia was one of just six states that voted for Jimmy Carter in 1980; last year, it gave Trump his second-largest margin of victory, forty-two points.

More importantly, the region’s afflictions cannot simply be cordoned off and left to burn out. The opioid epidemic that now grips whole swaths of the Northeast and Midwest got its start around the turn of the century in central Appalachia, with the shameless targeting of a vulnerable customer base by pharmaceutical companies hawking their potent painkillers. The epidemic spread outward from there, sure as an inkblot on a map. People like Frank Rich may be callous enough to want to consign Appalachians to their “poisons,” but the quarantine is not that easy.

We should be thankful, then, for what Steven Stoll, a historian at Fordham University, has delivered in Ramp Hollow: not just another account of Appalachia’s current plight, but a journey deeper in time to help us understand how the region came to be the way it is. For while much has been written about the region of late, the historical roots of its troubles have received relatively little recent scrutiny. Hillbilly Elegy, J. D. Vance’s best-selling memoir of growing up in an Appalachian family transplanted from eastern Kentucky to the flatlands of southwestern Ohio, cast his people’s afflictions largely as a matter of a culture gone awry, of ornery self-reliance turned to resentful self-destruction. In White Trash, the historian Nancy Isenberg traced the history of the country’s white underclass to the nation’s earliest days, but she focused more on how that underclass was depicted and scorned than on the material particulars of its existence.

Stoll offers the ideal complement. He has set out to tell the story of how the people of a sprawling region of our country—one of its most physically captivating and ecologically bountiful—went from enjoying a modest but self-sufficient existence as small-scale agrarians for much of the eighteenth and nineteenth centuries to a dreary dependency on the indulgence of coal barons or the alms of the government.

Stoll refuses to accept that there is something intrinsically lacking in Appalachians—people who, after all, managed to carve out a life on such challenging, mountainous terrain. Something was done to them, and he is going to figure out who did it. He links their fate to other threatened agrarian communities, from rice growers in the Philippines to English peasants at the time of the Enclosure Acts. “Whenever we see hunger and deprivation among rural people, we need to ask a simple question: What went on just before the crisis that might have caused it?” he writes. “Seeing the world without the past would be like visiting a city after a devastating hurricane and declaring that the people there have always lived in ruins.”

The missing history is above all a story about land and dispossession. For roughly a century, starting before the country’s founding, the settlers of central Appalachia—defined by Stoll as the southwestern corner of Pennsylvania and most of West Virginia—managed a makeshift life as smallholders. The terms of that “holding” were murky, to say the least: property claims in the region were a tangled patchwork of grants awarded to French and Indian or Revolutionary War generals and other notables, which were commonly diced and sliced among speculators, and the de facto claims made by those actually inhabiting the land. In some cases, those settlers managed to get official deeds by the legal doctrine of “adverse possession”; in many others, they were simply allowed to keep working the land by distant landlords who had never laid eyes on it.

Regardless of the legal letter, the settlers carved out their “homeplace,” as Stoll calls it. He is evocative in describing their existence, but stops short of romanticizing it, and takes pains to note that their presence was itself founded on the dispossession of the natives. They practiced “swidden” agriculture—burning out one clearing for cultivation, then letting it regenerate while rotating to another area—likely introduced by Scandinavians mixed in with the predominant Scots-Irish. Survival depended on shared use of the boundless forest beyond one’s own hollow or ridge—the “commons”—for hunting game, raising livestock, small-scale logging, and foraging bounties such as uganost (wild greens), toothworth, corn salad, and ramps. “People with control over a robust landscape work hard, but they don’t go hungry,” remarks Stoll.

Yet it was the area’s very natural bounty that would ultimately spell the end of this self-sufficiency. The Civil War’s incursions into the Shenandoah Valley and westward exposed the region’s riches in exactly the minerals demanded by a growing industrial economy. (By 1880, there were 56,500 steam engines in the country, all voracious for coal.) “Her hills and valleys are full of wealth which only needs development to attract capitalists like a magnet,” declared one joint-stock company. In swarmed said capitalists, often in cahoots with local power brokers from Charleston and Wheeling.

The confused legal property claims offered the aspiring coal barons a window: they could approach longtime inhabitants and say, essentially, “Look, we all know you don’t have full title to this land, but if you sell us the mineral rights, we’ll let you stay.” With population growth starting to crimp the wide-ranging agrarian existence, some extra cash in hand was hard to reject. Not that it was very much: one farmer turned over his 740 acres for a mere $3.58 per acre—around $80 today. By 1889, a single company, Flat Top Land Trust, had amassed rights to 200,000 acres in McDowell County in southern West Virginia; just thirteen years later, McDowell was producing more than five million tons of coal per year.

The coal industry had a positively soft touch in the early going, though, compared to timber. Stoll describes the arrival of the “steam skidder,” which “looks like a locomotive with a ship’s mast.” It “clanks and spits, chugs steam, and sweats grease from its wheels and pistons” as workers use cables extending from the mast to grab fallen trees, “pulling or skidding the logs hundreds of feet to a railroad flatbed.” The steam skidder crews would cut everything they could, “leaving the slopes barren but for the stumps, branches, and bark that burned whenever a spark from a railroad wheel or glowing ash from a tinderbox fell on the detritus.”

The harvest was staggering: “Of the 10 million acres that had never been cut in 1870, only 1.5 million stood in 1910.” Stoll quotes one witness from the time: “One sees these beautiful hills and valleys stripped of nature’s adornment; the hills denuded of their forests, the valleys lighted by the flames of coke-ovens and smelting furnaces; their vegetation seared and blackened . . . and one could wish that such an Arcadia might have been spared such ravishment. But the needs of the race are insatiable and unceasing.” Indeed, they were. As one northern lumberman put it: “All we want here is to get the most we can out of this country, as quick as we can, and then get out.”

Such rapaciousness did not leave much of the commons that had sustained the makeshift agrarian existence. Of course, there was a new life to replace it: mining coal or logging trees. By 1929, 100,000 men, out of a total state population of only 1.7 million, worked in 830 mines across West Virginia alone. But it is in that very shift that Stoll identifies the region’s turn toward immiseration. With the land spoiled and few non-coal jobs available, workers were at the mercy of whichever coal company dominated their corner of the region. They lived in camps and were paid in scrip usable only at the company store; even the small gardens they were allowed in the camps were geared less toward self-reliance than toward cutting the company’s costs to feed them.

Stoll quotes a professor at Berea College in eastern Kentucky who captured the new reality in a 1924 book: The miner “had not realized that he would have to buy all his food. . . He has to pay even for water to drink.” Having moved their families to a shanty in the camp, miners owed rent even when the mine closed in the industry’s cyclical downturns, which served to “bind them as tenants by compulsion . . . under leases by which they can be turned out with their wives and children on the mountainside in midwinter if they strike.” As Stoll sums it up, “Their dependency on company housing and company money spent for food in company-owned stores amounted to a constant threat of eviction and starvation.” Of course, Merle Travis had this dynamic nailed way back in his 1947 classic, “Sixteen Tons”: “You load sixteen tons, what do you get? / Another day older and deeper in debt. / Saint Peter, don’t you call me, ’cause I can’t go, / I owe my soul to the company store.”

Nor did the industries bring even a modicum of mass prosperity to compensate for this dependency. By 1960, more than half the homes in central Appalachia still lacked central plumbing, helping give rise to all manner of cruel stereotypes and harsh commentary, such as this, from the British historian Arnold Toynbee: “The Appalachians present the melancholy spectacle of a people who have acquired civilization and then lost it.” An extensive 1981 study of eighty Appalachian counties by the Highlander Research and Educational Center in Tennessee confirmed that, in Stoll’s summary, coal company capital had brought “stagnation, not human betterment,” and a “correlation between corporate control and inadequate housing.”

“Banks in coal counties couldn’t invest in home construction or other local improvements because the greater share of their deposits belonged to the companies,” Stoll writes. “No sooner did that capital flow in than it flowed out, depriving banks of funds stable enough for community lending.” Not only had the coal industry, along with timber, supplanted an earlier existence, but it was actively stifling other forms of growth and development.

Stoll recounts a scene from 1988, when a man named Julian Martin got up at a public hearing to oppose a proposed strip-mining project in West Virginia. Martin described the disappearance of Bull Creek along the Coal River, which he had explored as a kid decades earlier. He pointed out that places that had seen the most strip mining had also become the very poorest in the state. “My daddy was a coal miner, and I understand being out of work, okay?” Martin said. “I’ve been down that road myself. And I know you’ve got to provide for your family. But I’m saying they’re only giving us two options. They’re saying, ‘Either starve—or destroy West Virginia.’ And surely to God there must be another option.”

It’s a powerful moment, and it captures the tragic political irony that is one of the most lasting fruits of the region’s dependency: despite all the depredations of resource extraction—all the mine collapses and explosions (twenty-nine killed at Upper Big Branch in 2010) and slurry floods (125 killed in the Buffalo Creek disaster of 1972) and chemical spills (thousands without drinking water after the contamination of the Elk River in 2014)—many inhabitants, and their elected representatives, remain fiercely protective of the responsible industries. Even the empathetic Stoll can’t help let his frustration show, as he urges the “white working class of the southern mountains to stop identifying their interests with those of the rich and powerful, a position that leaves them poorer and more powerless than they have ever been.”

Well, yes, but many a book has been written to explain why exactly the opposite trend has been happening, as Appalachia turns ever redder. It shouldn’t be that hard to make sense of the coal-related part of this political turn, and voters’ rightful assessment that coastal Democrats are hostile to the industry. The region has been dominated by mining for so long that coal has become deeply interwoven with its whole sense of self. Just last month, I was speaking with a couple of retired union miners in Fairmont, West Virginia, who are highly critical of both coal companies and Trump, and suffer the typical physical ailments from decades spent underground. Yet both said without hesitation that they missed the work for the camaraderie and sense of purpose it provided. Their ancestors identified as agrarians; they identified as miners.

Stoll is on more original and compelling ground as he tries to determine what that “other option” might be for the region. He imagines a “Commons Communities Act,” under which land would be set aside for shared use, not unlike the great forests of old—farming, timber harvesting, hunting and gathering, vegetable gardening, cattle grazing—by a specified number of families. Residents would own their own homes and could pursue whatever sort of work they cared to beyond their use of the commons. Social services and education in the communities would be paid for by a surcharge on the top 1 percent of U.S. households and an “industrial abandonment tax” on any corporation that “closed its operations in any city or region of the United States within the last twenty years . . . and moved elsewhere, leaving behind toxic waste and poverty.”

It is an admittedly fantastical vision that will fare better with Wendell Berry than with Congress or the West Virginia legislature. But in one sense, it is not so far-fetched after all. Coal is on the wane in central Appalachia, however much uptick it enjoys in the Trump era. Not only is it being undercut by natural gas, but the easily obtainable reserves are gradually tapping out, at long last. Coal’s decline is having wrenching effects on its dependents, not least the depletion of local government and school coffers. Something will have to replace it, and the odds of Amazon picking Morgantown or Charleston for its second headquarters are slim. West Virginia’s population has fallen by nearly 10 percent from its peak in 1950, a reversal of the crowding that helped bring the agrarian existence to an end more than a century ago. So perhaps it is not so crazy after all to suppose that a region so proud of its heritage could reach back to an earlier, almost-forgotten part of it, before the steam skidder showed up, and lay new claim to its land.

This piece was co-published by ProPublica.

The post What J. D. Vance Doesn’t Get About Appalachia appeared first on Washington Monthly.

What good is Congress?” Josh Chafetz provokes readers with this question at the outset of Congress’s Constitution. It certainly is a timely query, given that nine out of ten Americans now routinely tell Gallup that they disapprove of how Congress does its job. Americans on both the left and the right are increasingly fed up with what is meant to be the people’s branch. Major problems and campaign promises languish on Capitol Hill, while the pace of tit-for-tat hyper-partisanship escalates alongside the flow of money and influence that fuels congressional politics. Yet Chafetz’s compelling new book, in combination with the presidency of Donald Trump, bids us to consider Congress’s roles and contributions in a new light. Even those more inclined to be skeptics after the 2016 election may reconsider their views by the time Trump leaves office.

Consider what’s happened since Trump’s inauguration. The GOP’s drive to repeal and replace the Affordable Care Act, despite seven long years of pent-up legislative fury—and all sorts of Twitter-borne cajoling and threats from @realDonaldTrump—ran aground on the opposition of dissident Republican senators who refused to cede legislative leadership to the White House and Senate Majority Leader Mitch McConnell. Arizona Senator John McCain, in the same week he cast a dramatic and decisive “no” vote on ACA repeal, declared on the Senate floor, “We are an important check on the powers of the executive. Our consent is necessary for the president to appoint jurists and powerful government officials and in many respects to conduct foreign policy. Whether or not we are of the same party, we are not the president’s subordinates. We are his equal!” Elsewhere, Congress has so far stiffed the president by refusing to fund his promised wall on the Mexican border, the centerpiece of his campaign. And arguably the most important legislation this Congress has passed to date—a bill tying Trump’s hands on Russian sanctions—was enacted over his strong objections by veto-proof and bipartisan majorities.

Congress has checked and balanced Trump in other ways. Much to the president’s frustration, Congress has continued bipartisan investigations into Russia’s involvement in the 2016 election (along with the possible collusion of Trump’s campaign). Twenty million Americans watched as former FBI Director James Comey gave his compelling testimony before the Senate Intelligence Committee, whose bipartisan investigation continues apace. Judiciary Committee members, including Chairman Chuck Grassley and fellow Republicans Ben Sasse and Lindsey Graham, have warned Trump that he would place his administration in even more jeopardy should he get rid of Attorney General Jeff Sessions, who has recused himself from the Russia investigation, as a way to eliminate Special Counsel Robert Mueller.

When Trump stumbled into his implicit endorsement of the neo-Nazis and Ku Klux Klansmen who marched with violence in Charlottesville, GOP leaders in Congress piled on rather than defending him, condemning white supremacy while the president flailed away with his “both sides” gambit. In September, Congress unanimously passed a joint resolution condemning the white supremacist hate groups responsible for the violence and calling on the president to repudiate these groups and their views. Trump may be sticking with his race baiting, but Congress effectively gave him no choice but to sign a resolution that overrode it.

This Republican-led sabotage of the traditional honeymoon period for a new administration might surprise the majority of Americans who have lost confidence in Congress. But these developments come as no surprise to Chafetz, whose book serves as a much-needed corrective to the view that Congress must always be the patsy in the ongoing contest of ambition between and among government’s three branches.

Congress’s Constitution focuses not on the institution’s most visible and collective law-making powers, but rather on how Congress, its two chambers, and individual legislators can deploy nonlegislative powers to check and balance the other branches, the executive in particular. Chafetz believes that “the exclusively legislation-focused view of Congress is far too narrow.” Given the difficulty of overriding a presidential veto, and the Supreme Court’s powers of judicial review, legislation is often not the best weapon for Congress to ward off inter-branch encroachments on its powers. Indeed, as noted above, the acts of congressional rebellion we’ve seen so far have had relatively little to do with legislating, of which there hasn’t been much, and everything to do with Congress’s other powers, such as its power to oversee and investigate the executive branch, to withhold appropriations for executive priorities, and to use its sturdy platform to speak freely in criticizing presidential missteps and overreach.

Chafetz traces the development of Congress’s nonlegislative powers back to the tumultuous political battles between Parliament and the Stuart monarchs in seventeenth-century England. This is an atypical but illuminating starting point. As he notes, the “conflict between Parliament and the Stuart Crown involved contending claims by institutional actors with independent sources of constitutional authority. These conflicts occurred before the rise and solidification of parliamentary sovereignty and ministerial responsibility to Parliament in the early eighteenth century.” The stakes and imperatives of Parliament’s running battle with the Stuart kings—punctuated at one point by a royal beheading, at another by the Glorious Revolution—were thus especially influential among the American colonial legislators later in the eighteenth century as they sought to protect their liberties against colonial governors. Chafetz carries the story forward through the revolutionary and founding periods to the present day with great effect.

The heart of Congress’s Constitution is six chapter-length assessments that bring this historical arc to bear on different sets of Congress’s nonlegislative powers. Borrowing a useful framework from international relations theory, Chafetz groups them into “hard” powers that enable Congress to coerce other branches and “soft” powers it can deploy to build up its public standing.

Congress’s hard powers include cinching the purse strings—for example, withholding appropriations, perhaps the ultimate nonlegislative act (as Trump is finding out with his wall). These powers also include the personnel powers of appointments, removals, and impeachment. The forced withdrawal of fast food CEO Andrew Puzder as Trump’s nominee for secretary of labor in the face of Senate rejection of his nomination is but the latest example of Congress wielding this set of powers; and we can bet Trump’s lawyers are not dismissing the possibility of impeachment. Finally, Congress has the hard power to subpoena witnesses and hold those who do not comply in contempt, a prerogative that backstops congressional oversight and investigations such as those now focused on the Russian affair.

Congress’s soft powers include “the ability of Members to engage discursively in the public sphere,” as protected by Article I’s “speech or debate” clause, as well as the ability to discipline members for legal or ethical violations and affronts to good order and decorum. The ham-fisted and quickly spiked attempt to kill the Office of Congressional Ethics at the start of this Congress points to the resonance of this power. Constituents want it even if some members of Congress do not. Finally, Congress has the soft power to set and play by its own rules, which can either bolster congressional capacity and legitimacy or, alternatively, undermine them (as has been the case with the GOP’s insistence on a partisan process for developing its various repeal-and-replace schemes).

While Chafetz focuses on Congress’s nonlegislative powers, the book also assesses how the separation of powers works in practice. His vantage point on this constitutional arrangement “highlight[s] the ways in which claims of authority multiply and overlap in a nonhierarchical constitutional order.” No one branch can effectively be the boss of either of the others; they are always jockeying for position in constitutional politics, fighting over and deciding who gets to decide, caught up in a rivalry for which there is no natural or logical stopping point. Yet there is some restraint, for the contest between Congress and the president occurs in the public sphere, with citizens watching. Officeholders need to make and rebut constitutional arguments in a compelling fashion for their position to win. Chafetz argues persuasively that this context privileges “not maximal combativeness but rather judicious combativeness” (his emphasis).

More broadly, Chafetz assumes a perspective that runs counter to typical notions of power flowing upward from the people to politicians who share and support their constituents’ points of view. Chafetz argues instead that elected officials—in Congress no less than the White House—create their own political power and authority based on the wisdom and popular appeal of what they say and do. In short, political leadership shapes its own fate, garnering or losing public legitimacy and the political leeway that comes with it. Consider how Trump’s biggest constitutional blunders so far—his travel ban and the firing of James Comey—have led to a public backlash and the other two branches of government boxing him in.

In making his case, Chafetz also challenges the argument that the current state of party polarization has led to the separation of parties, not powers, and that unified control of government by one party, as at present, leaves us with insufficient checks and balances. Chafetz observes that unified control is one thing in theory, quite another in practice. Moreover, the comparatively loose-jointed nature of American political parties, reinforced by the lack of centralized party control over nominations and policy positions, deflates the argument that party discipline can consistently override the institutional dynamics of the separation of powers. Finally, while intermittent, members of Congress can and do join forces across the aisle to defend their prerogatives and check the presidency, as we are now witnessing. However much President Trump feels betrayed and blocked by swamp-dwellers, legislators, federal judges, blue state officials, and others, he is simply the latest president to confront these realities.

Chafetz’s contribution is to rehabilitate not only the separation of powers but also Congress’s ability, through its nonlegislative powers, to hold its own within this system. That said, the suite of powers Chafetz describes will need expansion if Congress is going to assert itself institutionally, as he calls for it to do. One of these supplemental soft powers is the ability to clean up the illicit influence of moneyed interests that many citizens, not unreasonably, are convinced is corrupting the institution. A good place to start would be bolting shut the revolving door to K Street through which more than 50 percent of retired members pass after they leave office, according to the Center for Responsive Politics. Democratic Senators Michael Bennet and Al Franken and Republican Senator Cory Gardner have introduced a bill that would, among other things, ban former members from lobbying for the rest of their lives.

Another good step would be campaign finance reform. Legislators spend countless hours—up to half of their time, for legislators in competitive seats—dialing for dollars to support their next election campaign or those of their copartisans. Not surprisingly, many constituents see legislators as working primarily for their donors or their parties’ coffers, not them. But some promising reform ideas are now percolating. For example, Maryland Democratic Representative John Sarbanes has a bill that would help level the playing field and reconnect members with their constituents by providing a $25 tax credit to support individual small donor contributions, which would be matched by public funds in a six-to-one ratio for those candidates who swear off big contributions and PAC money. It’s not perfect, but it is a start down the road that members of Congress will eventually need to travel if they want to restore public confidence in their institution—and free up the time they need to carry out their constitutional responsibilities.

An additional soft power that Congress must exercise to restore its institutional heft is to fully fund the staff capacity and expertise it needs, in member offices, committees, and nonpartisan legislative support organizations like the Government Accountability Office and the Congressional Research Service. Chafetz notes that legislative reorganization acts passed by Congress in 1946 and 1970 bulked up this capacity, in part to provide for more systematic oversight and investigations of the executive branch. But when the GOP gained its dual congressional majorities in the mid-1990s, they shrank House committee staffs by one-third, disbanded the Office of Technology Assessment, and cut the budgets of the GAO and CRS. In effect, they lobotomized the institution they had fought so long to win control of at the very moment they should have been optimizing its capacity. Congress’s budgets and staff horsepower have never recovered. Until Congress allows itself—and pays for—the quantity and quality of staff and expertise it needs, its members cannot begin to oversee the executive branch adequately and will continue their overreliance on lobbyists for policy advice.

In fairness, lobbying and campaign finance reforms, along with more ample legislative appropriations, require new laws. Chafetz has thus not included them in his survey of Congress’s essential nonlegislative powers. But they will be necessary for Congress to fully exercise the powers that he has illuminated.

Will Congress rise to the occasion? That remains to be seen. Chafetz’s impressive accounting of Congress’s hard and soft powers is not a story of constitutional constancy among our representatives and senators over the years. For every episode of steadfastness, there is another of fecklessness. In tracing these vignettes, Chafetz shows us that Congress and its members can choose to exercise the considerable suite of constitutional powers at their disposal, or neglect them; they can do so judiciously, or rashly; and they can gain standing in the eyes of the people as a result, or lose it. Chafetz observes, “It is a contention of this book that Congress has the capacity to behave so as to foster public trust and thereby enhance its own power; it is likewise a contention of this book that Congress has only sometimes taken advantage of that capacity.” In the current moment, the former point should give us hope, and the latter should push us to demand that our elected representatives meet the challenge before them. For his part, Chafetz has given them a time-tested playbook to draw upon.

The post The Hidden Powers of the People’s Branch appeared first on Washington Monthly.

In 2014, a fund-raising gimmick involving dumping a bucket of ice water over somebody’s head raised $100 million toward research to conquer amyotrophic lateral sclerosis. Often known as Lou Gehrig’s disease, ALS is a devastating neurological illness that paralyzes the patient inch by inch, until the person can no longer speak, swallow, or breathe. Most people with ALS live less than two years after diagnosis.

The outpouring of generosity triggered by the ice bucket challenge was impressive. But it might have been dampened if donors had known an unpleasant fact about the research they were funding: one reason we don’t already have any effective treatment, much less a cure, is that ALS drug research has been done exceedingly poorly. In 2010, researchers at the ALS Therapy Development Institute, based in Cambridge, Massachusetts, launched a review of the animal experiments that serve as the basis for candidate drugs. Every single study had used too few mice to get a valid result. Some studies used as few as four mice. Four. Often, the researchers hadn’t had enough funding to use more mice. But regardless of the reason, when the institute conducted the same studies with enough mice, all the drugs failed to show a real effect—meaning that donors and funders, including drug companies and the federal government, had spent tens of millions of dollars on trials involving human ALS patients on the basis of spurious animal results.

This problem of “irreproducibility” of scientific results, also known as “research waste,” has begun to get some attention in both academic circles and the press, as more and more experiment results taken at face value have turned out to be false when subjected to retesting. The crisis is not so much a shortcoming of the scientific method itself, as some have suggested, but more that scientists aren’t adhering to it. Poorly designed and analyzed research is infecting the biomedical literature, causing other researchers to try to build on results that are the data equivalent of a house of cards.

Biomedical research is a $240 billion annual global endeavor. The United States is the biggest funder, with $70 billion in commercial spending and another $40 billion from nonprofits and government, mostly the National Institutes of Health. We are rightly known as the greatest research engine in the world. American labs are a wellspring of drugs and biologics that have eased suffering for millions of people.

But as Richard Harris argues in Rigor Mortis, bad science is rife in labs, both commercial and academic. Harris, a veteran National Public Radio science reporter, documents a litany of slipshod practices and biased analyses that have produced a disheartening series of scientific dead ends. Cutthroat academic competition, a headlong rush to publish in “high-impact” journals, and scarce funding all lead researchers to cut corners, and the self-correcting mechanisms of science can’t keep up.

Harris tells the story of C. Glenn Begley, a biologist who spent ten years as the head of a cancer research team at the biotech company Amgen. Begley and his team would start their research by scouring the basic science literature for promising studies, mostly by academics. (Basic science involves experiments on cellular material, whole cells, or animals, while clinical research involves human subjects.) Then they would repeat the original studies whose results suggested the most potential for new cancer drugs. Those they could validate would move on to the next phase of drug development.

After a decade, Begley decided to take stock of all the studies that had initially looked the most groundbreaking. He chose fifty-three to do over.

This time, the Amgen team asked for help from the scientists who had published the original results. They blinded the studies, which means that none of the researchers knew which was the treatment group and which was the control. (That’s a crucial way to weed out unconscious bias. If you’re testing a drug to grow hair, for instance, and you know which group is getting the drug and which the placebo, you may see hair growth among the test group even where it doesn’t exist, and discount hair growth among the placebo group.) Only six of the fifty-three re-experiments produced positive results. Begley and a colleague published the research as a commentary in the journal Nature in 2012—to resounding silence.

Harris points to other failures, many of them due to assumptions that what works for laboratory animals, mostly mice and rats, will work for people. “Lab animals are not small, furry humans,” he writes. He points to a series of experiments run by a Stanford lab that wanted to understand why, after decades of research, there has been virtually no progress in treating the serious, systemic infection known as sepsis. Sepsis, which involves an overreaction by the immune system’s inflammatory response, kills more than 200,000 Americans a year and costs hundreds of millions of dollars to treat.

The Stanford team decided to look at the genetics of the mouse strain that serves as the model for the vast majority of sepsis studies. They compared the 5,000 genes known to be involved in sepsis in humans to genes in the mouse model. Very few of the genes were turned on in the mice with sepsis, suggesting that the biology of the disease in the two species is radically different—and that decades of research on inflammation using those mouse strains had been a waste of effort.

No area of basic biomedical research appears to be immune. For many years, the National Cancer Institute promoted a line of breast cancer cells that could grow in a petri dish and were used in hundreds, if not thousands, of tests of potential breast cancer drugs. Those cell lines turned out to be melanoma, not breast cancer. More than 700 studies using a cell line called U-373 to study glioblastoma, a deadly form of brain cancer, turned out to be so full of mutations, writes Harris, that “they barely resembled glioblastoma at all.”

Nobody who understands the meandering, nonlinear path taken by scientific progress would argue that every study published should be true. As Harris puts it, the equivalent of a .300 batting average in biomedical science would be phenomenal, because much of biomedical science is about probing cellular and genetic mechanisms that are invisible. All science is iterative and looping, with one result being invalidated only to open a new line of investigation.

Serendipity plays a crucial role: breakthroughs in one arena often occur because a curious scientist was noodling around in an entirely different field. The discovery of an enzyme in an “extremophile” bacterium, which lives near undersea volcanic vents in water that can reach more than 175 degrees, led to the development of the polymerase chain reaction, or PCR, a Nobel Prize–winning technology that is now an essential instrument in genetics and diagnostics. A spinoff from research into the effect of electric fields on bacterial growth led to the development of potent anticancer compounds, such as cisplatin.

More than half of the total resources invested in biomedical research are allocated to basic research, and most ideas for studies are initiated by scientists themselves. This is a good investment—but only if the studies are conducted with rigorous attention to good scientific practice. It might sound strange, but good science is all about doing everything you can to find fault with your own theory. Or, as physicist Richard Feynman once put it, the first principle of science “is that you must not fool yourself—and you are the easiest person to fool.” Much of what ails the bad research that Harris chronicles—the poor lab techniques, incorrect application of statistics, selective reporting of data, and refusal to move away from studies that have been found to be faulty—seems to result from failing to adhere to this golden rule.

In Harris’s view, much of the irreproducibility problem has been driven by two interrelated forces: the ferocious competition for funding, and the culture of academic prestige. Researchers are judged by academic institutions, and often by their peers, on the basis of the number of papers they publish in journals with a high “impact factor.” At the top of the heap are Nature, Cell, and Science, which publish the papers that are cited the most often by other researchers—which means more eyeballs on their pages. For the journals, that translates into revenue from subscriptions and advertising. By that measure, People magazine has a much bigger impact factor than, say, the Atlantic or the Washington Monthly. And, like People, the high-impact journals often seek to publish the most fashionable, glitzy, eye-popping results, even if they are likely to turn out to be dead wrong.

Then there’s what I call the bullshit factor, the hyping of every little finding, no matter how preliminary, by academic research centers, which are ballyhooed by the press, all in the name of ginning up more money for research and more prestige for the institution—which, of course, leads to more money.

Harris’s principal remedy for the irreproducibility problem is greater scientific rigor, and many of his suggestions seem so obvious that it’s hard to believe they aren’t already standard practice: Check cell lines before beginning an experiment that depends on the cell line being correct. Use the right statistics. Use a big enough sample size to ensure that your results are not the result of chance. (Seriously. Four mice?) Harris quotes Malcolm Macleod, a stroke researcher at the University of Edinburgh, who says, “I simply don’t understand the logic that says I can take a drug to clinical trial [in human subjects] on the basis of information from 500 animals, but I’m going to need 5,000 human animals to tell me whether it will work or not. That simply doesn’t compute.”

Others have called for better peer review by journals, which are supposed to serve as gatekeepers of good science but so often simply fill their pages, sell ads, and don’t take responsibility to correct the record, even when faulty results are pointed out.

But addressing the root causes of all this shoddy science will not be so easy. Academic institutions should stop training so many PhD researchers, who are now forced to compete for a small handful of open academic and industry positions when they finish their studies. Of course, academic institutions don’t want to do that, because those grad students and postdocs are the cheap labor that keeps university labs humming. And universities need those labs to keep bringing in the grants that provide overhead fees that keep the rest of the university afloat. The few lucky postdocs who get hired may be those who have figured out how to game the publication race and produce the most papers, rather than the most creative and rigorous researchers.

Once hired, young researchers must then make a mad dash to publish as many articles as possible—in journals with as high an impact factor as possible—before they come up for tenure review. This encourages a focus on the quantity of studies and research that will guarantee short-term success, preferably in some fashionable area, even if it involves using slapdash methods.

It can feel overwhelming to think of the money being wasted and the patients who wind up participating in clinical trials that were futile from the start. Simply exhorting basic science researchers to be more rigorous hardly seems sufficient to halt the rush to get results. Until someone can find a way to alter the economic imperatives of academia and biomedical journals, we’re probably going to continue to see more research results that serve the cause of neither good science nor good medicine.

The post Trial in Error appeared first on Washington Monthly.

There was a time, in the not-so-distant past, when the U.S. Congress held hearings, drafted legislation in committees, and passed public-spirited bills into law with bipartisan support. Those of us who see this as the model for how Congress should operate often harken back to the mid-1960s through the late 1970s as a kind of golden age.

Michael Pertschuk was there for all of it. He arrived in Washington in 1962 as a junior staffer and worked his way up to staff director of the Senate Commerce Committee before leaving in 1977 to chair the Federal Trade Commission. His new book, When the Senate Worked for Us, is a memoir of his time as a staffer, and its thesis is straightforward: Congressional staff are really important. It was staffers like Pertschuk and his colleagues who did the hard work of shepherding consumer protection bills into laws. Lawmakers themselves—well, at least Pertschuk’s boss, Washington Senator Warren “Maggie” Magnuson—achieved their legislative legacies largely because their staff made it possible.

Pertschuk, now in his eighties, wants to inspire a younger generation. “I have been saddened,” he writes, “by how few look to government as the answer for themselves or for the country. . . . My fondest hope is that this book will awaken the interest of young people to the potential rewards of working in the federal government.”

Pertschuk’s stories do make being a congressional staffer seem exciting and rewarding. But they also reveal a political environment that was very different from today’s, one in which hard-charging do-gooder staffers had far fewer obstacles in their way, and in which a jovial but somewhat checked-out senator was comfortable delegating considerable policy development to a remarkably independent staff with little concern for fund-raising or the party brand.

So many of the details seem implausible in today’s Washington. But the comparisons are useful, because they remind us how much work it will take to build a Congress that can work for us again.

The book’s key story begins in 1962, when Magnuson, then fifty-seven, narrowly won reelection to his fourth term, receiving only 51 percent of the vote against a weak challenger. This put a scare into the senator—who had won his previous reelection with 62 percent of the vote—and his staff.

Jerry Grinstein, the hero of Pertschuk’s story, had been working as staff counsel for Magnuson on the Merchant Marine subcommittee, but in early 1963 got a promotion to staff director of the Senate Commerce Committee. His assignment was to find a way to use Magnuson’s committee chairmanship to propel him to a strong reelection in 1968.

Grinstein’s plan was to make Magnuson into a consumer champion. In the past, the senator had run as a bring-home-the-bacon kind of candidate, touting the federal dollars he had directed to Washington State’s dams and ports. But this was the early 1960s, the age of John F. Kennedy, and voters seemed to want something newer and bolder. Grinstein intuited that consumer protection was an emerging issue that fit the times. He drew up plans for a new consumer protection subcommittee within the Commerce Committee and hired Pertschuk, a young Yale Law School graduate who had recently come to Washington to work for Oregon Senator Maurine Neuberger, to a counsel position.

The first challenge was getting Magnuson to even agree to create the subcommittee, which he did reluctantly. As Pertschuk recalls, “Jerry’s task in harnessing Magnuson’s power for the public good was complicated by Magnuson’s insecurity, his resistance to change, his need to ingratiate himself even to Republican conservatives, and his preference for compromise driven by his aversion to conflict and confrontation.”

Magnuson comes across as a genial but cautious consumer champion. In Pertschuk’s telling, the important thing was that he could be prodded into doing well by doing good, presuming the incentives were cast in the right way for him. Thus, the next challenge was getting Magnuson to see that the consumer protection stuff was good politics. The first win came in 1965, when Pertschuk and Grinstein helped Magnuson shepherd into law a bill that would, for the first time, require all cigarette packages to have warning labels. After mostly favorable press coverage, “Magnuson’s image as the consumer’s champion began to glow, and his initial chill toward me melted,” Pertschuk writes. “Jerry was now freer and more able to free me and our staff colleagues to initiate (on Magnuson’s behalf) a wide range of consumer protection and other public health and public interest initiatives.”

Next came auto safety. In 1965, Ralph Nader published a scathing exposé of the auto industry, Unsafe at Any Speed. A year later, Congress passed the landmark National Traffic and Motor Vehicle Safety Act, which Pertschuk played a key role in writing. He did so with tremendous help from Nader, whose “passion and inexhaustible energy,” he writes, “was the greatest moving force behind that law.” So close were the two, Pertschuk recalls, that “apart from my wife and children, I spent more time talking with him than anyone else.” (Once, when Nader attended a birthday party for Pertschuk, Pertschuk’s wife extracted a birthday gift promise from him—to stop calling after 10 p.m.) Pertschuk’s close relationship with Nader shows that even then, congressional staff were not entirely independent, and skilled lobbyists (public interest or otherwise) could effectively serve as adjunct congressional staff.

In Pertschuk’s account of getting the vehicle safety bill passed, a few details stand out. First, the auto industry was caught flat-footed in a way no major industry would be now. General Motors’s clumsy response was to hire private detectives to try (unsuccessfully) to dig up dirt on the monkish Nader. This backfired. The publicity surrounding the ensuing harassment lawsuit was a public relations disaster for General Motors, and Nader used the $425,000 settlement to fund his growing network of watchdog groups.

Second, public interest lobbyists, led by Nader, were on roughly equal footing with industry. Pertschuk recalls how, while drafting the committee report on the bill, he had the industry lobbyist Lloyd Cutler in one adjoining room and Nader in the other. Today, the public interest side would be outgunned twenty or thirty to one by industry advocates.

Third, congressional hearings mattered. Staffers planned hearings carefully, confident that the right witnesses would matter—both in persuading senators and (more importantly) getting good press coverage. There was a genuine fact-finding quality to these hearings, a methodical building-the-case approach that today’s congressional procedures lack. Today, most hearings are merely scripted partisan theater, in which both sides present witnesses not to persuade anyone, but to generate sound bites; everybody’s mind is already made up.

Finally, in the current climate, party branding and messaging dominate congressional decisionmaking. In the 1960s, partisan identity was less central, and candidates ran on their personal brand. So it really did matter what individual members did in Congress.

As 1968 loomed, onlookers, and Magnuson himself, thought the big threat to Magnuson’s reelection was the popular Republican governor, Daniel Evans. Privately, Grinstein knew that Evans didn’t want to run for the Senate. But he wanted to make sure Magnuson didn’t find that out. Otherwise, he worried, the senator would lose interest in consumer protection.

In 1968, Magnuson ran on the campaign slogan “Keep the big boys honest. Let’s keep Maggie in the Senate.” His campaign staff put up billboards triumphing his consumer protection laws. But, Pertschuk writes, Maggie was uneasy. “I like it,” he told the staff. “But how come [the message is] all on consumers? . . . How about something like education and civil rights and ‘Veetnam’?” An adviser asked him what he had done on those issues. He was silent.

Magnuson won reelection, and soon after, Pertschuk became staff director of the Commerce Committee, which Magnuson continued to chair. The senator trusted Pertschuk, but seemed increasingly checked out (among other things, he was drinking more and more vodka). Magnuson’s standard direction was “Do what you think is right—so long as you don’t get me into trouble.”

By the early 1970s, Pertschuk had assembled a large staff with growing policy expertise, broad alliances inside and outside the institution, and a strong esprit de corps. The staff members called themselves “Bumblebees”—an epithet bestowed on the young staffers by John Ehrlichman, Richard Nixon’s domestic policy adviser, who complained about all the new regulatory laws Magnuson’s staffers generated.

Pertschuk recalls the work of the committee in the 1970s as a series of vignettes, recalling a cast of savvy and enterprising staffers and the public interest bills they ushered into law. Take, for example, Manny Rouvelas, a counsel on the Merchant Marine subcommittee. Rouvelas took it upon himself to learn about the safety and environmental hazards of ocean shipping, then decided he had to do something about it. When an oil spill at an Atlantic Richfield Refinery in Cherry Point, Washington, threatened to pollute Puget Sound, Rouvelas had his opportunity to get Magnuson engaged.

Rouvelas skillfully organized hearings on maritime safety and pushed for new vessel construction requirements. The requirements were opposed by both big oil companies and foreign governments, because it meant they’d have to spend huge sums on upgrading the safety of their ships. Even the State Department, at the prodding of foreign governments, opposed the bill. But Rouvelas helped speed passage of the provisions through the committee before committee members could be swayed by the official State Department opposition. Magnuson fought hard, and when Nixon signed the Ports and Waterways Safety Act in 1972, it included the safety requirements Rouvelas had secured.

“The longer we stayed,” Pertschuk writes, “the more useful to the committee we became.” Experience mattered, and staffers then had far more of it than now because they stuck around much longer. The more expertise the staff accrued, the more Magnuson relied on them—to the point where, Pertschuk writes, the senator sometimes “even reluctantly agreed to introduce a bill that we pressed him on, despite harboring serious doubts about it.”

Was this increasingly blind trust a good thing? In practice, with a large and entrepreneurial staff, it worked well. When I worked as a Senate staffer, in 2009–10, most senators I encountered also relied deeply on their staff and delegated considerable policy development to them. The ideal of the well-informed senator, carefully weighing all aspects of policy and debating it with colleagues, existed only rarely. More common was staffers working out policies and then filtering them up to their bosses in ways that gave the latter the final sense of agency. That hasn’t changed.

What has changed is the relatively uncrowded lobbying and media ecosystem of the 1960s. Much of the public interest legislation history of the 1960s and ’70s involved a nexus of public interest advocates, respected mainstream journalists, and congressional staffers working together to amplify the case for their law, with a handful of lobbyists struggling to respond. It is now much more difficult for messages to break through. In 1961, only 130 corporations had registered lobbyists in Washington; today, more than 4,000 companies do.

Second, the demands of fund-raising are very different now. Pertschuk suspects that some of Magnuson’s hesitation was due to his “hearing complaints from his corporate friends and advisors.” When it came time to fund-raise in 1967, he held a single $100-a-plate event, with 2,300 guests. “At the time it was almost certainly among the largest recorded hundred-dollar-a-plate fundraising dinners in the history of US politics,” Pertschuk writes. It was an impressive haul—about $1.8 million in today’s dollars. But that kind of event wasn’t as constant a presence back then as it is today, when the cost of an average Senate race is over $10 million (competitive ones cost more), and candidates are expected to fund-raise for their party as well. Most campaign money comes from very rich people, largely related to corporate businesses. In today’s fund-raising environment, it’s hard to imagine Magnuson letting his staff turn him into a champion of consumer protection. Facing a close reelection, he would have had to focus more on raising money, surrounding himself with the donors who would have told him to cool his consumer protection jets.

Finally, Congress just has fewer staff positions than it used to. In 1975, Pertschuk’s Commerce Committee had 112 staffers, which increased to 162 by 1985. By 2015, staffing on the committee had fallen to eighty-three. In the Senate, staffing levels stagnated in the 1980s and have declined slowly since. House staffing levels underwent an even sharper decline after Newt Gingrich became speaker in the 1990s and slashed committee budgets. Neither chamber has recovered. Nonpartisan sources of expertise in Congress have also declined. The Government Accountability Office and the Congressional Research Service, which provide nonpartisan policy and program analysis to lawmakers, now employ 20 percent fewer staffers than they did in 1979.

Some of this is the consequence of party leaders centralizing resources in order to ensure that they control the process. Some is a consequence of conservative small-government dogma and an unwillingness of members of Congress to defend their own institution. The upshot is that more and more policymaking is outsourced to the phalanxes of lobbyists who surround Capitol Hill, since they’re now the ones with the expertise, resources, and time to develop and build support for policies.

When the Senate Worked for Us is a helpful reminder that Congress didn’t always look the way it does now. A remarkable number of bright and talented young people still want to work in Congress, and do—it’s not that nobody wants the job. But few people stick around like Pertschuk and his Bumblebees did. In part they leave because the pay has gotten worse, and in part because there are simply fewer and fewer opportunities to do much of significance. A gridlocked Congress is a frustrating place to work, as is one in which party leaders dominate policymaking. Change that, and perhaps a new generation of Bumblebees will fly again.

The post Congress Wasn’t Always This Awful appeared first on Washington Monthly.