Political Animal

Warren’s Marriage Equality Joke Was Brilliant. The Handwringing Over It Is Not.

The irony of Tom Nichols having written a book decrying “The Death of Expertise” is that he maintains a large platform to wrongly opine on matters about which he has no relevant expertise. But it’s not just Nichols: there is an entire network of commentators who continue to hold vaunted positions on editorial pages while advocating for debunked and discarded conventional wisdoms about politics in the 21st century.

The latest and more prominent example is the handwringing over Elizabeth Warren’s joke at a recent LGBTQ+ forum in Southern California:

During the CNN forum on LGBT issues on Thursday, Morgan Cox, the chair of the Human Rights Campaign board of directors, asked Warren how she would react to a supporter who said: “I’m old-fashioned and my faith teaches me that marriage is between one man and one woman.”

Warren replied: “Well, I’m going to assume it’s a guy who said that. And I’m going to say, then just marry one woman. I’m cool with that…Assuming you can find one.”

The moment went viral almost instantly. Warren’s comedic timing was worthy of a stage professional, the zinger landing in a way that a transcript cannot do justice to. Like any good joke of its type, it went to a deeper truth that most “serious” people decline to discuss openly in polite society: that increasingly old-fashioned culturally conservative politics is speaking to the sort of man who rants angrily about women from basement webcams and selfie rants in SUVs, not to the well-adjusted man with healthy relationships. It was also deeply satisfying and validating not just for LGBTQ people across the country, but to all those who spent decades being maligned and marginalized in America as perverts and freaks outside the American mainstream. Marriage equality is the mainstream today, and those who continue to deny the fundamental rights of gay and gender-non-conforming people are not only out of step with the nation’s politics and culture, but increasingly at risk of damaging their own personal relationships with decent people.

But almost as soon as the plaudits began, so too did the handwringing. A Washington Post piece called the celebrants of the moment “glitterati” while grousing that it could validate conservative concerns about her being “condescending and dismissive.”

Longtime Republican Tom Nichols then weighed in at USA Today, preposterously asking the rhetorical question “Do we still agree on beating Trump? After your LGBTQ forum, I’m not sure.” He adds: “Republican culture warriors are lying in wait. Why let them divide us where we already agree?” and insists that Democrats are trying to lose the election for even holding an LGBTQ forum in the first place.

Not to be outdone, centrist columnist Michael Cohen tweeted that “Warren’s SSM quip made me chuckle but it came with a political downside.” Really?

To put it bluntly, there is no actual evidence for this nervous caterwauling that any person of real political expertise should listen to.

Marriage equality is now incredibly popular. One of the most recent polls on the subject showed 67% approval and only 28% disapproval. There are very few issues on which the public takes the conservative position over the liberal one by such lopsided margins, and in those rare cases there would not be even one public commentator stating with a straight face that a Republican political candidate should avoid marginalizing the few who disagree.

Second, is there anyone who believes that the sort of cultural conservative who actively holds a microminority 28% public opinion on a culture war matter isn’t already maximally engaged on behalf of Trump and Republicans in general? Evangelical Christians are Trump’s hardcore base, the ones who come to his rallies and stick with him no matter what. They come out to vote in fair weather and foul, a big reason why they continue to exercise outsize political power despite their shrinking numbers. They are already as motivated as they possibly can be or ever will be. Donald Trump is their Flight 93 president, their final savior from the politically correct heathens on the road to what they hilariously see as the perdition of Western Judeo-Christian civilization. A jab from Elizabeth Warren is a tiny lava drop in the fiery ocean of their collective hatreds and resentments.

The last thing Democrats should be concerned about is the snowflake-like fragility of straight-white-male-evangelical egos. Rather, it is essential to marginalize their version of toxic Christianity from mainline faith groups, and work to normalize a healthier, less hateful form of masculinity to which disaffected young men can aspire. This can take the form of high-minded lofty speeches about hope and tolerance, but a good pointed joke at the expense of bigots can also work wonders as both to affirm those who have long faced discrimination, as well as to de-center those who would continue to oppress them given the chance.

But it’s not just the bigots who need marginalization. The handwringers who continue to obsess over not riling them up, as if they still made up the contours of a conservative Silent Majority that simply no longer exists, should also be ignored and set aside in favor of those who understand the dynamics of America in the year 2020.

Health Care’s Biggest Problem Is Getting Worse

Many liberals and a growing number of Democratic presidential candidates have embraced a bold idea for reforming America’s broken healthcare system. The idea most in vogue—and the most debated—throughout the 2020 election has been to abolish private insurance in favor of a government-run national system, otherwise known as “Medicare for All.” Advocates of “single-payer” generally blame rapacious insurers as the principal villains of the current system, responsible for sky-high premiums and out-of-pocket expenses. Replacing for-profit insurance companies with a government program, the logic goes, would bring lower costs and coverage to everyone

But this singular focus on insurers means that the presidential hopefuls are neglecting an even bigger problem with far-reaching consequences for millions of Americans: the dominance of hospital monopolies in a growing number of health care markets nationwide.

Monopolies, in general, mean bad news for consumers. Health care is no exception. Mounting evidence shows that hospital consolidation exacerbates the system’s worst failings, bringing higher prices, fewer choices, and lower quality care to patients. And it’s only getting worse.

According to new research from the Health Care Cost Institute, nearly three out of four metro areas—72 percent—had “highly concentrated” hospital markets in 2016. Moreover, says HCCI senior researcher William Johnson, “almost 70 percent of metro areas were more concentrated in 2016 than they were in 2012.” This includes places like Milwaukee, Wisconsin, and Houston, Texas, which were “moderately concentrated” in 2012 but were “highly concentrated” just four years later. The most concentrated areas were places with populations under 300,000, like Springfield, Missouri. More densely populated areas, such as New York City and Philadelphia, were more competitive.

This trend has left Americans in concentrated hospital markets in a precarious position. A 2012 meta-review by economists Martin Gaynor and Robert Town found price hikes are especially dramatic—as much as 20 percent—when hospitals in already concentrated markets merge further. Even worse, the ultimate potential casualty of consolidation is often patient wellbeing. For instance, one major study by Daniel Kessler and Mark McClellan (later administrator of the Centers for Medicare and Medicaid Services) found that among Medicare beneficiaries, heart attack victims in more concentrated markets were 4.4 percent more likely to die than patients in the least concentrated markets. Gaynor and Town found similar results from other studies in their review. When hospitals stop having to compete for patients, their attention to quality suffers.

Driving the current state of concentration is a tidal wave of hospital mergers over the last decade. Local and regional facilities are disappearing, swallowed up by increasingly large and powerful hospital systems. Since 2016, hospitals have announced more than 350 mergers and acquisitions, according to the consulting firm Kaufman Hall. These include deals among such giants as HCA Healthcare, which runs 185 hospitals in 21 states, and Sanford Health, whose planned merger with UnityPoint Health this year would make it one of America’s 15 largest non-profit hospital systems.

These deals are getting bigger and more numerous. Kaufman Hall reports that, in 2018, seven transactions involved the sale of hospitals or hospital systems with net revenues of $1 billion or more, and that the average size of an acquisition was $409 million.

Defenders of hospital mergers, like the American Hospital Association, argue that consolidation can bring efficiencies of scale, encourage innovation, and lower costs, all of which should lead to better outcomes for patients. Unfortunately, the weight of research shows otherwise. Competition, not consolidation, is better for patients.

Monopoly hospital systems are more likely to use their power to extract extra profit—in other words, to act like monopolists—than to benefit patients. HCCI’s research, for instance, found that the metro areas with the greatest increases in concentration also tended to see the largest increases in price (although the researchers are careful to note that the relationship is one of correlation, not causation).

But even if prices don’t go up as a result of greater concentration, they don’t necessarily go down. A 2019 study by Stuart Craig, Matthew Grennan, and Ashley Swanson of the University of Pennsylvania found that merged hospitals don’t save money by reducing costs on hospital supplies that they presumably buy in greater bulk. Instead, the researchers found that mergers can result in expected savings of just 0.5 percent, after reviewing supply purchases made by 1,100 hospitals over a six-year period. “Our findings urge skepticism of the use of hospital purchasing efficiencies as justification for … hospital mergers,” they wrote.

The real reason for mergers is market power. As Gaynor and Town write, “Studies find that consolidation was primarily for the purpose of enhanced bargaining power with payers,” i.e., insurers. Simply put, when there is only one provider network in town, insurers have no choice but to pay what’s demanded unless they themselves gain leverage by—guess what?—consolidating. In fact, some evidence suggests that both insurers and hospitals are locked in a self-reinforcing arms race for monopoly power.  “Both are trying to strengthen their bargaining positions in order to raise or lower prices for their own individual profits,” says HCCI’s Johnson.

Interestingly, some of the best evidence for concentration’s negative impacts on patient health comes from the United Kingdom’s National Health Service (NHS), where the government introduced market reforms in 2006 to deconcentrate its hospital market. Before then, the NHS had essentially created hospital monopolies by assigning every patient to a designated hospital, resulting in long waits and poor-quality care. The 2006 reforms allowed patients to choose from five hospitals, forcing the hospitals to compete against each other for treatment dollars. The results were significant. Writing in JAMA, health economist Austin Frakt reported that even a 10 percent decrease in market concentration was associated with shorter hospital stays and fewer deaths. “Hospital competition is an important and significant driver of quality and outcomes improvement,” Frakt writes. “…[N]othing focuses the mind like an existential threat from a competitor.”

Unfortunately, none of the leading Democratic proposals for universal coverage includes a robust plan for attacking hospital consolidation. Rather, the principal goal of Medicare for All and like plans is simply access to coverage, with little regard to cost and quality of care.

Despite candidates’ interest in breaking up monopolies in tech or financial services, as Senator Elizabeth Warren has proposed and others have said they are willing to consider, hospitals are a sector that’s remained relatively unscathed in Democrats’ health care plans.

While it’s unquestionably the case that too many Americans lack affordable coverage, the goal of universal coverage can’t be achieved by expanding a broken system to all Americans at great taxpayer expense. The drive for affordable access to care must be coupled with reforms that ensure better quality and more innovation at a lower cost. For that to happen, Democratic candidates have to start by drawing more attention to the real root of the problem. They have to embrace a word that’s so far been largely missing from their rhetoric and proposals for an expansive government role in health care: competition.

Limiting The Scope of Impeachment Makes No Sense When New Crimes Are Revealed Daily

Two weeks ago I argued that Democrats would be wiser to expand the impeachment probe to include all of Trump’s alleged crimes than to attempt to restrict the inquiry to the his phone call with Ukrainian president. That advice seemed unlikely to be heeded at the time, as leadership remained stubbornly insistent that frontline members would best be served by keeping the process simple and short, avoiding any possible negative political consequences from stretching the proceedings into an election year.

But circumstances have shifted rapidly in two significant ways. First, several new polls are showing majority support for an impeachment probe, including an eye-opening uptick in support among Republicans. There isn’t publicly available district-by-district data yet, but polling is also simply a snapshot in time: just as support for impeachment has markedly increased in the last few weeks, there is every reason to expect it will continue to increase as more evidence comes forward. We don’t know what the plateau will be, but it’s very unlikely that we have already reached it.

Second and more important, however, is the fact that new crimes are seemingly being revealed by the day if not by the hour. Just reading the news in the last 72 hours is like drinking from a firehose. The president’s own attorney, Rudy Giuliani, is under investigation has been conducting a shadow foreign policy with allegedly criminal accomplices, two of whom were nabbed trying to fly out of Dulles Airport with one-way tickets to Vienna, where Mr. Giuliani was allegedly also headed to meet them. There appears to have been a wide-ranging conspiracy to launder foreign money to Republican politicians in exchange for various shady favors–in addition to the central extortion of Ukrainian leadership by withholding Congressionally mandated aid in an attempt to fabricate dirt on one of Trump’s feared rivals for the presidency.

We still don’t know what inducements Turkish autocrat Erdogan offered Trump in exchange for being allowed free rein against our long-suffering allies the Kurds, including bombing U.S. forces without repercussions. There is a whole other scandal around Trump son-in-law Jared Kushner, Saudi money and nuclear dealings, and Trump’s own publicly and proudly admitted use of our armed forces as paid mercenaries in the service of a journalist-murdering regime.

The scandals aren’t just embroiling Giuliani and the Trump family. Attorney General Barr is deeply implicated in much of the effort to illegally solicit foreign support in manufacturing a scandal against the president’s personal political opponents, as is Vice President Pence and Secretary of State Pompeo–all of whom are hemming, hawing and clamming up in response to questions.

All of this is coming out just in the last few days. It seems almost comical to set an arbitrary limit on the scope of high crimes and misdemeanors to include in an impeachment inquiry when additional wrongdoing is being revealed in a dizzying parabolic arc of scandal. The notion that the public will be able to understand the Ukraine affair because of its supposed simplicity is also falling apart: nothing about this affair is remaining simple as its layers begin to unsheathe like an onion.

At a broader level, though, it’s increasingly obvious that Trump is barreling toward an unprecedented constitutional crisis. Having already used specious legal reasoning to justify blockading all congressional subpoenas, he has threatened civil war and talked about his supposed loyal military support with all the subtlety of a gong. It seems only a matter of time before he begins to defy court orders as well.

In this context, curtailing an inquiry in an effort to possibly better protect a handful of Democrats in the most conservative districts is a form of cowardice. Republicans in the Senate will make the choices they will, but the gaze of history and the precedent set for future presidents lies with Democrats in the House. If they do not make clear that every one of these alleged crimes will carry a full accounting, a future president will be emboldened to commit them again.

In Minnesota, Trump Demonstrated His 2020 Strategy: Grievance and Racism

Having only lost Minnesota by 1.5 percentage points in 2016, the Trump campaign has made it clear that they think they can win the state in 2020. That’s what Thursday night’s rally in Minneapolis was all about. Peter Nichols wrote about the strategy.

One Republican operative close to the White House, speaking anonymously to discuss campaign strategy, told me that Trump is convinced of the old political adage “The race will hinge on turnout.” If he can mobilize and excite his base voters, they’ll show up in force, much as they did in 2016, impeachment be damned…

“His message is so edgy, and his core support is so intense and enthusiastic, and the rallies are so unlike anything we’ve seen in the modern era,” the strategist told me. “Arithmetically speaking, this election is about jacking up turnout of your own supporters on the theory that no one on their side of the ball excites them the way Trump excites us,” he said, referring to the Democrats.

If that’s the plan, then we can look at Thursday night’s speech to see how Trump plans to excite his supporters in order to get them to show up in force.

As Nichols pointed out, the first half of Trump’s speech was all about his personal grievances. He mocked FBI officials Peter Strzok and Lisa Page, said that Joe Biden was “only considered a good vice president because he understood how to kiss Barack Obama’s ass,” called Ilhan Omar an “American-hating socialist,” and referred to congressional Democrats as “sick” for pursuing an impeachment inquiry.

Then Trump engaged in his second strategy for exciting his voters: racism. Because Minnesota is home to the largest concentration of Somalis in the country, they became his target.

He then went on to say that “we will always protect American families first” and that hadn’t happened in Minnesota. He said that he would not “allow a violent ideology to take root in our country on our shores” like had happened in Europe. Equating the Somali community in Minnesota with a “violent ideology” is not only a racist lie, it is the same kind of rhetoric that inspired the gunman in El Paso.

This is, however, merely a repeat of what Trump did in 2016 when he visited Minnesota two days before the election and told the crowd that they had “suffered enough” as a result of “filthy refugee vetting” that had allowed an influx of Somalis into the state.

When it comes to this part of Trump’s strategy, Elad Nehorai, who describes himself as a “proud progressive Orthodox Jew,” put it best. He wrote that “This is the kind of hate rally seen in authoritarian and fascist countries. We Jews have seen this before, as have countless other minorities. This is the powerful hurting the vulnerable to empower themselves.” Senator Amy Klobuchar echoed that statement.

I have often been proud to point out that, when it comes to the economy, my home state of Minnesota consistently performs better than the national average. One of the reasons why is because of the very immigrant community the president attacked. Here is the data from the Federal Reserve Board of Minneapolis.

With high levels of labor force participation and employment, African immigrants brought in $2.5 billion in earnings during 2015. These households paid $419 million in federal taxes and $222 million in state and local taxes, leaving African immigrants an estimated $1.8 billion in spending power. Despite its relatively small size, the African immigrant population makes significant contributions to the Minnesota economy.

At the end of his speech on Thursday night, Trump threw out a couple of lines about health care and a promise to end childhood cancer. But as Nichols wrote, “he read those parts without any particular vocal affect, perhaps because he doesn’t truly believe they’re the way to win.” It could also be because he doesn’t really give a shit about things like health care. In the end, the plan is to excite his base of supporters with a combination of grievance and racism, because that is exactly what excites him. But the truth is, that’s all he’s got.