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      The G.O.P. Goes Full-on Extremist

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      There are no moderate Republicans in the House of Representatives.Oh, no doubt some members are privately appalled by the views of Mike Johnson, the new speaker. But what they think in the privacy of their own minds isn’t important. What matters is what they do — and every single one of them went along with the selection of a radical extremist.In fact, Johnson is more extreme than most people, I think even political reporters, fully realize.Much of the reporting on Johnson has, understandably, focused on his role in the efforts to overturn the 2020 election. Let me say, by the way, that the widely used term “election denial” is a euphemism that softens and blurs what we’re really talking about. Trying to keep your party in power after it lost a free and fair election, without a shred of evidence of significant fraud, isn’t just denial; it’s a betrayal of democracy.There has also been considerable coverage of Johnson’s right-wing social views, but I’m not sure how many people grasp the depth of his intolerance. Johnson isn’t just someone who wants to legalize discrimination against L.G.B.T.Q. Americans and ban gay marriage; he’s on record as defending the criminalization of gay sex.But Johnson’s extremism, and that of the party that chose him, goes beyond rejecting democracy and trying to turn back the clock on decades of social progress. He has also espoused a startlingly reactionary economic agenda.Until his sudden elevation to speaker, Johnson was a relatively little-known figure. But he did serve for a time as chairman of the Republican Study Committee, a group that devises policy proposals. And now that Johnson has become the face of his party, people really should look at the budget proposal the committee released for 2020 under his chairmanship.For if you read that proposal carefully, getting past the often mealy-mouthed language, you realize that it calls for the evisceration of the U.S. social safety net — not just programs for the poor, but also policies that form the bedrock of financial stability for the American middle class.Start with Social Security, where the budget calls for raising the retirement age — already set to rise to 67 — to 69 or 70, with possible further increases as life expectancy rises.On the surface, this might sound plausible. Until Covid produced a huge drop, average U.S. life expectancy at age 65 was steadily rising over time. But there is a huge and growing gap between the number of years affluent Americans can expect to live and life expectancy for lower-income groups, including not just the poor but also much of the working class. So raising the retirement age would fall hard on less fortunate Americans — precisely the people who depend most on Social Security.Then there’s Medicare, for which the budget proposes increasing the eligibility age “so it is aligned with the normal retirement age for Social Security and then indexing this age to life expectancy.” Translation: Raise the Medicare age from 65 to 70, then keep raising it.Wait, there’s more. Most nonelderly Americans receive health insurance through their employers. But this system depends greatly on policies that the study committee proposed eliminating. You see, benefits don’t count as taxable income — but in order to maintain this tax advantage, companies (roughly speaking) must cover all their employees, as opposed to offering benefits only to highly compensated individuals.The committee budget would eliminate this incentive for broad coverage by limiting the tax deduction for employer benefits and offering the same deduction for insurance purchased by individuals. As a result, some employers would probably just give their top earners cash, which they could use to buy expensive individual plans, while dropping coverage for the rest of their workers.Oh, and it goes almost without saying that the budget would impose savage cuts — $3 trillion over a decade — on Medicaid, children’s health coverage and subsidies that help lower-income Americans afford insurance under the Affordable Care Act.How many Americans would lose health insurance under these proposals? Back in 2017 the Congressional Budget Office estimated that Donald Trump’s attempt to repeal Obamacare would cause 23 million Americans to lose coverage. The Republican Study Committee’s proposals are far more draconian and far-reaching, so the losses would presumably be much bigger.So Mike Johnson is on record advocating policies on retirement, health care and other areas I don’t have space to get into, like food stamps, that would basically end American society as we know it. We would become a vastly crueler and less secure nation, with far more sheer misery.I think it’s safe to say that these proposals would be hugely unpopular — if voters knew about them. But will they?Actually, I’d like to see some focus groups asking what Americans think of Johnson’s policy positions. Here’s my guess, based on previous experience: Many voters will simply refuse to believe that prominent Republicans, let alone the speaker of the House, are really advocating such terrible things.But they are and he is. The G.O.P. has gone full-on extremist, on economic as well as social issues. The question now is whether the American public will notice.The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips. And here’s our email: letters@nytimes.com.Follow The New York Times Opinion section on Facebook, Twitter (@NYTopinion) and Instagram. More

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      Fixing America’s Health Care System

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      More from our inbox:Trump’s Trial Dates and the Odds of ConvictionDoes Barbie Really Need Ken?September Dawn Bottoms for The New York TimesTo the Editor: Re “How Do We Fix the Scandal That Is American Health Care?,” by Nicholas Kristof, with photographs by September Dawn Bottoms (column, Aug. 20):Nicholas Kristof scratches the surface of the failures of the health care system in this country. I have been in practice for 28 years as a cardiologist and internist and have seen firsthand the miraculous breakthroughs in cardiac care as well as the appalling level of care typical in treatment of chronic diseases, especially among minority populations.Most care in this country is delivered by large for-profit and nonprofit entities (which function largely as for-profit entities but avoid taxes). These systems are incentivized to invest in high-end tertiary care, typically cardiac, orthopedic, neurosurgical and oncologic care, as they have the highest reimbursement.Chronic care for conditions such as obesity, diabetes and high blood pressure are not sexy areas of medicine and for the most part offer low compensation from Medicare, Medicaid and commercial payers.Our health care system needs to incentivize primary care and force nonprofit entities to allocate larger portions of their budgets to primary care or lose their nonprofit status.Daniel ZangerBrooklynTo the Editor:Nicholas Kristof has written a cogent and damning column. One piece of the health care crisis we must also address is physician education and remuneration.New physicians have delayed earning potential in order to attend medical school and have endured at least three years of paltry pay and extremely demanding schedules as medical interns and residents. By the time they are able to practice medicine after at least seven years of post-college training, they are unlikely to set up practice in rural areas with the lowest pay, fewest colleagues for support, professional isolation and limited call coverage. They are also less likely to practice in pediatrics or family medicine than in a medical specialty.Indeed, no one can blame them for wanting to work in a place conducive to comfortably repaying student loans as well as paying for malpractice insurance.Bright, hardworking young people can find myriad other fields of work and skip the stress that is modern U.S. medicine.If we are serious about improving health outcomes and reducing infant mortality, depression and skyrocketing rates of diabetes and other illnesses, then we need to completely revamp physician education.Nurses, doctors and hospital staff are heroes. Let’s treat them as such. Pay for their education, and incentivize work in underserved and high-risk locales.Susan BaloghBostonTo the Editor:Only last month the Department of Health and Human Services found that some of the country’s largest for-profit insurance companies, which together manage Medicaid programs that cover the majority of the 87 million individuals on Medicaid, denied more than one of every four requests for doctor-ordered treatments or medications for patients enrolled in their Medicaid plans. Medicaid serves many who live with the disadvantages that often lead to higher rates of diabetes and other chronic illnesses for which timely and consistent care is essential to better outcomes. Providing the services that doctors prescribe for these patients would go a long way to fixing the scandal described by Mr. Kristof.Ted HermanProvidence, R.I.The writer is a former health insurance executive.Trump’s Trial Dates and the Odds of ConvictionDoug Mills/The New York TimesTo the Editor: Re “This Indictment Does Something Ingenious,” by Norman Eisen and Amy Lee Copeland (Opinion guest essay, Aug. 16): The Georgia indictment might be ingenious, but the fact remains that Donald Trump won Georgia in 2016 and missed by a whisker winning again in 2020. So there is an overwhelming likelihood that some of his base of supporters will be on his jury and will not vote for his conviction no matter the strength of the evidence.Harold J. SmithWhite Plains, N.Y.To the Editor:There are many legitimate factors to take into account in determining when any criminal trial might begin, but one factor not to take into account is the defendant’s job. At the moment, Donald Trump is looking for a job (president) and in essence interviewing to get the job (campaigning).So let’s hope that the one factor that none of the judges consider in setting Mr. Trump’s trial date is his “interviewing schedule.”The judges might consider that at least some of Mr. Trump’s potential “employers” might want to know before hiring him whether or not he is a felon and set to spend many years in prison.Eugene D. CohenPhoenixDoes Barbie Really Need Ken?Iris Schneider/Los Angeles Times, via Getty ImagesTo the Editor: Re “Why Barbie and Ken Need Each Other,” by Ross Douthat (column, nytimes.com, Aug. 9):As a young woman, I agree with Mr. Douthat that “Barbie” contains some real, not-talked-about ambivalence concerning what female empowerment truly means.However, the core failing of “Barbie” is not, as he suggests, its failure to unite Barbie and Ken romantically, but a failure to imagine a world in which people of all genders can successfully lead together. Mr. Douthat’s insinuation that romance and reproduction must be the basis of any kind of productive union between men and women is archaic and troubling.This being said, the assertion of the “Barbie” movie that Ken is “superfluous” is also concerning. It is not, of course, that women have a need for men, but that humanity requires all of its members’ collaboration to achieve its highest potential. And yet, at the end of the movie, when Ken is relegated to a status equal to that of women in the real world (read: oppressed), any hope for a world in which people — or dolls — of all genders can live fulfilled, empowered lives remains elusive.Mary ElliotLenox, Mass.To the Editor:Certainly, there is evidence that married people tend to be happier than the unmarried. But that largely applies to people who are happily married. Unhappily married people are not only less happy than the happily married, but also less happy than those who are divorced, and less healthy than those who are single, divorced or widowed.There are some important factors that suggest Barbie and Ken’s union might not be a happy one. Barbie never expressed any interest in a relationship with Ken or with anyone else. As Barbie was being ushered into a black S.U.V. and taken to the Mattel headquarters, Ken high-tailed it back to Barbieland solo. While there, as Gloria (played by America Ferrera) so clearly summarized, he took Barbie’s house, he brainwashed her friends, and he tried to control the government.No one needs 40 years of General Social Survey data to know that they would be miserable. Stop trying to convince women that the key to their happiness is committing to emotionally damaged men against their self-interest and better judgment.Theresa HastertAnn Arbor, Mich. More

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      in US Politics

      Republican debt ceiling plans could see most vulnerable Americans lose aid

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      As debt ceiling negotiations come down to the wire with the 1 June deadline looming, some Republican leaders seem determined to use critical safety net programs – specifically, Medicaid and Snap – as a bargaining chip, and millions of America’s most vulnerable families may pay the price.Cuts and restrictions to these essential programs, which offer healthcare and food assistance, will cause further hardship to families who are already struggling – and who in many cases can’t afford the basic essentials like food and shelter. The Republican fixation on appending work requirements to these benefits are also ineffective: data shows these policies are not needed and don’t produce any substantial solutions. Some critics say they also force people to find jobs that don’t actually lead to economic mobility, prolonging their need for federal assistance.“Most Americans with health coverage through Medicaid are already working if they are able to,” Senator Ron Wyden, chairman of the Senate finance committee, said in a recent statement. He also noted that “the track record shows work reporting requirements are a bureaucratic nightmare for Americans”.If Democrats make these concessions to the GOP, the cuts would also be one more blow to vulnerable people this year, many of whom just recently experienced slashed benefits when emergency Snap benefits ended along with the public health emergency for Covid-19 in May. At the same time, grocery prices are soaring: The US Department of Agriculture estimates all food prices are predicted to increase 6.5% in 2023, on top of the jumps in cost we’ve already seen over the past year or so.Maine resident Hazel Willow, single mother to a four year old, recently left an abusive relationship and says these programs provide the essential support she desperately needs to survive and heal.“The way I’m best able to provide for my child, to make sure I’m living my highest good as myself, a mother, a citizen and human in society, is to heal and recover with whatever ability I have in my body that day,” Willow said. “To do that safely and successfully, I need the societal safety net of Snap, Tanf, Wic, and others.”Willow notes that – like everyone else she knows who relies on these programs – she would love to be more self-sufficient, and wishes she had more options that would provide her with more financial breathing room and agency over her own life.“A life in which you live or die by your access to these programs is not an easy one. In my new world – where almost everyone is on most of these same programs – I have yet to meet someone who has an easy day, who is happy and safe with the way their life is and feels content to simply exist on these benefits.”Paco Vélez, president and chief executive of Feeding South Florida, said there are more than a million people struggling with food insecurity in his region and worries that more restrictions will make the situation even more dire.“The proposed work restrictions expand the minimum 20 hour per week work requirement from ages 18 to 49 to include ages 50 to 55,” said Vélez. “Many times, individuals that are unable to work fall through the cracks and have a hard time filing for an exemption or navigating the process to obtain disability, although their health is at risk, or they are unable to perform in a job they used to be able to do.”“My Snap benefits run out by the second week of the month and that is already shopping for whatever I can find on sale,” says Lilia Jorge Perez, 51, of Hollywood, Florida, who relies on Feeding South Florida. “I want to buy more healthy foods like vegetables, fruits, chicken or fish but that would take most of my benefits.”Perez came to the US from Cuba last year and has been struggling to find work because she is still waiting for her work permit. She was recently cut off from Medicaid and cash assistance and is grateful to be receiving Snap benefits.“It is already difficult to find work and even worse for those over 50 with little to no education and who don’t speak English,” says Perez. “I know people shouldn’t have to rely only on the government to provide for themselves, but if we are already facing the possibility of homelessness from the raise in rent, and people are going without food because of the prices, how can the politicians make it worse during such a difficult time in the United States?”Work restrictions often create obstacles for people accessing benefits, while also putting additional strain on staff and resources that are already stretched thin in such programs. Many families are required to navigate a notoriously complicated and time-consuming process in order to submit documentation proving they are meeting the requirements.And many communities – especially those in high-poverty areas – lack the resources to help residents who are facing food insecurity.“The families we serve may not have access to a computer, miss the required phone interview, or have notices mailed to a former address,” said Vélez. “Expanding the age for work requirements will force more folks to jump through these hoops to access food – a necessity.”Meanwhile, the cuts could deprive millions of Americans access to healthcare at a time when Covid continues to have significant impacts. The pandemic emergency status may have officially ended earlier in May, but tens of thousands of Americans are still getting sick with the virus or dealing with the lingering symptoms of long-term Covid.A mandatory national Medicaid recertification process involving all program enrollees – known as an “unwinding” – has already begun as states resume the annual eligibility verification procedures that had been on hold during the pandemic. KFF estimates that between 5.3 million and 14.2 million people will lose Medicaid coverage just through that process alone.States that saw some of the largest Medicaid enrollment surges during the pandemic – such as California, New York and Florida – are also likely to be among those with the largest number of people who lose coverage during this unwinding process. That means many people living in those states will soon be left uninsured – particularly in states like Florida, which didn’t adopt the Medicaid expansion, meaning fewer people meet the criteria for eligibility.Adding work requirements and other barriers to coverage will compound the healthcare access crisis – and place significant strain on community resources including emergency rooms (where uninsured patients will seek care if they have no other option).The US Department of Health and Human Services (HHS) says the red tape created by the Republicans’ proposed work restrictions would jeopardize the health coverage and access to care of 21 million Americans.Kimberley Causey-Gomez, commissioner of the Virgin Islands Department of Human Services, notes that more than 40% of the territory’s population relies on Medicaid, and she worries that many of them may be at risk of losing coverage (and the access to healthcare) should work requirements become a reality.Meanwhile, in Maine, Willow thinks the wealthy, including lawmakers and administrators who create and oversee these policies, don’t appreciate the consequences their actions have for people who rely on these programs – people who play an important role in our communities and society.“The people who make your coffee, cut your hair or bag your groceries. The staff at the gas stations and restaurants you frequent,” she said.“Your life is supported by these programs whether you see them or not.”This article was supported by the Economic Hardship Reporting Project More

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      Obamacare Keeps Winning

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      Its North Carolina victory is a sign of larger changes.The government benefits began their existence as objects of partisan rancor and harsh criticism. Eventually, though, they became so popular that politicians of both parties promised to protect them.It was true of Social Security and Medicare. And now the pattern seems to be repeating itself with Obamacare.Consider what has happened recently in North Carolina: Only a decade after the state’s Republican politicians described the law as dangerous and refused to sign up for its expansion of Medicaid, Republicans and Democrats came together to pass such an expansion. The Republican-controlled House in North Carolina passed the bill 87 to 24, while the Republican-controlled Senate passed it 44 to 2.“Wow, have things changed,” Jonathan Cohn wrote in a HuffPost piece explaining how the turnabout happened.Obamacare — the country’s largest expansion of health insurance since Medicare and Medicaid in 1965 — is still not as widely accepted as those programs. North Carolina became the 40th state to agree to expand Medicaid under Obamacare, which means that 10 states still have not, including two of the largest, Texas and Florida. In those states, more than 3.5 million adults lack health insurance as a result.But the list of states signing up for the program seems to be moving in only one direction: It keeps growing.Source: Kaiser Family Foundation‘Humiliation’In its growing acceptance, Obamacare resembles other major parts of the federal safety net:When Congress was considering Social Security in 1935, conservatives and many business executives bitterly criticized it. One Texas newspaper described Social Security as “a huge sales tax on everybody on behalf of the oldsters.” A Wall Street Journal editorial predicted that the law would eventually be reason for Congress to look back in “humiliation.” Not exactly: Social Security is so popular that it is known as a third rail in American politics.When Congress was debating Medicare in the 1960s, Ronald Reagan — then an actor with a rising political profile — attacked the program as a step toward socialism. If it passed, Reagan warned, “We are going to spend our sunset years telling our children, and our children’s children, what it once was like in America when men were free.” As president, Reagan praised and supported the program.After Congress created Medicaid — a health-insurance program primarily for low-income households — in 1965, some states did not initially join it. Arizona became the last to do so, in 1982.Roberts and McCainIn the initial years after Obamacare’s passage in 2010, it was similarly divisive. Blue states embraced it, while many red states rejected its voluntary Medicaid expansion. In Washington, congressional Republicans and Donald Trump tried to repeal it. Some Republican-appointed judges invalidated parts of it, and every Republican appointee on the Supreme Court except Chief Justice John Roberts voted to scrap the law.Twice, it survived by a single vote — first, by Roberts’s 2012 Supreme Court vote, and then by Senator John McCain’s late-night vote against its repeal in 2017. Since then, however, Obamacare has been gaining Republican support.The next year, voters in Idaho, Nebraska and Utah — red states, all — passed ballot initiatives expanding Medicaid. Oklahoma, Missouri and South Dakota have since done so. Montana’s state legislature has also approved an expansion.American Medical Association Communications DivisionIn 2019, Gov. Andy Beshear of Kentucky, a Democrat, narrowly won election in a Republican state by pledging to protect an earlier Medicaid expansion. In North Carolina, Roy Cooper, also a Democrat, became governor in a 2016 upset partly by campaigning in favor of an expansion — and was able to sign one this week.(Before it takes effect, Cooper and the legislature must agree on a state budget.)These developments are a sign of the law’s growing popularity. And that popularity isn’t especially mysterious: In a country with high levels of economic inequality and large numbers of people without health insurance, Obamacare has increased taxes on the affluent to subsidize health care for poor and middle-class families. At root, it is an effort to reduce inequality.Winning the middleEven with its flaws — including its often complicated process for signing up for insurance — the law has achieved many of its aims. The number of Americans without health insurance has plummeted. In states that have refused the Medicaid expansion, by contrast, rural hospitals are struggling even more than elsewhere because they do not receive the law’s subsidies for care.Greenwood Leflore Hospital — in the Mississippi Delta — is an example. It recently closed its intensive-care unit and maternity ward, as our colleague Sharon LaFraniere has reported. Nationwide, states that did not quickly accept Medicaid expansion have accounted for almost three-quarters of rural hospital closures between 2010 and 2021, according to the American Hospital Association.Similar problems in North Carolina were a reason that Republicans there reconsidered their opposition to Medicaid expansion. “We had these people coming down to Raleigh, farmers, business owners, people from rural areas, they were advocating, telling stories,” one Republican state representative told HuffPost.Many Republicans still oppose Obamacare, and some hard-right members of Congress also favor cuts to Medicaid — as well as to Medicare and Social Security. In a country as polarized as the United States, there isn’t much true political consensus. But Obamacare has won over the political middle more quickly than seemed likely not so long ago.Related: The number of people signing up for insurance through Obamacare has surged over the past two years, partly because of a new subsidies signed by President Biden.THE LATEST NEWSPoliticsMike Pence must testify to the grand jury investigating Trump’s role in the Jan. 6 Capitol attack, a judge ruled.Republicans are trying to create obstacles to voting for college students, who lean Democratic.An election for a swing seat on Wisconsin’s Supreme Court has become an expensive political fight.A.I. is already affecting the 2024 elections, producing fake images of Trump getting arrested and videos that mimic Biden’s voice.Migrant DeathsA mourner in Ciudad Juárez, Mexico.Go Nakamura for The New York TimesAt least 38 people died in a fire at a migrant detention center in Mexico, near El Paso, Texas. The fire started after a protest.U.S. policies have created overcrowding and desperation at the border.BusinessLawmakers grilled federal regulators who were supposed to supervise Silicon Valley Bank before it collapsed.Prosecutors added a foreign bribery charge to the list of crimes already pending against the FTX founder Sam Bankman-Fried.Alibaba Group, China’s e-commerce giant, is splitting into six business groups.Other Big StoriesThe shooter who killed six people at a Nashville school this week had legally purchased seven guns recently, the police said.Myanmar’s military dissolved the political party of the imprisoned opposition leader Aung San Suu Kyi.Russia sent a 13-year-old girl to an orphanage after her father criticized the war in Ukraine.An appeals court reinstated the murder conviction of Adnan Syed, the “Serial” podcast subject who was freed after more than 20 years in prison, and ordered a new hearing.OpinionsThe success of Israel’s protests suggests that its democracy is healthier than many feared, Bret Stephens writes.How can doctors better discuss dying with their patients? Start by trusting them, Dr. Sunita Puri writes.MORNING READS“La Ronde Enfantine,” painted circa 1862.The Fitzwilliam Museum, CambridgeStolen painting: He lost a Courbet when he fled the Nazis. His heirs are getting it back.15-minute city: A professor is getting death threats for his walkable urban design plan.A discovery: He solved a math problem by finding what’s known as an einstein.Midday snooze: Can a nap make up for a bad night of sleep?Advice from Wirecutter: Pick the best VPN.Lives Lived: Born into poverty in the segregated South, Randall Robinson galvanized Americans against South African apartheid and advocated on behalf of Haitian refugees. He died at 81.SPORTS NEWS FROM THE ATHLETICN.C.A.A. women’s tournament: Iowa vs. South Carolina is the Final Four matchup many wanted — and the one the sport deserves.A potential $6 billion deal: Multiple bidders have submitted offers to buy the Washington Commanders, including a group that includes Magic Johnson as an investor. Patriots won’t pursue Jackson: New England is out of the Lamar Jackson stakes, and plans to stick with Mac Jones as its quarterback.ARTS AND IDEAS The pistachio Suprême croissant from Lafayette.Julia Gartland for The New York TimesThe ever-changing croissantApparently there’s no end to the forms a croissant can take.Ten years after the Cronut, pastry chefs are twisting croissant dough into pinwheels and squiggles, tying it in knots and stacking it into cubes. They are turning it into breakfast cereal, tie-dyeing it and, in one case, wrapping it around baguettes.When the baker Scott Cioe wanted to lure crowds to Lafayette, a Manhattan restaurant, he turned to croissant dough, coiling it into a photogenic swirl he called the Suprême. “We eat with our eyes as well as our hands,” Cioe told The Times.PLAY, WATCH, EATWhat to CookJulia Gartland for The New York TimesTry cooking pasta like risotto, adding liquid gradually so that the noodles absorb it completely. The result is a creamy, rich dish.What to WatchRob Lowe and John Owen Lowe star in “Unstable,” a new Netflix series that exaggerates their barbed father-son dynamic.What to Listen toLana Del Rey’s ninth album asks big, earnest questions and isn’t afraid to get messy.Late NightStephen Colbert called the Nashville shooting horrible and familiar.Now Time to PlayThe pangrams from yesterday’s Spelling Bee were calculator and coloratura. Here is today’s puzzle.Here’s today’s Mini Crossword, and a clue: Really awesome (four letters).And here’s today’s Wordle. Thanks for spending part of your morning with The Times. See you tomorrow. — DavidP.S. Nicholas Nehamas is joining The Times from The Miami Herald, to cover Ron DeSantis.Here’s today’s front page. “The Daily” is about Israel.Matthew Cullen, Lauren Hard, Lauren Jackson, Claire Moses, Ian Prasad Philbrick, Tom Wright-Piersanti and Ashley Wu contributed to The Morning. You can reach the team at themorning@nytimes.com.Sign up here to get this newsletter in your inbox. More

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      in Elections

      What’s In (and Not In) the $1.7 Trillion Spending Bill

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      A big boost for the military, more aid for Ukraine, a preference for the lobster industry over whales and an overhaul of the Electoral Count Act are among the provisions in the 4,155-page bill lawmakers expect to pass this week.WASHINGTON — Billions of dollars in emergency aid to war-torn Ukraine and communities ravaged by natural disasters. A bipartisan proposal to overhaul the archaic law at the heart of former President Donald J. Trump’s effort to overturn the 2020 election. And a divisive oceanic policy that will change federal protections for whales in an effort to protect the lobster industry in Maine.In compiling the roughly $1.7 trillion catchall spending package that will keep the government open through September, lawmakers inserted several new funding and legislative proposals to ensure their priorities and policies become law before the end of the year.It includes funding that will guarantee the enactment of policies first authorized in bipartisan legislation approved earlier in this Congress, including money for innovation hubs established in the semiconductor manufacturing law and projects in the infrastructure law. The package also includes a round of earmarks, rebranded as community project funding, that allow lawmakers to redirect funds to specific projects in their states and districts.Here is a look at some of the provisions that would go into effect if enacted.Military spending is the big winner.The Defense Department would see an extraordinary surge in spending when adding its regular 2023 fiscal year budget together with additional funds being allocated to help respond to the war in Ukraine.All together, half of the $1.7 trillion in funding included in the package goes to defense, or a total of $858 billion. It comes after lawmakers bucked a request from President Biden and approved a substantial increase in the annual defense policy bill passed this month.The 2023 budget just for the Defense Department would total $797.6 billion in discretionary spending — a 10 percent increase over last year’s budget — representing an extra $69.3 billion in funds for the Pentagon, which is $36.1 billion above the president’s budget request.Sprinkled throughout the spending bill are hundreds of high-ticket add-ons that Congress wants to make to the president’s original Defense Department budget, such as an additional $17.2 billion for procurement that the Pentagon can largely distribute to military contractors to buy new ships, airplanes, missile systems and other equipment. The overall Pentagon procurement budget with these additional funds would be $162 billion.One of the biggest chunks of that extra money is for shipbuilding — an extra $4 billion that brings the Navy’s overall shipbuilding budget to $31.96 billion. That will allow it to buy 11 new ships, including three guided missile destroyers and two attack submarines.But that is just the start. There is $8.5 billion to buy 61 F-35 fighter jets made by Lockheed Martin and another $2.5 billion to buy 15 of Boeing’s new aerial refueling planes known as KC-46 tankers.There is also an extra $27.9 billion to help cover Defense Department costs associated with the war in Ukraine, as part of an emergency aid package to the country. That includes an extra $11.88 billion to replenish U.S. stocks of equipment sent to Ukraine — money that again will largely be used to purchase products from military contractors. That supplemental appropriation also includes $9 billion to assist Ukraine with training, equipment and weapons, as well as an extra $6.98 billion to cover U.S. military operations in Europe.— Eric Lipton and John IsmayMaking it easier (for some) to save for retirement.The package also includes a collection of new rules aimed at helping Americans save for retirement. The bill would require employers to automatically enroll eligible employees in their 401(k) and 403(b) plans, setting aside at least 3 percent, but no more than 10 percent, of their paychecks. Contributions would be increased by one percentage point each year thereafter, until it reaches at least 10 percent (but not more than 15 percent). But this applies only to new employer-provided plans that are started in 2025 and later — existing plans are exempt.Another provision would help lower- and middle-income earners saving for retirement by making changes to an existing tax credit, called the saver’s credit, now available only to those who owe taxes. In its new form, it would amount to a matching contribution, from the federal government, deposited into taxpayers’ retirement accounts.People struggling with student debt would also receive a new perk: Employees making student debt payments would qualify for employer matching contributions in their workplace retirement plan, even if they were not making plan contributions of their own.What to Know About Congress’s Lame-Duck SessionCard 1 of 5A productive stretch. More

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      How South Dakota Voters Won a Power Struggle With G.O.P. Legislators

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      Coming on the same night that voters in San Francisco ousted their lightning rod of a district attorney, Chesa Boudin — in what was widely interpreted as a setback for progressive ideas on criminal justice — it would have been easy to overlook what happened on Tuesday in South Dakota.But the results there are no less consequential for national politics. Voters in South Dakota sent a resounding message of their own to the state’s conservative power structure: We’re in charge here, not you.The immediate issue was a constitutional amendment requiring that certain voter-initiated referendums must pass by 60 percent, rather than a simple majority. The measure was defeated decisively, with more than two-thirds of voters rejecting the proposed new threshold.But this wasn’t just a political process story. It was the latest round in a national fight between voters and state legislatures, who have been battling for primacy on issues like marijuana legalization, gerrymandering and health care. Last year, my colleagues Reid Epstein and Nick Corasaniti took a broad look at Republican-led efforts to limit ballot initiatives, which have grown only more intense in the last 12 months.In South Dakota, the ballot question was pushed by Republican state lawmakers who are hoping to defeat a November referendum on expanding access to Medicaid. To David Daley, the author of several recent books on grass-roots democracy, it was a classic example of the power struggle playing out in state capitols across the country.“Whenever citizens effectively use the ballot initiative to make policy changes the legislature opposes, lawmakers bite back, and they bite back hard,” Daley said.Raising the threshold for ballot drives is an increasingly common tool. A new report by RepresentUs, a nonpartisan group that promotes ballot initiatives, found that since 2017, at least four states have passed laws that impose supermajority requirements and put them in front of voters as a ballot question, out of at least 64 bills proposed.And it’s not always Republican lawmakers pitted against progressive voters.“We’ve seen legislators attempt to threaten and limit the ballot-measure process in red, blue and purple states,” said Anh-Linh Kearney, a research analyst for RepresentUs, pointing to Democratic-controlled Colorado, which raised the requirement for passing ballot measures to 55 percent in 2016.Not-so-subtle tactics to target referendumsChris Melody Fields Figueredo, the executive director of the Ballot Initiative Strategy Center, described a “growing trend of tactical ways to make the process harder,” pointing to her group’s tally of 108 laws introduced this year in 26 states that would make technical tweaks to the rules surrounding ballot initiatives.Understand the June 7 Primary ElectionBy showing little enthusiasm for progressive and Trumpian candidates alike, voters in seven states showed the limits of the ideologies of both parties.Takeaways: For all the talk of sweeping away the old order, the primaries on June 7 largely saw the establishment striking back. Here’s what else we learned.Winners and Losers: Here is a rundown of some of the most notable wins and losses.California Races: The recall of a progressive prosecutor showed the shifting winds on criminal justice. In Los Angeles, Rick Caruso and Representative Karen Bass are heading to a runoff mayoral election.New Mexico’s Governor Race: Mark Ronchetti, a former television meteorologist, has won New Mexico’s Republican nomination for governor.Since 2017, Fields Figueredo said, the center had counted a fivefold increase in bills introduced and enacted that would make it more difficult to pass ballot measures.Sometimes those tweaks take Kafkaesque forms.In Arkansas, for instance, a drive to establish a nonpartisan redistricting commission ran into a deviously written 2015 law requiring that canvassers for the ballot initiative pass a federal background check conducted by the State Police.But there was a catch. The State Police could not do federal background checks. So the group behind the ballot drive, Arkansas Voters First, pulled what information it could from publicly available records and submitted thousands more signatures than required. The secretary of state rejected those background checks on the grounds that the canvassers had not “passed,” and threw out more than 10,000 signatures.Litigation followed. In a 2020 decision, the Arkansas Supreme Court sided with the secretary of state, ruling that the statute had mandated the background checks, whether or not the task was impossible. In a dissent, Justice Josephine Linker Hart pointed out the absurdity of the statute, noting that “the State Police do not ‘pass’ or ‘fail’ the subject of a background check” — they merely share the information from the relevant databases.“It was wild,” said Bonnie Miller, who led the Arkansas Voters First petition drive. “I’m still not over it.”A court later threw out the background-check requirement, but the cat-and-mouse game goes on: The Arkansas General Assembly passed a new law that lengthened the list of offenses that disqualify paid canvassers. And a measure similar to the one South Dakota voters just rejected, raising the threshold for successful ballot initiatives to 60 percent, is now on the ballot.Miller feels as if she’s battling for the very principle behind voter-led referendums. “This threshold, it’s just death to direct democracy in our state,” she said.‘People want the ability to make decisions for themselves’Opponents of the South Dakota amendment had a couple of factors working in their favor.There’s the state’s long history with ballot initiatives: Father Robert Haire, a radical Catholic priest, helped pioneer the concept as an activist with the Populist Party in the 1880s.Then there’s the fact that Medicaid is popular. Voter-led petitions have already powered Medicaid expansion in Idaho, Missouri, Nebraska, Oklahoma and Utah. The Kaiser Family Foundation, a nonprofit group that tracks information and trends about the country’s health care system, has found that three-quarters of Americans hold a favorable opinion of the program — including 76 percent of independents and 65 percent of Republicans.At this point, only 12 states have not expanded Medicaid under the Affordable Care Act, despite its popularity. As you can see from this interactive map, also put together by Kaiser, these states are concentrated in the Deep South, along with Kansas, South Dakota, Texas, Wisconsin and Wyoming. But when Kaiser asked people in those states whether they wanted to expand Medicaid’s coverage, 61 percent said yes.And finally, Fields Figueredo said, voters have a deep-seated aversion to having their choices limited by politicians — setting up inevitable clashes with lawmakers who “don’t like being told what to do.”“People want the ability to make decisions for themselves,” she said.What to read“We’re bleeding out, and you’re not there”: Families of the Uvalde, Texas, massacre pleaded with Congress today to enact new gun control laws.Attorney General Ken Paxton of Texas said this week that the state would investigate fake accounts on Twitter — an issue that Elon Musk, the world’s richest man, has pointed to as he appears to waver on a blockbuster deal to buy the platform. What’s in it for Paxton and Texas? David McCabe and J. David Goodman explain.The Supreme Court is expected to release some enormously important rulings in the coming weeks. David Leonhardt previews the five biggest ones.Rick Caruso will face Representative Karen Bass in the general election for Los Angeles mayor.Jenna Schoenefeld for The New York TimesAbout last night’s election results …Last night, we wrote about four candidates we were watching in Tuesday’s primaries, and 24 hours later, we have some results — but as expected, we’re still waiting for more.In one of the three Republican primary challenges we were monitoring, the incumbent is safe. In the other two, it’s too soon to say.Understand the 2022 Midterm ElectionsCard 1 of 6Why are these midterms so important? More

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      ‘It’s easy to dismiss Black women’s lives’: Texas drags feet on maternal mortality crisis

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      When medical staff prepped Shawn Thierry for an emergency C-section, she knew something was very wrong. After an epidural, excruciating pain ran through her legs. Soon, she could barely breathe.“I felt like my heart was going to jump out of my chest and that I might die,” she said.She screamed for her doctor to put her under anesthesia – which happened to be the solution. The epidural, Thierry later found out, was given too high in her spine, causing a paralysis that inched toward her heart.“I was an attorney who had full private healthcare coverage and I almost died,” said Thierry, of the birth of her daughter in 2012. “I cannot imagine what the outcome would be for the thousands of other African American women without health insurance.”Years later, as a member of the Texas House, Thierry was “stunned” to learn of the state’s maternal mortality crisis.The US has the highest maternal death rate among similarly developed countries and is the only industrialized nation where such deaths are rising. But according to data from the federal Centers for Disease Control and Prevention, in Texas the maternal mortality rate is above the US average, at 18.5 deaths per 100,000 live births.Black women in the state are “disproportionately” affected, accounting for 11% of live births but 31% of maternal deaths. Wide racial and ethnic disparities exist nationally too.I was shocked that black mothers like myself are three times more likely to die than our white counterparts“I was shocked that black mothers like myself are three times more likely to die than our white counterparts,” said Thierry. “And no one in the legislature was really talking about it.”She has repeatedly filed legislation to combat the glaring problem. Her proposals included racial bias training for medical professionals and a bill to fix a “severe” maternal health data backlog by creating a centralized registry.They did not advance in 2019, or in the current legislative session which ends this weekend. Focused on restricting abortion rights, the male- and Republican-dominated state legislature has dragged its feet on maternal mortality.Health advocates were cautiously optimistic that in 2021 Texas lawmakers would at least usher through a proposal to extend Medicaid care to a year after birth.Lawmakers did take action. A proposal was sent to Governor Greg Abbott on Friday. But it stopped short of providing the full Medicaid expansion.‘A large racial disparity’A state maternal mortality and morbidity review committee found that out of pregnancy related deaths in Texas in 2013, about a third occurred 43 days to a year after the end of pregnancy. It also discovered that nearly 90% of such deaths were preventable. Among the leading underlying causes of death with the highest chance of preventability were infection, hemorrhage, preeclampsia and cardiovascular conditions.“It was really striking,” said Dr Amy Raines-Milenkov, a University of North Texas Health Science Center professor and member of the review committee. “We found that most of these deaths could have been prevented but the system is just not set up to prevent them. And we found a large racial disparity, which is a reflection of how we in society value women, especially African American women.”Since 2016, the committee’s No1 recommendation to help save lives has been to extend Medicaid coverage postpartum for low-income mothers to a year. Currently, Texas kicks new moms off Medicaid after 60 days, leading to delayed and less preventative care. The American Medical Association and the American College of Obstetricians and Gynecologists support longer postpartum care.“So many health problems can develop in this really sensitive time period, so it is critical that new moms have that full year of extended coverage,” said Raines-Milenkov. “To think new mothers can identify problems, get timely appointments and follow up with their doctors within just two months of having a baby is unrealistic. Anything less than 12 months is really insufficient.”The Biden administration recently initiated incentives for states to expand postpartum coverage to 12 months. Illinois was the first to have its extension approved and other states including Florida and Virginia hope to implement measures soon.Toni Rose, a Dallas representative, joined Thierry in filing HB 133, to do just that in Texas. The Republican-dominated House passed the bill with rare bipartisan approval and nearly 70 groups, from the Texas Medical Association to the rightwing Texas Public Policy Foundation, expressed support.When it comes to saving the lives of Texas mothers, ‘splitting the difference’ is not appropriateHowever, the ultra-conservative Texas Senate – which ushered through extremist anti-abortion bills in March – did not pass the bill until the final minutes of its session. Even then, the legislation was not what was proposed. Without explanation, Republican Lois Kolkhorst of Brenham reduced the year of coverage to six months.Rose called the legislation a “victory” but said it still “falls short”. Thierry expressed dismay.“The data is clear that women are still at risk of maternal mortalities and pregnancy related complications for up to one year postpartum,” she said. “While the six months negotiated by the Texas Senate is better than the status quo, many new mothers will still be deprived of quality healthcare at a time when they are most vulnerable.“Given that this is an issue in which I have both personal and professional experience, I am disappointed. When it comes to saving the lives of Texas mothers, ‘splitting the difference’ is not appropriate.”Marsha Jones, executive director of the Afiya Center, a Dallas group that supports Black women with reproductive healthcare, said the lack of substantial progress was partly a reflection of the legislature’s misplaced priorities and lack of diversity.The Texas legislature is comprised mostly of white males: 61% of lawmakers in the House and Senate are white, even though white Texans make up just 41% of the population. Women are vastly outnumbered by men.“Black women are dying at an alarming rate for reasons that could be prevented and our state leaders cut down the main proposal that a state-appointed committee recommended to help them – why would that even happen?” said Jones. “I think it’s because it’s so easy to dismiss Black women’s lives.”The legislature expended time and energy on restricting abortion access, including passing one of the most extreme bans in the country, which allows any citizen to sue an abortion provider, as well as a “trigger” bill that bans the procedure in the event Roe v Wade, the 1973 ruling which safeguards the right to abortion, is overturned by the US supreme court.Both measures were “top legislative priorities” for the Senate leader, Lt Gov Dan Patrick, who did not make maternal mortality a listed priority.“It seems the only time we want to stand up and care about a life is when it’s in the womb,” Rose told Republicans on the House floor in May.‘Women are obviously choosing a life’In an ideological quest to punish abortion affiliates, Republicans have decimated the Texas reproductive health safety net by blocking low-income Medicaid patients from receiving life-saving preventative care at Planned Parenthood, a move resulting in reduced access to contraception and increased rates of Medicaid births, according to the Texas Policy Evaluation Project.A recent study in the medical journal Contraception showed a correlation between high maternal mortality rates and states that pass abortion barriers.“We have a maternal health crisis and conservative legislators once again made anti-choice bills a priority,” said Thierry. “They fail to realize all the women threatened by maternal deaths are obviously choosing life – they shouldn’t have to do so in exchange for their own.”Lawmakers made no significant gains for Medicaid in general. Texas is home to the highest number of uninsured residents in the US as well as the highest percentage of uninsured women of childbearing age, but it has declined to expand Medicaid under the Affordable Care Act and Republicans blocked legislative efforts to help extend healthcare coverage for the working poor.Texas has one of the steepest Medicaid eligibility requirements in the US. Of 1.4 million Texans who would benefit from expanded Medicaid, 75% are people of color.“Once again, we are kicking the can down the road with many of these solutions,” said Thierry. “It’s absolutely imperative we continue to work on reducing maternal mortality. One death is too many, especially when it’s preventable.” More

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      After 4 Years of Trump, Medicare and Medicaid Badly Need Attention

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      President-elect Joe Biden has pledged to “marshal the forces of science” in his administration. Undoubtedly he needs to start by bolstering the credibility of the Food and Drug Administration and the Centers for Disease Control and Prevention.But a third health agency, central to the lives of older Americans, low-income families and the disabled, is sorely in need of his attention. Science has also been under assault at the Centers for Medicare & Medicaid Services, which provides federal health insurance to more than 130 million Americans at a cost of more than $1 trillion, nearly twice the Pentagon’s budget.C.M.S. does more than just write checks for medical care. Its scientists and analysts determine which treatments should be offered — I am the chairman of the committee that advises Medicare on those decisions — and how best to care for the patients it serves.Unfortunately, the Trump White House has steadily eviscerated the agency’s dispassionate approaches to making those determinations.Recently, for instance, the Trump administration set in motion a plan to strip C.M.S. of its ability to assess for itself whether new medical devices approved by the F.D.A. are appropriate for the older patients it covers. This is important because the benefits and risks of such devices and procedures, which range from implantable hips and cardiac stents to digital apps and laboratory tests, can vary widely based on patient age and disability.The proposed rule requires Medicare to pay for any new device so long as the F.D.A. labels it a “breakthrough.” And that word does not mean what you think it does.The F.D.A. calls a device a “breakthrough” when it is expected — though not yet proved — to be helpful to patients with serious conditions. The designation has nothing to do with how the device works in older patients, or even if it was studied in that population at all. The proposed rule would also require Medicare to cover any new drug or device if at least one commercial insurer covers it for its members, even if its members are young and healthy.Already, companies seldom generate enough data on their products for C.M.S. to assess their value for its patients. In 2019, for instance, data was insufficient in just under half of new F.D.A. drug approvals to assess benefits or side effects in older patients. The proposed rule would drain the last remaining motivation that companies have to study their treatments in the patients who are likely to ultimately receive them.C.M.S. scientists and analysts do more than evaluate new treatments. They also test alternative ways to organize and pay for patient care. The agency has found, for example, that enrolling people at risk of diabetes in gym sessions reduced how often they were hospitalized. But some seemingly obvious ways to improve health care don’t work: C.M.S. also found it could not reduce hospitalizations for cancer patients by paying their doctors to actively manage their patients’ care.The fact that so many promising ideas don’t work as expected is the reason C.M.S. needs to double down on evaluations of how medical care is delivered to its patients.This administration has gone in the other direction. Just before the election, the White House conjured up a plan to send older people a $200 prescription drug discount card in the mail. Research has already demonstrated that if you give people money to buy prescription drugs, they will buy more of them. The pharmaceutical industry knows this, too. That’s why it hands out coupons worth billions of dollars.These same studies also show that when people are indiscriminately given cash for medicines — instead of only those who need that money the most — it costs much more overall than it saves. No wonder the discount card giveaway would have cost around $8 billion. Fortunately, the president has yet to follow through with it.In another troubling development, the administration announced on Nov. 20 that it would run an experiment in which reimbursements to physicians will be cut for dozens of high-cost drugs they administer in the office, such as chemotherapies and treatments for inflammatory diseases.C.M.S. financial analysts warned that the cuts will lead many Medicare patients to lose access to these important treatments. Scientists should evaluate this prediction by including a comparison group of patients whose doctors would not receive a cut in payment. But the agency administrator made it clear that she didn’t believe the warning. No comparison group is planned. That is no way to evaluate whether our nation’s vulnerable would be helped or hurt by this significant policy change.Another example of a poorly designed experiment involved taking Medicaid coverage away from able-bodied people who are not working or going to school, under an ill-founded theory that doing so would inspire them to seek employment. Such a study is best done narrowly, so that any harms are minimized. Instead, the administration invited multiple states in 2018 to test the outcome.A Harvard study found that a work requirement in Arkansas led to a rise in the number of uninsured people and no significant changes in employment. Thousands of Medicaid beneficiaries in Michigan and New Hampshire were set to lose their coverage before work requirements in those states were ended. Given those results, the overall program should have been canceled. The administration broadened it.Through its reliance on scientific evaluation of what it should pay for, and how, C.M.S. has remained financially viable for more than half a century. As the new president plans to fix the damage done by the current president, this vital agency demands his attention.Peter B. Bach is a physician at Memorial Sloan Kettering Cancer Center. He served as a senior adviser to the administrator of the Centers for Medicare and Medicaid Services in 2005 and 2006.The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips. And here’s our email: letters@nytimes.com.Follow The New York Times Opinion section on Facebook, Twitter (@NYTopinion) and Instagram. More