Paul Krugman: What’s the Matter with Trumpland?

April 4, 2018

Jack Ma –What’s the Matter with this American President?

These days almost everyone has the (justified) sense that America is coming apart at the seams. But this isn’t a new story, or just about politics. Things have been falling apart on multiple fronts since the 1970s: Political polarization has marched side by side with economic polarization, as income inequality has soared.

And both political and economic polarization have a strong geographic dimension. On the economic side, some parts of America, mainly big coastal cities, have been getting much richer, but other parts have been left behind. On the political side, the thriving regions by and large voted for Hillary Clinton, while the lagging regions voted for Donald Trump.

I’m not saying that everything is great in coastal cities: Many people remain economically stranded even within metropolitan areas that look successful in the aggregate. And soaring housing costs, thanks in large part to Nimbyism, are a real and growing problem. Still, regional economic divergence is real and correlates closely, though not perfectly, with political divergence.

But what’s behind this divergence? What’s the matter with Trumpland?

Trump won 2016 Presidential Elections but he is breaking up American society on the pretext of draining the swamp in Washington DC. The Republican leaders in the House (Paul Ryan) and the Senate (Mitch McConnell) are helping Trump do it.–Din Merican

Regional disparities aren’t a new phenomenon in America. Indeed, before World War II the world’s richest, most productive nation was also a nation with millions of dirt-poor farmers, many of whom didn’t even have electricity or indoor plumbing. But until the 1970s those disparities were rapidly narrowing.

Take, for example, the case of Mississippi, America’s poorest state. In the 1930s, per-capita income in Mississippi was only 30 percent as high as per-capita income in Massachusetts. By the late 1970s, however, that figure was almost 70 percent — and most people probably expected this process of convergence to continue.

But the process went into reverse instead: These days, Mississippi is back down to only about 55 percent of Massachusetts income. To put this in international perspective, Mississippi now is about as poor relative to the coastal states as Sicily is relative to northern Italy.

Mississippi isn’t an isolated case. As a new paper by Austin, Glaeser and Summers documents, regional convergence in per-capita incomes has stopped dead. And the relative economic decline of lagging regions has been accompanied by growing social problems: a rising share of prime-aged men not working, rising mortality, high levels of opioid consumption.

An aside: One implication of these developments is that William Julius Wilson was right. Wilson famously argued that the social ills of the nonwhite inner-city poor had their origin not in some mysterious flaws of African-American culture but in economic factors — specifically, the disappearance of good blue-collar jobs. Sure enough, when rural whites faced a similar loss of economic opportunity, they experienced a similar social unraveling.

So what is the matter with Trumpland?

For the most part I’m in agreement with Berkeley’s Enrico Moretti, whose 2012 book, “The New Geography of Jobs,” is must reading for anyone trying to understand the state of America. Moretti argues that structural changes in the economy have favored industries that employ highly educated workers — and that these industries do best in locations where there are already a lot of these workers. As a result, these regions are experiencing a virtuous circle of growth: Their knowledge-intensive industries prosper, drawing in even more educated workers, which reinforces their advantage.

And at the same time, regions that started with a poorly educated work force are in a downward spiral, both because they’re stuck with the wrong industries and because they’re experiencing what amounts to a brain drain.

While these structural factors are surely the main story, however, I think we have to acknowledge the role of self-destructive politics.

That new Austin et al. paper makes the case for a national policy of aiding lagging regions. But we already have programs that would aid these regions — but which they won’t accept. Many of the states that have refused to expand Medicaid, even though the federal government would foot the great bulk of the bill — and would create jobs in the process — are also among America’s poorest.

Or consider how some states, like Kansas and Oklahoma — both of which were relatively affluent in the 1970s, but have now fallen far behind — have gone in for radical tax cuts, and ended up savaging their education systems. External forces have put them in a hole, but they’re digging it deeper.

And when it comes to national politics, let’s face it: Trumpland is in effect voting for its own impoverishment. New Deal programs and public investment played a significant role in the great postwar convergence; conservative efforts to downsize government will hurt people all across America, but it will disproportionately hurt the very regions that put the G.O.P. in power.

The truth is that doing something about America’s growing regional divide would be hard even with smart policies. The divide will only get worse under the policies we’re actually likely to get.

A version of this article appears in print on April 3, 2018, on Page A23 of the New York edition with the headline: What’s the Matter With Trumpland?. Order Reprints | Today’s Paper | Subscribe

BOOK REVIEW: The Messy Ganga and India’s Future

January 24, 2018

BOOK REVIEW: The Messy Ganga and India’s Future

by John Elliott

https://www.asiasentinel.com/book-review/river-of-life-river-of-death-the-ganges-and-indias-future/

India’s River Ganges is a mess. The great and awe-inspiring sacred Ganga, as it is generally known, is revered by hundreds of millions of Hindus who foul its waters and assume that all will be well, however awful and health-endangering it becomes.

That in many ways is the story of modern India, a country that manages to be awe-inspiring and brilliant, but also frequently dysfunctional, defying most efforts to make it work better.

The challenge for an author is how to combine a study of all the enormous potential and the failings of this magical and frustrating country, and to explain how people tolerate the faults but do little to improve them, while making the most of what is available.

Successive foreign correspondents based in India have tackled this in different ways, mostly with broadly based surveys of political economic and social life, but with an increasing awareness in recent years of the negatives.

Victor Mallet (pic above) a widely experienced Financial Times journalist who is now the paper’s Hong Kong-based Asia news editor, has chosen a neat solution by writing about the Ganges after spending four years in Delhi as his newspaper’s South Asia correspondent.

He has explored the 2,525 km river’s history, religion, economics, industry, environmental and health issues, and the people, while using it as a metaphor to explain how India functions, or doesn’t. Politics comes in too because Narendra Modi, the Hindu nationalist Prime Minister, has failed so far to fulfil his 2014 promise to clean the river that Hindus both revere and pollute.

A keen yachtsman, Mallet first developed an interest in the river when he spotted an image on a Delhi map of a sailing boat in a red circle – the universal sign for a yacht marina. It is in an industrial zone called Okhla on the banks of Delhi’s (filthy) Yamuna River, a tributary of the Ganges.

There he found “an immaculately kept building and garden called the Defence Services Sailing Club” with sailing dinghies nearly stacked on racks. “It was obvious that the boats were rarely used. The caretaker confirmed it. The reason was there in front of the club: the stinking, foamy black filth that was once a river.”

Keeping Ganga clean? Fanatics don’t bother, feel the river is self-purifying, will take care of itself – COUNTERVIEW.ORG

After explaining how the Ganges was portrayed in India’s legends and paintings “as a natural paradise of lilies, turtles and fish” where “the cheerful god Krishna would play his flute amid a troupe of adoring female cow herds,” Mallet reports that “the water at Okhla is so polluted by human waste that it contains nearly half a million times the maximum level of faecal coliform bacteria established as the Indian standard for bathing water.”

That is a good introduction to modern India, enabling the author to show in the first two pages of his preface why the Ganga is such a great vehicle for exploring all the contradictions of a country that could be a world leader but somehow is not (yet?) getting there. As he travels, he meets a contrasting series of people from Saffron-clad Hindu priests to engineers and well-meaning environmental activists, and from tannery businessmen and bureaucrats to ashram devotees.

The most horrifying part of the book is a chapter headed “Superbug River.” Many of us living in Delhi (and elsewhere in India) tolerate air pollution many times above safe limits, as well as undrinkable tap water, because we are protected by purifying filters in our homes and offices.

Mallet however uncovers much worse health hazards in the Ganges, saying that people are liable to pick up a recently discovered bacterial gene that can make various diseases highly resistant to antibiotics.

He stumbled on the gene, known to scientists as NDM-1, while researching “normal” pollutants such as sewage and industrial waste. “It only takes a short visit and exposure to acquire such genes in your gut,” he was told in Britain by an environmental engineering professor. As Mallet notes, this is a politically sensitive matter – Indian officials and doctors “were furious” when The Lancet medical journal in 2010 named the new gene NDM after New Delhi.

Devout Hindus, says Mallet, are unwittingly spreading diseases, and antibiotic resistance to diseases, in the very river to which they have come to pay homage. Water samples have demonstrated that even what are usually regarded as the relatively pristine reaches of the upper Ganges near Haridwar suffer surges of bacterial pollution during visits by thousands of urban Indians during the May-June pilgrimage season.

Throughout the book, the Ganges is the main focus but, along the way, there are many other subjects and issues ranging from the poisoning of vultures and a state government suggesting the use of cow urine as a hospital disinfectant, to corruption among water tanker drivers (and others), and India’s desperate need for jobs that Modi’s Make in India campaign cannot begin to solve.

Modi was elected in 2014 both to change the way that India is run by making the machinery of government cleaner, more effective, and less bureaucratic, and to create jobs and opportunities for the aspirational young. Make in India is one of a myriad of high profile schemes that he has launched to try to inject focus and drive into a somnolent government, but it is difficult as yet to assess how much has actually been achieved as a result of all the razzmatazz.

Modi’s pledge to clean the Ganges and reverse the failure of many earlier attempts can however be assessed, especially at the holy city of Varanasi which he chose as his parliamentary constituency. Little seems to have been achieved in the city apart from some beautification of the ghats, or flights of stairs, on the Ganges banks.

Varanasi’s disillusioned residents reminded Mallet about Modi’s televised launch of a plan to clean tonnes of mud off the city’s famous Assi Ghat, and criticised the lack of progress on the more important problem of sewage. Such cosmetic projects were like “putting lipstick on a woman with a dirty sari”.

Curiously, Modi made Uma Bharti, a religious activist and politician the minister in charge of water, and thus the Ganges. Mallet says “she appeared more interested in proving the existence 5,000 to 6,000 years ago of the extinct Saraswati River… than in solving the very real crisis facing the contemporary Ganges.”  That demonstrates one of the Modi government’s limitations – that several ministers and leaders of his Bharatiya Janata Party are more interested in Hindu religion and mythology (and nationalism) than they are in building a strong nation that works.

Mallet is however too optimistic about the prospect of the Ganges being cleaned. He cites great and well-organised religious festivals like the Kumbh Melas, which bring millions of worshippers to the Ganges, as examples of even the most corrupt state governments being able to perform. “Good organization and efficient infrastructure, in short, are no more impossible in India than anywhere else,” he declares.

This misses the point that the Kumbh Melas are one-off events where a single official is given overall charge without political interference (though politicians are quick to claim credit when all goes well). There are other similar examples, such as the building of the Golden Quadrilateral highways around India 15 years ago and the construction of the Delhi Metro railway. In each case, politicians stood aside and left officials to get on with the job – and there was overwhelming support for what was being done.

Sadly, that is unlikely to work with cleaning the Ganges because there are too many interests and the project is neither time-bound like a Kumbh Mela nor of clear immediate benefit like a metro or highway.

Cleaning the Ganges is therefore a perfect metaphor for modernizing India. The task is just too huge and too complex for quick solutions – as Modi is discovering with a general election just over a year away.

A former “Financial Times” South Asia correspondent, John Elliott now writes for Asia Sentinel from New Delhi. He is the author of “Implosion: India’s Tryst With Reality” http://amzn.to/2gwrfjb   (HarperCollins)

 

 

Surviving America’s Political Meltdown

August 17, 2017

by Jeffrey D. Sachs*

*Jeffrey D. Sachs, Professor of Sustainable Development and Professor of Health Policy and Management at Columbia University, is Director of Columbia’s Center for Sustainable Development and of the UN Sustainable Development Solutions Network. His books include The End of Poverty, Common Wealth, The Age of Sustainable Development, and, most recently, Building the New American Economy.

The US is in the midst of a political meltdown, unable to manage a domestic economic agenda or a coherent foreign policy. The White House is in turmoil; Congress is paralyzed; and the world is looking on in astonishment and dread. If we are to survive and overcome this collapse, we must understand its sources.

There are two power centers in Washington, DC: the White House and the Capitol. Both are in disarray, but for different reasons.

The White House–Calm and Dignified from the Outside and Messy and Toxic Inside

The dysfunctionality of the White House is largely a matter of President Donald Trump’s personality. To many experts, Trump’s behavior – grandiose self-regard, pathological lying, lack of remorse or guilt, expressive shallowness, parasitic lifestyle, impulsiveness, failure to accept responsibility for his own actions, and short-term marital relationships – are symptoms of narcissistic personality disorder.

The consequences could be dire. Pathological narcissists have a tendency to indulge in violent conflicts and wars (think of Lyndon Johnson and Vietnam or of Andrew Jackson and the ethnic cleansing of Native Americans). At a minimum, Trump lacks the psychological characteristics needed for constructive governance: honesty, dignity, competence, empathy, relevant experience, and the capacity to plan. According to some observers, Trump also shows signs of diminished mental capacity.

The hope in Washington is that “adults in the room” will keep Trump’s dangerous tendencies in check. But the “adults” in Trump’s administration are increasingly military figures rather than civilians, including three generals (John Kelly, the new White House Chief of Staff, National Security Adviser H.R. McMaster, and Secretary of Defense James Mattis). Wise civilian leaders are the key to peace, especially given that America’s vast war machine is always revving. Recall John F. Kennedy’s military advisers, who advocated war during the Cuban Missile Crisis, or consider Mattis’s anti-Iran belligerence.

There are two other escape valves: the 25th Amendment, which charts a course for removing a president who is unable to discharge the responsibilities of office, and impeachment for “high crimes and misdemeanors.” Both measures are extreme in the US constitutional order, and both would depend on the agreement of Republican leaders. Nonetheless, one or the other may prove necessary and even urgent in the event that Trump’s psychological instability or political weakness leads him to launch a war.

The political meltdown in Congress is less dramatic, but serious nonetheless. There, the cause is not a personality disorder; it’s money. The legislative branch has been deeply corrupted by corporate lobbying and campaign contributions. Two brothers, the industrialists David and Charles Koch, worth a combined $100 billion, virtually own the votes, and voices, of Speaker Paul Ryan and Senate Majority Leader Mitch McConnell.

The result is politically perverse. Ryan and McConnell relentlessly push legislation favored by the Koch Brothers rather than the American people. The attempted repeal of President Barack Obama’s signature health-care legislation, the 2010 Affordable Care Act (“Obamacare”) had nothing to do with voters’ views or interests; it was simply what the Koch brothers (and other Republican mega-donors) wanted.

That’s why the repeal legislation was kept secret until the last moment and was never subjected to expert testimony or analysis – or even considered by a Congressional committee. The legislation could pass only if it was hidden from view and voted on in the middle of the night. In the end, three Republican senators jumped ship, siding with the American people rather than with the Kochs.

Between Trump’s narcissism and the Koch brothers’ money, the US government has become a shambles. Washington is still filled with many smart and talented people of both parties, but America’s political institutions and formal processes are diminished. The federal government is hemorrhaging scientific expertise, as researchers leave or are purged, and as agency budgets are targeted for deep cuts. Seasoned diplomats are flooding out of the State Department. Lobbyists, meanwhile, are installing cronies and hacks throughout the government.

Through the din, new drumbeats of war can be heard, most ominously against Iran and North Korea. Is it posturing or real? Nobody knows. Trump’s foreign and military policies are now announced in early-morning tweets, without the foreknowledge of the White House staff or senior officials. The situation is dangerous and deteriorating.

I suggest three immediate steps, and a fourth longer-term step.

The first step is to take Trump off Twitter. The US – and the world – needs public policy by consultation and deliberation, not one man’s worsening pathology. The American people, by a large margin, concur that Trump’s tweets are hurting national security and the presidency.

Second, congressional leaders should agree, on a bipartisan basis, to constrain Trump’s belligerent proclivities. Article I, Section 8 of the US Constitution vests the authority to declare war with Congress, and Congress needs to reassert that authority now, before it’s too late.

Third, the world’s major powers – most urgently, America’s NATO allies, China, and Russia – should make clear that any unilateral US attack on Iran or North Korea would constitute a grave and illegal violation of the peace, and that matters of war and peace must be agreed within the UN Security Council. If the US had heeded the UN Security Council’s collective wisdom in the recent past, it would have avoided several ongoing disasters, including the chaos in Iraq, Libya, and Syria, and saved trillions of  dollars and many hundreds of thousands of lives.

The fourth, longer-term step is constitutional reform to move away the US away from its volatile presidential system to a parliamentary system, or at least to a mixed presidential-parliamentary system, as in France. The power of the president – and therefore the danger of a runaway presidency – is far too great.

Much more needs to be done to restore democratic legitimacy in the US, including introduction of stricter limits on campaign financing and lobbying. First and foremost, however, we must survive the dangerous Trump presidency by preserving the peace.

John McCain’s Act of Defiance

July 30, 2017

by Mark Singer

http://www.newyorker.com

Republican Senator John McCain from Arizona–An American Legislator, Patriot and Vietnam War Hero

I had agreeable disagreements with two friends yesterday, several hours before the Senate’s 1:30 A.M. vote on the Republicans’ scaled-down motion to repeal the Affordable Care Act. When the final vote was called, three Republican senators—Susan Collins, of Maine; Lisa Murkowski, of Alaska; and John McCain, of Arizona—drove a long knife through the cold heart of Trumpcare/McConnellcare/Ryancare.

Senators Collins and Murkowski had stuck their necks out much further than any other Republican politicians in the country. For this they had been trolled, slandered, subjected to sexist insults, and bullied—most prominently by the President of the United States, a career scam artist who ages ago lost his marketing mojo. They weren’t buying it. For at least a few hours this week, Ryan Zinke, the never-not-an-Eagle Scout Secretary of the Interior and, until January 20th, a Republican member of Congress, was running strong in the competition for the most despicable thug in Washington, after he reportedly called Murkowski to indicate that her state would suffer as a result of her no vote. (Beautiful, Zinke! Beautiful!) Senators Collins and Murkowski weren’t buying that, either. Nor was Senator McCain.

One of my friends had read my piece about the dilemma McCain confronted, and told me candidly that he wasn’t really buying my argument, either. “An action that merely avoids indecency,” he said, “has only the palest claim to decency.” My friend has worked for many years in many ways on behalf of social and—especially—economic justice. Though he respected Barack Obama, and had voted for him, he took a dim view of many of Obama’s more centrist or conservative policies.

For McCain my friend had no regard (though he forgives him); his sins of commission and omission were many. Sarah Palin, in his view, was the most egregious transgression (hardly a minority viewpoint), but there were others, largely sins by association. In general, my friend loathes what he perceives as the rapacious capitalist cynicism of all the money-grubbing liars who run the banks and grease politicians of both parties and shuffle in and out of corporate boardrooms and Presidential Cabinets and talk out of every side of their mouths as the nation’s and the planet’s wealth and resources and social-justice gaps grow beyond their already criminally negligent dimensions. He detested Hillary Clinton’s candidacy. As for Trump, why bother? For months last year, the Republican nominee, anticipating electoral defeat and extreme humiliation, whined and screamed about a “rigged” election, all the while sliming his way to the White House.

 

My friend is certainly not alone in seeing that we are in a Hobbesian present. The United States as a nation of laws, as he sees it, is over. Certainly for the time being, and likely forever. The U.S. as a governable nation, also over. The U.S. as a world power bringing (mostly) democracy and goodness to others—over. And so on. My friend is a wholly decent, patriotic citizen of a country he no longer recognizes, even as the view from his window remains a rural New England pasture.

My other friend shared an equally jaundiced view: she had always thought of McCain as a conventional company man. “His sincere fidelity is to the institution,” she said. “It’s not an issue of humanity, or even a lack of humanity.” So, as an Annapolis graduate and a Navy pilot, and, likewise, as a prisoner of war, he behaved as he thought he should. McCain had been equally a creature, especially in recent years, of a Republican Party that moved further and further to the right, and further away from the bipartisan comity that he had for decades claimed to revere. “Let’s agree that a part of his biography is a tale of heroism and selflessness,” she said. “But if we’re talking about motivation, that’s far more banal.”

I agree with some of my friends’ sentiments. But, in my understanding, as the hour of the vote approached, John McCain elected not to be a company man. The institution that he had belonged to and loved for thirty years, the U.S. Senate, had become intolerable. Dishonorable.

For weeks and months, a burgeoning-until-overwhelming majority of Americans told their senators and congressmen that they did not want Obamacare declared null and void, its knotty flaws notwithstanding. Many of the forty-nine Republicans who cast votes in favor of this repeal knew that those votes bore the stench of unforgivable betrayal of the once-American ideal: equal treatment under the law, due process, and the unwritten imperative for a common purpose. Or perhaps they recognized that in their heads but were blind in their hearts—to their everlasting shame.

John McCain, bearing scars ancient and new, acutely aware of his mortality, humble but standing a very tall five feet nine, approached the hour when he had to choose. He chose to vote with his soul—in defiance of the bottomless soullessness that, when the ultimate moment arrived, he rejected.

Mark Singer, a longtime contributor to the magazine, is the author of several books, including Character Studies.

Trump was right about health care for most of his life

March 31, 2017

Trump was right about health care for most of his life–Go Back to Basics

by Dr. Fareed Zakaria

https://www.washingtonpost.com

Since becoming POTUS, DJT is under pressure

The recent Republican debacle on health care could prove to be an opportunity. It highlighted, yet again, the complexity of the U.S. system, which continues to be by far the most expensive and inefficient in the advanced world. But President Trump could actually use the legislative collapse to fix health care if he went back to basics and to his core convictions on the topic, which are surprisingly intelligent and consistent.

Markets would not work well in Healthcare

There is an understandable impulse on the right to assume that health care would work more efficiently if it were a free market, or a freer market. This is true for most goods and services. But in 1963, economist Kenneth Arrow, who later won a Nobel Prize, offered an explanation as to why markets would not work well in this area. He argued that there was a huge mismatch of power and information between the buyer and the seller. If a salesman tells you to buy a particular television, you can easily choose another or just walk away. If a doctor insists that you need a medication or a procedure, you are far less likely to reject the advice. And, Arrow pointed out, people think they don’t need health care until they get sick, and then they need lots of it.

Every advanced economy in the world has implicitly acknowledged his argument because they have all adopted some version of a state-directed system for health care. Consider the 16 countries that rank higher than the United States on the conservative Heritage Foundation’s Index of Economic Freedom. All except Singapore (which has a unique state-driven approach) have universal health-care systems that can be described as single-payer (Medicare for all), government-run (the British model) or Obamacare-plus (private insurance with a real mandate that everyone opt in). Hong Kong, often considered the most unregulated market in the world, has a British-style government-run system. Switzerland, one of the most business-friendly countries, had a private insurance system just like the United States’ but found that, to make it work, it had to introduce a mandate.

While producing a CNN documentary on health-care systems around the globe, I was particularly struck by the experience of Taiwan, another free-market haven. In 1995, 41 percent of its population was uninsured and the country had very poor health outcomes. The government decided to canvass the world for the best ideas before instituting a new framework. It chose Medicare for all, a single government payer, with multiple private providers. The results are astonishing. Taiwan has achieved some of the best outcomes in the world while paying only 7 percent of its gross domestic product on health care (compared with 18 percent in the United States). I asked William Hsiao, an economist who helped devise the country’s model, what lessons they took, if any, from the United States. “You can learn what not to do from the United States rather than learn what to do,” he replied.

Americans often assume that despite its costs, American health care provides better services than others. We often hear about the waiting time for care in other countries. But according to the Commonwealth Fund, among industrialized countries the United States is in the middle of the pack for wait times, behind even Britain . Moreover, one of the world’s leading experts, Uwe Reinhardt of Princeton, has found that Americans use less care than the average for developed countries when it comes to things such as seeing a doctor and spending time in the hospital. The problem with the free market is that there is little profit in prevention and lots in crisis care.

Trump has now taken up the call to repeal Obamacare. But until recently, health care was actually one of the rare issues on which he had spoken out, before his campaign, with remarkable consistency. In his 2000 book “The America We Deserve,” he wrote:

“I’m a conservative on most issues but a liberal on this one. We should not hear so many stories of families ruined by healthcare expenses. . . . We must have universal healthcare. . . . The Canadian plan . . . helps Canadians live longer and healthier than Americans. There are fewer medical lawsuits, less loss of labor to sickness, and lower costs to companies paying for the medical care of their employees. . . . We need, as a nation, to reexamine the single-payer plan, as many individual states are doing.”

Trump was right on this issue for much of his life. He has now caved to special interests and an ideology unmoored by facts. He could simply return to his convictions, reach out to Democrats and help the United States solve its health-care crisis.

From Obamacare to Ryancare to Don’t Care and maybe Trumpcare

March 15, 2017

Twenty-Four Million Reasons the G.O.P. Health-Care Bill Is No Good

 By John Cassidy

http://www.newyorker.com

Is Ryancare the alternative to Obamacare?

For days, the political world had been waiting nervously for the Congressional Budget Office (CBO) ’s assessment of the House Republicans’ Trump-endorsed proposal to replace Obamacare. On Monday afternoon, when the numbers-heavy report finally appeared, one figure it contained dominated all the others: twenty-four million.

This was the C.B.O.’s estimate of how many fewer people would have health insurance if the Republican legislation—which is called the American Health Care Act—passes. In 2018, the first year that many of the bill’s changes would go into effect, fourteen million “more people would be uninsured under the legislation than under current law,” the report said. The difference “would rise to 21 million in 2020 and then to 24 million in 2026.”

By anybody’s terms, twenty-four million is a lot of people. It is far larger than the fifteen million that two economists from the Brookings Institution had suggested last week that the C.B.O. might come up with. “To put the 24 million coverage loss in perspective, that reverses the entire coverage gain from the ACA,” one of the Brookings economists, Loren Adler, said Monday on Twitter.

As recently as January, Trump was promising that his Administration would provide “insurance for everybody.” Even for a President whose acquaintanceship with the truth is a casual one, explaining away the figures in the C.B.O. report could be tricky. It was not surprising, therefore, that the White House quickly dispatched Tom Price, the new Secretary of Health and Human Services, to rubbish the C.B.O. analysis. “We disagree strenuously” with the coverage estimates in the report, Price told reporters at the White House. Price insisted that the G.O.P. plan would “cover more individuals at a lower cost.”

Price didn’t provide any numbers to back up this claim. He hasn’t got any. (In fact, on Monday night, Politico reported that the White House’s own internal analysis of the health-care bill projected that twenty-six million fewer people would have coverage over the next decade.) The only thing that the Administration and its allies on Capitol Hill have to fall back on is the vague promise to follow up the A.H.C.A. with a second piece of legislation that would give insurers more freedom to offer cheaper, lower-quality plans, which, in turn, might persuade more young and healthy people to sign up. But that’s a pie-in-the-sky promise. Changing the rules for insurers would require sixty votes in the Senate, which the Republicans don’t have.

The C.B.O. analysis didn’t account for the possibility of insurers being able to offer cheap and lousy plans. The main thing driving its conclusions wasn’t changes to the individual market but the House Republicans’ reckless and deliberate assault on Medicaid, the federal program that provides health care for the poverty-stricken and the working poor. In estimating that twenty-four million people stand to lose their insurance coverage, the C.B.O. said that fourteen million of this total would be accounted for by reductions in Medicaid rolls.

Any Hope for Trumpcare?

It is important to understand how this estimate was arrived at, and why it is reasonable. Under the Affordable Care Act, the federal government lifted the income threshold for Medicaid eligibility to nearly a hundred and forty per cent of the poverty line. At the same time, Washington also promised states, which administer Medicaid, that it would pay ninety per cent of any costs entailed in this expansion. Thirty-one states, including sixteen that now have Republican governors, took the feds up on this offer. The G.O.P. bill would end the Medicaid expansion in 2020—sooner, possibly, if the White House accedes to demands from ultra-conservative groups. The legislation would also change the way the rest of the Medicaid system is financed, shifting to a “block grant” model in which Washington would pay a fixed amount to the states for each recipient.

As a result of these changes, the C.B.O. report said that “some states would discontinue their expansion of eligibility, some states that would have expanded eligibility in the future would choose not to do so, and per-enrollee pending in the program would be capped.” The end result would be a big drop in enrollment and also a big drop in spending—eight hundred and eighty billion dollars over ten years. “By 2026, Medicaid spending would be about 25 percent less than what CBO projects under current law,” the report says.

The drop in spending on Medicaid helps explain why the C.B.O. estimated that the G.O.P. reform would reduce the deficit by three hundred and thirty-seven billion dollars—a fact that some Republicans seized upon. But why, you might ask, would the deficit be reduced by just three hundred and thirty-seven billion dollars over ten years when spending on Medicaid would fall by eight hundred and eighty billion dollars? The answer is that the bill would take most of the money that is saved from reducing Medicaid and hand it out to rich people in the form of tax cuts. The legislation would abolish the 3.8-per-cent Medicare tax on investment income and the 0.9-per-cent surtax on ordinary income that the A.C.A. applied to people who make more than two hundred and fifty thousand dollars a year. According to the C.B.O., getting rid of these taxes and some annual fees that the A.C.A. imposed on insurers would reduce revenues by five hundred and ninety-two billion dollars over ten years.

If the Republicans really wanted to fulfill Trump’s promise of insuring everybody—or, at least, preventing a big fall in insurance rates—they could have taken the five hundred and ninety-two billion dollars and used them to maintain the Medicaid expansion. Or to enlarge the new tax credits they want to offer for the purchase of individual insurance, which, in some cases, would be much smaller than the subsidies offered under Obamacare.

And I mean much smaller. In a table at the end of its report, the C.B.O. provided some “illustrative examples” of how different types of people might fare under the new system. Take a single sixty-four-year-old with an annual income of twenty-six thousand five hundred dollars. Under Obamacare, after receiving a generous federal subsidy, this person would pay seventeen hundred dollars in annual premiums. Under Trumpcare, or Ryancare, or whatever we want to call it, this person would pay fourteen thousand six hundred dollars. That’s an increase of twelve thousand nine hundred dollars!

To be sure, the way the new system would be set up, not everybody would be a loser. For example, a single forty-year-old with an annual income of sixty-eight thousand two hundred dollars could end up saving more than four thousand dollars a year, according to the C.B.O.’s figures. But, in general, people would pay more, at least in the early years after the measure goes into effect.

In the first few years, as some healthy young people drop their insurance plans because they are no longer mandated to purchase them, premiums would go up fifteen or twenty per cent, the report says. After 2020, average premiums could start dropping, and by 2026 the C.B.O. projects they would be ten per cent lower than under the current law. But that would mainly be because insurers would be offering cheaper, crappier plans to young people, and older people would be dropping insurance because they could no longer afford it. It will be interesting to see how Trump tries to sell that prospect to his supporters, many of whom are older and living on modest incomes.

John Cassidy has been a staff writer at The New Yorker since 1995. He also writes a column about politics, economics, and more for newyorker.com