Where President Biden’s economic plan appears to stand right now: From taxes to climate policy to Medicare to immigration
Even as negotiations over President Biden’s economic package continue, Democratic officials have started signaling which parts of the White House agenda could be cut from the legislation and which are likely to be approved.
Biden, for instance, said on Thursday night that his plan to create universal free community college had fallen out of the bill. The president acknowledged his new clean energy plan to incentivize utility firms to move away from fossil fuels is in danger of being jettisoned. By contrast, universal prekindergarten and a national child care program are widely seen as all but guaranteed to be included, enjoying the backing of the Democratic caucus.
The bill is also likely to retain significantly smaller versions of a wide range of Biden’s proposals, such as initial plans to provide roughly $300 billion for housing and homelessness, $400 billion on eldercare for seniors, and $450 billion for the child tax credit. Each initiative stands to be cut from anywhere from a third to a half of their initial proposed amounts, though estimates on how much vary by significant margins.
And while a higher corporate tax rate may be out of a deal, due to the demands of Sen. Kyrsten Sinema (D-Ariz.), a new tax on billionaires’ accrued wealth is newly in play as part of potentially significant shifts in Democrats’ tax plans to fund the legislation.
The emerging changes to the package come as President Biden this week told House Democrats the legislation may have to spend up to $1.9 trillion. The White House and Democratic officials initially agreed to a $3.5 trillion plan — itself smaller than what the administration had initially pitched — and House Democrats’ version of the bill costs as much as $4.5 trillion, according to budget experts.
Sinema and Sen. Joe Manchin III (D-W.Va.) have been adamant that overall spending figures must be dramatically cut, forcing difficult decisions about which programs to shrink or eliminate. But Democrats are also worried that failure to reach an agreement could lead to no bill at all being passed, a potentially calamitous outcome for the party.
Administration officials have been in regular contact with congressional Democrats about potential avenues for compromise in recent days, but many of those these are likely to change substantially before a final product emerges.
“I don’t think we know exactly where things stand,” said Marc Goldwein, a budget expert at the Committee for Responsible Federal Budget, a think tank in Washington. “The administration came back with some ideas. So the question is which of those stick, which can be massaged, and which have to go. We know it’ll probably be just short of $2 trillion, but what’s in and what’s out is up in the air.”
Below is a rough rundown of where key provisions surrounding the bill stand, based on interviews with more than a dozen congressional aides, lobbyists and administration officials with knowledge of the negotiations. These people, who spoke on the condition of anonymity, stressed that negotiations are moving very swiftly and key provisions could change.
Democrats search for alternative to key climate measure. The single biggest part of the spending bill has been hundreds of billions of dollars to fight climate change. Democrats have remained optimistic that most of the initial White House climate proposal — including $300 billion in clean energy tax credits — is likely to be approved in the final bill.
But Manchin’s demands appear to have forced Democrats to question whether they will have to jettison perhaps the linchpin of their climate initiatives: the Clean Energy Payment Program that would create financial incentives and penalties for utility companies to encourage them to transition to clean energy sources.
Some Democratic lawmakers have been adamant that they can still reach their carbon reduction targets even without the clean energy program. But others are skeptical, arguing that without the utility program, the plan will lack sufficient impact to mitigate catastrophic warming. A host of potential alternatives — including a carbon tax and emissions trading system for industry — have surfaced in recent days, but it is unclear whether these alternative options will end up in the bill.
The White House and multiple senior Senate Democrats are currently working through what policies could both get Manchin’s approval and provide adequate financial resources or new regulations to address the threat of climate change.
Biden told CNN on Thursday that the provision had not yet been eliminated but acknowledged Manchin’s opposition. He also suggested adding the $150 billion originally allocated for the Clean Energy Payment Program for new incentives to reduce fossil fuel intensive expenditures.
Early education programs appear secure with party support. Beyond the climate provisions, the bulk of the Democrats’ package is designed to expand federal safety net and social programs through new initiatives in health care, education, housing, child care, elder care, and other areas.
Of the social programs, the two that have consistently emerged as the safest are Democrats’ plans to establish a universal prekindergarten program and a new national child care program. Manchin has indicated his support for universal pre-K, for instance, which already exists in West Virginia. Biden initially proposed $200 billion to extend free and universal pre-K, as well as an additional $225 billion to subsidize child care, proposing to cap at 7 percent of income the amount families can spend on child care for children younger than 5.
These plans appear likely to pass largely intact, although a report in the People’s Policy Project, a left-leaning think tank, argued this week that the child care provision could dramatically increase costs for middle class families not eligible for the program’s new subsidies. Democrats have denied that claim.
Crown jewel of White House antipoverty efforts faces challenges. In its stimulus bill passed in March, the White House approved a one-year expansion of the child tax credit, so the benefit gave out substantially more money per child and was also extended to reach millions of children in poverty previously denied the payment. The White House proposed extending the more robust child benefit through 2025 at a cost of roughly $450 billion, a measure it has called necessary to achieve major reductions in child poverty.
The program now appears vulnerable. Manchin has called for new work requirements on government programs as part of the package, which could prevent parents who do not work from receiving the benefit. The administration has also discussed whether the child tax credit would only be extended for one additional year, after which Democrats would seek to extend it further, as they try to bring down the cost of the package overall. If Democrats lose the midterms in 2022, it could mean that Biden’s signature expanded child tax credit may die after only a brief trial run.
Yet the White House is still trying to seek approval to permanently ensure the program reaches the poorest families. The original expansion of the child tax credit from earlier this year was able to reach more families because it was extended to those families who had no earnings. The White House wants to ensure that change does not expire, as it is set to under current law. Biden said Thursday he does not support adding a work requirement to the child tax credit.
Democrats weigh massive changes to their tax plan. To pay for all the spending in the measure, the White House proposed trillions of dollars in new tax hikes on corporations and the rich. House Democrats advanced a roughly $2 trillion tax plan that similarly raised tax rates on individuals, corporations and wealthy investors, among other measures.
But due to resistance from Sinema, the administration is being forced to consider alternative approaches as the package inches forward. On a call this week with congressional Democrats, senior administration officials said they are discussing a series of measures that would not raise tax rates — which Sinema has opposed — but still raise trillions of dollars in new revenue, primarily from companies and the rich.
The measures discussed by the administration officials on the call included a new minimum tax on corporations, a plan to beef up tax enforcement through the Internal Revenue Service, a tax on companies issuing stock “buybacks” to company shareholders and, perhaps most surprisingly, a new tax on the assets held by American billionaires.
The White House has been adamant its spending package will be fully paid for with new revenue, meaning it likely has to reach a deal on the tax provisions for the proposal as a whole to advance.
Health priorities are putting senior Democrats at odds. While there is close to unanimous support among Democrats about the early education programs, party leaders are dramatically split on how to expand health care through the legislation.
Although left out of the administration’s initial economic plan, White House officials this summer agreed to back Senate Budget Chairman Bernie Sanders’ (I-Vt.) proposal to extend new dental, vision and hearing benefits to tens of millions of American seniors on Medicare. The initial provision cost as much as $380 billion, but Democratic lawmakers have suggested this week that the program may have to be cut to above $150 billion.
But including all three benefits is a “reach,” Biden said at a CNN town hall on Thursday. He said Manchin is opposed but that Democrats could cut a deal on an $800 voucher for dental care instead. On hearing benefits, Biden pointed to a new proposal from federal health officials to allow consumers to buy over-the-counter hearing aids as a way to make products more affordable without changing Medicare. On vision, Biden says there is no consensus yet.
Meanwhile, drafters of President Barack Obama’s Affordable Care Act, including House Speaker Nancy Pelosi (D-Calif.), have pushed hard for more robust subsidies for those purchasing insurance on the public exchanges. That measure could also prove expensive. Democrats are considering only extending the improved subsidies for Obamacare shoppers for only four years, though Pelosi wanted the plan approved for significantly longer.
Separately, other party leaders have pushed for the inclusion of an expansion of Medicaid to 2.2 million poor adults in mostly Republican-led states refusing Obamacare’s expansion. Lawmakers such as House Majority Whip James E. Clyburn (D-S.C.) and Sen. Raphael G. Warnock (D-Ga.) — Democrats in southern states that rejected the Obamacare expansion — have argued doing so is crucial to closing the racial inequities in the country’s health care system.
Most Democrats would support all three health care programs, but party officials differ on which should be funded with limited resources.
Drug pricing reforms face defections by Democrats. To pay for the health care spending, Democrats have pushed for changing existing law to allow Medicare to negotiate lower prescription drug prices, a measure aimed at both saving the government money and reducing seniors’ prescription drug costs.
But that plan is under fire from a trio of House lawmakers who support a more limited drug negotiation measure and voted against the bill during a key committee hearing in September. On the other side of the Capitol, a plan has not yet come together, as Senate Finance Committee Chairman Ron Wyden (D-Ore.) has worked for months to try to strike a balance between moderate and more liberal Democratic members.
Housing, elder care and paid family leave face downsizing. The White House is widely expected to be forced to cut a range of other programs — such as its proposals for housing, elder care for seniors, and paid family and medical leave — from its initial ambitions.
The administration’s initial housing plan included hundreds of billions of dollars to create millions of new housing units and to house hundreds of thousands of homeless Americans. The housing program also would have funded vouchers for low-income tenants and repairs to public housing units. The overall amount of spending on housing is expected to be cut dramatically, possibly from $300 billion to $100 billion. But it’s not clear which housing programs are on the chopping block.
Similarly, the White House initially pitched as much as $400 billion to help the elderly and those with disabilities receive in-home care from workers who often make below minimum wage. With the nation rapidly aging, the administration said the plan is necessary to help clear the backlog of thousands of people waiting years to receive in-home care from Medicaid. But the home care program may be cut by as much as a third or more.
Yet another White House program — $225 billion to create a national paid family and medical leave program — also faces major downsizing. Initially, Democrats had looked to create 12 weeks of benefits for families and sick workers, but that number is now down to four weeks, and the program might not start until 2024, well after the 2022 midterms. Biden confirmed the four-week plan on Thursday.
There remains some hope for immigration reform. Democrats have not given up on including immigration reform from the reconciliation bill, allotting $100 billion to the matter. But how it gets divided up still depends on what the Senate parliamentarian rules as germane to include in the sweeping budget proposal.
Democratic senators, led by Majority Leader Charles E. Schumer (N.Y.), Richard J. Durbin (Ill.), Alex Padilla (Calif.) and Robert Menendez (N.J.), are preparing their third proposal for the parliamentarian in the coming days. Unlike the previous proposals that focused on creating a pathway to citizenship for a broad swath of undocumented immigrants, current negotiations are focused on reforming the green card visa system to make it more accessible to certain undocumented groups like farm workers and recipients of Deferred Action for Childhood Arrivals. Division among Democrats on whether the parliamentarian’s word is final, with some pushing to override her recommendation.
“More and smaller” prevailing over “bigger and fewer.” When it became clear the White House would have to shrink its legislation by as much as 60 percent, administration officials faced a difficult choice: They could either pursue a plan that contains partial investments across a wide range of areas, or one that approved a handful of programs but each one done in a durable and robust way. Several administration officials privately said they prefer legislation that took aggressive and comprehensive action on only a handful of priorities.
Ultimately, however, the party appears to be pursuing the more diffuse approach. While free community college appears to be out of the plan, Democrats say they remain intent on pursuing virtually all of their biggest programs, at least for now. While, some administration officials agree that it would be better to implement a few large-scale programs, the White House needs every Democrat in the House and Senate to support the legislation for it to pass, and no Democrat wants his or her particular priority axed entirely.
Opinion | Why Is Raising a Child in the United States So Hard?
If you’re active on social media there’s a decent chance you came across this chart this month from a Times article about how much less the U.S. government spends on young children’s care than other rich countries.
The infrastructure and family plan that President Biden proposed and that’s now being negotiated in Congress is an attempt to shrink the gap through four key policies: a federal paid family and medical leave program, an extension of the child tax credit (in the form of a monthly payment) that debuted this year, subsidized day care, and universal pre-K.
Two weeks ago, however, the unofficial kingmaker of the Senate, Joe Manchin of West Virginia, said Democrats would have to choose only one of the first three proposals. “I don’t believe that we should turn our society into an entitlement society,” he said.
Why does the United States have such an exceptional approach to family and child care benefits, and what are the arguments against expanding them now? Here’s what people are saying.
Why family policies never took off in the United States
As Mona Siegel, a historian at California State University, Sacramento, explained in The Times in 2019, the origins of paid parental leave programs date back to 1919, when the first International Congress of Working Women — a group of female trade unionists, feminists and allies from around the world — convened in Washington and called for 12 weeks of paid maternity leave as a medical necessity and a social right.
European and Latin American countries began enacting these policies over the next two decades, but the end of World War II accelerated the process, particularly in Europe, whose economies had been ravaged by mass death and destruction.
“Part of it had to do with fears of demographic decline — just the sheer population loss during World War II and what felt like the need to recover from those years and to ensure that there was a strong work force going forward,” Siegel told the BBC.
Having experienced fascism up close, European countries also looked to the welfare state as a means of safeguarding democracy against authoritarianism. In the United States, by contrast, opposition to the Soviet Union — and to any political program that might be maligned as socialist or communist — made building support for social insurance more difficult.
Where things stand today: Out of 185 countries with available data, the United States and Papua New Guinea are the only ones whose citizens are entitled to no paid parental leave. In Europe, on the other hand, parents have paid leaves of 14 months, on average, and children commonly start public school at age 3. Before that point, governments pay a significant portion of the cost of child care. A child allowance similar to the new child tax credit is also common among America’s peer nations.
The United States has made some changes to its family policies in the past century, as New York magazine’s Eric Levitz points out. In 1993, Bill Clinton signed the Family and Medical Leave Act, which requires most employers to provide workers with 12 weeks of job-protected, but unpaid, leave to care for a new child or gravely ill family member. About 40 percent of U.S. workers don’t qualify, however, and only 23 percent of private-sector workers have paid family leave through their employers.
Half of Americans live in places where there is no licensed child care provider or where there are three times as many children as slots. One in three children also doesn’t attend preschool; those who don’t are more likely to be Hispanic or from low-income families.
Debatable Agree to disagree, or disagree better? Broaden your perspective with sharp arguments on the most pressing issues of the week.
Why family policies still face an uphill battle
As The Times columnist Jamelle Bouie explains, the “entitlement” critique that Manchin voiced this month is a running theme in the history of America’s opposition to a larger social safety net. At its root is a centuries-old tendency to sort the population into productive makers and unproductive takers, a binary that formed the basis of “producerism”: the idea that people who made and grew things were most valuable to society.
In the 19th century, producerism fueled revolts against corporations, which progressives argued were stealing the fruits of labor.
But in the 20th century, producerism was recast by conservatives and neoliberals: The taker was no longer a greedy employer or an enslaver but the government, expropriating its citizens’ hard-earned money through taxes and redistributing it to undeserving welfare cheats, who were often coded as Black.
“Entitlement” logic may be one reason the child tax credit is less popular than its proponents had hoped. When the Biden administration made all but the most well-off families eligible for monthly checks of up to $300 per child this summer, Democrats predicted that the program would be a big hit. But in a recent poll of registered voters, only 36 percent said it should be made permanent.
“The biggest divide may be on the importance of work,” writes Patrick T. Brown, a fellow at the Ethics and Public Policy Center who helped convene focus groups of working parents to discuss the issue. “The parents we talked to felt a tension between the obvious benefits a monthly benefit could bring but still wanting some kind of work requirement. Work made a family deserving of government support; without it, family benefits were seen as welfare.”
Matt Bruenig of the People’s Policy Project had a very different interpretation of the poll Brown cites, which also found that 53 percent of respondents supported making the child tax credit permanently available to households with no workers. You can read Bruenig’s analysis here.
Americans also have personal and social objections to universal day care. For some parents, their opposition is a matter of wanting to retain choice: In Brown’s focus groups, even the self-described more progressive parents tended to favor vouchers or tax credits to government-run child care programs.
But many Americans also have conflicted feelings about whether the government should be making it easier for parents — and mothers, specifically — to work outside the home. Most Americans say it’s not ideal for a child to be raised by two working parents, and in most opposite-sex couples in which one parent stays home, it’s the mother who does so.
In 1971, Congress passed a bill that would have laid the groundwork for a national child care program — but President Richard Nixon vetoed it, arguing that it placed the government’s authority on “the side of communal approaches to child-rearing” and “against the family-centered approach.”
Today, many social conservatives still oppose state-subsidized child care as a form of social engineering. “Democrats don’t want to put the option to stay home on equal footing with day care,” The Washington Examiner wrote in an editorial in May. “They know that, overwhelmingly, it would be mothers who choose to care for children full time, and these are the very complementary gender roles that they want to eradicate.”
It’s a similar story with opposition to universal pre-K. New research has shown that public pre-K programs have the potential to improve children’s development and long-term well-being, if not their standardized test scores.
But some argue that these benefits can be achieved through other methods — more time at home with a parent, for example — and that it’s not the government’s role to favor one at the exclusion of others. “People’s values and needs are extremely diverse,” Samuel Hammond, the director of poverty and welfare policy at the Niskanen Center, told The Times. “I would say: Just give the parents the money.”
Worth noting: In some conservative intellectual circles, “entitlement” logic still shapes opposition to state-sponsored paid leave programs. “If the private sector doesn’t provide it and we have to go to the government to get it, then you’re relying on the government,” Rachel Greszler of the Heritage Foundation said in 2019. “You’re not relying on yourself.”
But this argument may hold less sway with the American public on paid leave than it does with the child allowance: A recent CBS News/YouGov poll found that 73 percent of adults surveyed supported federal funding for paid leave. According to another poll conducted in May, 69 percent of respondents, including 55 percent of surveyed Republicans, would support such a policy even if it raised their taxes.
Which to choose?
The Times recently asked 18 academics which of the four policies in the infrastructure bill they would make law if they had to pick only one. Public pre-K for children ages 3 and 4 was the winner, with half the experts choosing it. They said it was most likely to achieve multiple goals of family policy:
It could help decrease poverty and ease family life by making child care free for toddlers.
It could increase gender equality by enabling mothers to work.
It could decrease long-term inequality by giving children from different backgrounds the same preparation for kindergarten.
“When my collaborators and I have explored different outcomes — employment, wages, poverty — across a range of wealthy countries, the policy that has had the most powerful effect has been universal early childhood education,” said Joya Misra, a sociologist at the University of Massachusetts, Amherst.
Other policy analysts disagreed with the ranking:
Many experts, though, said it was a choice they would not want to make. “People need resources for coordinating family and employment across the life span,” said Joanna Pepin, a sociologist at the University at Buffalo. “Picking just one policy is akin to putting a fire out in one room of a house engulfed in flames and stopping.”
The Unvaccinated May Not Be Who You Think
Back when a viral pandemic killing millions around the world was just the plot of a scary movie, the film “Contagion” was lauded for how accurately it depicted the way such an outbreak would occur.
On the science of viral contagion, it was quite sharp, clearly explaining things like R0 (the measure of how widely one infection could spread to others, on average).
Of the human dimension of contagion, it did not prove as prescient. In the movie, fearful nurses walked off the job at the start of the pandemic, which begins to end as soon as vaccines become available, with people lining up eagerly for their turn.
The opposite happened in real life. Despite enormous personal risk, almost all health care workers stayed on the job in the first months of the Covid pandemic. Despite vaccines being widely available since spring in the United States, tens of thousands of people are dying every month because they chose not to be inoculated.
The failure of the United States to vaccinate more people stands out, especially since we had every seeming advantage to get it done. As early as the end of April of this year, when vaccines were in dire short supply globally, almost every adult who wanted to get vaccinated against Covid-19 in the United States could do so, free of charge. By June, about 43 percent of the U.S. population had received two doses while that number was only about 6 percent in Canada and 3 percent in Japan.
Now, just a few months later, these countries, along with 44 others, have surpassed U.S. vaccination rates. And our failure shows: America continues to have among the highest deaths per capita from Covid.
Science’s ability to understand our cells and airways cannot save us if we don’t also understand our society and how we can be led astray.
There is a clear partisan divide over vaccination — Republicans are more likely to tell pollsters that they will not get vaccinated. Some Republican politicians and Fox News hosts have been pumping out anti-vaccine propaganda. The loud, ideological anti-vaxxers exist, and it’s not hard to understand the anger directed at them. All this may make it seem as if almost all the holdouts are conspiracy theorists and anti-science die-hards who think that Covid is a hoax, or that there is nothing we can do to reach more people.
Real-life evidence, what there is, demonstrates that there’s much more to it.
Almost 95 percent of those over 65 in the United States have received at least one dose. This is a remarkable number, given that polling has shown that this age group is prone to online misinformation, is heavily represented among Fox News viewers and is more likely to vote Republican. Clearly, misinformation is not destiny.
Second, reality has refuted dire predictions about how Americans would respond to vaccine mandates. In a poll in September, 72 percent of the unvaccinated said they would quit if forced to be vaccinated for work. There were news articles warning of mass resignations. When large employers, school districts, and hospital systems did finally mandate vaccines, people subject to mandates got vaccinated, overwhelmingly. After United Airlines mandated vaccines, there were only 232 holdouts among 67,000 employees. Among about 10,000 employees in state-operated health care facilities in North Carolina, only 16 were fired for noncompliance.
The remarkable success of vaccine mandates shows it is not firm ideological commitments that have kept everyone from getting vaccinated, and that the stubborn, unpersuadable holdouts may be much smaller than we imagine.
Let’s start with what we do know about the unvaccinated.
There has been strikingly little research on the sociology of the pandemic, even though billions of taxpayer dollars have been spent on vaccines. The assumption that some scientific breakthrough will swoop in to save the day is built too deeply into our national mythology — but as we’ve seen, again and again, it’s not true.
The research and data we do have show that significant portions of the unvaccinated public were confused and concerned, rather than absolutely opposed to vaccines.
Some key research on the unvaccinated comes from the Covid States Project, an academic consortium that managed to scrape together resources for regular polling. It categorizes them as “vaccine-willing” and “vaccine-resistant,” and finds the groups almost equal in numbers among the remaining unvaccinated. (David Lazer, one of the principal investigators of the Covid States Project, told me that the research was done before the mandates, and that the consortium has limited funding, so they can poll only so often.)
Furthermore, its research finds that the unvaccinated, overall, don’t have much trust in institutions and authorities, and even those they trust, they trust less: 71 percent of the vaccinated trust hospitals and doctors “a lot,” for example, while only 39 percent of the unvaccinated do.
Relentless propaganda against public health measures no doubt contributes to erosion of trust. However, that mistrust may also be fueled by the sorry state of health insurance in this country and the deep inequities in health care — at a minimum, this could make people more vulnerable to misinformation. Research on the unvaccinated by KFF from this September showed the most powerful predictor of who remained unvaccinated was not age, politics, race, income or location, but the lack of health insurance.
The Covid States team shared with me more than a thousand comments from unvaccinated people who were surveyed. Scrolling through them, I noticed a lot more fear than certainty. There was the very, very rare “it’s a hoax” and “it’s a gene therapy,” but most of it was a version of: I’m not sure it’s safe. Was it developed too fast? Do we know enough? There was also a lot of fear of side effects, worries about lack of Food and Drug Administration approval and about yet-undiscovered dangers.
Their surveys also show that only about 12 percent of the unvaccinated said they did not think they’d benefit from a vaccine: so, only about 4 percent of the national population.
In law, “dying declarations” are given special considerations because the prospect of death can help remove the motivation to deceive or to bluster. The testimony we’ve seen from unvaccinated people in their last days with Covid, sometimes voiced directly by them from their hospital beds, gets at some of the core truths of vaccine hesitancy. They are pictures of confusion, not conviction.
One woman who documented her final days on TikTok described being uncertain about side effects, being worried about lack of F.D.A. approval, and waiting to go with her family to get the shot — until it was too late.
Or consider Josie and Tom Burko, married parents who died from Covid within days of each other, leaving behind an 8-year-old daughter. They hadn’t taken the pandemic lightly. They were “100 percent pro-vaccination,” a close friend told The Oregonian afterward, but Josie reportedly had a heart murmur and chronic diabetes and worried about an adverse reaction. Tom reportedly had muscular atrophy, and similar worries. Afraid, they had not yet gotten vaccinated.
It’s easy to say that all these people should have been more informed or sought advice from a medical provider, except that many have no health care provider. As of 2015, one quarter of the population in the United States had no primary health care provider to turn to for trusted advice.
Along with the recognition of greater risk, access to regular health care may be an important explanation of why those over 65 are the most-vaccinated demographic in the country. They have Medicare. That might have increased their immunity against the Fox News scare stories.
One reason for low vaccination rates in rural areas may be that they are “health care and media” deserts, as a recent NBC report on the crises put it, with few reliable local news outlets and the “implosion of the rural health care system” — too few hospitals, doctors and nurses.
Plus, let’s face it, interacting with the medical system can be stress-inducing even for many of us with health insurance. Any worry about long-term side effects is worsened by a system in which even a minor illness can produce unpredictable and potentially huge expenses.
Then there is the health system’s long-documented mistreatment of Black people (and other minorities) in this country. Black people are less likely to be given pain medication or even treatment for life-threatening emergencies, for instance. I thought of those statistics while reading the poignant story of a Black physician who could not persuade her mother to get vaccinated because her mother’s previous interactions with the medical system included passing out after screaming in agony when a broken arm got manipulated and X-rayed without sufficient care for her pain.
While the racial gap in vaccination has improved over the last year — nonwhite people were more likely to express caution and a desire to wait and see rather than to be committed anti-vaxxers — it’s still there.
In New York, for example, only 42 percent of African Americans of all ages (and 49 percent among adults) are fully vaccinated — the lowest rate among all demographic groups tracked by the city.
This is another area in which the dominant image of the white, QAnon-spouting, Tucker Carlson-watching conspiracist anti-vaxxer dying to own the libs is so damaging. It can lead us to ignore the problem of racialized health inequities with deep historic roots but also ongoing repercussions, and prevent us from understanding that there are different kinds of vaccine hesitancy, which require different approaches.
About a month ago, the rap artist made headlines after tweeting that she was worried about vaccines because she had heard from her cousin that a friend of his had swollen testicles after being vaccinated. (Experts pointed out that, even if this had happened, it was most likely caused by a sexually transmitted disease.) She was justifiably denounced for spreading misinformation.
But something else that Minaj said caught my eye. She wrote that she hadn’t done “enough research” yet, but that people should keep safe “in the meantime” by wearing “the mask with 2 strings that grips your head & face. Not that loose one.”
“Wear a good mask while researching vaccines” is not the sentiment of a denier. She seemed genuinely concerned about Covid, even to the point that she seemed to understand that N95s, the high-quality masks that medical professionals wear, which have the “2 strings that grips your head & face,” were much safer.
Lazer said that the Covid States Project’s research showed that unvaccinated people who nonetheless wore masks were, indeed, more likely to be Black women. In contrast, those who were neither vaccinated nor masked were more likely to be Republicans, and more likely to be rural, less educated and white. (Among the vaccinated, Asian Americans were most likely to be still wearing masks.)
Lazer also highlighted an overlooked group with higher levels of vaccine hesitancy: young mothers. They were hesitant, both for themselves and their children, an alarming development especially if it starts affecting other childhood vaccinations. Similarly, from real-life data, we know that only a little more than one-third of pregnant women are vaccinated, which has led to many tragic stories of babies losing their mothers just as they are being whisked into the neonatal intensive care unit after an emergency cesarean section.
It may well be that some of the unvaccinated are a bit like cats stuck in a tree. They’ve made bad decisions earlier and now may be frozen, part in fear, and unable to admit their initial hesitancy wasn’t a good idea, so they may come back with a version of how they are just doing “more research.”
We know from research into human behavior but also just common sense that in such situations, face-saving can be crucial.
In fact, that’s exactly why the mandates may be working so well. If all the unvaccinated truly believed that vaccines were that dangerous, more of them would have quit. These mandates may be making it possible for those people previously frozen in fear to cross the line, but in a face-saving manner.
Research also shows that many of the unvaccinated have expressed concerns about long-term effects. Consider an information campaign geared toward explaining that unlike many drugs, for which adverse reactions can indeed take a long time to surface, adverse effects of vaccines generally occur within weeks or months, since they work differently, as the immunologist Andrew Croxford explained in The Boston Review. Medical professionals could be dispatched to vaccination clinics, workplaces and stores to get that point across. (Yes, medical professionals are overwhelmed, but the best way to reduce their burden is to vaccinate more people.) This would let some hesitant people feel like they had “done their research,” while interacting with a medical professional — the basis for more trust.
Finally, consider something hidden amid all the other dysfunction that plagues us: fear of needles.
Don’t roll your eyes. Prepandemic research suggests that fear of needles may affect up to 25 percent of adults and may lead up to 16 percent of adults to skip or delay vaccinations. For many, it’s not as simple as “suck it up”: It’s a condition that can lead to panic attacks and even fainting. During the pandemic, a study in Britain found that as many as one in four adults had injection phobia, and that those who did were twice as likely to be vaccine-hesitant. Research by Covid States shows that about 14 percent of the remaining unvaccinated mention fear of needles as a factor.
Countries with far higher rates of vaccination, Canada and Britain, have responded by mobilizing their greatest strength: a national health care system. Cities in Canada held clinics aimed especially at people with such anxiety, which included privacy rooms and other accommodations. Britain’s national health care system offers similar accommodations.
I’ve yet to find a systematic program in the United States addressing this fear. Worse, much of our public communications around the vaccines feature images of people getting jabbed with a needle, even though that can worsen anxiety.
In researching, I was inundated with stories from people who struggled with this fear and were often unable to find help. Some women said they were treated like drug seekers because they asked for a single anti-anxiety pill to get through a shot. (They also said their male family members and friends had an easier time.) It may seem hard to believe that people might risk their lives over seemingly small fears, but that’s exactly how people behave in many situations.
Of course, there are some people who it seems will never be persuaded. One strategy that has been shown to work is to highlight deceptive practices. In campaigns to keep teens from smoking, advertisements pointed out how the tobacco industry manipulated people. For Covid, the unvaccinated could be shown that they have been taken in by people who have misled them even while those people themselves got vaccinated.
Just recently, there was a brief glimpse at how Fox News actually looks behind the camera: Everyone in the office was wearing masks, even as the hosts have often talked about the alleged tyranny of it all. Stars like Tucker Carlson rant against vaccines, even as their network says that more than 90 percent of full-time employees have been vaccinated. Realizing that one may have been conned and manipulated by opportunists who do not practice what they preach may — just may — be the breakthrough for some.
Responding to our societal dysfunctions has been among the greatest challenges of this pandemic, especially since this includes a political and media establishment stirring up resentment and suspicion to hold on to power and attention in an increasingly unresponsive political system.
Anger — and even rage — at all this may be justified, but deploying only anger will not just obscure the steps we can and should try to take, it will play into the hands of those who’d like to reduce all this to a shouting match.
Instead, we need to develop a realistic, informed and deeply pragmatic approach to our shortcomings without ceding ground to the conspiracists, grifters and demagogues, and without overlooking the historic inequities in health care and weaknesses in our public health infrastructure. It’s not all fair, and it is not a Hollywood ending, but it’s how we can move forward.
A 30-Year Campaign to Control Drug Prices Faces Yet Another Failure
Democrats have made giving government the power to negotiate drug prices a central campaign theme for decades. With the power to make it happen, they may fall short yet again.
WASHINGTON — When a powerful Democratic Senate chairman assembled his Special Committee on Aging to confront what he called a “crisis of affordability” for prescription drugs, he proposed a novel solution: allow the government to negotiate better deals for critical medications.
The year was 1989, and the idea from that chairman, former Senator David Pryor of Arkansas, touched off a drive for government drug-price negotiations that has been embraced by two generations of Democrats and one Republican president, Donald J. Trump — but now appears at risk of being left out of a sprawling domestic policy bill taking shape in Congress.
Senior Democrats insist that they have not given up the push to grant Medicare broad powers to negotiate lower drug prices as part of a once-ambitious climate change and social safety net bill that is slowly shrinking in scope. They know that the loss of the provision, promoted by President Biden on the campaign trail and in the White House, could be the single most embarrassing defeat in the package, since it has been central to Democratic congressional campaigns for nearly three decades.
“Senate Democrats understand that after all the pledges, you’ve got to deliver,” said Senator Ron Wyden of Oregon, the chairman of the Finance Committee.
“It’s not dead,” declared Representative Richard E. Neal of Massachusetts, the chairman of the Ways and Means Committee.
But with at least three House Democrats opposing the toughest version of the measure, and at least one Senate Democrat, Kyrsten Sinema of Arizona, against it, government negotiating power appears almost certain to be curtailed, if not jettisoned. The loss would be akin to Republicans’ failure under Mr. Trump to repeal the Affordable Care Act, after solemn pledges for eight years to dismantle the health law “root and branch.”
And after so many campaign-trail promises, Democrats could be left next year with a lot of explaining to do.
“It would mean that the pharmaceutical industry, which has 1,500 paid lobbyists, the pharmaceutical industry, which made $50 billion in profits last year, the pharmaceutical industry, which pays its executives huge compensation packages, and which is spending hundreds of millions of dollars to defeat this legislation, will have won,” Senator Bernie Sanders, the Vermont independent and Budget Committee chairman, said on Wednesday. “And I intend to not allow that to happen.”
It is not clear how Mr. Sanders can pull that off. The length of the fight speaks to the durability and popularity of the issue, but also the power of the pharmaceutical industry.
Senator Pryor teed it up in the late 1980s, hoping to muscle through lower prices for Medicaid, with an eye on the bigger prize, Medicare. President Bill Clinton included government price negotiations in his universal health care plan in 1993, and throughout the 1990s, as Democrats pressed to add a prescription drug benefit for Medicare, government negotiations were central to holding the cost down.
Then in 2003, a Republican Congress and president, George W. Bush, secured passage of that drug benefit — but with an explicit prohibition on the government negotiating the price of medicines older Americans would purchase.
Repealing that so-called noninterference provision has been a centerpiece of Democratic campaigns ever since. Senator Chris Van Hollen of Maryland, a former head of House Democrats’ campaign arm, recalled that “Medicare shall negotiate drug prices” was one of the six planks in the “Six for ’06” platform that helped the Democrats win control of the House in 2006.
It has passed the House numerous times, including in 2019 with yes votes from the three House members now opposing it — Representatives Kathleen Rice of New York, Scott Peters of California and Kurt Schrader of Oregon — only to die in the Senate. Even Mr. Trump adopted the effort in his 2016 campaign, only to see it go nowhere.
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That futility is why Mr. Schrader said he opposed it: “Why do the same thing again and again and expect to have a different result?” he asked.
To proponents, defeat after defeat speaks solely to the power of the pharmaceutical industry and its attendant lobbyists.
But opponents say it reflects the complexity of the issue. Once lawmakers realize they could actually secure government price negotiations, they see how problematic that could be.
“If anyone thinks this is the easy political route for me, that’s just laughable,” said Mr. Peters, who has endured scorn and pressure from his Democratic colleagues but whose San Diego district includes almost 1,000 biotechnology companies and 68,000 jobs directly tied to pharmaceutical work.
Mr. Schrader and Mr. Peters said the House version of prescription drug price controls, tucked into the broader social policy legislation, would stifle innovation in one of the country’s most profitable global industries.
The Pharmaceutical Research and Manufacturers of America, known as PhRMA, also maintains that government negotiations would severely limit the types of prescription drugs that would be available to Medicare beneficiaries as companies withdraw their products from the program. With the good will the industry has accrued with its coronavirus vaccines and treatments, drug companies have pressed their case with key lawmakers, and roped in the larger business community.
American Action Network, a conservative group with business money, unveiled a new set of ads on Wednesday targeting vulnerable Democrats such as Representative Carolyn Bourdeaux of Georgia and decrying “another socialist health care plan to control what medicines you can get.”
“We are taking on the greed and the corruption of the pharmaceutical industry — I know their power, believe me, I know their power,” Mr. Sanders said. “But this is a fight we’ve got to win.”
Mr. Wyden insisted that any legislative effort to tackle rising drug costs must include government negotiating power, but alternatives are emerging.
Some simpler solutions would change the formula of the existing Medicare prescription drug benefit to limit out-of-pocket costs, especially in the event of a catastrophic health event.
Mr. Wyden is also pressing to resurrect legislation he drafted with Senator Charles E. Grassley, Republican of Iowa, that would force drugmakers to offer rebates to consumers on products whose prices rise faster than inflation. Mr. Grassley said he still supports the measure, as does Senator Bob Menendez, Democrat of New Jersey and a traditional ally of the pharmaceutical industry in his state.
Mr. Schrader and Mr. Peters said negotiations were progressing around their proposal, which would grant the government power to negotiate prices under Medicare Part B, which covers outpatient services and some of the most costly medications, once outpatient drugs like chemotherapy have outlived their patent exclusivity.
Their bill would also force rebates for drug prices rising faster than inflation, and limit out-of-pocket medication expenses for older Americans. That is projected to save the government $300 billion over 10 years, about half what the broader measure would save.
“Frankly, based on discussions we’ve had with the White House, senators and other members in our party, this could get done,” Mr. Schrader said. “That’d be huge.”
Ultimately, if any significant price controls survive, it will be the logic of the policy overcoming the power over the lobby, said Representative Ron Kind, a Democrat whose Wisconsin district is being hit with pharmaceutical industry advertising. Mr. Kind, an influential centrist, said he has been speaking with like-minded Democrats, trying to buck them up against the onslaught.
Industry shapes battle over health costs
SACRAMENTO — Gavin Newsom put California’s health care industry on notice when he was a candidate for governor, vowing in 2018 to go after the insurance companies, doctors and hospitals that leave many Californians struggling with enormous medical bills and rising insurance premiums.
He pledged to lead California’s single-payer movement, a high-stakes liberal dream that would eliminate private health insurance and slash how much providers are paid. The tough rhetoric continued after he was elected, when Newsom told insurers to “do their damn job” to improve mental health treatment or face fines, and he vowed to cut the health care industry’s soaring revenues.
“We’ve got to get serious about reducing health care costs,” the first-term Democrat said in January 2020 as he unveiled his proposal to establish an Office of Health Care Affordability that would do the unthinkable in a system powered by profits: set caps on health care spending and require doctors and hospitals to work for less money. “We mean business.”
Industry leaders were rattled. But rather than mobilize a full-throttle defense to sink Newsom’s effort to regulate them, they have used their political clout and close ties with the governor to devise a friendlier alternative that doctors, hospitals and insurance companies could live with.
When Newsom ultimately drafted legislation for the office, he took an idea health care executives had pitched and made it his own: Instead of capping prices or cutting revenues, he would allow industry spending to grow — but with limits.
Political infighting killed the legislation this year, but it is expected to come back in January and spark one of next year’s blockbuster health care battles.
“They’re fearful of what might happen to them, and they’re trying to protect their interests because they’re threatened,” David Panush, a veteran Sacramento health policy consultant, said about health care industry players. They know “there’s blood in the water and the sharks are coming.”
If Newsom’s plan to rein in health care spending succeeds, it could provide him some political cover as he campaigns for reelection next year, giving him a major health care win even as he sidesteps progressive demands such as creating a single-payer system.
But it could also cement the power of an industry that continues to wield immense influence — negotiating behind the scenes to protect its massive revenues and secure exemptions and side deals in exchange for its support.
“Every time we try to do something to reduce health care costs, it meets with huge opposition,” said state Assembly member Jim Wood (D-Santa Rosa), head of the Assembly Health Committee who is working closely with the Newsom administration on this proposal.
Industry power players have only pushed back harder as lawmakers have tried to take them on, Wood said. “Anybody or anything that disrupts the status quo is met with huge resistance and huge resources to fight it,” he said.
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When Newsom took office in 2019, he knew public sentiment was turning against the health care industry. On average, health care costs were around $11,600 per person that year, up from $4,600 in 1999, according to federal data. In California, hospitals account for the biggest share of spending, nearly one-third, while 20% of health care dollars goes to doctors.
California consumers are demanding action, with 82% of state residents saying it’s “extremely” or “very” important for the governor and legislature to make health care more affordable, according to a 2021 poll from the California Health Care Foundation.
Much of Newsom’s tough talk on industry spending came early in his term. “We’re going to create specific cost targets for all sectors to achieve, and we are going to assess penalties if they don’t achieve those targets,” Newsom said in January 2020. “If that didn’t wake up members of the system, I don’t know what will.”
Newsom’s wake-up call came on the heels of tense legislative debates on bills that would have empowered the state to set health care prices and created a single-payer system. The measures gained surprising momentum but ultimately buckled under opposition from health care giants.
Then the covid-19 crisis hit and propelled the recall effort to oust him from office — and the wake-up call was met with a slap of the snooze button. The governor and his health industry allies nestled closer. Just as he needed them to be the state’s front line of defense, they needed him to keep hospitals from overflowing, to secure protective gear and to push vaccinations.
Health care titans became regular fixtures in Newsom’s orbit. His calendars, obtained by KHN, show that doctors, hospitals and health insurance leaders have routinely received access to the governor.
Carmela Coyle, head of the California Hospital Association, stood beside Newsom at the state emergency operations center in the early days of the covid crisis, and Paul Markovich, CEO of Blue Shield of California, obtained a lucrative no-bid state vaccination contract to implement Newsom’s vaccination effort.
Newsom did not respond to questions about the industry’s influence, but spokesperson Alex Stack said his proposal to regulate health care spending “is a priority for this administration, and we look forward to continuing to work on this issue to get it done.”
Doctors and Blue Shield have given Newsom millions of dollars to support his political career over many years, including a $20 million donation in September 2020 from Blue Shield for his homelessness initiatives.
The recall effort earlier this year only solidified Newsom’s relationship with health care executives. Industry groups wrote checks to the California Democratic Party, which fought to keep Newsom in office. It received $1 million each from Blue Shield and the hospital lobby and $875,000 from the doctors’ lobby, according to state campaign finance records.
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Though Newsom vowed to go after industry, he hasn’t aggressively taken it on, and health care executives and lobbyists continue to wield their influence as they shape the debate over the Office of Health Care Affordability.
That could put Newsom in a political bind as he runs for reelection — first in the June 2022 primary and then the November general election — because he will face intense opposing political pressure from liberal Democrats who want him to keep his campaign promise and adopt single-payer.
Health and political experts say Newsom can help alleviate that pressure by adopting a strict law going after spiraling health care spending.
But it won’t be easy. After powerful industry leaders joined forces with organized labor and consumer advocates to propose a plan to the governor, they jammed negotiations with their demands, splintering the coalition and killing the effort this year.
With battle lines drawn, industry groups are poised for a major fight next year as Newsom and state Democratic lawmakers muscle through legislation. Their primary goal will be to protect their interests, said Mark Peterson, a professor of public policy, political science and law at UCLA.
“There’s no question this industry has power. The real question is what they do with it,” Peterson said. “They’re getting wins, and important ones.”