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Tag: state level

  • Trump Repeats Obama’s Mistake

    Trump Repeats Obama’s Mistake

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    Donald Trump has long detested Barack Obama and sought to present himself as the opposite of his presidential predecessor in every way. But in his takeover of the Republican National Committee, he risks echoing one of Obama’s biggest political mistakes.

    Last night, Trump’s handpicked leadership of the RNC took charge and conducted a purge. The new regime, led by the new chair, Michael Whatley; the vice chair, Lara Trump; and the chief of staff, Chris LaCivita, fired about 60 employees—about a quarter of the staff—as part of “streamlining.” The “bloodbath” includes members of the communications, data, and political departments. Insiders told Politico they anticipate that existing contracts with vendors will be voided.

    When the new leaders were announced last month, I suggested that the GOP was ceasing to function as a political party, and becoming another subsidiary of Trump Inc. But there is another way to view it. For years now, the RNC has struggled. Republicans might have lost the 2016 presidential election if not for the emergence of Trump, who shook up the party’s longtime platform and forged a new coalition, turning out voters no other recent candidate had. Since then, however, Republicans have continued to lag, even with Trump juicing turnout. Republicans got slammed in the 2018 midterms, lost the 2020 presidential race, and missed expectations in 2022. Special elections have been a Democratic playground. The RNC is entering the 2024 election with a third of the Democratic National Committee’s reserves.

    From this perspective, it’s about time that Trump took charge and cleared out the deadwood. Allies such as Charlie Kirk and Representative Marjorie Taylor Greene were jubilant at the overhaul. Although Trump’s appointments of his daughter-in-law and a top campaign aide are unusual, nominees typically take over the campaign apparatus ahead of a presidential election, the better to align aims.

    David A. Graham: Republicans are no longer a political party

    Truth be told, Trump can’t really distance himself from the recent mismanagement. The deposed chair, Ronna McDaniel, was Trump’s pick in 2017, and his main complaint about her is that she was insufficiently compliant. If Trump just wants more of the same, that’s bad news for the party. Trump critics within the GOP also fear that he intends to use the party coffers as a personal defense fund, underwriting his substantial legal bills. Last week, the committee pointedly rejected a proposal by an old-line member to prevent that.

    Let’s take the best-case scenario for Republicans, though. In the past, the RNC seemed like the professionals compared with the chaotic, amateurish Trump campaigns of 2016 and 2020. (There’s a reason Trump resorted to appointing RNC Chair Reince Priebus as his first White House chief of staff, despite Priebus representing the establishment Trump hated.) This year, however, the Trump campaign has seemed organized and disciplined, and LaCivita is reportedly a big part of that. National committees tend to be bloated and old-fashioned. A more focused, streamlined operation could fix what ails the GOP.

    The problem is that Trump sees his own success and the success of the Republican Party as bound up together. But some things that are good for Trump are not good for the Republican Party over the long run. This is where Obama offers a cautionary tale.

    When he won the Democratic presidential nomination in 2008, Obama was an insurgent; the DNC had long been dominated by allies of Hillary Clinton, whom he defeated in the primary. He wasn’t as deeply embedded in the old way of doing things. Obama viewed the Democratic Party as essentially a national organization, with the goal of supporting his political goals and his reelection. Upon winning the presidency, he moved key DNC functions to Chicago, his hometown and political base, despite the protests of party insiders who worried that downballot efforts would be overshadowed by Obama’s reelection campaign. He also created a group outside the DNC, Organizing for America, to support his political movement.

    The result was a badly weakened DNC. The national focus led to a neglect of other elections. After Senator Ted Kennedy died, Democrats managed to lose a 2010 special election for his seat in Massachusetts, of all places—a failure that some Democrats blamed on the national party. The loss delayed the passage of the Affordable Care Act and required congressional Democrats to water it down to pass it.

    The Bay State special was a harbinger. As Matt Yglesias calculated in 2017, the Obama years saw Democrats lose 11 Senate seats, 62 House seats, and 12 governorships. The damage was especially bad at the state level. Democrats lost nearly 1,000 seats in state legislatures, the worst loss since Herbert Hoover dragged down the GOP. Republicans captured 29 separate chambers and gained 10 new trifectas—control of both chambers of the legislature and the governor’s mansion. All of this happened at the same time that Democratic presidential candidates won the national popular vote in the 2008, 2012, and 2016 presidential elections (as they would again in 2020).

    Read: What happens to the Democratic Party after Obama?

    Democrats, including Obama, suffered for their missteps. As the Obamacare experience shows, it’s harder to push a policy agenda when you lose elections. Losing control of the Senate makes it difficult to confirm judges, especially to crucial spots such as the Supreme Court—just ask Justice Merrick Garland. And implementing policy is challenging if governors and state Houses are working against you.

    An excessive focus on presidential races is also the danger of Trump’s RNC takeover. He and his aides have announced that, like Obama, they see the party committee as basically an instrument for the presidential election. “Our mission is straightforward: maximize the Republican Party’s resources to get President Trump elected,” LaCivita told The New York Times last month. Echoing Obama’s Chicago move, the RNC is reportedly already moving most of its operations to Palm Beach, Florida, near Trump’s Mar-a-Lago headquarters. All of this makes sense. Trump is a narcissist who can’t and won’t separate his self-interest from the party’s or the nation’s.

    Slashing the national footprint of the RNC may weaken the party at lower levels. Several state parties are already a mess. The chair of the Florida GOP was recently ousted amid a sex scandal. Michigan’s GOP chair, a fervent Trump backer, was also deposed after a tumultuous stint, and the state party is reportedly broke. The Arizona GOP also recently lost its chair and has been racked by feuds. But more MAGA is unlikely to be the solution to these problems, because infighting and obsession with Trump’s election denial have been at the center of several blowups. The most effective wing of the GOP apparatus right now, the National Republican Senatorial Committee, has succeeded by managing to create some insulation from Trump, allowing it to select strong candidates. In 2020, Republican congressional candidates mostly ran ahead of Trump.

    And even if Trump’s theory of the RNC works out in 2024, what happens next? Trump will not always be the president or the nominee. Someday, Republicans will need to choose a new leader, and they may be left with only a shell of a party committee, gutted and stretched to be part of Trump’s personal election apparatus. It’s a hard and long road to rebuilding from there. Just ask a Democrat.

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    David A. Graham

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  • The New Pro-life Movement Has a Plan to End Abortion

    The New Pro-life Movement Has a Plan to End Abortion

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    The unpleasant reality facing the anti-abortion movement is that most Americans don’t actually want to ban abortion.

    This explains why the pro-life summer of triumph, after the U.S. Supreme Court overturned Roe v. Wade, led to a season of such demoralizing political outcomes. Voters in Montana, Kansas, and Kentucky in November rejected ballot measures to make abortion illegal; just last month, in Wisconsin, voters elected an abortion-rights supporter to the state supreme court.

    Yet the movement’s activists don’t seem to care. Thirteen states automatically banned most abortions with trigger laws designed to go into effect when Roe fell; a Texas judge this month stayed the FDA approval of the abortion pill mifepristone, setting in motion what is sure to be a drawn-out legal battle; and some lawmakers are pursuing restrictions on traveling out of state for the procedure—what they call “abortion trafficking.”

    Even as the anti-abortion movement lacks a Next Big Objective, a new generation of anti-abortion leaders is ascendant—one that is arguably bolder and more uncompromising than its predecessors. This cohort, still high on the fumes of last summer’s victory, is determined to construct its ideal post-Roe America. And it’s forging ahead—come hell, high water, or public disgust.

    The groups this new generation leads “are not afraid to lose short term if they think the long-term gain will be eliminating abortion from the country,” Rachel Rebouché, a family-law professor at Temple University, told me.

    One such leader is Kristan Hawkins, the president of the anti-abortion group Students for Life. After Dobbs v. Jackson Women’s Health Organization, “some organizations had to go through this period where they had to reflect and figure out what they were going to do,” she told me. “But nothing changed in our organization—we’d already had that conversation years ago.” Students for Life participants have been calling themselves “the post-Roe generation” since 2019; that’s the year they launched a political-action committee to beef up their state-level presence and begin drafting legislation for a post-Roe society. In 2021, the organization started the Campaign for Abortion-Free Cities to promote what they call “alternatives to abortion” and neighborhood resources for pregnant women.

    Read: What winning did to the anti-abortion movement

    “What the anti-abortion movement is, who’s leading it, and what it stands for are still being contested,” Mary Ziegler, a UC Davis law professor who has written about abortion for The Atlantic, told me. But organizations such as Students for Life will, in all likelihood, “be the ones running the movement going forward.” To understand the goals of people like Hawkins is, in other words, to peer into the future of America’s anti-abortion project.

    The thing about Hawkins is that she’s an optimist—and not a cautious one. So when the draft opinion suggesting that the Supreme Court was about to overrule Roe v. Wade leaked last May, she wasn’t particularly surprised, she told me—she felt vindicated. Other pro-lifers had refused “to let themselves even dare think that a post-Roe America was coming,” Hawkins said. “Of course it was.” She’d always assumed it would happen in her lifetime.

    As soon as the draft opinion came out, anti-abortion leaders began to consider their response. Some were worried that taking any kind of victory lap would be inappropriate—that it might scare the justices into moderating or reversing their ultimate decision. Hawkins didn’t care about any of that. “Why would we be guarded? It was important, good news!” she told me. “Folks across the country needed to see this generation celebrating.” Students for Life was one of the first anti-abortion organizations to release a statement praising the draft opinion—while being careful to condemn the leak itself.

    Hawkins, who is 37, styles herself as a straight shooter. She doesn’t dress up arguments with religious rhetoric—despite being Catholic herself—and she can be an effective, if sometimes abrasive, debater. Which makes sense, because she came to the pro-life movement through electoral politics. Hawkins knocked on doors for local and state Republican candidates; in college, she worked for the Republican National Committee to reelect President George W. Bush—and, for a year, she worked in his administration. Then, when Students for Life came looking for a new president in 2006, she eagerly accepted.

    Hawkins “saw the politics in this in ways a lot of people don’t,” Ziegler told me—and she brought that acumen to the movement. She knew how to lead a grassroots campaign, and how a state legislature functions. Then just 20, she was younger than other pro-life leaders, so she had a better idea of how to engage young people. Hawkins is trying, Ziegler said, “to grow the movement in a way that no one else really ever did.”

    The organization’s 14,000 participants campaign for state-level anti-abortion candidates and legislation in their local legislatures. Hawkins, who oversees a staff of 100 paid employees, spends her days traveling to meet with chapter leaders, organizing demonstrations, delivering speeches, and generally doing her best, as she put it to me, “to stir up discussion.” In March, during a visit to Virginia Commonwealth University, protesters shouted over Hawkins when she tried to speak. Demonstrators called her a Nazi and a fascist. Eventually, campus security shut down the event, and police arrested two protesters (who weren’t actually VCU students). Hawkins, who livestreamed the drama, later went on Fox News to offer a full account.

    The Students for Life YouTube channel has a 22-minute highlight reel called “Greatest Pro-Choice Takedowns,” in which Hawkins responds to questions from young, often-emotional abortion-rights advocates. As you might expect, the videos feel mean. In each clip showing Hawkins facing off against a different student with a shaky voice, she makes them look silly and ill-informed, a relatively easy thing to do when your opponent is not being paid to perfect her talking points. But these exchanges don’t seem intended to change minds; they’re meant instead to humiliate—and thereby reveal the purported weaknesses in abortion-rights arguments.

    Doggedness and moral conviction have always characterized the anti-abortion movement. Activists have sustained their energy for 50 years “by believing that success was possible, even in the absence of clear victories,” Daniel K. Williams, a history professor at the University of West Georgia, told me. Dobbs gave this new generation a taste of victory. Activists like Hawkins are bolder now. Without Roe, they reason, anything is possible.

    Daniel K. Williams: This really is a different pro-life movement

    Students for Life, in particular, is “more abolitionist than prior generations of similar groups,” Rebouché told me. In contrast to other organizations that have pursued incremental progress, the group adopts strategies that are “totalizing and absolute.” Throwing out the rule book, they operate as though they’ve got nothing to lose.

    “I admire their persistence; I admire their sacrifices,” Lila Rose, the president of the anti-abortion nonprofit Live Action, says of previous generations of anti-abortion activists. “But we’re playing to win. This isn’t just some nonprofit job.” Rose, who is 34, achieved early prominence in the movement back in 2006 for partnering with the conservative activist James O’Keefe to film undercover exposés at abortion clinics. Live Action doesn’t have the kind of nationwide membership that Students for Life has, but its email list contains more than 1 million contacts, Rose told me, and its social-media following runs into the millions.

    Students for Life and Live Action frame their anti-abortion efforts as not just saving babies but empowering women—enabling them to avoid the depression and regret the organizations say can be caused by having an abortion. These aren’t new ideas in themselves, but they’ve been repackaged in a way that mimics the language of a modern social-justice movement appealing to young people. “They’re using phrases like born privilege,” Jennifer Holland, a gender-and-sexuality professor at the University of Oklahoma, told me. “Language that’s hip—in the culture—but that still leads back to this one point of view that maybe you thought was old or conservative.”

    Historically, there’s been “a lack of vision” in the movement, Rose said. It was great, she allowed, that the National Right to Life Committee fought so hard in the 2000s to ban what they called “partial-birth abortion” (using a pro-life term not recognized by medical professionals). But, to Rose, pill-induced abortion is just as “anti-human and anti-woman”; a 15-week abortion limit is nothing to celebrate. “I don’t think that we do ourselves any favors as a movement by, like, walking over to the opponent’s side of the field and saying that that’s a victory.”

    Hawkins’s master plan to completely eradicate abortion in America begins with passing as many state controls as possible. She calculates that 26 state legislatures contain enough anti-abortion Republicans to be amenable to a strict ban of some sort, and her organization is pushing an “early abortion” model, which means that it drafts and supports legislation restricting abortion either entirely or after six weeks. Hawkins claims credit for pressuring reluctant Republican state leaders in Florida to take up the six-week abortion ban that Governor Ron DeSantis signed late Friday night. Gone are the days of small-ball second-trimester limits, Hawkins says, because most abortions happen before then. “We’re not going to spend a significant amount of resources to pass legislation that’s going to save only 6 percent of children.”

    Right now the centerpiece of Students for Life’s campaigning is the effort to ban medication abortion—what Hawkins and her allies call “chemical abortion.” For two years, the group lobbied Republicans in Wyoming to prohibit mifepristone from being sold in pharmacies; the governor signed that measure into law last month. Now it’s setting its sights on the pharmacy chains Walgreens, Rite Aid, and CVS—which Hawkins singles out as “the nation’s largest abortion vendor.”

    Mary Ziegler: The Texas abortion-pill ruling signals pro-lifers’ next push

    On campuses, Students for Life leaders are trying to mobilize young people who might otherwise be ambivalent about the abortion pill; Hawkins says they’ve had luck with the message that mifepristone, when flushed, enters the water system and threatens the health of humans and wildlife. “Young people are aghast to find out that something they care deeply about—the environment—is now conflicting with their views on abortion,” Hawkins told me. Never mind that there is no evidence for these claims. According to Tracey Woodruff, the director of the Program on Reproductive Health and the Environment at UC San Francisco, the amount of mifepristone found in drinking water is so small that it might not even be measurable.

    “Of all the things we have to worry about with our drinking water,” she told me, “this is not one of them.” Students for Life’s messaging on this, she added, is “a perverse use of science.” The organization is nonetheless backing new laws in several states that would require women prescribed abortion pills to use medical-waste “catch kits” and return them to a health-care provider.

    Hawkins is realistic about the fact that her movement’s progress has a ceiling. Some states, especially the liberal strongholds of Illinois and New York, are never going to go for the kinds of laws that she’s pushing for. This is when, she says, her organization will shift its emphasis to the federal government—pushing for a constitutional amendment that would recognize fetal personhood, or for a ruling from the Supreme Court to affirm that the Fourteenth Amendment already does.

    Abortion should become “both illegal and unthinkable” in America, Hawkins said. But even when the anti-abortion movement can no longer change hearts and minds, it plans to find a way to change the law anyway. She favors using the law as a tool because, in her view, people tend to derive morality from legality: “Nothing’s going to change their minds until the law changes their minds.” Hawkins envisions a future, 20 years from now, in which university students will discover with abject horror that other states allow the murder of babies in the womb—culturally, she believes, “that’s gonna be massive.” The idea that young people in college would be shocked to learn that different states have different laws on abortion may seem implausible now, but Hawkins is articulating her larger goal—of making abortion unconscionable.

    Yet American culture seems to be moving in the opposite direction. The Dobbs ruling, though exciting for anti-abortion activists, was so enraging for abortion-rights supporters that, in some places, they responded by enshrining the right to abortion into state law. These and other political losses suggest that the pro-life movement is already overreaching—and generating a backlash. “It’s breathtaking to see people so motivated and so well funded to push an agenda that is so incredibly unpopular,” Jamie Manson, the president of the abortion-rights organization Catholics for Choice, told me. The months since Dobbs have exposed a fundamental tension between the outcome that abortion-rights opponents want and the one democracy supports.

    As it becomes clear that abortion is not always an election winner—that, on occasion, it is even a predictable loser—some Republican legislators have broken from the movement in order to support rape and incest exceptions; others have simply avoided the issue. “Most of the members of my conference prefer that this be dealt with at the state level,” Senate Minority Leader Mitch McConnell told reporters last fall. Hawkins and Rose are happy to criticize those Republicans they see as wishy-washy on abortion. When former President Donald Trump blamed Republicans’ 2022 midterm losses on the extremism of the anti-abortion movement, Rose called it “sniveling cowardice.” But Hawkins and Rose may be underestimating how much more challenging and complex the post-Roe environment is.

    “This is much more expensive politics around abortion,” Holland said. “It used to be cheap: You could promise all sorts of things” without penalty, because with Roe intact, such radical measures would never pass.

    Does this give Hawkins any pause—the idea that her movement’s aims are so antithetical to what most Americans want? Hawkins said that public opinion doesn’t concern her. The fact that most Americans support abortion access doesn’t make them morally correct, she argued, and neither does it make her own efforts undemocratic. “Do I look upon abolitionists in pre–Civil War America as undemocratic for trying to change people’s minds and prevent the proliferation of owning another human being for your own financial gain? No,” she said.

    Hawkins has spent a lot of time thinking about this question. Consider the civil-rights era, she went on. “We had states that stubbornly refused to integrate.” In the end, federal legislation forced them to comply. The implication is that the same sort of national ban should eventually happen for abortion.

    Given this goal, we can expect that abortion will be an issue in almost every single election, in almost every single state, for the next many cycles. In some parts of the country, the anti-abortion-rights movement will fail. In others, it will skate along with utter success. Lawmakers will tighten laws, ban pills, and restrict travel. They may even feel audacious enough to venture into the broader realm of reproductive tools—outlawing or restricting IUDs, the morning-after pill, and even in vitro fertilization.

    Post-Roe, we can expect these hungry, mobilized activists to seek new conquests. But even as they do, pro-life leaders will have to wonder whether they are guiding their movement toward righteous victory—or humiliating defeat.

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    Elaine Godfrey

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  • What Winning Did to the Anti-abortion Movement

    What Winning Did to the Anti-abortion Movement

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    In a normal year, the March for Life would begin somewhere along the National Mall. The cavalcade of anti-abortion activists in Washington, D.C., would wind around museums and past monuments, concluding at the foot of the Supreme Court, a physical representation of the movement’s objective: to overturn Roe v. Wade. The march happens in January of each year to coincide with the anniversary of the Roe decision.

    But this is not a normal year. Tomorrow’s march will be the first without Roe on the books.

    Read: The anti-abortion movement’s Gen-Z victors

    In recognition of that fact, the march has a new route. It will finish somewhere on First Street, between the Capitol and the Court building, an acknowledgment of the enormous and somewhat nebulous task ahead: banning or restricting abortion in all 50 states. That task will involve not only Congress, the courts, and the president but also 50 individual state legislatures, thousands of lawmakers, and all of the American communities they represent.

    At the march, activists and other attendees will be jubilant. Speakers will congratulate their fellow marchers on a job well done. Yet at the same time, a current of uncertainty ripples beneath the surface of the anti-abortion movement. Advocates are technically closer than ever to ending abortion in America, but in some ways, the path forward is more treacherous now than it was before. The movement is not in disarray, exactly, but its energy is newly decentralized, diffused throughout the country.

    “There’s a much more choose-your-own-adventure feel” to the movement now, Mary Ziegler, a University of California, Davis School of Law professor who has written about abortion for The Atlantic, told me.

    Overturning Roe was only the first step. The next isn’t exactly obvious.

    Since the 1980s, rescinding the Supreme Court’s 1973 ruling in Roe, which established a nationwide right to abortion, had been the movement’s top goal, because it was the key that unlocked everything else. There could be no real prohibitions on abortion as long as Roe was in effect. Charging into battle was easier under a single banner, with resources and energy directed toward a single national project: filling the Supreme Court with abortion foes.

    Now, though, across all 50 states, different leaders are pressing for abortion restrictions of varying types and degrees: heartbeat bans, gestational limits, restrictions on the abortion pill, or outright bans with few or no exceptions.

    America’s anti-abortion movement has always been a rich tapestry. Although its members share an overarching goal—ending abortion—they have disagreed on tactics and approach. Some groups—including Susan B. Anthony Pro-Life America, Americans United for Life (AUL), and the National Right to Life Committee (NRLC)—have prioritized legal and political strategies; others, including many Catholic organizations, have advocated more for funding the country’s 2,700 pregnancy centers or expanding the social safety net. But there was always a power hierarchy among these groups. “If you were wondering where the bills came from, the lawsuits, it was obvious: A handful of national groups dictated everything,” Ziegler said. The NRLC and AUL organized the troops and drafted model legislation. They planned judicial strategy and pushed court cases forward.

    In the post-Roe world, those groups are less powerful and less relevant. The central players now are the thousands of state-level politicians, local leaders, and grassroots activists who are writing and passing legislation, often independent of those once-dominant national groups.

    From the May 2022 issue: The future of abortion in a post-Roe America

    The influence of the national groups has been waning since even before the fall of Roe. A Texas pastor and a former state solicitor general, for example, came up with Texas’s 2021 S.B. 8, which banned abortion once a fetal heartbeat was detectable (typically after six weeks) and authorized private citizens to sue abortion providers. The two men did so without much input from any national group, according to the experts I spoke with. Abortion restrictions in Alabama and Georgia, which passed in 2019 and went into effect in 2022, were drafted by different state activists and leaders and contain starkly different language, showing little influence from national groups.

    The national anti-abortion movement clearly wasn’t ready for this flurry of activity. But it could have been better prepared, Daniel K. Williams, a history professor at the University of West Georgia, told me. When Amy Coney Barrett was nominated to the Court, or even as soon as Trump was elected president, national organizations could have put forward a single model law for lawmakers, and uniform guidance for health-care providers and hospitals. Instead, America ended up with a chaotic patchwork of abortion restrictions—a mixture of newly written trigger laws and dusty legislation from the late 19th century. Some of these new policies are vague or fail to address health complications such as miscarriage and ectopic pregnancy. They propose varying consequences for abortion providers and different mechanisms for enforcement.

    In November, the AUL released its American Life Initiative and its model legislation, the Ready for Life Act, which bans abortion after conception and includes a life-of-the-mother exception, as well as clarifications regarding miscarriage and ectopic pregnancy. But it came five months after the Dobbs v. Jackson Women’s Health Organization decision overturning Roe. That groups were drafting these guidelines “months after Dobbs and not experiencing any uniformity in state legislatures is a sign of how decentralized and swift-moving all of this has been,” Williams said.

    Clarke Forsythe, the senior counsel for AUL, defends his organization’s strategy: “We needed time to analyze Dobbs and its impact and implications and needed time to put the package together,” he told me. “It’s a long-term initiative and a long-term vision. There was no need to get it out before the election.”

    Abortion opponents insist that a state-level free-for-all could turn out to be helpful for the movement. With more people involved and working toward different initiatives, the argument goes, activists might come up with innovative ideas and policy proposals. Democracy, by nature, is messy. “It’s good for the country and good for our politics to decentralize the issue,” Forsythe told me. “The Court sent it back to the local level, where public policy can be better aligned with public opinion, where the people responsible for it are responsive to people at the local level.” Decentralization is the movement’s strength, Lila Rose, the president of the national anti-abortion group Live Action, told me. “It requires a diverse and multifaceted approach. It’s not strategic conflict so much as strategic differences.”

    This particular moment gives anti-abortion activists a chance to think creatively and to forge new alliances, some in the movement argue. Now that Roe is gone, do they need to keep up their ties with the GOP? “I would like to see the movement disentangle itself from particular political parties,” Erika Bachiochi, an anti-abortion writer and a fellow at the Ethics and Public Policy Center, told me. Maybe, she added, there’s room for a return of the “old pro-life Democrat.”

    But an unintended consequence of overturning Roe could be that the movement has inadvertently pushed its highest objective—ending legal abortion—further out of reach. “On the one hand, when there’s a free-for-all, ideas that may never have been given the time of day can emerge and work,” Ziegler said. “On the other, you can have bills that are damaging nationally get passed.” Texas’s S.B. 8—the Texas Heartbeat Act—frustrated some movement leaders because it empowered individual citizens to sue, which meant that those individuals would control the narrative, Ziegler said. Others worry about the vocal “abortion abolition” groups, which have been calling for women who obtain abortions to be punished.

    These days, Ziegler says, “there’s no single voice in the movement to say, ‘No, that’s not what we stand for.’” A few extremists, in other words, could damage the movement’s reputation—and interfere with its ultimate goal.

    Before Dobbs, anti-abortion advocates seemed confident that once a handful of states banned abortion, many more would follow—that they could build a “culture of life” in America that would put the country on a righteous path. In some ways, the opposite has occurred. As a few states put limits on abortion rights, others, such as Vermont, California, and Michigan, have reacted by enshrining those rights into state law. Meanwhile, voters in red states including Kansas, Montana, and Kentucky rejected attempts to restrict abortion. Former President Donald Trump—the man whose nomination of three Supreme Court justices led directly to the overturning of Roe—has gone so far as to blame Republicans’ disappointing midterm performance on the anti-abortion movement. (In response, Rose called his comments “sniveling cowardice.”)

    Nationally, the movement’s relationship with the Republican Party is troubled. Last fall, when Senator Lindsey Graham proposed legislation restricting abortions after 15 weeks, only a handful of his Republican colleagues were publicly supportive. “Most of the members of my conference prefer that this be dealt with at the state level,” Minority Leader Mitch McConnell told reporters at the time.

    David Frum: Roe is the new prohibition

    Even in the new Congress, where Republicans have a House majority, one of the first pieces of legislation passed in the lower chamber was the so-called Born Alive bill, which would require health-care providers to treat babies in the vanishingly rare cases of failed abortions. Here was a chance for Republicans to pass a bill restricting abortion after 15 weeks or even six, in a show of support to the movement that they purport to champion. But they didn’t. Republicans in Congress are “afraid to do anything on this issue that’s meaningful” for fear of the political consequences, Ziegler says.

    Anti-abortion leaders like Rose believe that they’re being unfairly blamed for these recent Republican losses and missed opportunities. They argue that in the midterms the GOP chose candidates who were insufficiently anti-abortion, or simply problematic, such as Mehmet Oz and Herschel Walker. But there was also a communication issue, they say. Candidates weren’t outspoken enough about abortion; they should have talked more about the Democrats’ support for abortion at late gestational ages, and their plan to codify abortion rights into law. “That’s where the real problem was” in the midterms, Marilyn Musgrave, the vice president of government affairs for Susan B. Anthony Pro-Life America, told me. “Republicans weren’t pointing out the extremism on the other side.”

    It’s true that some Republicans campaigned successfully on abortion restrictions last year, including GOP Governors Ron DeSantis of Florida, Kay Ivey of Alabama, Brian Kemp of Georgia, and Greg Abbott of Texas, each of whom won reelection by a substantial margin. Still, the recent state referenda and post-Dobbs polling suggest that the anti-abortion movement is too optimistic about the level of support for their goals.

    “We’ve clearly lost the narrative,” Charlie Camosy, an ethics professor at Creighton University School of Medicine and a columnist for the Religion News Service, told me. Activists like Camosy hope that the movement’s new emphasis will be a grassroots effort to educate Americans and persuade them to oppose abortion. Camosy isn’t attending the March for Life tomorrow; instead, he’s giving a speech at a Catholic seminar in Freehold, New Jersey, where he lives. “Something is wrong in our ability to communicate what’s at stake,” he said of the broader movement. “Focusing on the national level distracts from getting Michigan or Montana or Kentucky or Kansas right.”

    But eventually, Camosy’s movement will have to face the reality of abortion in America: Some states just aren’t going to budge. “Fewer than 50 percent of states are likely to meaningfully curtail abortion,” Williams estimates. Even if the movement gains ground in some states, “that’s likely only to harden the resistance in more strongly pro-choice states.” Which means that, rather than a growing national consensus on abortion, Americans probably can expect more polarization—a cultural standoff.

    Tomorrow’s March for Life will be the first time activists have held a major national gathering since Roe was overturned in June. But it will probably be a much smaller event than before. Some activists have wondered whether it should happen at all. More states and cities will be hosting their own rallies, because that’s where the next round of work needs to be done. And many people will be at those local marches instead—to start, or maybe to double down, on their difficult project of creating a “culture of life.”

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    Elaine Godfrey

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  • How Many Republicans Died Because the GOP Turned Against Vaccines?

    How Many Republicans Died Because the GOP Turned Against Vaccines?

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    No country has a perfect COVID vaccination rate, even this far into the pandemic, but America’s record is particularly dismal. About a third of Americans—more than a hundred million people—have yet to get their initial shots. You can find anti-vaxxers in every corner of the country. But by far the single group of adults most likely to be unvaccinated is Republicans: 37 percent of Republicans are still unvaccinated or only partially vaccinated, compared with 9 percent of Democrats. Fourteen of the 15 states with the lowest vaccination rates voted for Donald Trump in 2020. (The other is Georgia.)

    We know that unvaccinated Americans are more likely to be Republican, that Republicans in positions of power led the movement against COVID vaccination, and that hundreds of thousands of unvaccinated Americans have died preventable deaths from the disease. The Republican Party is unquestionably complicit in the premature deaths of many of its own supporters, a phenomenon that may be without precedent in the history of both American democracy and virology.

    Obviously, nothing about being a Republican makes someone inherently anti-vaccine. Many Republicans—in fact, most of them—have gotten their first two shots. But the wildly disproportionate presence of Republicans among the unvaccinated reveals an ugly and counterintuitive aspect of the GOP campaign against vaccination: At every turn, top figures in the party have directly endangered their own constituents. Trump disparaged vaccines while president, even after orchestrating Operation Warp Speed. Other politicians, such as Texas Governor Greg Abbott, made all COVID-vaccine mandates illegal in their state. More recently, Florida Governor Ron DeSantis called for a grand jury to investigate the safety of COVID vaccines. The right-wing media have leaned even harder into vaccine skepticism. On his prime-time Fox News show, Tucker Carlson has regularly questioned the safety of vaccines, inviting guests who have called for the shots to be “withdrawn from the market.”

    Breaking down the cost of vaccine hesitancy would be simple if we could draw a causal relationship between Republican leaders’ anti-vaccine messaging and the adoption of those ideas by Americans, and then from those ideas to deaths due to non-vaccination. Unfortunately, we don’t have the data to do so. Individual vaccine skepticism cannot be traced back to a single source, and even if it could, we don’t know exactly who is unvaccinated and what their political affiliations are.

    What we do have is a patchwork of estimations and correlations that, taken together, paint a blurry but nevertheless grim picture of how Republican leaders spread the vaccine hesitancy that has killed so many people. We know that as of April 2022, about 318,000 people had died from COVID because they were unvaccinated, according to research from Brown University. And the close association between Republican vaccine hesitancy and higher death rates has been documented. One study estimated that by the fall of 2021, vaccine uptake accounted for 10 percent of the total difference between Republican and Democratic deaths. But that estimate has changed—and even likely grown—over time.

    Partisanship affected outcomes in the pandemic even before we had vaccines. A recent study found that from October 2020 to February 2021, the death rate in Republican-leaning counties was up to three times higher than that of Democratic-leaning counties, likely because of differences in masking and social distancing. Even when vaccines came around, these differences continued, Mauricio Santillana, an epidemiology expert at Northeastern University and a co-author of the study, told me. Follow-up research published in Lancet Regional Health Americas in October looked at deaths from April 2021 to March 2022 and found a 26 percent higher death rate in areas where voters leaned Republican. “There are subsequent and very serious [partisan] patterns with the Delta and Omicron waves, some of which can be explained by vaccination,” Bill Hanage, a co-author of the paper and an epidemiologist at Harvard, told me in an email.

    But to understand why Republicans have died at higher rates, you can’t look at vaccine status alone. Congressional districts controlled by a trifecta of Republican leaders—state governor, Senate, and House—had an 11 percent higher death rate, according to the Lancet study. A likely explanation, the authors write, could be that in the post-vaccine era, those leaders chose policies and conveyed public-health messages that made their constituents more likely to die. Although we still can’t say these decisions led to higher death rates, the association alone is jarring.

    One of the most compelling studies comes from researchers at Yale, who published their findings as a working paper in November. They link political party and excess-death rate—the percent increase in deaths above pre-COVID levels—among those registered as either Democrats or Republicans, providing a more granular view. They chose to analyze data from Florida and Ohio from before and after vaccines were available. Looking at the period before the vaccine,  researchers found a 1.6 percentage-point difference in excess death rate among Republicans and Democrats, with a higher rate among Republicans. But after vaccines became available, that gap widened dramatically to 10.4 percentage points, again with a higher Republican excess death rate. “When we compare individuals who are of the same age, who live in the same county in the same month of the pandemic, there are differences correlated with your political-party affiliation that emerge after vaccines are available,” Jacob Wallace, an assistant professor of public health at Yale who co-authored the paper, told me. “That’s a statement we can confidently make based on the study and we couldn’t before.”

    Even with this new research, it is difficult to determine just how many people died as a result of their political views. In the “excess death” study, researchers dealt only with rates of excess death, not actual death-toll numbers. Overall, excess deaths represent a small share of deaths. “On the scale of national registration for both parties,” Wallace said, “we’re talking about relatively small numbers and differences in deaths” when you look at excess death rates alone.

    The absolute number of Republican deaths is less important than the fact that they happened needlessly. Vaccines could have saved lives. And yet, the party that describes itself as pro-life campaigned against them. Democrats are not without fault, though. The Biden administration’s COVID blunders are no doubt to blame for some of the nation’s deaths. But on the whole, Democratic leaders have mostly not promoted ideas or enforced policies around COVID that actively chip away at life expectancy. It is a tragedy that the Republican push against basic lifesaving science has cut lives short and continues to do so. The partisan divide in COVID deaths, Hanage said, is just “another example of how the partisan politics of the U.S. has poisoned the well of public health.”

    What’s most concerning about all of this is that partisan disparities in death rates were also apparent before COVID. People living in Republican jurisdictions have been at a health disadvantage for more than 20 years. From 2001 to 2019, the death rate in Democratic counties decreased by 22 percent, according to a recent study; in Republican counties, it declined by only 11 percent. In the same time period, the political gap in death rates increased sixfold.

    Health outcomes have been diverging at the state level since the ’90s, Steven Woolf, an epidemiologist at Virginia Commonwealth University, told me. Woolf’s work suggests that over the decades, state policy decisions on health issues such as Medicaid, gun legislation, tobacco taxes, and, indeed, vaccines have likely had a stronger impact on state health trajectories than other factors. COVID’s high Republican death rates are not an isolated phenomenon but a continuation of this trend. As Republican-led states pushed back on lockdowns, the impact on population death rates was observed within weeks, Woolf said.

    If the issue is indeed systemic, that doesn’t bode well for the future. Other factors could explain the higher death rate in Republican-leaning places—more poverty, less education, worse socioeconomic conditions—, though Woolf said isn’t convinced that those factors aren’t related to bad state health policy too. In any case, the long-term decline of health in red states indicates that there is an ongoing problem at a high level in Republican-led places, and that something has gone awry. “If you happen to live in certain states, your chances for living a long life are going to be much higher than if you’re an American living in a different state,” Woolf said.

    Unfortunately, this trend shows no signs of breaking. The anti-science messaging that fuels such a divide is popular with Republican leaders because it plays so well with their constituents. Far-right crowds cheer for missed vaccine targets and jokes about executing scientific leaders. In an environment where partisanship trumps all—including trying to save people’s lives—such messaging is both politically effective and morally abhorrent. The data, however imperfect, demand a reckoning with the consequences of such a strategy not only during the pandemic but over the past few decades, and in the years to come. But to acknowledge how many Republicans didn’t have to die would mean giving credence to scientific and medical expertise. So long as America remains locked in a poisonous partisan battle in which science is wrongly dismissed as being associated with the left, the death toll will only rise.

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    Yasmin Tayag

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  • What the Student-Loan Debate Overlooks

    What the Student-Loan Debate Overlooks

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    A core conservative critique of President Joe Biden’s executive action on student-debt forgiveness is that the plan requires blue-collar Americans to subsidize privileged children idly contemplating gender studies or critical race theory at fancy private colleges.

    That idea, articulated by Senators Ted Cruz and Marco Rubio, among others, aims to portray the GOP as the party of working Americans and Democrats as the champions of the smug, well-educated elite. But it fundamentally misrepresents who’s attending college now, where they are enrolled, and the reasons so many young people are graduating with unsustainable debt.

    Read: A Democratic economist’s case against Biden’s student-loan plan

    Many factors have contributed to the explosion in student debt, but one dynamic is almost always overlooked: the erosion of the commitment to affordable public higher education as an engine for upward mobility that benefits the entire community.

    Contrary to the stereotype conjured by critics, the number of debtors from public colleges today (about 22 million) exceeds the number from private and for-profit colleges combined (about 21 million), according to federal data. One reason so many of those students from public schools are in debt is that they have graduated in an era when states have shifted more of the burden for funding higher education from taxpayers to students—precisely as more of those students are minorities reared in families on the short side of the nation’s enormous racial wealth gap.

    Biden’s plan, despite its imperfections, recognizes that this massive cost shift is crushing too many young people as they enter adulthood. It is also a belated reaffirmation that society benefits from helping more young people obtain degrees that will allow them to reach the middle class.

    Public colleges and universities are the principal arena in which the debt and affordability crisis will be won or lost because—again, contrary to popular perception—the majority of postsecondary students (about four in five) attend public, not private, institutions.

    When Baby Boomers were in college, few seemed to question whether society benefited from helping more young people earn their diploma at an affordable price. States provided public colleges enough taxpayer dollars to keep tuition to a minimum. In the 1963–64 academic year, around the time the first Boomers stepped onto campuses, the average annual tuition for four-year public colleges was $243, according to federal statistics. Tuition at those public schools was still only about $500 to $600 a year by the time most of the last Baby Boomers had started college, in the mid-1970s. (Adjusting for inflation, prices grew at a modest rate while Boomers matriculated, rising only from about $2,100 in constant 2021 dollars when the first ones started to about $2,600 when the last ones did.) The renowned University of California and City University of New York systems didn’t even charge any tuition until the mid-’70s.

    Read: What it takes to get into New York City’s best public colleges

    Dowell Myers, a demographer at the University of Southern California, told me that the generous mid-century funding for public higher education drew on the legacy of the GI Bill after World War II and the post-Sputnik investments in education and research, each of which had broad political support. “The attitude was ‘We should invest in young people,’” he said. “It was just an ethic.” Also important, he noted: “The young people they were thinking about were young white kids primarily.”

    But for racially diverse Millennials and Generation Z students, the experience has been quite different. By 1999, the year the first Millennials entered campuses, the average annual cost for a four-year public college or university, measured in inflation-adjusted dollars, had doubled since the mid-’70s to more than $5,200. By the time the last Millennials (generally defined as those born between 1981 and 1996) entered college in the 2014 academic year, the cost had soared by another 80 percent to roughly $9,500 a year. So far, the average annual tuition cost has stayed at about that elevated level as the first members of Generation Z (born between 1997 and 2014) have started their studies.

    As these numbers show, tuition at four-year public universities increased more than three times as fast while Millennials attended than it did over the span when most Baby Boomers did. The failure of colleges to control their costs explains part of this disparity. But it’s also a political decision at the state level. “The trend of having students and their families pay more for their college today is absolutely linked to the state disinvestment in higher education,” Michele Siqueiros, the president of the California-based Campaign for College Opportunity, told me.

    Public colleges and universities relied on tuition and fees for only about one-fifth of their total educational revenue in 1980, the first year for which these figures are available, with state tax dollars providing most of the rest. Today the share funded by tuition has more than doubled, according to analysis by the State Higher Education Executive Officers Association. Even that figure is somewhat misleading, because it includes community colleges, which don’t rely as much on tuition. In four-year public colleges and universities, tuition now provides a 52 percent majority of all educational revenues nationwide. Even with some recent increases in state contributions, 31 states now rely on tuition for a majority of four-year public-college revenues, the executives’ association found.

    Even as those costs have increased, Pell Grants, the principal form of federal aid for low-income students, have failed to keep pace. In 2000, Pell Grants covered 99 percent of the average costs of in-state tuition and fees at public colleges, according to research by the College Board. Today, the grants fund only 60 percent of those costs—and only half that much of the total bill when room and board are added on.

    This historic shift in funding has occurred as college campuses have grown more racially diverse. As recently as the late 1990s, white kids still constituted 70 percent of all high-school graduates, according to the federal National Center for Education Statistics. But NCES estimates that students of color became a majority of high-school graduates for the first time in the school year that ended this June. Their share of future graduates will rise to nearly three-fifths by the end of this decade, the NCES forecasts. That stream of future high-school grads will further diversify the overall student body in postsecondary institutions—especially in public colleges and universities, where kids of color already constitute a slight majority of those attending, according to figures provided to me by the Georgetown University Center on Education and the Workforce. (Most private-college students, especially on the campuses considered most elite, are still white.)

    The inevitable result of less taxpayer help has been more debt for public-school graduates. Even in the ’90s, only about one-third of public-college graduates finished with debt, federal figures show. But today a daunting 55 percent of public-college graduates leave with debt, not much less than the share of students who finish with debt at private schools (somewhere around 60 percent, depending on the data source). What’s more, the average undergraduate debt held by students from public colleges isn’t much less than that held by those who attended private campuses. In effect, as USC’s Myers noted, because states generally are prohibited from borrowing to fund higher education (or anything else) by their constitutions, “they pushed the borrowing onto the individual families.”

    This shift has hurt families of all types, but it’s been especially difficult for the growing number of Black and Latino postsecondary students. Those families have far less wealth than white families to draw on to fund college. That increases pressure on kids of color to borrow—and to support other family members after they graduate, reducing their capacity to pay down their debts. To compound the problem, as the Georgetown Center has repeatedly documented, Black and Latino students are heavily tracked into the least selective two- and four-year public colleges, which have the smallest budgets and produce the weakest outcomes, both in terms of graduation rates and future earnings. White kids, the center calculates, still constitute three-fifths of the total student body at the better-funded, more exclusive “flagship” public universities, with Black and Latino students together representing only one-fifth. “The money is going to where the affluent and preponderantly white students are, and the money is not going to where the minority and less advantaged students are, which exacerbates the dropout crisis,” Anthony Carnevale, the center’s director, told me.

    The Republican attacks on Biden’s loan-forgiveness plan are aimed at convincing the GOP base of older white voters, especially those without a college education, that diverse younger Americans constitute a threat to them. Yet compared with the taxpayer investments in the first decades after World War II (in everything from education to housing to roads) that helped so many of those Baby Boomers live better lives than their parents, Biden’s plan represents only a modest effort. Older generations of college students didn’t have as much debt not because they were more individually virtuous but because they benefited from a collective social investment in their education. Many of those arguing against debt forgiveness, Siqueiros told me, seem to be conveniently forgetting all of the ways the government provided “benefits to Baby Boomers.”

    The irony is that it’s in Boomers’ self-interest to reduce the debt burden on younger students. As they age into retirement, Boomers are relying on younger generations to bear the payroll taxes that sustain Social Security and Medicare. I’ve called these two giant cohorts the brown and the gray, and though our politics doesn’t often acknowledge it, there is no financial security for the gray without more economic opportunity for the brown.

    Derek Thomson: Why the old elite spends so much time at work

    The debt-forgiveness program, which White House officials pointedly insisted to me was a “onetime” deal, is only the first of many steps needed to equip those younger generations to succeed. The college-debt crisis will simply repeat itself if Washington and the states don’t pursue other policies to undo the burden shift toward students—such as the free-community-college program, more generous Pell Grants, and crackdown on predatory for-profit colleges that Biden has proposed.

    It’s reasonable to question whether Biden’s debt plan could have been targeted more precisely or tweaked in myriad different ways. But the plan got one very big thing right: All Americans will benefit if our society provides today’s diverse younger generations with anything approaching the investments we made in the Baby Boomers more than half a century ago.

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    Ronald Brownstein

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  • Lowering the Cost of Insulin Could Be Deadly

    Lowering the Cost of Insulin Could Be Deadly

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    When I heard that my patient was back in the ICU, my heart sank. But I wasn’t surprised. Her paycheck usually runs short at the end of the month, so her insulin does too. As she stretches her supply, her blood sugar climbs. Soon the insatiable thirst and constant urination follow. And once her keto acids build up, her stomach pains and vomiting start. She always manages to make it to the hospital before the damage reaches her brain and heart. But we both worry that someday, she won’t.

    The Inflation Reduction Act, passed last month, aims to help people like her by lowering the cost of insulin across America. Although efforts to expand protections to privately insured Americans were blocked in the Senate, Democrats succeeded in capping expenses for the drug among Americans on Medicare at $35 a month, offering meaningful savings for our seniors, some of whom will save hundreds of dollars a month thanks to the measure. In theory, the policy (and similar ones at the state level) will help the estimated 25 percent of Americans on insulin who have been forced to ration the drug because of cost, and will prevent some of the 600 annual American deaths from diabetic ketoacidosis, the fate from which I’m trying to save my patient.

    Indeed, laws capping co-payments for insulin are welcome news both financially and medically to patients who depend on the drug for survival. However, in their current version, such laws might backfire, leading to even more diabetes-related deaths overall.

    How could that be true? Thanks to the development of new drugs, insulin’s role in diabetes treatment has been declining over the past decade. It remains essential to the small percent of patients with type 1 diabetes, including my patient. But for the 90 percent of Americans with diabetes who have type 2, it should not routinely be the first-, second-, or even third-line treatment. The reasons for this are many: Of all diabetes medications, insulin carries the highest risk of causing dangerously low blood sugar. The medication most commonly comes in injectable form, so administering it usually means painful needle jabs. All of this effort is rewarded with (usually unwanted) weight gain. Foremost and finally, although insulin is excellent at tamping down high blood sugar—the hallmark of diabetes and the driver of some of its complications—it is not as impressive as other medications at mitigating the most deadly and debilitating consequences of the disease: heart attacks, kidney disease, and heart failure.

    Read: People are clamoring to buy old insulin pumps

    Large clinical trials have shown that two newer classes of diabetes medicines, SGLT2 inhibitors and GLP-1 receptor agonists, outperform alternatives (including insulin) in reducing the risk of these disabling or deadly outcomes. Giving patients these drugs instead of older options over a period of three years prevents, on average, one death for about every 100 treated. And SGLT2 inhibitors and GLP-1 receptor agonists pose less risk of causing dangerously low blood sugar, generally do not require frequent injections, and help patients lose weight. Based on these data, the American Diabetes Association now recommends SGLT2 inhibitors and GLP-1 receptor agonists be used before insulin for most patients with type 2 diabetes.

    When a young person dies from diabetic ketoacidosis because they rationed insulin, the culprit is clear. But when a patient with diabetes dies of a heart attack, the absence of an SGLT2 inhibitor or GLP-1 receptor agonist doesn’t get blamed, because other explanations abound: their uncontrolled blood pressure, the cholesterol medication they didn’t take, the cigarettes they continued to smoke, bad genes, bad luck. But every year, more than 1,000 times more Americans die of heart disease than DKA, and of those 700,000 deaths, a good chunk are diabetes-related. (The exact number remains murky.) Diabetes is a major reason that more than half a million Americans depend on dialysis to manage their end-stage kidney disease, and that about 6 million live with congestive heart failure. The data are clear—SGLT2 inhibitors and GLP-1 receptor agonists could help reduce these numbers.

    Still, uptake of these lifesaving drugs is sluggish. Only about one in 10 people with type 2 diabetes is taking them (fewer still among patients who are not wealthy or white). The main cause is simple and stupid: American laws prioritize profits and patents over patients. Because SGLT2 inhibitors and GLP-1 receptor agonists remain under patent protections, drug companies can charge exorbitant rates for them: hundreds if not thousands of dollars a month, sometimes even more than insulin. Doctors spend hours completing arduous paperwork in the hopes of persuading insurers to help our patients, but we’re frequently denied anyway. And even when we do succeed, many patients are left with painful co-payments and deductibles. The most maddening part is that despite their substantial up-front expense, these medications are quite cost-effective in the long run because they prevent pricey complications down the road.

    Read: The risks of over-the-counter diabetes treatments

    This is where addressing the cost of insulin—and only insulin—becomes problematic. Doctors are forced daily to decide between the best medication for our patients and the medication that our patients can afford. Katie Shaw, a primary-care physician with a bustling practice at Johns Hopkins, where I’m a senior resident, told me that plenty of her patients can’t afford SGLT2 inhibitors and GLP-1 receptor agonists. In such instances, Shaw is forced to use older oral alternatives and occasionally insulin. “They’re better than nothing at all,” she said.

    If the cost of insulin is capped on its own, insulin will be more likely to jump in front of SGLT2 inhibitors and GLP-1 receptor agonists in treatment plans. That will mean more disease, more disability, and more death from diabetes.

    Medicare patients might avoid some of these effects thanks to provisions in the IRA allowing Medicare to negotiate drug prices and capping out-of-pocket spending on prescriptions at $2,000 a year. The law also guarantees price negotiations for a handful of medications, but SGLT2 inhibitors and GLP-1 receptor agonists won’t necessarily be on the list. And most Americans are not on Medicare. Already, Shaw said, the patients in her practice who tend to be least able to afford SGLT2 inhibitors and GLP-1 receptor agonists are working-class people with private insurance. Some health centers, including the one Shaw and I work at, enjoy access to a federal drug-discount program that can make patent-protected medications, including SGLT2 inhibitors and GLP-1 receptor agonists, more affordable for the uninsured. But most Americans without insurance aren’t so lucky.

    It would be cruel to choose between a world in which more people with type 2 diabetes are nudged toward a drug that won’t stave off the most dangerous complications, and one in which those with type 1 diabetes are priced out of life. In place of capping the out-of-pocket cost of just insulin, lawmakers should cap the out-of-pocket cost of all diabetes medications. This will both protect Americans dependent on insulin and smooth SGLT2 inhibitors’ and GLP-1 receptor agonists’ path to their revolutionary public-health potential.

    Read: Big Pharma’s go-to defense of soaring drug prices doesn’t add up

    The argument for lowering the cost of these drugs for patients is the same as the argument for insulin affordability: that it is both foolish and inhumane to make lifesaving diabetes medications unaffordable when their use prevents costly and deadly downstream complications.

    Patients like mine need affordable access to insulin. But even more need access to SGLT2 inhibitors and GLP-1 receptor agonists. If the laws stop at insulin, many Americans could die unnecessarily—not from inadequate access to insulin, but from preferential access to it.

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    Michael Rose

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  • Abortion Could Define California’s Elections

    Abortion Could Define California’s Elections

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    CERRITOS, Calif.—Abortion rights dominated the message when the Democratic congressional candidate Jay Chen sent off a small group who had gathered to canvass for him here early on Sunday morning.

    “A right that we had all assumed we would have, the right of a woman to have control of her own health-care decisions, was taken away after 50 years,” Chen told the volunteers. He reminded them that his opponent, Republican Representative Michelle Steel, had co-sponsored “a federal ban on abortion” that would prohibit the procedure even in deep-blue California.

    “You name it, she’s on the extreme end of all these issues,” Chen said. “She’d be a complete outlier even in deep-red Kansas because even in Kansas they protected the right to an abortion. So for her to try to represent [this district] does not make any sense.”

    Chen’s exhortation captured the outsize role abortion rights could play across this year’s unusually large field of competitive U.S. House races in California, after the Republican-appointed Supreme Court majority overturned Roe v. Wade earlier this summer. The Golden State offers Democrats the nation’s single largest concentration of opportunities to offset losses elsewhere by flipping House seats now held by Republicans. And the abortion-rights issue offers Democrats their best chance to do so—particularly with a state constitutional amendment protecting access to the procedure also on the November ballot as Proposition 1.

    “Because we have this on the ballot, Republicans cannot run away from this issue,” says Dave Jacobson, a Democratic consultant who is advising Christy Smith, the party’s nominee against Republican Representative Mike Garcia in another Los Angeles–area district. “Every Republican in a competitive district is vulnerable with this issue at the top of the ballot as a constitutional amendment. I think it is going to drive turnout.”

    Read: The Kansas abortion shocker

    California will provide a crucial measure of how broadly the abortion issue may benefit Democrats this year. On both sides, there’s agreement that abortion’s increased prominence will strengthen Democrats in districts with a large number of white-collar voters—including the coastal seats south of Los Angeles now held by Democratic Representatives Katie Porter and Mike Levin. Less clear is whether the issue will prove as powerful in districts, such as those held by Republican Representatives Garcia and David Valadao, with larger numbers of blue-collar and Latino voters who may be acutely feeling the effects of inflation. The district in which Chen is challenging Steel demographically falls somewhere in between.

    “Presumably you’ll see coastal Republicans split with the party on things like choice,” predicts Darry Sragow, a veteran Democratic strategist and the publisher of the nonpartisan California Target Book, which analyzes state elections. “On the other hand, when you are looking at some inland and Central Valley districts, they are very different,” he told me. Although “there’s all this chatter that abortion is so important,” Sragow added, “I suggest most Americans do not wake up with abortion the thing they are most worried about,” particularly in working-class communities.

    Though solidly Democratic at the state level—Democratic Governor Gavin Newsom is cruising to reelection this year without serious Republican opposition after defeating a GOP-backed recall effort—congressional contests in California have proved highly susceptible to swings in the national mood. As part of the “blue wave” in 2018, the party flipped seven Republican-held seats, reducing the GOP to its smallest share of California’s congressional delegation since the 1880s. But in 2020, Republicans recaptured four of those districts—a key part of their unusual success at gaining House seats nationwide while losing the White House.

    Earlier this year, when inflation was raging and the Democratic legislative agenda seemed stalled, Republicans were optimistic about advancing farther across California by potentially ousting Democratic Representatives Josh Harder in the Central Valley and Porter and Levin in Orange and San Diego Counties. Although Democrats acknowledge that those races (and another Democratic-held open seat) remain competitive, they now see the opportunity to go on the offensive against Steel, Valadao, and Garcia, as well as potentially Representatives Ken Calvert and Young Kim in Southern California; they also see an opportunity to contest a Republican open seat in the Sacramento area.

    Several other issues have also contributed to this reversal of fortune: increased attention to gun violence after the Uvalde, Texas, school shooting; renewed focus on Donald Trump amid the revelations from the House January 6 committee and the firestorm over his mishandling of classified documents; and climate change after the passage of the Democrats’ slimmed-down reconciliation bill. But analysts in both parties see the Supreme Court decision reversing Roe as the pivotal factor shifting the congressional landscape across California. “We are just seeing an unprecedented level of outrage,” Representative Levin told me in an interview.

    As in other states, Republicans continue to express cautious optimism that frustration over inflation and disenchantment with the performance of President Joe Biden will outweigh views on abortion. “Of course [abortion] is going to be an issue, way more than it was in May of this year,” Lance Trover, a Republican consultant advising Representative Steel, who ousted a Democratic incumbent in 2020, told me. “But at the end of the day, the fundamentals of the economy are going to be key.”

    California Republicans face an unusually powerful headwind in moving beyond the abortion issue. Almost all Republicans holding or seeking congressional seats have staked out hard-line anti-abortion positions that directly collide with polls showing deep and broad support for abortion rights across the state.

    Polling in July by the nonpartisan Public Policy Institute of California found that more than two-thirds of state residents opposed the Supreme Court decision overturning Roe. That included about three-fourths of African Americans and Asian Americans, seven in 10 white voters, and just over three-fifths of Latino voters. About three-fourths of independents, whom Republicans need to compete in California, because they are so outnumbered by registered Democrats, opposed the ruling. Opposition to the decision was greatest in the big blue metropolitan areas of Los Angeles and San Francisco, but even in areas where Republicans have traditionally performed somewhat better, such as Orange and San Diego Counties and the Central Valley, preponderant majorities opposed the decision.

    In another survey released last week by UC Berkeley’s Institute of Governmental Studies and the Los Angeles Times, more than seven in 10 California voters said they intended to support the constitutional amendment inscribing abortion rights into the state constitution.

    “From a public-opinion perspective, it’s a settled issue in California,” Mark Baldassare, the PPIC president, told me. “We have seen what we would describe as overwhelming support for abortion rights in California consistently in our polls over many, many years … That’s pretty consistent across demographic groups and regions of the state.”

    The state’s Republican congressional delegation—as well as the party’s challengers in the key races—have placed themselves firmly on the opposite side of that consensus. Four of the House Republicans facing the potentially toughest contests—Steel, Garcia, Valadao, and Calvert—signed a legal brief urging the Supreme Court to overturn Roe. All of them but Calvert have co-sponsored the Life at Conception Act, a Republican bill that would define the unborn as a person under the Constitution from “the moment of fertilization” and effectively ban abortion nationwide, legal scholars say. Representative Kim, another Republican facing a potentially competitive race in an Orange County district, did not co-sponsor that bill, but has described herself as a “proud pro-life woman” who believes “the rights of the child must be respected.” The GOP challengers to Harder, Levin, and Porter have also publicly declared their opposition to legal abortion.

    As signs have grown of the backlash to the Supreme Court decision—including the Democratic victory in a New York congressional special election and the resounding defeat of a Kansas ballot initiative that would have opened the door to state abortion restrictions—several of the California Republicans have tried to obscure their positions. For instance, although the Life at Conception Act offers no exceptions and Steel earlier this year said she supported legal abortion only when the mother’s health was endangered, she told me in a statement, “I am pro-life with exceptions for rape, incest, and the health and life of the mother, and baby.” In a statement to the Los Angeles Times this week, Representative Garcia backed the same exceptions—which, again, are not included in the “life begins at conception” bill he is co-sponsoring.

    In her statement, Steel downplayed the possibility that a Republican-controlled Congress would seek to ban abortion nationwide, though notably without disavowing the idea: “Discussions surrounding a nationwide ban on abortion are purely hypothetical at this point,” she declared.

    But such vague dismissals may not dispel the vulnerability California Republicans face over the possibility of a national ban on abortion, particularly amid the parallel debate over amending the state constitution.

    Though neither supporters nor opponents of the constitutional amendment have yet raised much money, Newsom, who is emerging as a national leader for Democrats on cultural issues, is expected to campaign heavily for it and raise its visibility this fall. “I don’t want to give away our plans … but I would expect him to play a very prominent role,” Sean Clegg, a senior strategist for Newsom, told me. Abortion rights and the constitutional amendment to protect them, he added, are “going to have an effect in every single race in California.”

    Conor Friedersdorf: Gavin Newsom, the Ron DeSantis of the left

    The proposed amendment on the ballot in November represents the third level of protection for abortion rights in California. In earlier rulings, the state supreme court has already decided that the procedure is protected under the state constitution’s guarantees of liberty and privacy. This amendment, placed on the ballot by Newsom and the state’s Democratic-controlled legislature, adds an explicit guarantee that “the state shall not deny or interfere with an individual’s reproductive freedom … which includes their fundamental right to choose to have an abortion and their fundamental right to choose or refuse contraceptives.”

    Yet even all those reinforcing levels of protection for abortion rights in the California constitution would be preempted if Congress approved a national ban, legal analysts agree. The Life at Conception Act would surely face legal challenges if a future Republican-controlled Congress passes it, but should the law be upheld, it would override any California action to guarantee abortion rights, according to Cary Franklin, a constitutional-law professor at UCLA and the faculty director of its Center on Reproductive Health, Law, and Policy. “If Congress were to pass a national ban on abortion, that would trump state law, even state constitutional law,” she told me.

    That’s a message Democrats are likely to pound across the state in the campaign’s final months. “If Steel has her way, she will pass a federal ban on abortion, which will override our protections here, and I think Californians are coming to realize that,” Chen, a Naval reservist and the owner of a business that manages commercial properties, told me. By contrast, Chen, like the other Democratic incumbents and challengers, supports legislation restoring a national right to abortion.

    Opponents of the state constitutional amendment, such as Steel, say it would authorize abortions at any point in pregnancy, ending current state restrictions after a fetus is viable outside the womb (unless the mother’s life is endangered). Its sponsors deny that interpretation, but it will likely become the centerpiece of the campaign against the amendment. “Pro-life people may have had enough,” Susan Swift Arnall, the vice president of legal affairs at California’s Right to Life League, told me. “They may say, ‘This is too far. This is too extreme … And we want to send a message back to the legislature that we don’t support abortion on demand for all nine months and even into the birth of the baby.’”

    But the greater likelihood is that the amendment mobilizes turnout among the decisive majority in the state who support abortion rights. “There’s no question the [Supreme Court] decision has really created a great deal of increased interest from women voters for sure, and not just Democrats,” Levin said. “We are talking about independents, even some Republicans. Those who historically haven’t voted in midterm elections, I think, are motivated.”

    By solidifying Democrats in suburbia, abortion rights’ growing visibility, like the increased focus on gun violence and renewed attention to Trump, may narrow the range of House districts the GOP can realistically contest both in California and nationwide, and lower the ceiling on their potential gains. But not enough voters may prioritize abortion to neutralize Republicans’ other advantages in economically strained areas. Like so much else in modern American politics, the Supreme Court decision overturning Roe seems likely to further widen the chasm between white-collar and culturally cosmopolitan metropolitan areas trending toward the Democrats and blue-collar, socially conservative smaller places hardening in their support for the GOP, even in staunchly Democratic California.

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    Ronald Brownstein

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