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      Tim Walz pick excites hopes of taking US healthcare beyond Obamacare era

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      When Kamala Harris picked the Minnesota governor, Tim Walz, as veep for the Democratic presidential ticket, advocates for healthcare reform felt a jolt of electricity.Here, they saw a man who proclaimed healthcare a “basic human right”, reformed medical debt collections, and who laid the groundwork for expanded government insurance and denied corporate health insurers contracts with Medicaid, a state-run health insurance program for the poor. Walz even once joined Harris at an abortion clinic in support of abortion rights.It was a sense of possibility some had not felt since the Obama era, and hard for some to contain their excitement.“We’re celebrating here at the cabin,” said the Democratic Minnesota state representative Liz Reyer, who helped Walz pass a medical debt collection reform bill in 2023. She was on vacation in northern Wisconsin, sipping coffee next to her sleeping dog – a quiet, midwestern kind of celebration. Reyer felt compelled to stress “how absolutely strongly I was pulling for Governor Walz to be the VP pick”.“It feels really important and like a huge opportunity,” said Reyer, about the possibility of making such reforms nationally. “I share with Governor Walz the bedrock belief that healthcare is a human right. So, to me – yeah, let’s go.”Since the Obama era, health reformers have had a tough run. After the passage of the Affordable Care Act (ACA) better known as “Obamacare”, in 2010, the Democratic party suffered heavy midterm losses to what would become known as the conservative Tea Party movement.Perhaps worse, the ACA became a focal point of Republican rage well into the Trump administration. Republicans only abandoned calls to “repeal and replace” the ACA in 2017, after the now-deceased Republican senator John McCain stunned party leaders by casting the decisive vote against Trump’s plan, returning to Washington amid a brain cancer diagnosis.Although Republicans were not able to repeal Obamacare, they were successful in another way: years of attacks left little room to expand coverage or rein in healthcare prices, essentially the unfinished work of Obamacare.Republicans policy wonks have since retreated to time-worn proposals for a second Trump term, primarily fleshed out in the Project 2025 document. Among the early 2000s hits now on a nostalgia tour: Make healthcare shoppable! More privatization! Less regulation! Tax-free savings accounts!The former president has disavowed Project 2025, though the official Republican platform does not look dissimilar. Notably, Trump’s current campaign and former administration has close ties to authors of the project.The 2024 Republican platform focuses on “transparency”, “choice” and “competition” (read: shoppable prices and fewer regulations). It also promises “no cuts” to Medicare, a government program for the elderly, though Project 2025 promotes further privatizing the program.Today, about 92% of Americans have health insurance. That still leaves about 26 million people out of the system – potentially vulnerable to the full force of market prices in the world’s most expensive health system. A catastrophic illness or ailment can easily lead to financial ruin.What’s more, even for people who have health insurance, medical debt remains a persistent problem. Forty-one per cent of Americans owe money to a medical provider, credit card or family member for healthcare. Often, when people have or fear medical debt, they cut back on food, clothing and other household items, according to a widely cited Peterson-KFF Health System Tracker poll. People with medical debt tend to be sicker and die sooner.At the same time, the cost of healthcare now eats up 17% of America’s gross domestic product, nearly double that of peer nations. That is in spite of the fact that Americans see the doctor less than peers in other wealthy nations and have worse health outcomes.View image in fullscreenWhile not all of America’s health problems can be pegged to problems with the insurance industry, anecdotal reports show at least some can be – such as adults waiting until they reach Medicare eligibility age to get cataract surgery or Americans feeling reticent to smile for fear of revealing a mouth full of decay.Exactly what Harris and Walz’s healthcare platform will be remains to be seen. The 2020 Democratic platform included a call for a public option, reining in pharmaceutical spending and strengthening Obamacare. The administration accomplished some of this.Notably, the Biden administration just finished its first Medicare prescription drug price negotiation – a process common in peer nations but which was prohibited when Biden took office. The most recently released Democratic party platform came in July, before Biden dropped out of the race.What is clear is the similarities in Harris’s and Walz’s records. The Biden administration capped insulin prices at $35 a month for Medicare beneficiaries. So did Walz for Minnesotans not on Medicare – an act he named after resident Alec Smith, a 26-year-old who died from rationing his $1,300-a-month insulin supply.Walz worked closely with Reyer to pass a comprehensive package of reforms for medical debt collection, which included a prohibition on hospitals from denying care to patients with outstanding balances, and which stopped the automatic transfer of debt liability to spouses. Similarly, the Biden administration has sought medical debt restrictions through rule-making with the Consumer Financial Protection Bureau.Walz said in his inaugural address as governor that he believed healthcare was a “human right”. That’s widely accepted wisdom outside the US, and all but the unofficial tagline for single-payer healthcare advocates – the kind of government-run universal healthcare that is a source of pride for the UK’s National Health Service.Similarly, Harris co-sponsored 2019 legislation introduced by Senator Bernie Sanders that would have established single-payer healthcare nationally. The revolutionary proposal stood no chance of passing, and she has since sought to moderate from that moment. Her campaign has said she would “not push” single-payer as president. Still, it has got advocates excited.“From our standpoint, this is fantastic,” said Dr Philip A Verhoef, a critical care doctor in Hawaii and president of Physicians for a National Health Program, the nation’s largest single-payer advocacy organization.“Ten years ago, single-payer burst on to the scene,” with Sanders’s presidential run, said Verhoef. “Prior to that, nobody ever talked about this.” Similarly, single-payer advocates were “shut out” of Obamacare discussions, Verhoef added.Walz also laid the groundwork for a “public option” health insurance plan in Minnesota, where the government would allow people to buy into Medicaid, and banned private health insurance companies, such as behemoth UnitedHealth, from contracting with Minnesota’s Medicaid plan.How the Harris-Walz ticket will translate the excitement of reformers into action – and what exactly their proposals will be – remains to be seen. For the time being, activists are enjoying a sense of possibility, knowing difficult discussions lie ahead.“So often, we see people in positions of political power are thinking, ‘Well, what can we get done without blowing up the system,’” said Verhoef. “I appreciate that attitude – in a way that’s what the ACA was. It helped a lot of people. But it still left 30 million people uninsured in this country and it hasn’t stopped people from going bankrupt from healthcare bills.” More

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      Arizona supreme court delays enforcement of 1864 abortion ban

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      The Arizona supreme court on Monday granted a motion to stay the enforcement of an 1864 law that bans almost all abortions, a win for reproductive rights activists in the swing state.The state’s highest court agreed to the Arizona attorney general Kris Mayes’s request for a 90-day delay of the near-total ban, further pushing back enforcement of the 1864 legislation after a repeal of the ban was passed earlier this month.The stay will last until 12 August. A separate court case on the legislation which granted an additional 45-day stay means the law cannot be enforced until 26 September, Mayes said in a statement.“I am grateful that the Arizona supreme court has stayed enforcement of the 1864 law and granted our motion to stay the mandate in this case for another 90 days,” she said.Mayes added that her office is weighing the “best legal course of action”, including a petition to the US supreme court.The latest decision comes two weeks after the Democratic Arizona governor, Katie Hobbs, signed a law to repeal the ban.But the most recent repeal can only take place 90 days after the Arizona legislative session ends, possibly allowing for a small window when the ban could be enforced.Last year’s session ended on 31 July, NBC News reported. If lawmakers adhere to that timeline, the ban could be in effect for approximately a month, until late October.Hobbs has said that she will not prosecute any medical practitioners under the 1864 law.The Arizona supreme court rejected a motion from Planned Parenthood Arizona on Monday to hold off on enforcing the 1864 ban until the repeal takes effect.On the latest court ruling, the reproductive health organization vowed to continue fighting to “[ensure] all Arizonans can access the care they need in a safe, caring environment”, according to a statement.“We will not be intimidated or silenced by anti-abortion extremists, because our bodies and our autonomy are at stake.”In Arizona, abortion is currently banned after 15 weeks of pregnancy. The 1864 abortion law bans nearly all abortions, except to save a woman’s life. The US civil war-era law does not make exceptions for rape or incest.Residents of the swing state will probably vote on a referendum on abortion come November after a coalition of reproductive rights organizations collected enough signatures to get the issue on the 2024 ballot. More

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      US investigates organ collection groups for potentially defrauding government

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      US authorities are investigating organizations that coordinate organ donations over allegations that the non-profits are potentially defrauding the federal government.The federal investigation, first reported by the Washington Post, is looking at several organ procurement organizations (OPOs) that secure organs for transplants within the United States.A focus of the inquiry is investigating whether the organizations knowingly overbilled the Department of Veteran Affairs as well as Medicare, two agencies that reimburse OPOs for the procurement of organs.The investigation is also looking into whether OPOs arranged kickbacks between organizations, the Post reported, citing one person with knowledge of the investigation.The latest investigation, led by the Department of Health and Human Services as well as inspector general Michael Missal with the Department of Veterans Affairs, could lead to a mass overhaul of the organ transplant industry, the Post reported.Missal and the Department of Health and Human Services did not return the Guardian’s request for comment.At least six people with knowledge of the investigation told the Post that the inquiry has been taking place for several months. But it recently intensified as investigators visited the offices and homes of at least 10 chief executives at different OPOs.In a message to its membership, the Association of Organ Procurement Organizations also acknowledged that federal investigators had visited several OPOs in February “as part of an inquiry”.Lawmakers in recent years have attempted to reform the organ transplant system, which has been rife with issues.Last March, the Biden administration announced that it would break up the monopoly on the US’s organ transplant system, the New York Times reported.The organ transplant system for 38 years has been run by United Network for Organ Sharing (UNOS).Within the system, a total of 56 organizations collect organs for donations and coordinate their transportation to US surgeons, the Post reported.Several organizations for years have not collected enough organs to meet growing demand. But of the 56 organizations, none of have been decertified by the federal overseers, the Post reported.A 2022 investigation by the Senate finance committee uncovered additional problems within the organ transplant system. The committee discovered that transporters had lost donated organs and that poor screening of donated organs led to 70 deaths between 2008 and 2015.More than 100,000 Americans are now on the national transplant waiting list, with 17 people dying each day while waiting for an organ, according to the federal government. More

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      Anti-abortion centers raked in $1.4bn in year Roe fell, including federal money

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      Anti-abortion facilities raked in at least $1.4bn in revenue in the 2022 fiscal year, the year Roe v Wade fell – a staggering haul that includes at least $344m in government money, according to a memo analyzing the centers’ tax documents that was compiled by a pro-abortion rights group and shared exclusively with the Guardian.These facilities, frequently known as anti-abortion pregnancy centers or crisis pregnancy centers, aim to convince people to keep their pregnancies. But in the aftermath of Roe’s demise, the anti-abortion movement has framed anti-abortion pregnancy centers as a key source of aid for desperate women who have lost the legal right to end their pregnancies and been left with little choice but to give birth.Accordingly, abortion opponents say, the centers need an influx of government cash.“Those are the centers that states rely on to assist expecting moms and dads,” Mike Johnson, the speaker of the US House of Representatives, told anti-abortion protesters at the March for Life in January. The Louisiana Republican praised the centers for providing “the important material support that expecting and first-time mothers get from these centers”.Earlier this year, under Johnson’s leadership, the House passed a bill that would block the Department of Health and Human Services from restricting funding for anti-abortion pregnancy centers. State governments are also in the midst of sending vast sums of taxpayer dollars to programs that support anti-abortion pregnancy centers. Since the demolition of Roe, at least 16 states have agreed to send more than $250m towards “alternative to abortion” programs in 2023 through 2025. Those programs funnel money towards anti-abortion pregnancy centers, maternity homes and assorted other initiatives meant to dissuade people from abortions.Still, abortion rights supporters say, much of the anti-abortion pregnancy center industry remains shrouded in mystery – including their finances.“Stewards of both taxpayer and charitable funds should insist on a real impact analysis of the industry, whether investments that are being made are achieving their desired outcomes and are cost-effective,” said Jenifer McKenna, the crisis pregnancy center program director at Reproductive Health and Freedom Watch, the group behind the analysis of tax documents. “Taxpayers deserve performance standards and hard metrics for use of their dollars on these centers.”The analysis by Reproductive Health and Freedom Watch examined 990 tax documents, which most US tax-exempt organizations must file annually, from 1,719 anti-abortion pregnancy centers in fiscal year 2019 and from 1,469 in fiscal year 2022. The analysis confirms that the anti-abortion pregnancy center industry is growing: while the centers’ revenue in 2022 exceeds $1.4bn, it was closer to $1.03bn in 2019, even though more centers were included in the earlier analysis.Centers reported receiving hundreds of millions of dollars in donations from private funders between 2018 and 2022. While only a relatively small fraction of the centers reported receiving grants from state and federal governments in both 2022 and 2019, that number is on the rise, according to the Reproductive Health and Freedom Watch analysis memo. In 2022, the centers said they received $344m in such grants, but they received less than $97m in 2019.Just 21 centers identified the federal grants that they received in 2022, the analysis found. Those grants included the Fema-funded Emergency Food and Shelter Program, which is primarily meant for organizations that alleviate hunger and homelessness, and the Temporary Assistance for Needy Families, a program for low-income families.This accounting does not represent the full financial picture of the anti-abortion pregnancy center industry. More than 2,500 anti-abortion pregnancy centers are believed to dot the United States – a number that far outstrips the number of abortion clinics in the country.‘What did they do with all that money?’Much of the modern, publicly available information on anti-abortion pregnancy centers comes from one of their biggest cheerleaders: the Charlotte Lozier Institute, which assembles reports on the industry and operates as an arm of Susan B Anthony Pro-Life America, one of the top anti-abortion organizations in the United States.In 2019, the Charlotte Lozier Institute said that 2,700 anti-abortion pregnancy centers provided consulting services to 967,251 new clients on-site. In 2022, the Institute said 2,750 centers provided consulting services for 974,965 new clients – an increase of 0.08%.Even though the US supreme court overturned Roe at the halfway point of 2022, it did not appear to result in a crush of new clients – despite anti-abortion advocates’ argument that the pregnancy centers need an infusion of funding to handle post-Roe clients.“The new client numbers alone don’t fully tell the story,” a bevy of Charlotte Lozier Institute scholars – Moira Gaul, Jeanneane Maxon and Michael J New – said in an email to the Guardian, adding that anti-abortion centers and groups have seen an increase in violence following the fall of Roe. (The abortion clinics that remain post-Roe have also faced rising violence. That has not stoppered the demand for their services, as rates of abortions have risen since Roe’s demise.)Anti-abortion pregnancy centers are seeing a dramatic rise in calls for certain kinds of help. Data from the Charlotte Lozier Institute reports show that centers handed out 64% more diapers, 52% more baby clothing and 43% more wipes in 2022, compared to 2019. Demand for new car seats and strollers also increased by about a third.All of these items would presumably go to new parents. The fall of Roe led to an estimated 32,000 more births, particularly among young women and women of color, a 2023 analysis found.The total dollar value of these goods and services was about $358m, according to the Charlotte Lozier Institute report. Reproductive Health and Freedom Watch found that the roughly 1,500 centers included in the group’s 2022 analysis reported expenses of more than $1.2bn on their 990 tax documents.“They took in – according to the 990s – $1.4bn, and they spent $1.2bn on expenditures,” McKenna said. “What did they do with all that money? There’s so many questions begged by their own reporting.”The Charlotte Lozier scholars said there were other expenses not listed in the report, such as maternity clothing, property-related payments, fundraising, marketing and staff salaries. Data from their report indicates that, between 2019 and 2022, the number of volunteers who work at the centers fell while the number of paid staffers rose. (Volunteers still make up the overwhelming bulk of the workforce.)“Most non-profits prefer to use staff when possible. Centers are attracting more professionals that desire to help women,” the scholars said. “Many centers are now in a place where they can pay them so they are less reliant on volunteers.”The institute’s report on anti-abortion pregnancy centers in 2022 is a very different document to the reports that it released to cover the centers in 2019 and 2017. The earlier reports span dozens of pages; the 2022 report is only four. A longer report is now in the works, the Charlotte Lozier scholars said, which will include information about government funding of centers.A lack of regulationAlthough anti-abortion pregnancy centers may appear to be local mom-and-pop organizations, in reality many are affiliated with national organizations like NIFLA, Care Net and Heartbeat International. These centers thrive in a kind of regulatory dead zone, providing medical services like ultrasounds. But many are not licensed as medical facilities, leaving them unencumbered by the rules or oversight imposed on typical medical providers.“They are changing their names a lot and changing their names in ways like including ‘clinic’ or ‘medical’ or ‘healthcare’ into their names and dropping things like ‘Care Net’ and other types of wording that might instantly identify them as a CPC,” said Andrea Swartzendruber, an associate professor at the University of Georgia College of Public Health who tracks anti-abortion pregnancy centers.These centers, she said, are “changing their names in ways that make them seem more like medical clinics”.The Charlotte Lozier Institute scholars said “calls for governmental regulation are nothing new” post-Roe and that “such efforts have been ongoing for decades”.“They have been found to be politically motivated and have been largely unsuccessful,” the scholars said. “Abortion facilities are in need of far greater government regulation.”Anti-abortion pregnancy centers’ taxes can also be deeply intricate. The analysis by Reproductive Health and Freedom Watch found that the centers used a variety of tax codes to describe themselves, frequently describing themselves as organizations that provide “family services” or “reproductive healthcare”. They were sometimes listed as organizations that work to outlaw abortions, or as explicitly Christian, religious organizations.The National Committee for Responsive Philanthropy, a charity watchdog group, has previously found that many centers share tax identification numbers with much larger organizations that do multiple kinds of charity work, such as non-profits run by Catholic dioceses. By sharing numbers, these organizations are effectively collapsed into one legal and tax entity, the committee said.The Charlotte Lozier Institute scholars told the Guardian that “this is not our understanding at all”. NIFLA, Care Net and Heartbeat International do not share tax identification numbers with affiliated centers, they said.Just because these particular groups do not share tax identification numbers does not preclude centers from sharing them with other organizations. For example, Care Net is affiliated with a string of Florida pregnancy centers – which, rather than sharing Care Net’s tax ID, are instead listed on tax documents for a wide-ranging charity run by a local Catholic diocese.Anti-abortion pregnancy centers tend to be faith-based. Given the industry’s religious bent, courts have proven reluctant to restrict centers in order to avoid treading on their free speech rights.In 2018, the US supreme court ruled to toss a California law that would have forced centers to disclose whether they were a licensed medical provider. Then, last year, a federal judge in Colorado paused a law that would have banned “abortion reversal”, an unproven drug protocol that aims to halt abortions and is often offered by anti-abortion pregnancy centers. (The first randomized, controlled clinical study to try to study the “reversal” protocol’s effectiveness suddenly stopped in 2019, after three of its participants went to the hospital hemorrhaging blood.)“More regulation could lead to better reporting, which would also then help with reducing all of these risks,” said Teneille Brown, a University of Utah College of Law professor who studies anti-abortion pregnancy centers. “Then the consumers could get some sense of like, ‘Oh, this clinic has had a bunch of violations,’ and if there were regulation, they could actually even shut them down.” More

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      Ady Barkan, activist who fought for US healthcare overhaul, dies aged 39

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      Ady Barkan, an attorney and healthcare activist whose journey with motor neuron disease prompted a fight to overhaul the US healthcare system, has died at the age of 39 from complications with amyotrophic lateral sclerosis (ALS).Barkan’s wife, Rachael Scarborough King, announced his death in a post to X, formally known as Twitter.“You probably knew Ady as a healthcare activist. But more importantly he was a wonderful dad and my life partner for 18 years,” wrote King.“Ady fought for the 24/7 care he needed to be home with us until the end of his life,” King added, thanking Barkan’s caregivers and “their labor and care, which allowed us to live as a family through Ady’s health challenges”.“Everyone should have that chance,” she said.Barkan was first diagnosed with ALS in 2016 at the age of 32, the healthcare advocate wrote in a 2022 piece for the Guardian.The progressive degenerative illness targets nerve cells in the spinal cord and the brain. The disease is often terminal, with those diagnosed usually having a three to five year survival rate.Barkan lost his ability to walk and was unable to eat, speak or breathe on his own without the use of a ventilator machine.Since his diagnosis, Barkan said that he became acutely aware with the issues regarding the US healthcare system, especially for those dealing with a serious illness.“I knew that US healthcare was broken before my diagnosis, but having a serious illness clarified the cruelty of our profit-driven system,” Barkan wrote.Barkan’s health insurance company denied coverage of critical medical supplies, including a ventilator and a FDA-approved ALS drug.He was only able to pay for his round-the-clock care after suing his insurance company in federal court, and with the help of friends who covered part of his care.“It shouldn’t take a team of lawyers, an experienced activist, and the generosity of friends and strangers to get the healthcare you need to survive,” Barkan wrote.Barkan used his experience to advocate for universal healthcare and a complete overhaul of the US healthcare system.Barkan first went viral in 2017 after confronting the former Arizona senator Jeff Flake about Flake’s support of tax cuts that would cause healthcare costs to soar, an encounter that was filmed by organizer Liz Jaff.“Think about the legacy that you will have for my son and your grandchildren, if you take your principles and turn them into votes,” Barkan said to Flake.“You can save my life,” Barkan said.In 2018, Barkan co-founded the non-profit Be A Hero, an organization working to expand access to healthcare amid other political priorities. Jamila Headley, the organization’s co-executive director celebrated Barkan’s life and work in a post to X.“It’s hard to imagine a world without [Ady Barkan] learning, strategizing, fighting, and laughing alongside me but his work lives on in [Be A Hero] and the powerful movement of patients we are building,” wrote Headley.His activism was subsequently documented in the 2021 documentary Not Going Quietly, which showed his May 2019 testimony to Congress about his family’s struggles to afford his care.Speaking through a computerized device, Barkan told lawmakers that his family paid $9,000 a month out-of-pocket to cover the remainder of his care.“We are cobbling together the money, from friends and family and supporters all over the country,” he said to Congress. “But this is an absurd way to run a healthcare system.”Barkan is survived by his wife Rachael and their two children. More

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      Who profits from blood plasma donations in the US? Politics Weekly America podcast

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      Kathleen McLaughlin has a rare chronic illness and needs regular treatments using people’s blood plasma. She started researching the US blood plasma industry a decade ago and has written a book, Blood Money, about what it says about class, race and inequality.
      This week, she speaks to Joan E Greve about what she’s learned about the for-profit blood plasma industry
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      Biden administration seeks to expand health coverage to Dreamers

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      The Biden administration is seeking to allow immigrants known as Dreamers, who were brought to the US as children by undocumented parents, greater access to health insurance through federal programs, the White House said on Thursday.The proposal would allow participants in the Deferred Action for Childhood Arrivals program, or Daca, to access to health insurance under Medicaid and Affordable Care Act (ACA) exchanges, it said.“Healthcare should be a right. I’ve worked hard to get more Americans health insurance than ever before,” Joe Biden said on Twitter, adding the move would give “Dreamers the same opportunities.”The proposed rule comes as efforts to further protect Dreamers stalls in Congress and faces legal challenges. About 580,000 people were enrolled as of last year in the Obama-era 2012 Daca program, which grants protection from deportation and work permits.An expansion would allow Daca recipients to enroll in coverage under the joint federal-state Medicaid program or through private insurers participating in the exchanges established by the 2010 ACA law also passed under Democratic then President Barack Obama and Biden, his vice-president.Eight US states have already expanded state insurance access to health coverage regardless of immigration status, according to data from the healthcare policy organization Kaiser Family Foundation.Biden promised during his 2020 presidential campaign to protect “Dreamers” and their families after Republican then President Donald Trump tried to end Daca. Biden this week said he plans to seek a second four-year term but has not formally announced his re-election bid.The president, in a video, reiterated his call for Congress to establish a pathway to citizenship for Daca recipients, adding: “While we work toward that goal … we need to give Dreamers the opportunities and the support they deserve.”One source familiar with the plan said it could take months or longer to finalize through the federal regulatory process.Democratic representative Pramila Jayapal, chair of the congressional progressive caucus, which last month urged the administration to expand access, called the move “a long overdue step toward immigrant justice”.Republicans, however, have cast doubt on Daca and other immigration reforms.Texas and other US states with Republican attorneys general are challenging the program in court. More

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      Defeating the Dictators review: prescriptions for democratic health

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      Charles Dunst’s “aspirational” book about how democracies can do a better job of competing with autocracies is bursting with statistics and lots of common sense.The statistics are there to convince us that many autocracies spend much more sensibly than the world’s richest democracies do. A few examples:
      China has increased spending on education as a percentage of its gross domestic product by 75% since 1975.
      In 2018, 15-year-old Chinese students had the highest average scores in the world on tests for math, science and reading, followed by Singapore, Macao and Hong Kong – “none of which is a democracy”.
      Citizens of Singapore have an average life expectancy of around 84 and an infant mortality rate of two per 1,000 – “better than almost every democracy”.
      Singapore achieves that good health by spending just 4% of its GDP on healthcare – versus 17% of GDP spent in the US, which gets much less impressive results.
      Dunst’s commonsense observations include ideas like these: weak safety nets damage citizens’ confidence in their governments (and therefore should be strengthened); bad healthcare systems cost more money in the long run than good ones; and investments in infrastructure repay themselves many times over.Dunst is deputy director of research and analytics at The Asia Group and an adjunct fellow at the Center for Strategic and International Studies. Looking at his own country, he is heartened that Joe Biden managed to push through a $1tn infrastructure bill, but then points out that’s only 1.25% of GDP, compared with the 8.5% of GDP China spent on infrastructure every year from 1992 to 2011.“China today spends more on infrastructure than the United States and Europe do combined,” Dunst writes.By spending more on things that actually matter, countries that oppress their citizens in other ways can engender remarkable levels of confidence in government.“In 2019,” Dunst writes, “nearly 90% of Chinese reported trust in their government … as did almost 70% of Singaporeans.”Practically the only good news for democracies in this story is the fact that almost every major economy faces similar declining birth rates. Most dramatically, China has gone from 2.25 children per woman in 1990 to just 1.3 today. No major economy is producing enough children to maintain its current population.At the same time, since 2017, China’s net migration rate – the number of immigrants minus the number of emigrants – “has worsened every year”.China lost about 335,000 people in 2022 alone.Democracies like the US, Germany and the UK all posted positive net migration rates of at least 2.7%. These numbers support one of Dunst’s more optimistic notions. While “China and others may promise economic stability”, democracies remain attractive because they offer “more freedom, equality and opportunities to pursue happiness”.Dunst argues that one of the biggest challenges for democracies is to convince their populations of the benefits of immigration, instead of listening to politicians like Donald Trump in the US and Marine Le Pen in France, who have been so successful in reviving ancient xenophobia.Dunst also thinks education systems in places like the US and Britain need to become much more democratic. At Harvard, the acceptance rate for the children of alumni is 30%, versus 6% for the general population. In 2021, “nearly a third of legacy freshmen hailed from households making more than half a million dollars”.When non-connected parents “see the underperforming children of top financiers and politicians vaunted into top schools and jobs because of connections, these parents will rebel against the system that allowed this to happen … They will vote for the would-be dictator.”Dunst thinks we must offer more scholarships “for people studying science and technology … more funding for vocational schools” and “constant skill training” for the workforce.He wisely suggests that a “key reform would be to make non-regular [American] workers eligible for high-quality health insurance that travels with them from job to job”. But he is also bizarrely opposed to universal healthcare – the kind that is the norm all over Europe. Suddenly, he sounds like a flack for a greedy pharmaceutical company, writing that such a system “could undermine the competitive attitude that makes the United States one of the world’s leaders in medical innovation”.America’s continuing failure to provide decent health insurance to its most needy citizens is hardly a spur to innovation. And the fact we are the only major democracy with a healthcare system dominated by the profit motive isn’t mentioned here at all.Dunst is almost entirely silent about the explosion of fake facts on the internet, which makes it so much more difficult to sell the commonsense ideas he pushes for. Another problem is his failure to acknowledge that America now has only one major political party that is genuinely interested in solving any of these fundamental problems, while the other prefers to cater to its base with attacks on wokeness or any prosecutor who thinks it makes sense to prosecute a former president for any of his dozens of alleged crimes.This is the fundamental problem facing American democracy now. As long as the Republicans control the House of Representatives or any other part of the government, the chances of enacting any of the proposals Dunst thinks necessary to help defeat the dictators – serious educational reform, immigration reform and additional infrastructure projects – are exactly zero. More