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Senate Majority Leader Mitch McConnell at the US Capitol on March 18. | Win McNamee/Getty Images What Senate Democrats are learning from Mitch McConnell. Mitch McConnell was elected to the US Senate in 1985. He was named Senate minority leader in 2007, and Senate majority leader in 2015. It was, for McConnell, the culmination of decades of planning, labor, and, when necessary, self-abasement. “The ultimate goal of many of my colleagues was to one day sit at the desk in the Oval Office,” McConnell writes in his memoir, The Long Game. “That wasn’t my goal. When it came to what I most desired, and the place from which I thought I could make the greatest difference, I knew deep down it was the majority leader’s desk I hoped to occupy one day.” And oh, what a difference McConnell has made. He will go down as one of the most consequential Senate leaders in history. But his legacy isn’t defined by bills passed or pacts struck. McConnell’s legislative record, in terms of both his accomplishments and those he’s shepherded through as leader, is meager. He has passed tax cuts, cut regulations, and confirmed judges. He failed to repeal Obamacare, shrink or restructure entitlements, or pass infrastructure or immigration reform. Historians will not linger long over the laws McConnell passed. As McConnell himself has said, his most consequential decision was an act of negation: blocking Merrick Garland from being appointed to the Supreme Court. McConnell’s legacy, rather, will be in transforming the United States Senate into a different institution, reflecting a different era in American politics. Historically, the Senate has been an institution unto itself, built around norms of restraint and civility, run according to informal understandings and esoteric rituals, designed around the interests of individuals rather than the stratagems of parties. This is the Senate McConnell claimed to revere, naming Sen. Henry Clay — known as “the Great Compromiser” — as his model and promising a restoration of the old traditions. This is the Senate McConnell has eviscerated, through his own actions and those he has provoked in the Democrats. Despite his theatrical embrace of sobriquets like “Darth Vader” and “the Grim Reaper,” McConnell isn’t an evil genius. He is a vessel for the currents and forces of his time. What sets him apart is his fulsome embrace of those forces, his willingness to cut through the cant and pretense of American politics, to stand athwart polarization yelling, “Faster!” Tom Williams/CQ-Roll Call via Getty Images Senate Majority Leader Mitch McConnell is seen after the Senate Republican policy luncheon on March 17. Under McConnell, the Senate has been run according to a simple principle: Parties should use as much power as they have to achieve the outcomes they desire. This would have been impossible in past eras, when parties were weaker and individual senators stronger, when political interests were more rooted in geography and media wasn’t yet nationalized. But it is possible now, and it is a dramatic transformation of the Senate as an institution, with reverberations McConnell cannot control and that his party may come to regret. Indeed, McConnell’s single most profound effect on the Senate may be what he convinces Democrats to do in response to his machinations. “What makes McConnell successful is he gets his party colleagues and the Democrats to buy into his vision of the Senate rather than trying to change it,” says James Wallner, a fellow at the R Street Institute and a former executive director of the Senate Steering Committee under Sens. Pat Toomey (R-PA) and Mike Lee (R-UT). I will confess to a deep pessimism about American politics right now. We stand on the precipice of a legitimacy crisis — minoritarian rule has become the norm, an unpopular president has all but promised to refuse to accept a loss at the polls, and a political system that has only ever worked with weak parties is proving unable to govern amid the collisions of strong ones. But there is a glimmer of an optimistic tale that can be told, too. And, to my surprise, it revolves around McConnell, and the vision of the Senate that he is convincing Democrats to embrace, the reforms he might, at last, convince them to make. What did Mitch McConnell do wrong? Rewind the clock to 2016. Justice Antonin Scalia has died. President Barack Obama has nominated Merrick Garland, a moderate Democrat whose confirmation would end conservative dominance over the Court, to replace him. Mitch McConnell commands a 54-vote Senate majority, lifted into office by conservative voters who loathe the idea of a liberal Supreme Court. McConnell does two things here, and they are worth separating. One is philosophical, and even principled. He decides to treat Supreme Court nominations as what they are: one of the most ideologically consequential votes the Senate takes. The other is cynical: He refuses to even hold a hearing on Garland, instead inventing an absurd rule, one that he will later break, that states that Supreme Court seats shouldn’t be filled in presidential election years. McConnell’s calculation was simple: If Garland was permitted to testify, some Senate Republicans might revert to treating the nominee on his merits and swing to support Garland. McConnell needed Republicans to act like a caucus, not individual senators. And so he froze the process on a vote that united his party rather than one that divided them. “It’s a question of power and only secondarily of explanation,” says Steven Smith, author of The Senate Syndrome: The Evolution of Procedural Warfare in the Modern US Senate. “But politicians need to talk, so they need explanations.” Liberals focus on the wanton hypocrisy of McConnell’s comments. “The American people‎ should have a voice in the selection of their next Supreme Court justice,” he said at the time. “Therefore, this vacancy should not be filled until we have a new president.” But focusing on what McConnell said obscures the underlying logic of what he did: Republicans didn’t want Obama to fill Scalia’s seat, they had the power to stop him, and so they did. All the rest of it was just mouth noises. Chip Somodevilla/Getty Images McConnell in 2016 tells reporters that support among Senate Republicans has not waned for his refusal to hold confirmation hearings for Merrick Garland. This is the true McConnell rule: What parties have the power and authority to do, they should do. And to give him his due: It is much stranger, by the standards of most political systems, for the reverse to be the case, for senators to refuse to use their power to pursue their ideological ends on a question as important as a lifetime appointment to the Supreme Court. But that’s how American politics has traditionally worked. It worked that way because the parties, and their Supreme Court nominees, were different than they are now. The parties were ideologically mixed rather than ideologically polarized, and Supreme Court nominees were ideologically unpredictable rather than heavily vetted and ideologically consistent. From the 1950s through the 1990s, knowing the party that nominated a justice told you little about how that justice would vote. All of that lowered the stakes on each nomination. Today, we have ideologically disciplined coalitions naming their most reliable foot soldiers to lifetime appointments to the most powerful judicial body in the land. Those changes predate McConnell; his contribution was taking them to their logical conclusion in the Senate: Treat Supreme Court nominees like any other major ideological vote, and do whatever you need to do to win. “I am not sure that any majority leader in history has had less regard for the institution than Mitch McConnell” This attitude also drove McConnell’s record-breaking use of the filibuster during the Obama era. The Senate has long had a filibuster, and it was technically more powerful in the past than today. Until 1917, there was no procedure by which any number of senators could vote to end a filibuster. From 1917 to 1975, it took a two-thirds supermajority to close a filibuster. Even so, filibusters were rare in this period — with the gruesome exception of the Southern bloc of Dixiecrats who used them to block civil rights legislation. But as the Dixiecrats proved, it was relatively easy for a united group of senators to block any and all legislation, if they so chose. The rules gave them that power, and the minority party could’ve used it with abandon. The norms, and the diffuse nature of the parties themselves, kept them from routinely using it. What’s changed the US Senate isn’t changes to the rules, and it’s not just McConnell. It’s been the sorting of the parties into ideologically and demographically distinct coalitions. And it’s this trend that McConnell has, depending on how you look at it, harnessed for his ends or embraced because of his weaknesses. Either way, he has wrenched the Senate away from its traditional role as an institution unto itself, governed by norms of restraint and civility, and midwifed its transformation into another forum for party combat. He has created a parliamentary environment in an institution where the rules were designed for comity and cooperation. The result has been gridlock, fury, and confusion. “I am not sure that any majority leader in history has had less regard for the institution than Mitch McConnell,” says Sen. Michael Bennet (D-CO). “He claims he’s an institutionalist, but that’s a lie. Instead of having any shred of responsibility for the institution, he simply has done what he believes he can get away with and still win. And up until now, that’s been true. But I think the cost of that is going to turn out to be extraordinary.” What McConnell has wrought Over the past few months, I’ve been talking to Senate Democrats about the future of the filibuster. To my surprise, something had cracked in the ice. Moderate members who used to dismiss calls to abolish the filibuster were taking them seriously, predicting or even advocating its fall. And the reason they gave me was always the same: Mitch McConnell. The singular lesson Senate Democrats learned from the Obama years was McConnell simply wouldn’t let them govern if they retook the majority. The hope that their cross-aisle friendships, technocratic compromises, open committee processes, or informal “gangs” could break McConnell’s obstruction had dissolved. And with the world warming, and the virus raging, and millions unemployed, they knew that if they retook power, they would have to govern. “We’re not going to pass on a historic set of opportunities to allow garden-variety obstruction,” says Sen. Ron Wyden (D-OR). “We’re going to get this done.” I want to note, here, that both sides have their narratives of persecution and blame. Republicans believe Democrats broke norms, abused rules, corroded traditions. In 2013, for instance, Democrats nuked the filibuster on executive branch appointees and non-Supreme Court judicial nominations. They argue, I think correctly, that McConnell forced their hand, filibustering an unprecedented number of appointments and making it functionally impossible for Obama to govern. Republicans argue that Democrats changed the rules rather than naming more moderate choices to key positions and have reaped what they sowed. Chip Somodevilla/Getty Images President Obama greets Senate Minority Leader Mitch McConnell at the Capitol in 2013 to discuss tax reform, spending cuts, gun control, and immigration. I think Democrats have the better of this argument, but it doesn’t really matter. It’s the underlying dynamic that’s important. Smith calls it “Senate syndrome.” In a 2010 paper that is all the more useful for predating the past decade of escalation, he wrote, “In today’s Senate, each party assumes that the other party will fully exploit its procedural options — the majority party assumes that the minority party will obstruct legislation and the minority assumes that the majority will restrict its opportunities.” What Democrats now believe is McConnell won’t let them govern if they win, and in the aftermath of Garland and of Ruth Bader Ginsburg’s death, he won’t show them any quarter if he wins. Republicans, to be fair, believe the same about Democrats. Compared to the Senates of yore, both sides are right. McConnell has gone further, faster, than the Democratic leaders in torching old precedents and making the realpolitik principles of the new era clear. But in doing, he’s potentially done something that liberal activists and pundits were never able to achieve: convince Senate Democrats that the Senate is broken, and that new rules are needed. In this, McConnell’s strengths are also his weaknesses. He possesses a brazenness about American politics, a cynicism about the use of power, that lets him execute stratagems other leaders would be constrained by their reputations or fear of backlash from attempting. But that same comfort with the dark side, that willingness to play the Grim Reaper of politics, robs his opponents of their excuses for inaction, of their comforting belief that comity and compromise waits around the corner. “It is a little bit frustrating when liberals complain, because McConnell is not doing anything wrong per se, he’s just using his power very aggressively in ways that are permitted by the rules,” says Adam Jentleson, a former staffer for Senate Majority Leader Harry Reid and author of the forthcoming book Kill Switch: The Rise of the Modern Senate and the Crippling of American Democracy. “You can complain about that all you want, or you can respond by doing the same thing when you have power. And Democrats are starting to realize they have a responsibility to the health of our democracy to pass the structural reforms that will make the Senate, and thus the government, more reflective of the country.” In the long run, McConnell may reshape the Senate more completely through what he compels Democrats do than through what he himself does. Could McConnellism lead to democratization? I began this piece by saying my optimistic vision for politics revolves around McConnell, and it’s time I made good on that argument. Before I do, let me state the obvious: Crisis is not always opportunity. Sometimes, it is just crisis. And America may simply fall into fracture or illegitimacy. If it is to avoid these fates, it will require actions that few politicians enjoy contemplating, and the safest bet is always that politicians will duck hard choices. What follows here, then, is not a prediction but a possibility. Representative democracy is a good system, provided it is both sufficiently representative and sufficiently democratic. America, in 2020, is neither. The Senate gives the Republican party a 6- to 7-point advantage. The Electoral College gives the Republican Party a 65 percent chance of winning elections in which it narrowly loses the popular vote. Because of these advantages, the Republican Party has managed to secure startling dominance of the Supreme Court, despite rarely winning a majority in national elections. And that same Supreme Court then delivers rulings that further help Republicans win elections; in fact, President Trump has said explicitly he is counting on the Court to help him challenge mail-in ballots. "We need 9 justices. You need that. With the unsolicited millions of ballots that they're sending ... you're gonna need 9 justices." -- Trump suggests he's counting on SCOTUS to have his back when he makes claims of election fraud following November's election— Aaron Rupar (@atrupar) September 22, 2020 Democracy works because it disciplines politicians and parties: It forces them to hew closer to what the voters want, and punishes them when they diverge too far. But that disciplining function dissolves when the pathway to minoritarian rule strengthens. That’s broadly understood. What’s less understood is that it also dissolves when the mechanisms of governance weaken, when government begins routinely failing to deliver voters the change that has been promised. “It’s very difficult right now for Americans to see why it is that they go to the polls and — maybe — the people they vote for get elected, but then not much seems to change,” says Suzanne Mettler, co-author of Four Threats: The Recurring Crises of American Democracy. “They don’t follow the fact that, well, there weren’t 60 votes for cloture in order to bring something to the floor in the Senate.” The Senate sits at the center of both these currents of dysfunction, and its toxic role in American politics, and American life, has been protected by the thick shroud of mythos and tradition that surrounds it. It is why American citizens in DC and Puerto Rico remain disenfranchised. It is why reforms to make democracy more responsive, to protect it from the flood of cash and the perversions of gerrymandering and voter suppression, have no chance of passage. It is why, even on the occasions when one party holds both chambers of Congress and the White House, so little gets done. “One of the worst things about the filibuster is it allows senators to say they support something without ever having to stand behind a vote,” says Stasha Rhodes, director of the 51 for 51 campaign, which advocates for a DC statehood vote free from the filibuster. “It’s one thing to say you support DC statehood and another to say you support bypassing the filibuster to see it actually happens. It is one thing to talk about the need to reduce gun violence in America. It’s another to say you’re going to remove the hurdles that stand in that bill’s way. The difference between removing the filibuster and not is the difference between theory and action.” McConnell’s use of the filibuster, and his approach to Supreme Court nominations, is heightening the contradictions. Democrats are now considering reforms that are, from the standpoint of democratic governance, overdue, but that were, from the standpoint of Senate traditions and mores, unthinkable: eliminating the filibuster, adding DC and Puerto Rico as states, even changing the composition of the Supreme Court. To Republicans, these reforms would represent escalation. To Democrats, they would represent the only path forward. Perhaps both are right. Drew Angerer/Getty Images McConnell has been adamant that the Senate will vote this year on President Trump’s nomination to replace the late Justice Ruth Bader Ginsburg. The fundamental conflict in American politics is whether we will, going forward, be a true multiethnic democracy, or whether we will backslide into something closer to minoritarian rule. The crisis McConnell has forced can play out in many ways, some of them terribly destructive. But the certain path to backsliding is simple inaction, in which the status quo persists, minoritarian rule perpetuates itself, and the 20th-century understanding of the US Senate is used to choke off multiethnic democracy in the 21st century. “When I got to the Senate, people used to say, ‘If anyone can do it, Mitch can do it,’” recalls Wallner. “They stopped saying it after he failed a lot.” But in this case, it may be true: If anyone can get the Democrats to take the urgency of reinvigorating democracy seriously, Mitch can do it. Help keep Vox free for all Millions turn to Vox each month to understand what’s happening in the news, from the coronavirus crisis to a racial reckoning to what is, quite possibly, the most consequential presidential election of our lifetimes. Our mission has never been more vital than it is in this moment: to empower you through understanding. But our distinctive brand of explanatory journalism takes resources. Even when the economy and the news advertising market recovers, your support will be a critical part of sustaining our resource-intensive work. If you have already contributed, thank you. If you haven’t, please consider helping everyone make sense of an increasingly chaotic world: Contribute today from as little as $3.
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Retired astronaut Mark Kelly with his wife, former Congress member Gabrielle Giffords, in 2017. | Bill Clark/CQ Roll Call/Getty Images The same voters who helped Kyrsten Sinema win could boost Mark Kelly, too. The Senate race in Arizona is giving a lot of people déjà vu. Just two years after running — and narrowly losing — to Sen. Kyrsten Sinema, Sen. Martha McSally is running again, this time against retired astronaut Mark Kelly, in an attempt to keep her seat. In a unique twist, McSally was appointed to an open Senate seat by Gov. Doug Ducey to serve out the term of the late Sen. John McCain after she’d previously lost. And experts say McSally’s candidacy isn’t the only thing that feels familiar. “I would be willing to wager Sinema just handed Kelly her playbook and said, ‘Here you go, here’s how you win the US Senate in Arizona,’” quipped OH Predictive Insights pollster Mike Noble. Many of the dynamics that defined 2018 — and contributed to the state’s shift to the left — have only become more apparent in the two years since. Independent voters, which make up about a third of the state’s electorate, are still dissatisfied with President Donald Trump and likely to favor Democrats this fall. In a recent ABC News/Washington Post poll, Democratic presidential nominee Joe Biden led Trump 57 percent to 38 percent among independent voters in the state. Democrats are also making inroads with moderate Republicans, particularly suburban women, who are interested in less polarized leadership and concerned about Trump’s handling of the coronavirus. And the state’s growing population of Latinx voters is continuing to skew Democratic. Caitlin O’Hara/Getty Images Sen. Martha McSally speaks during a rally for President Trump in Phoenix, Arizona, on February 19. “The shift is these Ducey-Sinema voters. You’re a Republican and you’re willing to vote for a Democrat. That’s where I think the most growth has been,” said Lorna Romero, a former communications director for McCain’s 2016 campaign. There are some key differences this cycle that are poised to have major implications on the race, too. The state, like the rest of the country, is still grappling with the public health and economic consequences of a devastating pandemic, which hit Arizona particularly hard this past summer. Plus, the presidential election is poised to loom over any down-ballot races. Strong anti-Trump sentiment in the state, driven by his divisive rhetoric and poor handling of the pandemic, could ultimately amplify the same trends already evident in the last two cycles. Although Sen. Mitt Romney won Arizona by 9 points in the 2012 presidential race, Trump only took it by 3 in 2016. Sinema then won the state’s Senate seat by 2 points in 2018. Following her defeat that year, members of McSally’s team put out a memo that touched on the reasons behind her loss. In it, they summed up several issues — including her decision to align herself closely with the president — that could well lead to the same outcome again. “A significant segment of the AZ GOP was hostile to the President,” the memo read. “This segment of moderate Republicans, especially [women], proved very difficult to bring home to a Republican candidate that supported President Trump and the confirmation of Justice Kavanaugh.” In addition to maintaining her steadfast backing for Trump, McSally is poised to take another potentially polarizing Supreme Court vote in the coming weeks, making some of the circumstances she’s dealing with very similar to 2018. Democrats are making gains with moderate Republicans in Arizona According to exit polling from the midterms, Sinema won 12 percent of Republicans as well as 50 percent of independents and an overwhelming majority of Democrats. That same coalition of voters could be the ones to buoy Kelly to victory this cycle. In the RealClearPolitics average, Kelly is ahead of McSally by more than 6 points. And an OH Predictive Insights poll published in mid-September found that 15 percent of Republicans and 55 percent of independents would support him. “Sinema voters — they are the Jeff Flake Republicans, they are the John McCain Republicans who want civility,” says Derrik Rochwalik, a political consultant based in Phoenix who was previously chair of the Maricopa County Young Republicans. Caroline Brehman/CQ-Roll Call/Getty Images Sen. Kyrsten Sinema departs from the Senate floor after a vote on September 16. Trump’s hardline stances on immigration and racist comments about Mexican immigrants are among the factors that have turned these voters away. And McSally’s willingness to back Trump on issues including the national emergency for his border wall and the recent Supreme Court vacancy means many view her as just another extension of his administration. “I want a candidate that will represent my family and that will make decisions based on personal convictions and not just follow the President from their party,” said Mark Tucker, a resident of Gilbert, Arizona, in a recent statement that included a hundred Republicans backing Kelly. While McSally has made a more partisan appeal, experts in the state note Kelly’s messaging has been designed — much like Sinema’s — to reach a specific subset of crossover Republicans and independents. “When you look at his ads, he’s not talking about Democrat-this or Democrat-that. He’s running largely as somewhat of an independent,” says Joe Garcia, the executive director of the Chicanos Por La Causa Action Fund. McSally herself nodded at Kelly’s approach in an August event, going so far as to suggest that some people may not be aware he is a Democrat. “Somebody actually could vote Trump-Kelly,” she warned. Carolyn Kaster/AP Mark Kelly takes the stage during the Democratic National Convention in 2016. Kelly’s policy positions, like his messaging, hew to the center: He’s supportive of a public option and reducing drug prices through Medicare negotiation, and he has called out the need to generate more clean energy jobs while stopping short of backing the Green New Deal. Much like many Democrats did in 2018, he’s made defending protections for people with preexisting conditions a centerpiece of his campaign. Kelly is also married to former Arizona Rep. Gabby Giffords, and the two have been leading gun-control advocates in the wake of the 2011 shooting during which a gunman shot Giffords in the head at a constituents’ meeting in Tucson. Presently, he backs universal background checks and red-flag laws, which enable law enforcement to bar individuals from accessing firearms if they are flagged as a danger to themselves or others. “I’m running — to be an independent voice for Arizona,” Kelly has said. Kelly’s campaign declined to make him available to Vox for an interview. McSally’s campaign did not immediately respond to a request for comment. Kelly’s focus on his independent streak echoes messaging Sinema once used about being able to work with “literally anyone” to get policy done, and it’s one that has played well with Arizona voters, who often boast about how independent they are. McSally, meanwhile, has continued to link herself to Trump in a bet that this connection will be enough to rally members of the GOP’s conservative base in November, even as she’s lost moderates. She’s focused some on her biography as the first woman to fly in a combat mission for the Air Force, but much of her messaging has been dedicated to emphasizing her conservative bona fides. Latinx voters are poised to have huge influence over the election, which could bode well for Democrats A big factor in Arizona’s leftward shift is the uptick in Latinx voters in the state. In 2018, Latinx voters overwhelmingly favored Democrats, with 70 percent supporting Sinema while 30 percent backed McSally. And since the last presidential election, Latinx voter share in the electorate has grown from 19.6 percent to 24.6 percent, with thousands of younger voters reaching voting age. According to Garcia, more than 100,000 new Latinx voters have turned 18 in recent years — and Latinx voters are younger, on average, than white voters in the state. It’s important to note that Latinx voters are not a monolith; the majority who live in Arizona are Mexican American and more likely to be left-leaning. According to the ABC News/Washington Post survey this week, a higher proportion of Latinx voters in Arizona favored Biden than in Florida, for example, a trend that’s indicative of the diversity among members of the group. The pandemic is ultimately an issue at the forefront for all Arizonans, including Latinx voters, who have been disproportionately impacted by it. “For the most part, Covid-19 and the cost of health care are overwhelmingly top issues,” says Edward Vargas, a researcher for polling firm Latino Decisions. “What we’ve seen in our polling is that they trust Democrats much more in addressing issues toward Covid-19.” Both campaigns have focused more of their efforts on reaching Latinx voters — including participating in a virtual forum that will air in October — who historically haven’t seen as much formal outreach from candidates. In 2018, because of more dedicated organizing driven by advocacy groups including LUCHA and Mi Familia Vota, Latinx voter turnout saw a spike compared to 2014. Experts say they expect this same energy — if not more — in 2020. “I think it’s going to be a record-setting election,” says Vargas. The fight for control of the Senate and the presidency looms over this race Because of how she’s positioned herself, McSally’s fate is viewed as inextricably tied to Trump’s. “I do think that the strategy for the president — and Martha McSally — is making sure that the Trump supporters came out of the woodwork to support him in 2016, the play right now is to make sure that those people turn out,” says Romero. McSally has also repeatedly emphasized that her seat is a bulwark against potential Democratic control of the Senate, an effort aimed at targeting those same Republicans, especially as the GOP seeks to confirm a Supreme Court nominee to take the late Justice Ruth Bader Ginsburg’s seat. “Arizona is the tipping point for whether Chuck Schumer is going to be in charge in the Senate,” McSally said during an August appearance on CBS News. “A vote for Mark Kelly is a vote for ... the radical left agenda.” Matt York/AP Vice President Mike Pence greets Sen. Martha McSally at a Veterans for Trump campaign rally in Litchfield Park, Arizona, on September 18. In the past week, the two candidates provided a glimpse of how they’d handle the Supreme Court nomination: McSally swiftly backed a vote on Trump’s Supreme Court pick, while Kelly argued that a nominee should be put forth by whoever wins the general election. One of McSally’s chief arguments is, “Let’s make sure we don’t lose that second seat and that the Republicans don’t lose the Senate in 2020,” says Rochwalik, the Phoenix political consultant. The pivotal role Arizona could play in determining control of the Senate has also meant that an overwhelming amount of funding has been flowing into this race, with Kelly, in particular, raising a staggering sum. According to the Center for Responsive Politics, Kelly had raked in more than $45 million as of a July report, dwarfing McSally, who had brought in $30 million as of a September report. If Kelly can channel this support as effectively as Sinema did, he could see a repeat of her success, too. Will you help keep Vox free for all? The United States is in the middle of one of the most consequential presidential elections of our lifetimes. 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On This Day: 24 September 1991
Funk rockers Red Hot Chili Peppers released their seminal album "Blood Sugar Sex Magik." (Sept. 24)
Beijing's Terrifying Repression Campaigns | Opinion
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How Health Care Can Stop Amplifying Racism
The coronavirus pandemic didn’t create the health disparities among Americans, but it has exposed once again how stark the problem is. Black and Latino patients are two to three times as likely as white patients to be diagnosed with COVID-19, and more than four times as likely to be hospitalized for it. Black patients are more than twice as likely to die from the virus. They also die from it at younger ages. COVID-19 has exacerbated long-standing trends: Black and Latino Americans have lower rates of insurance coverage, a higher prevalence of chronic diseases, worse health outcomes, and a lower life expectancy. People in the health-care world sometimes speak of these patterns as if they are inevitable facts of life—something the industry is powerless to change. More doctors and hospitals need to acknowledge and address how the U.S. health-care system is rife with structural racism. For decades, American medicine has discriminated against people of color.The health-care system, by one estimate, is responsible for only about 10 to 15 percent of preventable mortality in the United States. Socioeconomic factors, such as housing, food, and education, have a greater overall impact. Policies that effectively address these factors will be required to significantly reduce disparities in health outcomes for Black and Latino people. Nevertheless, many choices that health-care professionals commonly make—such as not accepting Medicaid patients, having fewer staff members at facilities in minority neighborhoods, and blaming patients for not taking their medicine and for poor overall outcomes—perpetuate disparities and even amplify them.[Read: How to fix the health gap between Black and white America]These health gaps are not immutable. Concrete changes to public policy, industry practices, and medical education could turn the health-care system into a force for greater equality. Here are five such changes:First, when states are indifferent to whether their Black and Latino citizens have health coverage, the federal government should step in. According to research published earlier this year, 9 percent of white adults were uninsured in 2018, compared with 14 percent of Black adults and 25 percent of Latino adults. The coronavirus recession is making the coverage gap worse. Already, as many as 12 million Americans have lost insurance sponsored by their employer or a family member’s employer. Black, Latino, and other workers of color have faced especially steep declines in employment.The Affordable Care Act did reduce disparities in insurance by setting up insurance exchanges and making more Americans eligible for Medicaid, but some states opted out of the latter—with terrible consequences for disadvantaged minorities. Indeed, an estimated 46 percent of Black working-age adults live in the 15 states that refused to implement the ACA’s expanded Medicaid benefits, leaving low-wage workers with no way to pay for their family’s care. The disparity rises when joblessness grows: Medicaid covers 36 percent of unemployed adults in states that expanded eligibility for the program, but only 16 percent in states that did not.So far, federal inducements have not been enough to persuade states such as Texas, Georgia, and Florida to expand Medicaid. The next president and Congress can solve that problem by federalizing Medicaid and removing its administration from states. Such a change could yield universal enrollment standards and greatly reduce the racial health-insurance gap.Second, policy makers can make insurance coverage meaningful by having Medicaid pay physicians and hospitals more. Having health coverage is necessary, but not sufficient, for patients to obtain good health care in a timely manner. Because Medicaid pays doctors less than Medicare or private insurance does, many doctors refuse to see—or delay appointments for—Medicaid patients. A 2014–15 survey showed that only 68 percent of family-practice physicians accepted new Medicaid patients, while 91 percent accepted those with private insurance. Some doctors did not accept new patients at all or didn’t accept insurance. Only a third of psychiatrists accepted new Medicaid patients.In 2013 and 2014, the ACA temporarily raised Medicaid payments to primary-care doctors. This fee bump improved patients’ access to doctors. Just as predictably, when states returned to lower fee levels, Medicaid enrollees had more trouble making appointments. The lesson is clear: The federal government needs to permanently raise Medicaid payments to doctors. For hospitals, payment reforms should penalize poor performance on measures of health equity. For example, higher payments to hospitals could be tied to improvements in emergency-room wait times—which have often been found to be longer for Black patients than white ones.[Read: Medicaid’s dark secret]Third, hospitals—which often anchor a community’s health-care system—must address social factors that affect health outcomes. Hospitals that do so could see benefits in the long run. In the mid-2000s, for example, Boston Children’s Hospital began a community-outreach program for low-income Black and Latino children who, based on previous information, seemed likely to be hospitalized with asthma. Case workers worked with families and community groups to reduce the prevalence of conditions that lead to asthma attacks. The result: Unnecessary readmissions, emergency-room visits, missed school days by students, and lost workdays among parents all fell. The program generated $1.73 in benefits for every dollar spent. At a variety of other hospitals, initiatives to address the social determinants of health have led to a fall in readmissions.The government has leverage over hospitals. In return for avoiding substantial federal and state taxes, nonprofit hospitals are required to provide community benefits. Many hospitals count discounted care to Medicaid and uninsured patients as community benefits. Instead, state and federal policies should specifically encourage hospitals to invest in community health—for instance, in anti-hunger programs or “nurse-family partnerships” that assist low-income mothers. Many hospitals also receive extra funds because they operate in low-income communities, make less money from private insurance, and provide a disproportionate share of their services to patients without the ability to pay. These government payments should be tied to investments that address social determinants of health.Fourth, increasing diversity among physicians and nurses is vital. In an experiment in Oakland, California, the researchers Marcella Alsan, Owen Garrick, and Grant C. Graziani found that the involvement of Black doctors could reduce the cardiovascular mortality gap between Black and white men by 19 percent. Yet only 5 percent of American physicians are Black, compared with 13 percent of the general population. Latino and Indigenous physicians are similarly underrepresented. Structural barriers, including the excessive cost of attaining a medical or nursing degree and bias in the admissions process, substantially contribute to this lack of diversity. Many states already offer loan-repayment services and other incentives for physicians to work in underserved areas, but expanding these programs could recruit even more underrepresented minorities to the medical field. Not all the obstacles to diversity are economic, of course. Minority students are also more likely to experience discriminatory comments and public humiliation during their medical training. Medical schools and hospitals need to enforce serious disciplinary measures for such behavior, while ensuring that students who complain are not labeled as “troublemakers.”[Read: America’s health segregation problem]Finally, all health-care workers could also benefit from a curriculum that specifically addresses implicit bias and the historical roots of racism in the medical system. To this day, medical textbooks still depict mostly white skin tones. Many medical students hold empirically false beliefs about race-based physiological differences—including the notion that Black patients have a higher tolerance for pain than white patients. These beliefs affect the kind of decisions that doctors make. One analysis early in the pandemic found that doctors were less likely to refer symptomatic Black patients for testing than they were to refer white ones. Educating aspiring doctors about these dynamics will improve the care that patients receive.These five steps won’t cure America’s health disparities, but they outline a course of action. Reducing racial bias in health care will have broad benefits: A country whose residents have fewer chronic conditions, better access to care, and longer lives has a greater capacity for happiness and prosperity. As America faces a national reckoning with structural racism, leaders in the health-care system must confront the role we play and assume responsibility for solving the problem.Amaya Diana and Aaron Glickman contributed research to this article.
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Trump's amateurish mistake ahead of debates
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