366 Comments

The one saving grace here is Congressional Dems are running well ahead of Biden. Root for some split ticket voting.

Expand full comment

Or, more pointedly, start to adjust your strategy for engaging with this campaign accordingly. Matt's been catching a lot of shit on Twitter for his doomerism stance, but Biden's been behind for *months* in most polls. Swing state races look especially grim. Behind in Nevada. NH is in play. Maybe even Minnesota. Etc. If Trump's lead widens much more AND Democrats abandon ticket reset effort, emphasis will start to shift to protecting down ticket races. That's the cold reality.

Expand full comment

The biggest problem is we are working in an uncertain information environment. The accuracy of polls is hard to measure.

I don’t think replacing Biden will change the malaise and ill defined discontent many people feel. I also don’t see how changing who governs resolves any of the supposed problems the country faces.

Expand full comment

>The accuracy of polls is hard to measure.<

Polling analysis is challenging, agreed! But not impossible. I've read enough to be convinced Joe Biden's chances are very weak. The question of how Democrats would fare with a different ticket is the "uncertain information" bit. I personally believe the answer is "better." We'll never know for sure (even if Harris-Pritzker beat Trump-Vance, we'll still be unable to visit the universe where Biden-Harris was the ticket. So you can never be *sure* what's what).

>I also don’t see how changing who governs resolves any of the supposed problems the country faces.<

I think Democratic Party governance can't solve all of our problems. But implying it can't solve *any* of them seems wrong. And from my perspective governance by the party of FDR is a lot less likely to create terrible *new* problems (Withdrawal from NATO? Trade War on steroids? Sabotage of safety net programs? War with Iran? Pushing the judiciary even further to the right? Cutting off Ukraine? Climate change denialism? Massive increase in deficit?). I also, needless to say, don't think a serious assault on our constitution is implausible.

Expand full comment

My second comment was in reference to voters handing things to Republicans, not a different Democratic administration (which would be effectively status quo.)

Expand full comment

Ah, got it. So you're not quite as nihilistic as I feared!

Expand full comment

I just think we are operating in a black box and replacing Biden would result in a weaker Democratic position than if Biden remained. (Lots of the wishcasters understate how damaging it would be for the person replacing Biden and all the negative media spin.)

Expand full comment

"The accuracy of polls is hard to measure."

Eh. Nate Silver's "the polls are typically off by at most 4-5 pps" hasn't failed yet.

Expand full comment

The risk for congressional Dems might be marginal voters becoming so meh to Biden, even ones that can't stand Trump, that they stay home, depriving congressional Dems of coattails.

Expand full comment

Dems need to put the ”stop Trump from gaining a super majority and controlling all branches of government plus the SC” message front and center now that it’s clear Biden will lose. Even many people who will vote for Trump might want to have some checks and balances.

Expand full comment

If voters are most concerned about cost of living, Trump + Dem Congress could be a worse situation than Biden + GOP Congress when it comes to deficit reduction and thus freeing up Fed on interest rates a bit more.

Expand full comment

Polymarket has the odds of a GOP sweep at 54%. And Biden is now more likely than not to lose the national POPULAR vote for the first time since that contract started. Even a fair bit of split ticket voting may not save the Dems in the house at this point, and the Senate map is terrible for the Dems.

Expand full comment

What are the chances we get good policy outcomes from the present batch of craven cowards inhabiting the Democratic benches in Congress? Maybe it’s better to heighten the contradictions and get politicians with the balls to win.

Expand full comment

”Let’s sit out this election to heighten the contradictions and after Hitler fails we will take over” / The German Communist Party in 1929

Expand full comment

Can't really agree with this as strategy; however, it might work as consolation.

Expand full comment

I don't think these ordinary policy questions are reason enough to vote for an empty chair or blank check for President. The only thing that can justify that is concern about a serious even if low-probability threat to democracy.

For example, many of these federal safety net programs could stand to be rethought and redesigned. A real debate over that in itself isn't something to fear to shy away from. The problem is that, on their own, Democrats won't do it. And on their own, Republicans will do it badly.

So, if we're setting aside democracy concerns for a moment, the key to all of this -- whether it's an opportunity for good changes or just bad ones -- seems to be whether Democrats keep enough seats in Congress to keep a seat at the negotiating table. And then assuming they have leverage, whether they use it well.

For example, if funding is kept constant, what exactly is the problem with changing Medicaid to a block grant program, and letting states do more experimentation to find better ways of funding healthcare for those of limited means? There are many ways to skin that cat, and the way Medicaid currently does is just one way, by no means the only or best way. But Democrats treat even the mention of change as a threat to be demonized, and Republicans just want to slash and burn. And so nothing productive ever advances, just stasis and political trench warfare nobody is happy and neither side is able to break out of a status quo that everyone seems to agree isn't that great.

Expand full comment

Fixed block based funding for medicaid would allow less flexibility for program expansion and give red state governors the ability to make program cuts. Basically every think tank in Washington, from center-right to the left, thinks it's a surefire way to take health care away from lower-income Americans.

Also, even with Biden's current state, he's clearly not an empty chair or blank check.

Expand full comment

It seems reasonable to think that, even if he’s not an empty chair now, Biden may be by 2028. And I don’t have confidence in those around him to remove him from office in the event that he significantly deteriorates to the point where he clearly can’t do the job.

Expand full comment

Why would block grants allow *less* flexibility?

Expand full comment

So what would happen if those cuts go through? Migration of those poorer people to blue states?

Expand full comment

Probably not, but it's a very interesting question. Housing is generally much less affordable in blue states, and if you're poor enough for medicaid to matter to you then you a move to NJ or California might leave you homeless.

Expand full comment

This also seems like a questionable way of assessing the likely policy outcomes of a Republican trifecta.

What if someone had analyzed the likely outcomes of a Democratic trifecta in 2020 like this? Going off of the party’s platform and members’ stated policy goals, you would’ve thought we’d maybe get a massive change in the “care economy”, a Green New Deal, student loan forgiveness, and an overhaul of the healthcare system, at the very least.

But understanding the messy nature of congressional policy making (plus all the trifecta-proof veto points), it was utterly predictable that the outcome would be factional infighting leading to a hodgepodge of spending that typical voters don’t have the expertise to understand.

Similarly, with Republicans my guess is that once again factional infighting and internal ideological disagreements will lead to much less substantive policy progress than what, say, McConnell would hope for. Is Trump better able to control intrafactional infighting than Biden? I doubt it.

Expand full comment

One of the things that makes the Republican trifecta significantly more daunting than the democratic trifecta is the way big ticket republican priorities fit into reconciliation and big ticket lefty ones don’t.

Like you could zero out most spending on the poor and let people starve to death on the streets with 50 senators but you can’t change almost anything that isn’t moving money around.

Expand full comment

Also the Supreme Court is far less of a check on Republicans.

Expand full comment

A quibble with this line of reasoning: a simple, bare trifecta with the minimum possible of majorities has the features you describe. But a trifecta within the reach of Republicans presently doesn’t. A minority in the House effectively has no power whatsoever. They can’t even shape debate effectively due to the way the House structures committees and controls votes. The Senate is a little different, but a 3-4 Senator majority basically makes every moderate Republican vote irrelevant if Republicans are willing to make their agenda work through simple majorities (either through reconciliation or by nuking the filibuster).

Expand full comment

I think the Republicans probably correctly see the filibuster as more beneficial to them than not. They've also shown time and time again that they prefer (illegal) immigration as an issue to actually doing something about it. Absent super majority I think chances of big time legislation are low. Only then will they have no choice but to pass things. Instead we will have tax and program cuts through reconciliation, executive action, and more federalist society judges. Aka repeat of Trump 1.

Expand full comment

I think you're discounting the sense of hubris that a huge victory would imbue them with. To say they'll think they're on a mission from the Almighty may not be that much of a stretch.

I mean, shoot, even the Democrats coming in with the tiniest majority possible in 2021 thought they were the reincarnation of the 1933 FDR majority.

Expand full comment

1) Most Republican policy goals can be adopted through reconciliation and don’t require a supermajority even under the current filibuster rules.

2) I don’t believe a Republican Senate would resist demands by President Trump to eliminate the filibuster for significant legislation. There are only a couple Republican Senators that could be confident in surviving a Trump backed primary challenge.

3) I think a 4-6 Senator lead will cause Republicans to be confident in holding the majority of the Senate for a long time. Whether that confidence would be misplaced is debatable, but there’s little doubt the map heavily favors Republicans presently.

Expand full comment

re #2, they resisted in his first administration, why wouldn't they do so again?

They should recognize that Trump is gone in at most 4 years, while they hope to be around for a longer.

Expand full comment

McCain and Romney are gone. McConnell and Graham have fallen into line. It is a different Republican Senate.

Expand full comment

Unclear though how they will react to “big time legislation” endorsed by Trump—if they owe him their seats, why wouldn’t they go for it? This is looking like a one-man party, men like that tend to get their way.

Expand full comment

I suspect this is less and less likely to be that big a deal. Trump is old, and, like, look, we aren't going back to 2019. Presidents don't have a lot of control over the macroeconomic situation, and Trump benefitted from that in 2016-2019 and today will have either inflation or high interest rates no matter what he does (which will rapidly degrade his popularity among people who currently remember 2019 and imagine that reelecting Trump will reproduce 2019). And of course he can't run in 2028.

I think all of that empowers Congressional Republicans to not care THAT much about what he wants. I mean, don't get me wrong, he'll still be President, he'll still have influence, but I don't think he'll have as much power as you're imagining.

Expand full comment
Comment removed
Jul 15
Comment removed
Expand full comment

They will get immigration as an issue by doing huge, constitutional-boundary-pushing enforcement acton in front of the cameras and letting everyone react.

Expand full comment

If they got rid of the awful, undemocratic filibuster they would at least accomplish one positive thing.

Expand full comment

I think what you are describing is "the system working". Winning elections requires papering over disagreements that then burst into the open when trying to govern. For Republicans, that disagreement is over reproductive rights.

There is clearly a large faction of Republicans who see Trump as a vehicle for their goals of fetal personhood, banning birth control, etc. And they are becoming louder as a second Trump term comes into focus. "Leave it up to the states" might work for the campaign, but not once they take power. When that fight breaks out in public, it is likely to be paralytic to legislating and electoral poison for Republicans. I can easily picture the "we have to blow up the filibusterer to protect unborn life" faction butting heads with the "imagine what Democrats will do with that power in the future" McConnell faction.

Expand full comment

Remember the courts. Remember Chevron being overturned.

The greatest trick Mitch McConnell ever pulled, was hiding the football with GOP economic platform and having it shadow enacted in the courts. The culture war stuff unfortunately distracts from the fact that courts are where most of the GOP donor class platform (outside of tax cuts) will get passed.

Expand full comment

Overturning Chevron isn't a 'shadow GOP economic platform'

Expand full comment

Arguably it is. The GOP wants the federal bureaucracy to have less power to regulate business, and they want lawsuits against regulation to be more likely to succeed. Overturning Chevron achieves that.

Expand full comment

Maybe at the margins? It also constrains GOP administrations from weakening regulations so it's far from clear that even that is true.

Expand full comment

I am not a scholar but I am an attorney in the federal govt who works on rulemakings. I have seen the hot takes that the end of Chevron may occasionally cause headaches for conservatives attempting regulatory rollbacks. And, sure, it could happen and probably will in at least a few instances.*

But there is a reason the conservative legal movement has been pursuing this for decades and a reason the conservative Justices have been licking their chops to water down, weaken, and ultimately abrogate any deference enjoyed by executive agencies. It forces agencies to engage in activity only expressly within their statutory mandates. That means fewer industries that can be regulated, fewer transactions that can be regulated, less conduct that can be regulated, etc. Because when the administrative state is built upon statutes that are mostly from the Big Government era of ~1936 to ~1976, there is a lot of ambiguity as to what modern conduct is reached by those statutes. The times change, businesses evolve, and labels that once squarely applied no longer do. Chevron allowed agencies to operate in those gray areas, which almost necessarily grew as statutes aged. Regulation of those gray areas will now be extremely difficult. And agency heads are often risk-averse (except I suppose some of the Warrenite ones) so they try to avoid the embarrassment of a regulatory effort being wasted on a gray area.

Maybe regulation is bad! I've certainly seen that. And yes, I get the argument that Congress can always pass a new law if courts prevent executive agencies from carrying out a law in line with Congress's intent. But the idea that the end of Chevron was a mixed basket for the Right... I do not see it that way, from my limited but relevant vantage point.

*I mainly see Chevron as presenting risk for regulatory rollbacks where a statute *requires* an agency to engage in certain regulation. So, in theory, the end of Chevron could make it harder for agencies to avoid that statutory mandate. But, in my experience, there are far more statutes that *empower* agencies to regulate certain conduct. And even the statutory mandates usually empower agencies to create exception and exemptions, so... in summation: the loss of leeway to regulate is greater than the loss of leeway to deregulate.

Expand full comment

We won't know the balance of things for years - but I'm deeply skeptical that overturning Chevron is going to have a measurable impact for several reasons.

a) The grey areas that you are highlighting is covered under major questions doctrine not Chevron, so isn't implicated at all.

b) Just because a statue is ambiguous doesn't mean that a court will never agree with the agency.

c) The judiciary, for all practical purposes, is split ideologically with very, very few cases ever reaching SCOTUS.

Expand full comment
Comment removed
Jul 16
Comment removed
Expand full comment

I think it'll probably end up somewhere in between what you and TR are saying. It all comes down to getting lower level courts to bite on what interpretation they're going for, and then for enough justices on SCOTUS to not see it as an absurd interpretation.

EDIT: and to your second sentence, that's one of the mysteries that will need to be answered. Will SCOTUS be even handed in being more active in determining ambiguous language, or will Alito style hackery win out the day and they'll only pick on Democratic administrations?

Expand full comment

Yeah, I mean, the original Chevron decision was about allowing Reagan’s EPA to relax environmental regulations without interference from the courts. But I do think TR is right about where the GOP's head is at right now.

Expand full comment

Yes, and the only chance of that being stopped is having a Democratic president and Senate majority. Unfortunately, it seems like Matt has given up on even trying to hold the Presidency. But it's worth noting that even if Democrats somehow win back the House, Trump and a Republican Senate can maintain a 6-3 majority or even expand the majority, in addition to adding judges in other courts.

I know it's difficult to assess the policy implications of the Court, but seems like something Matt should consider doing some time between now and November.

Expand full comment

>There are many ways to skin that cat<

When Mississippi and Oklahoma skin the cat, lower income Missippians and Oklahomans get fucked over. Blunt language, I know, but also honest language.

A disaster for the poor isn't an exaggeration.

Expand full comment

Honestly I would trust most red states to figure out the best way to handle their own poverty issues over most 1-size-fits-all federal government programs. Big blue states struggling with homelessness and overburdened tax systems seem to be farther away from solving their own problems.

Expand full comment

That must be why the Old Confederacy's HDI kicks so much ass.

Expand full comment

This is not a serious reply.

First because I'm pretty sure we're talking about GOP vs Dem controlled states and not the Old Confederacy. Otherwise, yes, Virginia's HDI does kick ass, but West Virginia's does not, and you have to get into reasons for that which are not relevant.

But it's also just substantially a weak dodge. Many red areas (but not all) do a good job caring for their poorest, but they often go about it in very different ways. And many Blue areas (not all) are really struggling with certain social issues that are very rare in red areas. Is the "Old Confederacy" struggling with homelessness and drug addiction? Not nearly as much the liberal West Coast or Northeast. So I think we can safely say that Blue states haven't figured out the answer to every question.

Wrt poverty the question is which levels of government are best situated to help. I don't think it's so crazy to think the answer could be the state-level or lower.

Expand full comment

>First because I'm pretty sure we're talking about GOP vs Dem controlled states and not the Old Confederacy.<

Yes. You know perfectly well what I'm referring to. Thanks for the reveal. Also, I didn't talk about slicing and dicing that region: if we indeed look at the Old Confederacy, I'm quite confident HDI would be indeed be less than the national average, and quite a bit less than states outside that region controlled by Democrats. Mississippi, Louisiana, Arkansas, Alabama etc would swamp the one state that managed to join Blue America. This is broadly true if we're talking about poverty, life expectancy, obesity, highway safety, homicide, income, per capita GDP., and so on.

So yes, you'll have to forgive me for being squeamish about handing over large chunks of no-strings federal revenue to (MAGA-dominated) state government so utterly determined to hold back progress, and the development of their own people. It seems like it might on net be bad for both the people in question and America!

Expand full comment

" You know perfectly well what I'm referring to."

I sincerely don't, partly because I can't tell if this is sarcasm. Initially you mentioned Oklahoma, but now you seem to be angrily focused only on the old confederacy.

But anyhow - how did Virginia "join Blue America"? It did that by having it's population shift towards urbanized, educated professional due to their urbanized, high-paying areas. This is similar to Atlanta or the Research Triangle in NC or Florida or Houston or Dallas. The causality isn't "voted Blue and then the cities grew".

Rural areas the world over lag urban ones in development and lag in HDI...so what? West Virginia, Arkansas, and many Appalachian or Southern states were behind in all the metrics you mentioned when they were Blue states and now they are as red states. Again, so what? Forgive me for looking at how badly run Los Angeles or Chicago are and then sympathizing with those who wonder if Democrats' vision of progress will be the best thing for Alabama.

Expand full comment

If my tax dollars are going to Mississippi for supporting their poor, damned if I'm OK with giving local politicians there carte blanche about how my money is going to be spent.

Expand full comment

I thought we were talking about what would happen if tax dollars for poverty stopped going there?

Expand full comment

In this twisted braid of a comment thread, who the hell knows. But it was kicked off with a comment about making Medicaid a fixed block grant to the states.

Expand full comment

Ah I see.

Expand full comment

But should you be making those decisions for Mississippi and Oklahoma (unless you live in Mississippi or Oklahoma)? The whole point of federalism is that the federal government doesn't make every decision about how states run their affairs, including with regard to the economically disadvantaged.

Expand full comment

I think if medicaid were a wholly state program I'd agree with you but in every state I know of the Feds pick up a lot of the bill. Giving them a bunch of money they can spend on unrelated things to balance their state budgets while poor residents don't get the meds they need is a federal concern.

Expand full comment

I mean, do we really want to get into the historical reasons why too much deference to federalism or to put in maybe more accurate, states rights has been problematic?

And yes it applies here. It's not a mistake that the deep south has the stingiest social safety net in the country. I mean, I feel like this is sort of under the radar one of the ugliest scandals of the last few years. https://www.nytimes.com/2022/09/22/us/brett-favre-welfare-mississippi.html. It matters to me that a state government can be this callous to its most vulnerable citizens.

Expand full comment

And this is one of the main ways we get Trumpism - the (accurate) perception of many that elites are telling them how to run their lives or their local governments.

I may agree with you about safety nets, but I live in NY, not Mississippi. And, jeez, have you ever seen how the NY state government is run? We're not really an examplar. It would be pretty hypocritical of me to quarrel with the probity of Mississippi state expenditures.

Expand full comment

Live in NY, depressingly aware.

I would really take a look at Mississippi state governance. Read that welfare scandal again and then look at how stingy welfare benefits are in Mississippi including how onerous they make qualification. This is some real "sheriff of Nottingham" stuff.

We an also get into Jackson, Mi water crisis. https://www.splcenter.org/news/2023/06/28/timeline-jackson-mississippi-water-problems

NY gets a ton more press for some pretty obvious reasons...and a lot of valid (NYC somehow only discovering trash cans work is this Simpson clip come to life https://www.youtube.com/watch?v=2ZgtEdFAg3s). But this not actually mean that states with a lot less national press scrutiny are themselves paragons of good governance or good policy.

Expand full comment

"I mean, do we really want to get into the historical reasons why too much deference to federalism or to put in maybe more accurate, states rights has been problematic?"

Too much of anything is a problem. Are you arguing that letting states decide poverty issues will lead directly to segregated water fountains? This is completely silly, and appealing to what is may be the poorest and most corrupt state in the union is pure cherry-picking. Should we take NM's many failures as the best reflection of Dem policies, also?

The fact that Mississippi is messing something up is not much of a reflection on what Georgia or Idaho is going to do. If it's red state politics than look into how Blue-run Jackson, MS, and other Dem areas of that state are doing.

Expand full comment

I would read about the process by which necessary improvements to the water system were not enacted. https://www.pbs.org/newshour/nation/mississippi-governor-who-opposed-water-system-repairs-blames-jackson-for-crisis

I don't post this to say Jackson, MS shouldn't have done more, but talking about "blue cities" and "red states" when stuff like infrastructure is being discussed is a red herring.

Expand full comment

Do you think crime, poverty and education problems in Jackson, MS, are primarily the fault of the red state legislature?

Or look at the ranking of corruption on this page:

https://worldpopulationreview.com/state-rankings/most-corrupt-states

Is red / blue control the biggest predictor? Sure doesn't seem like it to me.

Expand full comment

Beat me to referencing that scandal by seven minutes, for a moment I thought I had awoken soon enough to fit it in.

Expand full comment

Why shouldn't I? If poor Virginians are in my circle of empathy, why not poor Oklahomans and Mississippians?

Expand full comment

Because claiming to care equally about everything and everyone everywhere, is virtually indistinguishable in practice from not caring much about anyone anywhere.

All else equal, your circle of empathy should largely overlap with your circle of efficacy. Otherwise you're spending a lot of time and energy thinking and getting upset about things that aren't in your control anyway.

Expand full comment

Personally I think that Americans should care about our countrymen but YMMV

Expand full comment

A glib response that completely misses the point, or intentionally avoids it, as the case may be. Nobody who's not crazy thinks every issue in the vast country should be decided at the federal level, nor that every issue should be handled at the local or state level. There's a huge range for reasonable disagreement about what issues, at any given period, are best handled at what level. What made sense fifty years ago might not make sense or be the best that we can do today, or fifty years from today. And trying to shut down any discussion of that with glib dodges that either don't comprehend the issue or intentionally try to keep it from being discussed is not constructive.

Expand full comment

Caring about someone who you have little ability to impact doesn't count for much

Expand full comment

This just seems like a recipe for total political disengagement.

Expand full comment

I would say it's a recipe for #1) focusing more on local gov, which would be a great thing and #2) focusing your national attention on your local representatives in the national government

Expand full comment

But I don't believe that block granting creates efficiency. If I make the leap towards wanting my tax dollars to pay for Medicaid in my own state, I don't really see how it's significantly complicated by making it federal. That hasn't been show of claimed in Zack's comment. The claim is about preferences, and yes, to me, treating these groups differently doesn't make any moral sense. I haven't seen any on efficiency grounds.

Expand full comment

Not necessarily. This assumes Democrats outside those states have no leverage in the redesign or if they do, they don't use it well. And that the voters in Mississippi and Oklahoma have no say or don't care whether people in their state can't get medical care.

Expand full comment

https://www.cbpp.org/research/welfare-reform-tanf/how-states-use-federal-and-state-funds-under-the-tanf-block-grant

Conceptually I can sort of agree to the idea but then we look at how tanf funds are spent and it's not great. Giving states a lot of leeway to redesign medicaid seems genuinely dangerous to the health and wellbeing of its recipients.

Expand full comment

An intelligent redesign of Medicaid would be worthwhile. The most recent expansion cost over $5 million per statistical life saved. That’s far more than it’s beneficiaries earn in a lifetime. Devoting over a lifetime of earnings to saving a life is pretty ridiculous.

Expand full comment

Value of a Statistical Life is still well above $5m. DOT has it at $13.2m.

Wages and income are not the only value of one’s life.

On another note, the government can’t use the statistical value of life years or age adjusted VSL is because AARP will riot.

Expand full comment

I reject wretched safetyism and strongly disagree with the DOT bureaucrats. If you really value a life that much, you’ll squeeze out quite a bit of consumption for safety type stuff and rarely have any fun.

Expand full comment

I don’t see your point. The only implication from your statements are that you think VSL should be tied to a person’s earnings and that a number lower than most government VSLs is too high.

Expand full comment

Do you think India should adopt $13.2 million as their VSL? That would be absurd, they are too poor to do that. If they tried, they would have to adopt a western quality health care and sanitation system overnight, all other social goals would be deprioritized. There has to be a sensible discussion about how much of the economy ought to be given over to safety and how much to enjoyment.

Expand full comment

“ Do you think India should adopt $13.2 million as their VSL?”

This is nowhere implied or suggested. The follow on statement also suggests that you haven’t read up on how VSL is constructed or used. You kind of sound like Thomas Friedman with that vague appeal to sensibility.

Do you or do you not believe the value of a person’s life is measured by the (market) income they generate? That is what you suggested in your initial statement.

Expand full comment

"An intelligent redesign"

As usual with GOP legislative policy, all rounds lead back to tax cuts. You're right in theory that an "intelligent design" of Medicaid could be good thing. But I have serious doubts that's what's going to happen based on what we know. Block granting Medicaid in the manner Paul Ryan would want (and seems to be what Project 2025 wants) would amount to massive decrease in Medicaid funding over time. Also, devil is in the details. How much of that block granting would likely result in gobs of money to be used towards churches. SCOTUS has already shown itself to be astonishingly deferential to church interests. A ruling noting that states are allowed to funnel Medicaid dollars to churches seems astonishingly likely to me.

My model for this prediction is school vouchers. In theory, I actually think school choice has merit...in theory. In practice? Yeah after Betsy DeVos I jumped off that train because I realized "school choice" was never about improving outcomes for poor kids it was about cultural war crap (so allowing religious schools to get government money) and back door tax cuts. Don't believe me on the latter? https://itep.org/tax-avoidance-fuels-school-vouchers-privatization-efforts/. And regarding money for religious schools, https://www.washingtonpost.com/nation/2024/06/03/tax-dollars-religious-schools/

Just everything we see regarding how school vouchers is actually implemented just seems like an absolute blueprint for Medicaid.

Expand full comment

Do you have the balls to tell Debbie no chemo for her breast cancer? I think you, like many voters, talk a good game but have no tolerance for actual implementation.

Expand full comment

Chemo for breast cancer — especially if one was healthy before— is pretty high efficacy and not horribly costly. It would clear the bar of $500k/statistical life.

I totally have the balls to tell alcoholics no expensive treatments for cirrhosis.

Expand full comment

Alcoholics are already ineligible for liver transplants.

Expand full comment

No but there are other treatments. There are also really expensive procedures for the obese, for people with mobility issues who would be mobile if they had exercised, etc

Expand full comment

Vitamin O will take care of the obese.

Expand full comment

What if they're active in AA and have been sober for five years?

Expand full comment

Still not worth $13 million.

Expand full comment

Are there no benefits to healthcare other than lives saved? Or is all of that being included in the price you quote?

Expand full comment

VSL includes litigation, labor market, insurance, medical, and non-market costs of a life.

Expand full comment

Yes. For example, if you look at a list of the largest integrated health systems by revenue, #20 last year had revenue of $10.5 billion. Many of these are ostensibly nonprofit institutions. What are they doing for the poor to earn their nonprofit status? Not a lot.

They have high fixed costs and sometimes struggle with that, such as when demand and revenue dipped during the pandemic and then they were hit with inflation on top of that. On their own they could do a bit more. With different types of government programs and concentrated help, they could do a lot more, possibly better and more cost-effectively than the way Medicaid currently filters and disperses its money though the system. But none of those possibilities are easy or feasible to try when everything has to pass through the needle of a single agency veto point in Washington, and even broaching the subject brings down vicious knee jerk opposition from one party, for no clearly articulated reason except the perceived threat to the status quo.

https://www.beckershospitalreview.com/finance/47-health-systems-ranked-by-annual-revenue.html

Expand full comment

Ah, intelligent design. Good times. Coming soon to a school near you.

Expand full comment

If we have block grants, some centrist governor will figure out how to squeeze a dollar.

Expand full comment

One of Medicaid's big problems is wealthier states simply have the tax base to produce greater spending for matching grants. This is producing a lot of additional spending growth. Even when controlling for expansion states, this story plays out where we're getting federal spending transfers to richer states on net without a ton in the way of strictly anti-poverty policy to defend this.

MI's senior fellow Chris Pope has written an excellent piece on how to keep Medicaid focused on its key goals and ultimately set it on a path to federalize [1], and he has quite a bit in further research to back it up. Leaving it to the states is neither the most fiscally conservative nor most progressive anti-poverty approach. We already have enough of these shenanigans with TANF.

[1]https://thehill.com/opinion/healthcare/4022852-a-better-way-to-rein-in-medicaid/

Expand full comment

The ACA was in fact a very middle of the road strategy to tackle the problems with the way we fund and deliver healthcare in the United States and there is a lot that could be done to build on its success and improve its weaknesses but that requires two functioning parties and since 2008 we have had one party interested in governing and making incremental progress and one simply determined to block progress in order to gain power and cut taxes. I don’t know how deep the impacts of a GOP trifecta will be but I know that poor people will feel them the hardest and it makes me nauseous to watch those who claim to care about the most vulnerable simply shrug and look forward to reviving their resistance focused vibes.

Expand full comment

Sigh. Part of this is the fault of the out of touch elitism of the Democratic Party. Part of this is the result of a moral failing of the American people.

People have childish expectations that things will be taken care of without cost and easily, and then ignore the promises made by those they empower.

Expand full comment