To echo the Washington Post columnist David Ignatious, America is a nation both glowing and showing unmistakable signs of decline. “Our social cohesion has unravelled so much,” he writes, that “we often feel like two nations rather than one.” Trump and his administration presented one of those nations to the world using the commemoration as a vehicle for divisive propaganda and political gain.

The contrast with the celebrations for the bicentennial back in 1976 is stark. America was emerging from the traumas of the Vietnam war and Watergate; the economy, foreign policy and race were all cause for concern. Yet there was also a sense — as Gerald Ford said when he became president in August 1974 following Richard Nixon’s resignation — that America’s “long national nightmare is over” and the guardrails of democracy had held. People remember the feelings of patriotism and nostalgia those celebrations inspired.

Looming over this year’s celebrations are the midterm elections and the very real possibility of the Republicans losing the House and even the Senate. Either scenario would bring most of Trump’s autocratic and corrupt behaviour to an end — a fact that he and Republicans fully recognise.

House speaker Mike Johnson summed up their fears: “If we were to lose the midterms, heaven forbid, these Democrats, y’all, impeachment’s not even the big concern. They will turn every committee of Congress into an investigative body, and they’ll go after the president’s family, the cabinet, his donors and friends, half of you in this room will be targeted.”

But while Republicans facing voters in November are justifiably worried about their prospects, Trump seems to have little interest in helping them out, either on policy or electoral finances. Voters are most concerned about the cost of living, especially the impact of the Iran war on gas prices and the soaring costs of health insurance, healthcare and housing. Yet Trump has endlessly mocked mounting concerns about affordability, calling it a “hoax” perpetrated by Democrats, and has downplayed Republicans’ efforts to tackle cost-of-living pressures by refusing to sign a bipartisan housing bill.

“I don’t think about Americans’ financial situation,” he said in May. “I don’t think about anybody.” He was referring to the attention he was giving to negotiating an end to the unpopular war with Iran (still pending) but the remark went down like a lead balloon.

At the same time, with campaigning starting in earnest, Trump is sitting on some US$350 million in campaign funds lodged in his MAGA Inc. super PAC. Perhaps to hold close the funds he personally controls, perhaps to boost his standing in the polls, he has proposed a midterm election convention — a “Trumpapalooza” — to be held in September in Texas (a red state where, unusually, a key Senate race is virtually a dead heat). The Republican National Committee has proposed that state parties use the convention to raise funds for their local candidates.

Trump’s playbook for the midterms encompasses two broad approaches. The first involves undermining the upcoming elections and overturning voting rights. These include having Republican states gerrymander electoral boundaries at the expense of Democrats; illegally attempting to charge the US Postal Service with determining who can vote by mail and refusing to deliver ballots sent by anyone not included on federal mail voter lists; and demanding via the Department of Justice that states turn over sensitive voter information.

Trump is increasingly obsessed with having the SAVE America Act passed. This bill requires citizenship proof to vote, strict ID requirements for in-person and mail voting, and complete voter rolls to be submitted to the Trump administration by the states. He thinks this would eliminate noncitizen and fraudulent voting (extreme rarities); it would certainly make it harder for many disadvantaged Americans to vote.

The SAVE America Act doesn’t have the needed sixty votes in the Senate to overcome a filibuster, and Republican leaders are reluctant to get rid of the filibuster to pass the bill, as Trump has suggested. In a speech given at Mt Rushmore as part of the 4 July celebrations, he stated bluntly why he thinks this is so important: “If we terminate the filibuster as we should do and immediately vote for the SAVE America Act, then we will not lose an election for a hundred years.”

Trump’s second strategy for the midterms is a resort to the hoariest of right-wing tropes, with accusations that Democrats and immigrants are communists. This was a recurrent theme in his 4 July speeches — indeed, Reuters reports he warned about communism eighty-one times in the two weeks between 23 June (when a string of left-wing Democratic candidates won primary contests in New York) and 8 July.

“There is now a resurgence of the communist menace in our land,” he said at Mt Rushmore, “including from newcomers to our country who embrace ideas totally opposed to our way of life and our great success. You can be a communist, or you can be a patriot. You cannot be both.” Elsewhere, he described the Democratic Socialists, who have been surprisingly successful in recent primaries, as “animals.” He went on: “We have to stop this… horrible threat of cancer that’s permeating our country called communism.”

Here, Trump is attempting to revive the “red baiting” of the McCarthy era, which he learned about from his mentor, the sinister lawyer Roy Cohn. Trump sees the communist threat as an easy sell.  “All we have to do is define our opponent as being a communist or a socialist or somebody who is going to destroy our country,” he said last week.

For Democrats, the upcoming midterm elections are about just one goal — taking back the legislative branch of government. To do this they will need to convince voters, Democrats and Independents alike, that they can deliver on the issues that matter. Part of this involves dealing with young voters’ concern that the current, ageing generation of lawmakers is unable or unwilling to mount strong and consistent opposition to Trump.

Many younger and swing voters are looking for what can be called progressive populism — Medicare for All, taxing the rich, help with educational fees and childcare, and more social housing. So it’s not surprising that candidates who identify as Democratic Socialists have been successful in recent primaries. This success can be read as a rebuke to elected officials and a shift by Democratic voters to the left, but there is also clear evidence that a range of Democratic voices are choosing the candidates most likely to win in their districts.

It’s important to note that Democratic Socialist candidates — often with endorsements from elected officials including Bernie Sanders, Alexandria Ocasio-Cortez and Zohran Mamdani — have only succeeded (at least to date) in solidly Democratic-leaning cities where their progressive policies (and, in most cases, their strong criticisms of Israel) are more popular.

In Texas, James Talarico, the Democratic nominee for the Senate seat currently held by John Cornyn (who lost the Republican primary to Trump’s candidate Ken Paxton), is one of those new voices. Probably best described as a liberal Democrat, Talarico is a thirty-six-year-old state legislator appealing to Texans looking for an alternative to the corrupt status quo most obviously demonstrated by Paxton, who was impeached by the Republican-controlled Texas House in 2023.

Talarico’s campaigning is an interesting blend of religion and progressive Democratic politics and optimism. His campaign messages appeal because they are so unlikely in this partisan era. He is against greedy billionaires who want to divide people, and for the power of love; he has shown a willingness to embrace political difference and invites the support of independents and Republicans who once supported Cornyn. His appeal has translated into fundraising far outpacing Paxton’s and polls that suggest the race is too close to call. Worried Republicans have resorted to vicious personal attacks.

The mood of Democratic voters is exemplified in the results of the Colorado primaries, held late last month. A surge of primary voters, angry at a do-nothing Congress, picked candidates without ties to Washington. House member Diana DeGette, a thirty-year incumbent also best described as a liberal Democrat, lost her primary to a youthful and somewhat controversial Democratic Socialist, Melat Kiros, who ran a savvy social media campaign arguing that DeGette was part of the party’s out-of-touch establishment.

In the race to succeed Democrat Jared Polis as governor, Colorado attorney-general Phil Weiser decisively won against senator Michael Bennet. Weiser argued that the sixty-nine lawsuits he has filed or joined against the Trump administration makes him better equipped to protect the state and its communities than Bennet, who is well-liked but whose eighteen years in Congress didn’t persuade voters he is the governor they want.

Given the list of Trump’s egregious actions against the state, it’s easy to see why Weiser’s argument appealed to voters. Trump has shifted the US Space Command headquarters out of the state, is trying to shut down Colorado’s globally recognised climate research centre and vetoed a water pipeline for drought-stricken farmers. Now he is requiring states to change the way they conduct elections or risk losing tens of millions of federal terrorism-prevention funds. Colorado has had mail-in and email voting for more than a decade and so Trump’s efforts to have the US Postal Service implement voting restrictions is being strongly resisted.

Trump is deeply unpopular in the state and residents are telling candidates they are tired of combative, partisan, us-versus-them political battles that are not solving their problems. Once a Republican state, Colorado’s rapidly growing population has become younger and highly educated. Political analysts largely attribute the collapse of the Republican party there to the rise of MAGA, which has created fertile ground for Democratic Socialists. Four of the ten Coloradans serving in the US House of Representatives are Republicans; of these, only Jeff Hurd (District 3) and Lauren Boebert (District 4) are expected — without Trump’s support — to retain their seats. Jeff Crank is slightly favoured in District 5 and Gabe Evans’s race in District 8 is considered a toss-up.

But the midterm elections are still four months away. With fighting continuing between Ukraine and Russia, an unresolved war in the Middle East, petrol prices, food prices and employment fluctuating, and Trump’s increasingly erratic language and vindictive decision-making, it’s impossible to predict how the American electorate will feel on 3 November. And, as the implosion of Graham Platner’s campaign in Maine demonstrates, it impossible to predict how candidates from both parties, especially those who are untested politically, will appear to those they seek to represent.

In a nation where getting out the vote is essential, having candidates with voter appeal will be vital. In a nation where the president has threatened the upcoming elections multiple times by multiple means, it is essential that state election officials and voters take coordinated action to defend democratic processes. And in a nation where trust in the federal government is at an all-time low, it is imperative that capable, ethical, and community-driven individuals to step forward and are voted into political service. •

The post Midterm manoeuvring appeared first on Inside Story.

And the second half of this year promises more of the same, maybe even worse, with a “supercharged” El Nino (characterised by warming of the ocean surface in the central and eastern tropical Pacific Ocean) expected to reach history-making strength. The US National Oceanic and Atmospheric Administration says there’s a 63 per cent chance this El Niño will grow so intense it will rank among the largest El Niño events on record.

UN secretary-general António Guterres has described El Niño as an “urgent climate warning.” El Niño conditions will “pour fuel on the fire of a warming world,” he has forecast, triggering billions of dollars in damage from heatwaves, floods, droughts, tornadoes and wildfires.

Even in the absence of an extreme El Niño, billions of people around the world are experiencing increasingly frequent, intense and long-lasting heatwaves. Studies show 489,000 heat-related deaths globally each year, with 45 per cent in Asia and 36 per cent in Europe. But the true toll remains unclear, especially for low- and middle-income countries, because most countries lack consistent systems to track heat-related casualties. Vulnerability to heat is shaped by age, health status and other physiological factors, by occupation and other exposure factors, and by socioeconomic factors including housing.

Real hardship has already fallen on the less-developed areas of Southeast Asia, the Middle East, Africa and the Pacific. India and the Middle East are experiencing severe and sustained extreme heatwaves, with summer temperatures consistently exceeding 50°C.

In its December 2025 State of the Climate in the Arab Region report, the World Meteorological Organization highlights how the regions and people of the Middle East and North Africa, where water is always in short supply, are under constant pressure from rising temperatures and increasingly extreme weather. WMO secretary-general Celeste Saulo says intense and longer-lasting heatwaves are “pushing society to its limits… Human health, ecosystems and economies can’t cope with extended spells of more than 50°C — it is simply too hot to handle.”

On a single day in late April this year, all of the top-fifty hottest cities in the world were in India. In such temperatures farmers are unable to work outside, livestock are under heat stress, crops fail and food supplies are severely curtailed. The heat reinforces longstanding inequalities of caste, class and gender in poor and marginalised communities. It is causing heart attacks and kidney injury among outdoor workers and homeless people and exacerbating diabetes, respiratory illnesses, mental ill-health and other chronic conditions.

Refugees, internally displaced and stateless people are on the frontlines of this crisis. Refugee settlements are disproportionately located in climate-stress zones — including the Horn of Africa and the Middle East — where makeshift shelters, little access to water, and no means to manage heat make tens of millions highly vulnerable to record-breaking temperatures.

In the developed world, meanwhile, reports of heat waves too often focus on the impact on sporting events, energy bills and strained electricity grids, ignoring the costs to productivity, medical services and the health of vulnerable people and livestock. As the Financial Times reports:

Once indoor temperatures rise above the low-twenties centigrade, or around 75 Fahrenheit, humans start to suffer. Sleep duration and quality fall rapidly when temperatures rise above 23°C. Cognitive performance fares similarly… The same is true of office workers’ productivity, which peaks at around 21°C and rapidly deteriorates as the mercury rises. And that’s all before we get on to mortality, where death rates climb steeply once temperatures hit 30°C.

The effects of heat may be exacerbated in cities where, despite better access to cooling, dense populations generate urban heat islands, amplifying risks for the elderly, pregnant women, outdoor workers and anyone who can’t afford airconditioning. Around 200 million city-dwellers in more than 350 cities live with summer temperature highs of above 35°C. Without dramatic change, around 970 cities will be at least this hot by 2050, with much higher exposures in Asia, Africa and North America.

In Australia, the national climate risk assessment, released in September 2025, suggests annual heat-related deaths at 2°C of warming would go up by 190 per cent in Sydney and 126 per cent in Melbourne compared with today’s levels.

Extreme heat is one of Australia’s most dangerous natural hazards and it’s getting worse. It has caused more deaths in Australia than any other natural hazard and has a major impact on ecosystems and infrastructure. The Australian Institute of Health and Welfare estimates that in the ten-year period from 2012 to 2022 extreme heat accounted for 7104 hospitalisations (with 2143 of these occurring in the last three years of the decade) and 293 deaths. Other research suggests higher numbers: one study estimates heatwaves caused more than 1000 deaths in Australia in the four years between 2016 and 2019, with the highest mortality rates in communities with older populations and lower incomes or education.

Indigenous Australians are disproportionately vulnerable to extreme heat due to compounding factors that include substandard and poorly insulated housing, energy insecurity and higher rates of chronic, climate-sensitive health conditions

Humidity makes the heat much more lethal. Heat stress limits for human survivability were previously defined using a wet-bulb temperature of 35°C . Combined with 100 per cent humidity, more than six hours’ exposure to this temperature will cause heatstroke and organ failure, even among young, healthy adults. But recent research suggests extreme dry heat can be just as deadly as humid conditions. A 2023 study warns that, if the world warms by more than 2°C above pre-industrial levels (it had warmed by 1.37°C in 2025), as many as four billion people, particularly those in communities across Pakistan, India, China, and several African countries, would be at risk.

The impact of increased average temperatures extends to animals and the broader environment. They alter the distribution and intensity of pests and diseases, affecting flora, insects, livestock and humans. The spread of many infectious diseases is accelerating, as are the mosquitos and other vectors spreading them. (The Japanese encephalitis virus, for example, spread by the common banded mosquito, is now endemic in northern Australia and was last summer was found as far south as Victoria.) Some existing pathogens are becoming more virulent or widespread. (High temperatures increase the survival and biting rates of mosquitos carrying West Nile virus, for example.)

Despite the mortality, morbidity and economic costs, heatwaves rarely receive adequate attention because the death tolls and destruction are not always immediately obvious. But the impact of high temperatures on sport, obvious even to the politicians who pay more attention to sporting heroes than to scientists, might offer help prompt action.

The FIFA World Cup host cities are among those currently experiencing unusually ferocious heat and humidity. It’s tough for players, for those lucky enough to be in the stands, for the crowds gathering at outside venues, and for security and transport services staff.

Soon the focus will shift to the US Open in New York, where the weather is often hot and humid. After many players had problems with the heat at the French Open, they are calling for stronger responses from tournament organisers to a problem increasingly affecting their ability to play and earn. Could their voices finally drive greater climate action? •

The post The heat is on appeared first on Inside Story.

The International Society for Infectious Diseases ProMED website, which provides an early warning system for infectious diseases, has a long and disturbing list of reports from around the globe. Beyond the growing number of Ebola cases — now also from Uganda and suspected in Italy — come reports of the Andes Hanta virus spreading from an initial outbreak on a cruise ship as passengers have travelled further after disembarking. Covid-19 cases in Singapore have risen dramatically; measles cases have broken out in Spain and Mexico; Crimean-Congo haemorrhagic fever has resurged in Iraq.

Little of what we learned from the Covid-19 pandemic and previous outbreaks of Ebola has been implemented effectively. Despite widespread agreement that the risk of pandemics is increasing, only lip service is being paid to preparedness and global cooperation.

The Ebola epidemic, which appears to have been reported only after early cases went undetected for many months, is spreading rapidly and outpacing containment efforts. As of 27 May, the Democratic Republic of the Congo had reported more than 1077 suspected cases and 246 suspected deaths. Neighbouring Uganda confirmed seven cases and one death. With the DRC also sharing porous borders with Burundi, Rwanda and South Sudan, the fear of cross-border transmission is rising. The Africa Centres for Disease Control and Prevention warns that ten African countries are now considered to be at risk.

Most of these countries have limited healthcare resources and many are experiencing major population movements as a result of political violence, famine and climate change. In Ituri province, where the outbreak began, multiple attacks have been reported on Ebola treatment centres, on hospitals treating patients with suspected and confirmed cases, and on the morgues that receive the dead, further hindering control efforts.

Fast detection and response are obviously crucial. But programs designed to support local health systems and international organisations at work in these countries — vital to detecting outbreaks and alerting communities, building medical stockpiles and dispatching response kits and personnel — have had their funding reduced or eliminated.

Particularly damaging has been the abrupt cutting of hundreds of millions of dollars in international health funding by Donald Trump’s administration. The United States used to fund robust disease surveillance networks across Africa and maintain emergency teams to respond to crises like this one. Most of this work ended with the shutdown of USAID and cutbacks at the US Centers for Disease Control and Prevention. A National Institutes of Health laboratory designed for Ebola work was closed last year and expert staff laid off.

The formal withdrawal of the United States from the World Health Organization has created a US$553 million gap in the organisation’s budget. While emergency response funds have been allocated by WHO and a number of other nations, the systemic damage is not easily repaired.

Making the situation worse is the fact that the outbreak involves the rare Bundibugyo strain of Ebola, for which no approved vaccine or treatment exists. Urgent efforts are underway to develop an effective vaccine, but American laboratories and expertise are notably absence from the push. The Oxford Vaccine Group is working to produce and scale doses of a monovalent Bundibugyo Ebola virus vaccine in partnership with the Serum Institute of India.

World Health Organization officials calling call for international cooperation caution that “no single country can respond to this magnitude of outbreak alone.” What the Trump administration fails to see is that American leadership delivered real benefits for the United States. It allowed US public health officials to learn first-hand about emerging threats and the coordinating of countermeasures; it decreased political and economic instability in fragile states; it protected American citizens at home and abroad in a world where any pathogen is just a plane flight away.

When Ebola tore through West Africa in 2014 and threatened to become a global catastrophe, the White House installed an “Ebola czar” to coordinate a massive response across agencies and governments. A detailed playbook was developed for responding to future outbreaks. The Trump administration has dismantled all that. Many US health agencies now lack key political leadership and senior staff.

Instead, the American focus is on minimising any direct impact on the United States. “We cannot and will not allow any cases of Ebola to enter the United States,” declared secretary of state Marco Rubio earlier this week. This approach extends to sending any Americans likely to be infected to offshore facilities in Kenya. In one case, reports the Washington Post, an American doctor with Ebola was flown to Germany for treatment after being refused entry to the United States.

Reports indicate the administration is blocking key US researchers from attending global virus response talks and, reflecting the current anti-vaccine stance of senior health personnel, no apparent efforts are being made to develop a vaccine against the Bundibugyo strain. Instead, American health officials are working with a small biotech company to provide an experimental treatment (a monoclonal antibody) that may be used in patients exposed to Ebola. With limited production and significant costs, this approach is clearly designed to help only those from wealthy countries.

The Ebola threat to Australia is also just a matter of one infected person arriving on an overseas flight. But the current response here seems rather too laissez-faire. The Department of Health, Disability and Ageing hasn’t made any changes to management strategies for airport arrivals. The website of the Australian Centre for Disease Control states the risk to Australians is very low and Ebola has never been diagnosed in Australia. If Australian volunteers working in Ebola areas become infected, or simply want to return home, how will they be managed?

The list of other recent failures in outbreak management doesn’t inspire confidence either. The Hanta virus outbreak on the Hondius cruise ship has produced thirteen cases and three deaths, with infected patients travelling to a number of countries and several isolated islands visited by the ship threatened with outbreaks. But international law still lacks clear rules for public health emergencies on cruise ships, despite the lessons learned from the Diamond Princess and the Ruby Princess during Covid-19

The Hanta virus’s transmission dynamics mean this outbreak won’t become a pandemic, but its long incubation period (up to forty-two days) and high mortality rate nevertheless require appropriate precautions to be taken. In a number of cases, people who might have been infected were allowed to travel without any precautionary measures to reduce airborne transmission.

In the United States, where Hanta virus infections are often reported in western rural areas, the news of a foreign strain soon had social media spreading rumours, speculation and falsehoods, including inevitable claims that the MAGA favourite, ivermectin, was an effective treatment. Health and human services secretary Robert F. Kennedy announced on 23 May that he had signed a targeted declaration to support the development and deployment of medical countermeasures to the Andes Hanta virus, noting specifically that this would not include the development of a new mRNA vaccine.

Worldwide, healthcare systems are being confronted with significant disease outbreaks entirely preventable with effective vaccination programs. They may not reach epidemic levels, but they cost lives, use up healthcare resources and demonstrate system failures, often as a result of political interference.

A measles outbreak in Bangladesh is estimated to have reached more than 67,000 and killed more than 500, mostly small children, since March. Bangladesh was getting measles under control until, in 2024, a new government upended vaccination efforts by attempting to revamp the program and how vaccines were ordered. Malnutrition, common in many parts of Bangladesh, is one reason this outbreak has hit hard; the number of severe cases and the death rate is considerably higher than typically seen in high-income countries.

Significant measles outbreaks in first world countries have been attributed largely to growing anti-vaccination sentiment. The United States is currently experiencing its largest measles resurgence since the disease was declared eliminated in 2000. A recent outbreak in Mexico, with some 17,000 infections and at least forty deaths mostly among unvaccinated people, is attributed to a young Mexican boy who visited relatives in Texas, a state where conscience- or religious-based exemptions for childhood immunisations have allowed a measles upturn.

Below-target vaccination rates are driving measles transmission across England — so much so that the WHO stripped the United Kingdom of its measles elimination status in January this year. This follows Canada losing its measles-free status in November 2025. Measles is extraordinarily infectious and for outbreaks to occur countries don’t need to slip much below the required 95 per cent immunisation rate needed for herd protection. The resurgence of measles transmission in England in 2024 occurred when coverage for the first dose of vaccine was 92.3 per cent and for the second dose 84.4 per cent.

In Australia, diseases like measles, whooping cough and diphtheria, once considered banished or rare, are making a comeback as childhood vaccination levels drop below herd-immunity levels and adults are missing booster shots. More cases of measles have been reported in Australia in 2026 (106 cases) than the same period in 2025 (seventy-eight). Most have been in unvaccinated or under-vaccinated people who acquired their infection overseas and then transmitted the disease locally to unvaccinated or under-vaccinated contacts.

Australia is facing the worst diphtheria outbreak in decades, with 223 notifications made as of 19 May. The majority have been cases of cutaneous diphtheria, but around 30 per cent have been more serious respiratory infections. The vast majority (94 per cent) of the affected have been Indigenous Australians. Factors contributing to the outbreak include low immunisation rates, specifically in adults whose immunity levels have fallen, the prevalence of skin infections in affected communities, overcrowded housing and limited access to healthcare services.

Other viral threats — old and new — loom. A paper from Gavi, the vaccine alliance, lists the following as immediate threats to global and regional health: conflict-associated outbreaks of disease such as cholera; climate change’s reshaping of the geography of diseases caused by mosquito-spread arboviruses; and Marburg virus, which is related to Ebola. Other viruses — including the H5N1 avian flu, which has acquired some ability to infect humans and for human-to-human transmission, and Mpox (related to smallpox), now been reported in 145 countries and territories — also demand timely reporting and monitoring and a coordinated global response.

It’s also important to note that a 2025 international workshop found that high-burden, endemic diseases of poverty — tuberculosis, hepatitis, cholera, malaria and others — are considered to pose a greater infection threat than novel or emerging pathogens.

At a time when the need is very obvious, it is concerning that WHO member states failed to finalise the pathogen access and benefit-sharing annex (which guarantees access to medical tests, vaccines and treatments in exchange for sharing information on emerging pathogens) to last year’s WHO Pandemic Agreement ahead of the World Health Assembly on 18–23 May this year. This annex is legally required for the broader treaty to enter into force, and so it remains in limbo until negotiators can bridge some stark divides.

As the Global Preparedness Monitoring Board points out, the growing distrust of public health expertise, attacks on science, global inequalities and geopolitics and nationalism are all undermining pandemic preparedness. •

The post Ebola’s warning appeared first on Inside Story.

Democrats need to flip just three seats in the House of Representatives to secure the majority. In the Senate, where Democratic gains were until recently considered unlikely, some pollsters see a possibility of a Democratic majority, with four seats in play.

A president’s job approval always strongly influences congressional losses in midterm elections and Trump’s is at an all-time low. (One poll average on 14 April had it at 39.7 per cent.) Approval of Trump among population groups that provided key support in 2024 — young voters, Hispanics, and independents — is low enough to more than offset gerrymandering by some Republican-led states. (California’s and Virginia’s retaliatory redistricting will help too.)

Trump — ever one to deny the facts — recently insisted in a Fox News interview that the Republican party is “going to do good” this year. Yet he also acknowledged the size of the task, telling host Maria Bartiromo: “When somebody gets elected president, that party always loses the midterms. I don’t know why. I don’t know why. Nobody can explain it. I ask people who are deep into the psychological world. I said, ‘Why is it that a voter votes for the opposite party?’ even when you have a good president. It doesn’t make sense to me. So we’re going to try turning it around.”

He’s worried because he knows what the loss of the narrow but unified Republican majorities in the House and perhaps the Senate would mean. There would be no more legislative victories (not that he has been keen on legislating this term) and lots more congressional oversight, potentially including more impeachment hearings. History also points to the likelihood of down-ballot losses in governorships and state legislatures.

Despite his concerns about the outcome, Trump’s focus has so far been scattered. He has implemented measures to undermine election integrity, issued orders to Republican states about gerrymandering, pushed to restrict mail-in voting (which could also work against his own supporters) and limit voting rights in general, and made selective endorsements of MAGA candidates. But his administration is doing little to tackle the issues voters are most worried about: cost-of-living pressures, the affordability of healthcare, jobs and the economy. Trump’s rallies almost always end up being about him and his grievances, and his insistence that the economy is booming is meeting with scepticism even among his supporters.

Republicans are increasingly worried that the Middle East conflicts, violent immigration enforcement and tariffs, along with Trump’s obsession with Washington buildings and monuments and nasty, unnecessary fight with Pope Leo, are making a difficult election even more so.

“Everything is made more difficult by the nonsense coming out of 1600 Pennsylvania Avenue,” a Republican close to the White House told Politico, which also reported a senior adviser to Trump’s 2024 campaign as saying, “The road to victory runs through a consistent economic message. Unfortunately, President Trump ignores the road map.”

Outside the United States, Trump is increasingly seen as out-of-touch, even unhinged, a bully on the issues he cares about, and an unreliable ally. Foreign policy and international opinion are rarely significant for American voters, but this year might be an exception.

Trump campaigned on a promise of American isolationism, pledging to end foreign military engagements and focus on domestic renewal. Instead he has inserted himself incessantly into global affairs — threatening Canada, Greenland and Cuba, bullying Ukraine, supporting right-wing politicians in Europe, violently changing the leadership in Venezuela, setting up a personally selected Board of Peace to run Gaza, and launching a war with Iran without any apparent exit strategy. Small wonder voters are anxious about global issues, and especially Iran.

Polling shows a majority of Americans (59 per cent, including 29 per cent of Republicans) say striking Iran was the wrong decision, with 61 per cent, including 31 per cent of Republicans, disapproving of Trump’s handling of the conflict. The fighting in the Middle East has led to MAGA factionalism and a significant drop in support among young Republicans.

It isn’t just that voters are concerned about increasing military involvement and the use of nuclear weapons. The enormously expensive war must be paid for, and Trump’s budget for the financial year that starts of 1 October demands a record-breaking US$1.5 trillion for defence. That means cuts to the social programs so many Americans rely on. At an Easter lunch, Trump said it’s “not possible” for the federal government to fund Medicare, Medicaid and childcare costs and argued these programs should be the states’ responsibility because “we’re fighting wars.” On top of that, petrol prices — always a consumer obsession — are continuing to climb.

In the months ahead, Trump and Republicans must walk a political tightrope to keep happy a number of key constituencies beyond those worried about the costs of Trump’s engagement in foreign affairs.

There are the many women are worried about how the Dobbs decision on Roe v Wade is limiting their access to reproductive healthcare, counterposed with the anti-abortion activists who have blasted Trump’s “lack of action” and claim he has “fooled” the pro-life movement with his failure to restrict abortion pills and decision to approve a new, generic version of mifepristone, which is used for medical abortions. There are Catholics appalled at his war of words with the Pope and his co-opting of religious imagery, and the ultra-conservative evangelicals and media figures (not to mention vice president J.D. Vance and House speaker Mike Johnston) who support this blasphemy. And there are the Make America Healthy Again supporters who are angry that Trump and his health secretary are supporting increased production and use of the toxic weedkiller glyphosate and want to see more done to eliminate vaccine mandates.

With Republicans’ planned hyping of Trump’s economy now looking less like a winning strategy, indications suggest the party will use the threat of impeachments to get MAGA out to vote. It will be interesting to see how individual members of Congress up for re-election behave over the next few months, especially as 15 April, the deadline for tax returns, is seen as the unofficial start to the midterm campaign.

A huge wave of Republican retirements can be read as a sign of congressional frustration. While none of those sticking around for re-election so far seem likely to speak out publicly against Trump — his control over congressional Republicans remains complete and unrelenting — their concerns about their own electoral futures might see them overcome this obeisance if his approval ratings continue to sink.

Democrats, meanwhile, have been buoyed by strong fundraising and some spectacular wins in special and state elections. Partly the wins reflect shrewd candidate picks, including Mikie Sherrill and Abigail Spanberger in the New Jersey and Virginia gubernatorial races. Democrats have flipped four state legislative seats in special elections this year after flipping seven in 2025.

Congressional Democrats know they can’t just be anti-Trump. They are reported to be focusing on affordability and the Trump administration’s fiscal policies, and planning to highlight healthcare, housing, electricity and other utilities, and caregiving. They will need to outline legislative solutions to these problems. To fund improvements in the social safety net, progressive Democrats have proposed (yet again) raising taxes on the rich. This time it might fly, after all, even if Trump has considered it.

Inspired by the ouster of Hungarian prime minister Viktor Orbán, Democrats are also looking to use the anti-corruption playbook against Trump, his family and his administration. House Democrats have just announced a taskforce to overhaul ethics rules, protect access to the ballot and examine the Trump family’s business dealings, corruption in the executive branch, and the president’s transformation of the federal government.

At the same time Democratic representative Jamie Raskin, the ranking member of the House Judiciary Committee, has introduced a bill to establish a “Commission on Presidential Capacity to Discharge the Powers and Duties of the Office” to examine whether the president is fit to serve in office (as per section 4 of the 25th Amendment). This bill won’t go anywhere in this Congress, but it signals how Democrats in the majority will push back against Trump and his administration.

While Democrats are demonstrating how they might function should they take back the House, Senate Republicans are acting to safeguard the conservative nature of the US Supreme Court (a sure sign they are worried about the outcome of the midterms). Trump has been nudging Justices Samuel Alito and Clarence Thomas to retire so he can appoint their replacements (they both say they are sticking around). Senate majority leader John Thune has said the Senate is prepared to confirm a replacement for Alito before the midterm elections should he retire — clearly indicating that Thune would not abide by the rule his predecessor Mitch McConnell invoked to block Merrick Garland from succeeding Justice Antonin Scalia (but then ignored so Amy Coney Barrett could succeed Ruth Bader Ginsburg).

More broadly, there is much uncertainty and anxiety about whether this will be a normal election year. As historian Robert Kagan has pointed out, it would be a mistake to think Trump will be happy to let adverse results stand: “There’s no chance in the world that Donald Trump is going to allow himself to lose in the 2026 elections, because that would be the end of his ability to wield total power… They could not be more obvious about what their intention is.”

Earlier this year, a Washington Post article showed how Trump, guided by the Heritage Foundation’s Project 2025 and what he and his advisers learned in 2020, is using “every tool he can find to try to influence the 2026 midterm elections and, if his party loses, sow doubt in their validity.” He may not have the authority to make many of these interventions, but history shows that doesn’t mean he won’t try. •

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Where is the political opposition to citizens being snatched off the street and deported, the costs of health insurance skyrocketing, universities and media companies being forced to pay ransoms to keep operating, the breakdown of public health services, the summary dismissal of senior female and Black military leaders? Where are the voices speaking out strongly and persuasively against Trump’s autocratic behaviour, his kakistocratic cabinet, his kleptocratic family and associates, and his appalling and expensive taste in architecture and gilded trimmings?

The polls highlight Trump’s dramatic loss of support. Not just generally but even among his base and even on such touchstone issues as immigration and the economy. A recent CNN poll has 68 per cent of respondents saying the country is going pretty badly or very badly. Voter disaffection has been clear in recent state elections (where Democrats took twenty-five state Senate and House seats from Republicans) and at special elections in Florida, Virginia, Arizona and Tennessee. Yet Congressional Democrats seem unable to capitalise on the failures of the administration or Trump’s increasingly erratic behaviour and harness the community concern expressed in the No Kings rallies.

Yes, there have been a few standout moments: senator Cory Booker’s marathon speech on the Senate floor; rallies led by senator Bernie Sanders and representative Alexandria Ocasio-Cortez; representative Bennie Thompson accusing homeland security secretary Kristi Noem of abuses of power and demanding her immediate resignation; and Democrats holding town hall meetings in Republican-held districts.

But there has been no coherent, coordinated response. We rarely see House and Senate leaders take to the media to name the issues and how they would deal with them. Senate Democrats did take a stand on health insurance costs during the recent government shutdown; but then, amid fear they would be blamed for job losses and the hardships facing unpaid federal workers, enough of them folded to enable the Republican bill (which offered nothing on health insurance) to pass. After forty days, the Democrats were left with nothing.

While the margins are thin, Republicans’ control both chambers of Congress means they control which legislation comes to the floor and which issues are examined in committee. Coordinated, controlled and timely responses to announcements by Trump and Republicans are hampered further because the opposition has no designated leader — although that shouldn’t stop House minority leader Hakeem Jeffries and Senate minority leader Chuck Schumer from holding daily press conferences — and Trump eats up all the media airtime.

There is every reason to believe the Democrats can take back the House in the 2026 midterm elections: a November NPR/PBS News/Marist poll showed Democrats leading Republicans 55–41 per cent when people were asked who they would vote for if the election for Congress were held today. Taking the Senate will be more of a challenge, with the Democrats needing to flip four seats to take a fifty-one seat majority.

But the midterms are a year away and — as the past eleven months have shown — the Trump administration could do an enormous amount of damage in that time. Congressional Democrats can’t just sit passively, look optimistically at the polls and hope voters prefer them to the Republicans.

The most effective Democratic opposition so far has come from outside the Congress — from Democratic state governors, in particular Gavin Newsom (California), J.B. Pritzker (Illinois) and Josh Shapiro (Pennsylvania). These three are almost certainly looking to run as the Democratic nominee for president in 2028.

They will join what is predicted to be a sizeable lineup of Democrats. Senators Cory Booker and Chris Murphy, House members Joe Neguse and, possibly, Ocasio-Cortez are all likely to step forward for the nomination.

Given the appallingly low levels of public trust in Congress, candidates from elsewhere — with name recognition and demonstrable experience — will stand a better chance. To the list of governors above, add Gretchen Whitmer (Michigan), Wes Moore (Maryland), Andy Beshear (Kentucky) and Tim Walz (Minnesota). Of these, Newsom clearly fancies himself as a winner, but he needs more than the ability to hilariously troll Trump, and he is carrying personal and political baggage. There are some also-rans to add to the list of candidates — most notably Kamala Harris and Pete Buttigieg.

If past experience is any guide however, the likely final candidate is a name not yet mentioned.

Two key factors should guide the Democrats in selecting a presidential candidate.

The first is that Americans, especially younger voters and people of colour, appear to be looking for a different type of politician and a different style of campaigning. This is most obviously demonstrated in the recent upstart victory of Zohran Mamdani in the New York City mayoral race.

The win was a surprise not so much because he was relatively young, a Muslim and a Democratic socialist proficient on social media, but rather because he ran a campaign based on listening and then responding to what he heard about voters’ needs.

Mamdani has described the need to change “a political impulse of lecturing” to a commitment to “listening.” When he conducted an in-person survey, asking life-long Democrats why they had voted for Trump or failed to vote at all, what he learned is that “many did so because they remembered having more money in their pocket four years ago,” and that they craved from Democrats “a relentless focus on an economic agenda.”

That is how he ran his mayoral bid. He spent the entire campaign mainly talking about affordability. Instead of the political message, so often heard in difficult times, about undeserving welfare dependents and working-class people missing out to recent immigrants, he talked about working together to provide everyone with a better life.

This focus on affordability also helped Democrats Mikie Sherrill and Abigail Spanberger win their governors’ races in New Jersey and Virginia respectively.

To win in 2028, Democrats will need to woo back a lot of working-class voters, including some of those blue-collar workers who voted for Trump. Recognising the very real financial issues confronting many American families, and offering realistic solutions, will win them over in ways that talking about civil rights will not.

Meanwhile the presidential candidate who vowed to lower prices, Donald Trump — even as he spruiks the state of the US economy (which is hardly booming) — is calling affordability concerns a “hoax” perpetrated by Democrats. As pollster Frank Luntz says, he runs a grave risk of appearing out of touch when Americans not only feel like they’re paying more but actually are.

The second factor Democrats must consider in choosing a presidential candidate is: who will they need to beat?

Given the craven state of the Republican party, the choice is Trump’s to make. The frontrunner might appear to be vice-president J.D. Vance, but Trump has already invoked secretary of state Marco Rubio’s name as well. The man with the most appeal beyond hardcore MAGA voters might be senator Tim Scott from South Carolina, although he was forced to withdraw from the 2023 Republican presidential primary due to lack of support.

The two most politically ambitious members of the Trump administration, the ones most likely to throw their hats in the ring, are health and human services secretary Robert F. Kennedy Jr. and White House deputy chief of staff Stephen Miller.

Of course the elephant in the room is whether Trump will attempt to run a third time. Constitutionally it’s impossible, but that might not stop him trying something nefarious. It’s clearly on his mind in more ways than his Trump 2028 baseball cap. “There are methods which you could do it,” he said in an interview with NBC News in March. More recently, in October, he said cryptically: “Based on what I read, I guess I’m not allowed to run. So we’ll see what happens.”

If a member of the Trump family were elected president, Trump senior could retain his power and influence. Both his older sons Donald Jr. and Eric have indicated they might “one day” run for president. Trump himself has suggested that a dynasty “could” be established, and he certainly regards his name as a political brand.

The 2028 election is still three years away, although campaigning will start in earnest as soon as the midterms are over. At this stage there are just two certainties: it will be about how voters perceive the state of the economy, and it will reflect voter disgust with the current political establishment. If the Democrats gain control of at least one chamber of the Congress in the midterms and begin to act more aggressively against unpopular and undemocratic Trump initiatives, the political dynamics could change dramatically, especially as — we hope! — Trump himself will not be on the ballot. •

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Trump has since ramped up his pledge to reduce what Americans pay for prescription drugs, in recent months making bold, mathematically impossible undertakings to cut drug prices by as much as 1500 per cent. But there is little evidence that Trump can achieve his stated aim and serious concern that his plans would create shortages, increase prices and disrupt research and development, drug approvals and manufacturing.

Americans have always paid more for brand-name prescription drugs than consumers in most other countries. A 2024 report by the RAND Corporation found that brand-name drugs cost at least four times more in the US than they do in comparison countries. (By contrast, unbranded generics, 90 per cent of US prescriptions, averaged 67 per cent of prices in comparison countries.) This largely reflects a complex and fragmented reimbursement system, the lack of national price control mechanisms and the industry’s zealously guarded patent protections.

Government-funded programs have failed to capitalise on their large-scale bargaining power. The Veterans’ Administration is unique in negotiating prices directly with manufacturers, and the Medicaid Drug Rebate Program requires drug manufacturers to negotiate prices with the states. But Medicare has been prohibited until very recently from negotiating the price of medications for seniors.

In the private sector, health insurers typically rely on intermediaries known as pharmacy benefit managers to negotiate costs, and hospitals and physicians’ offices charge insurers or patients whatever price they can negotiate. The lack transparency provides countless opportunities for mark-ups. Many Americans look for cheaper medicines from online pharmacies or import them from Canada, Mexico and elsewhere.

Trump’s threats and promises come in an environment in which many Americans struggle to access affordable medicines and healthcare and the immense lobbying power of the pharmaceutical industry. That power, and Trump’s inability to focus on any issue for a concerted period, is a major reason why his pharmaceutical price initiatives are so disjointed and contradictory.

The process started in February during a White House gathering of governors and new cabinet members at which Trump declared “Americans are being screwed” on drug costs. But then, in April, he issued an executive order directing the Department of Health and Human Services to work with Congress to modify the only recent attempt to reduce Medicare spending on prescription drugs. Pharmaceutical industry lobbying had already paid off handsomely.

Joe Biden’s Inflation Reduction Act enabled Medicare to negotiate prices for the most commonly used and expensive drugs the program covers. The first set of negotiated prices for just ten drugs — estimated to deliver annual savings of US$1.5 billion in out-of-pocket costs for Medicare beneficiaries and US$6 billion for the Medicare program — are not due to go into effect until 2026. Negotiated prices for another fifteen drugs, including blockbuster diabetes drugs like Ozempic, are due to be implemented in 2027.

The Republican Congress delivered on the industry’s demands in the One Big Beautiful Bill, which further limited which drugs can be included in Medicare’s negotiation program. The health policy centre KFF estimates that this change alone will increase Medicare spending by at least US$5 billion. It’s unclear whether the Trump administration will ever implement the previously agreed savings in 2026.

The April executive order also required disclosure of the direct and indirect compensation received by pharmacy benefit managers and a report on anti-competitive behaviour by prescription drug manufacturers. The required transparency regulations are yet to appear and several “listening sessions” on anti-competitive behaviours have yet to yield recommendations for reform.

There’s confusion and an irony in the fact that the April executive order attempted to make it easier for states to import prescription medicines, given that it came just one day after the Trump administration announced a national security report into the pharmaceutical industry as a precursor to the tariffs that were to come just a few months later.

An executive order issued in May aimed to tackle the disparities in drug prices between the United States and other high-income countries using voluntary “most-favoured-nation,” or MFN, pricing, under which prices in the United States could be lowered to match the lowest price in other similar markets. Non-compliance could trigger compulsion. “Big Pharma will either abide by this principle voluntarily,” Trump declared as he signed the order, “or we will use the power of the federal government to ensure that we are paying the same price as other countries to accelerate these price restrictions and reductions.”

Yet he also alleged European governments are the real enemy. Referring to what he described as “price gouging and profiteering,” he claimed it was “really the countries that forced Big Pharma to do things that, frankly, I’m not sure they really felt comfortable doing, but they’ve gotten away with it, these countries. The European Union has been brutal, brutal, and the drug companies actually told me stories — it was just brutal, how they forced them.”

The May executive order also requires a review of other countries’ policies and practices to pinpoint those that work against American interests — a review that will surely consider how Australia approves drugs for PBS listing — as well as efforts to facilitate direct-to-consumer purchasing programs at MFN prices.

This latter proposal reiterates a first-term attempt by Trump to benchmark prices for drugs administered in doctors’ offices to the lowest price in OECD countries — a move that encountered legal and political obstacles. The latest decision will face the same challenges, but for the moment it seems the administration is focused on what can be achieved through bargaining with individual pharmaceutical companies.

Discussions so far between the Department of Health and Human Services and the pharmaceutical industry have not yielded meaningful results. Big Pharma will fight hard to keep their largest and most profitable market. Their most potent argument is that cutting prices in the United States would stifle innovation by reducing funds for research and development. PhRMA used the same argument in a letter early this year to the US Trade Representative, saying that the Australia’s PBS pricing policies “undervalued American innovation.”

In a shift in focus, however, the pharmaceutical industry took the view that Trump’s tariff policies could be used decrease the gap between prices in the United States and Europe (and Australia) by forcing governments in these countries to stop bargaining down prices. “European governments are not signing up to pay more for drugs. We need trade tools to rebalance that equation,” said the CEO of one large international pharmaceutical company.

Such an approach would protect only the profits of the pharmaceutical industry, of course, and would do nothing to reduce prices for governments or patients. In fact, there is near-universal agreement that prices would actually increase in the United States and shortages of some medicines would be exacerbated.

Undeterred, Trump announced that a 100 per cent tariff will be levied on any branded or patented pharmaceutical product from 1 October “unless a Company IS BUILDING their Pharmaceutical Manufacturing Plant in America.” Given that he previously suggested tariffs would be phased more slowly, giving companies time to build factories and relocate production, this announcement came as a shock to companies outside the US.

The tariff edict was not the subject of an executive order and came with little detail. Trump’s threats had already spurred international pharmaceutical companies to announce billions of dollars of investments in their US operations. Trump had agreed in July to the framework of a deal with the European Union — where nearly all of the biggest companies have a significant manufacturing presence — that would levy only a 15 per cent tariff on drug imports, with some exceptions for certain generic drugs. A framework agreement with Japan, meanwhile, applied a baseline 15 per cent tariff to nearly all Japanese imports, with an exemption for generic drugs.

Whether these deals hold or have been abandoned isn’t clear. Carve-outs for European and Japanese exports and companies engaged in US manufacturing could shield most branded drugs from the 100 per cent levy. But it’s feared the tariffs will have the greatest impact on drugs for rare diseases and speciality pharmaceuticals from smaller manufacturers without an American presence.

Australian company CSL is hoping that its US-based facilities and large workforce will protect its exports of vaccines, anti-venoms and blood product to the United States. Blood products made up 87 per cent of the A$2.1 billion in medicinal and pharmaceutical products exported to the United States in 2024. Made from blood plasma collected in the United States and fractionated in Melbourne, these products are used in a range of medical and surgical treatments, including responses to a number of life-threatening diseases. Any increase in prices would have serious health and financial consequences for many Americans.

For the moment these concerns are in abeyance because the implementation of these tariffs has been paused while individual negotiations continue. Just this month Trump has revealed deals with Pfizer and Astra Zeneca. These companies will participate in a new direct purchasing platform named TrumpRx.gov that will let American patients buy a “large majority” of their products at a discount. In return, Pfizer and Astra Zeneca will receive a three-year reprieve from certain tariffs. Trump called this “bringing MFN pricing to American patients” but it is a long way from that.

There are concerns that TrumpRx is yet another move by the Trump family to cash in on the presidency and that the brand name will discourage some Americans from using it. There are also doubts about its ability to compete with the other, similar online pharmacy services that have proliferated in the United States, and about the actual the discounts to be offered. It’s seen as a win for the companies, with very modest gains for consumers. More companies are expected to join.

The White House is now saying it may not need to impose tariffs. Asked earlier this month when pharmaceutical tariffs would go into effect, commerce secretary Howard Lutnick said the administration is “going to let [the talks] play out and finish these negotiations, because they are the most important thing to the American people.”

In all this activity, two key areas have been ignored. First, generic drugs, which account for more than 90 per cent of prescriptions and 10 per cent of costs, are mostly imported from places like China (currently subject to a 30 per cent tariff) and India (a 50 per cent tariff). The tariff on imported Indian generics is estimated to increase US healthcare spending by roughly US$7 billion.

Second, in the push to increase onshore manufacturing, little attention is paid to why drug manufacturers move operations overseas in the first place. The pharmaceutical industry is a global web, with ingredients and finished drugs manufactured in a multitude of locations based in costs and expertise. Much of the US expertise in science and medicine is meanwhile being actively undermined by Trump policies on research funding. These issues, neither of them readily addressed under Trump’s current policies, explain why America imported nearly US$233 billion in pharmaceutical and medicinal products in 2024.

As prime minister Anthony Albanese heads to Washington for much-vaunted talks this week, there is considerable speculation about topics for discussion. Will Australia quietly accept 10 per cent tariffs as a best-case scenario, or will Albanese push for fairness based on Australia’s trade deficit (Australia contributes less than 1 per cent to the US trade deficit in pharmaceuticals) and existing trade agreements? Whether the PBS is still on the table will depend on who has had Trump’s ear last — including the well-funded lobbyists from Big Pharma.

The Saturday Paper’s Jason Koutsoukis recently pointed out that Australia is one of the two or three countries most likely to set the MFN prices in the United States; it topped a Trump administration list of eighteen countries in a “MFN  basket” for reference pricing. Koutsoukis reports that health minister Mark Butler is engaged in talks designed to protect the PBS. Let’s hope Butler recognises that the Australian pharmaceutical companies whose US-based parent companies see the PBS as a free-rider undermining their profits are not the Albanese government’s allies in this fight. •

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Depending on your political point of view, this 900-page legislative package — with its US$4.5 trillion in tax cuts and new spending adding more than US$4 trillion to the national debt — represents either the beginning of a new golden age that “unleashes economic prosperity and empowers every American while strengthening our nation’s defences and boldly looking to the future” (to quote the White House) or a dark day for the nation’s fiscal future and the upending of healthcare for patients, doctors and hospitals.

In so many ways, this is the archetypal Trump bill. It has all the superlatives he loves. It starts with the boastful name that reflects its size — it is the biggest reconciliation bill ever in terms of pagination and of spending and healthcare cuts. It also exemplifies all of Trump’s shortcomings — it ignores the impact on the federal budget and the national debt, egregiously benefits the rich over the poor, and breaks his commitments to never cut Medicare and Medicaid.

What originally started out as a fiscal bill covering one of Trump’s key domestic commitments — making permanent his 2017 tax cuts for the wealthy and corporations — quickly ballooned into the biggest and most expensive draw on the national debt ever seen, with impacts likely to be felt for decades. On its passage through the House and the Senate, Republicans couldn’t resist adding a welter of measures culled from the MAGA and Project 2025 agendas. Among them were $170.7 billion for immigration enforcement (making Immigration and Customs Enforcement the largest federal law enforcement agency in the nation’s history); cuts to clean energy spending predicted to result in decreased electrical capacity, increased power prices and an assault on efforts to tackle climate change; measures that will make it harder for Americans to finance their higher education; and provision for some individuals to deduct a certain amount of tip wages and overtime from their taxes (a Trump campaign commitment).

Perhaps the bill’s huge cost to the budget meant Republicans felt they had no choice but to make severe compensatory cuts in health and social services, but it’s just as likely that the $1.2 trillion cuts to Medicaid (the health insurance program for the poor) and the supplemental nutrition assistance scheme (or SNAP, known colloquially as food stamps) are an expression of their long-held attitudes to welfare. These cuts ignore the fact that Republican states (and the people who live in them) are disproportionately dependent on federal aid. And they ignore the fact that, while their severity will devastate millions of people, the savings will go nowhere near offsetting the cost of the high-income tax cuts.

Trump is claiming victory, although he had little to do with the shape of the final bill. He sat on the sidelines, he and his staff relatively disengaged from the policies and processes that go into pulling together a bill of this size (and one that is subject to the rules of reconciliation). His engagement came only when it looked like the votes were lacking and his 4 July deadline would not be met, when he resorted to arm twisting (or what sometimes looked more like political blackmail).

It’s clear that neither Trump nor the vast majority of Republicans who voted for the bill are aware of all its provisions and their implications. They have resorted to ideological slogans and made claims that will be hard to justify. “We really have independence now over the over-taxation, where we were being taxed out of our lives, independence from over-regulation, we have independence now from radical-left bureaucrats and independence from the largest alien invasion that I think any country has ever seen,” declared Trump after final passage.

The president now owns this bill and everything that is in it — the good and the bad and the ugly. And for a piece of legislation that contains so many provisions (some of which will take quite some time in implementation) affecting so many Americans, it has had a very poor start. Although Trump claimed the new law is the “most popular bill ever signed” it is historic in a way Trump will not admit to: it is the most unpopular piece of lawmaking since the 1990s. On average across pollsters, just 31 per cent of Americans support OBBBA, with 54 per cent opposing it. So it’s no surprise that it has done nothing to help Trump’s approval ratings, which, at 38 per cent, are lower than for any other modern president at the same time in their administration.

An examination of the main OBBBA provisions shows that many Americans face tough times — and given that the adverse impacts will fall hardest on people in Republican states who are (or have been) Trump supporters, tough times also loom for congressional Republicans who must face the voters in the midterms in November next year.

Republicans have embraced tax cuts since the Reagan era, claiming they spark economic growth. Trump is all in on this: “After this [OBBBA] kicks in, our country is going to be a rocket ship economically.” But there’s little evidence for this optimism and considerable evidence that past tax cuts, rather than supercharging growth, have driven budget deficits and increases in the national debt, as the independent Congressional Budget Office predicts in this case. The CBO says the federal debt will increase by US$3.3 trillion over the next decade; this does not include US$690 billion in additional interest.

The tax provisions in OBBBA generally benefit everybody, at least a little, but the wealthy will gain the most. People with incomes above US$1 million will save around US$60,000 compared with their tax bill if the current rates expired; those with incomes below US$30,000 (around the federal poverty level) will benefit by less than US$200. The poorest 20 per cent of Americans will receive just 1 per cent of the bill’s tax cuts next year, while the highest-earning five per cent will receive 44 per cent. “The bill stands alone historically for its unique upside-down mix of large tax cuts for the top, deep cuts that affect low- and middle-income people, and massive increases in deficits and debt,” said the president of the bipartisan Center for Budget and Policy Priorities.

The very people who gain least from the tax cuts will be hardest hit by the cuts to healthcare and food stamps. The new legislation will reduce federal spending on Medicaid by US930 billion and on food stamps by US$186 billion over the next decade. Most of these cuts are achieved by implementing work reporting requirements (despite the lack of evidence for their effectiveness) and setting up paperwork and procedural barriers (which hit hard at people with lower health literacy, lack of internet access and who live in isolated and under-served areas).

Other provisions undermine the Obamacare’s incentives for states to expand access to Medicaid and its subsidies to purchase insurance. Larry Levitt, the executive vice-president for health policy at the independent research centre KFF, says this bill will “cripple Obamacare” — effectively achieving what the president and Republicans failed to do in Trump’s first term.

Trump and the Republicans have engaged in the worst sort of gaslighting, claiming they are not cutting programs, merely cutting fraud, waste and abuse, and that no one will lose coverage as a result of this bill. They are playing a nasty game, insinuating that millions of the people who receive Medicaid and food stamp benefits are healthy and able-bodied and simply gaming the system. But their numbers don’t add up; experts say the majority of Medicaid beneficiaries currently already meet the work requirements or are in one of the exception categories; Medicaid is the primary provider of coverage for 63 per cent of nursing home residents; and research and real-world experience both show that work requirements don’t help people find or maintain work and are almost impossible to implement. As he signed the bill into law Trump acknowledged it included deep spending cuts but suggested that people “won’t even notice it.” “The people are happy, they’re happy,” added the president whose disapproval figures are plumbing new depths.

Experts estimate that between eleven million and seventeen million Americans will lose health insurance, which could lead to more than fifty thousand new preventable deaths each year. The loss of health insurance also means hundreds of rural hospitals will lose payments for the care they deliver and are at increased risk of closing. The majority of rural areas most affected are in red states.

The cuts to food stamps will affect more than forty million people (many of them the same people who will lose health insurance). This includes some sixteen million children, eight million seniors, and four million non-elderly adults with disabilities. As just one example of the pettiness embodied in OBBBA, people applying for food stamps are no longer able to deduct their internet costs when calculating their household’s net income, which is then used to determine how much households are entitled to receive in benefits.

Along with the major provisions in this package, a growing number of surprise smaller provisions are emerging. These include measures to strip Medicaid from Planned Parenthood for a year; eliminate the tax on gun silencers and short-barrel rifles; tax some of the remittances immigrants send home to their families; spend $40 million on Trump’s pet project, the Garden of Heroes; create Trump-branded savings accounts for children born in the next few years; subsidise Alaskan whaling and rum distilleries in Puerto Rico and the US Virgin Islands; refurbish the plane Qatar gave Trump; and enable private jet owners to write off the full cost of their aircraft in the first year of purchase.

And then there are the implementation details Trump and Republicans are not so keen to talk about. A statutory requirement to automatically impose budget cuts when legislation increases the deficit means there must now be automatic sequestration cuts across all government programs, including Medicare. The Congressional Budget Office calculates these cuts to Medicare will amount to US$490 billion over the next ten years, starting in the fiscal year that begins in October. Republicans’ recognition of the political risks inherent in the package are reflected in the timing of its most generous tax breaks, which come early, and the delaying of most of its painful benefit cuts until after the 2026 midterm elections.

Getting OBBBA through Congress was a struggle for Republicans. There were major disagreements within the party and the bill passed both chambers only by the narrowest of margins. It will undoubtedly provide great campaign material for the Democrats in next year’s midterm elections, and already some Republicans, including senator Josh Hawley of Missouri, are indicating they are open to efforts to undo some of the most punitive provisions.

Emboldened by their victory, seemingly unhindered by public opinion, and perhaps cognisant that they might have only one more legislative shot in the barrel, Trump and the Republican leadership are now attempting to implement further spending cuts identified by the “Department of Government Efficiency.”

This week the Senate will take up a $9.4 billion package — already passed by the House — that includes more spending cuts, more tax cuts, and some of the provisions ruled ineligible under the reconciliation rules and excluded from OBBBA. Most of the funds targeted in this rescission package were enacted in March legislation passed by Congress, including on a bipartisan basis in the Senate, which Trump signed into law to fund the government for the rest of fiscal year 2025. Now the administration is setting about revoking them.

The spending cuts include the withdrawal of funding from global health programs, international peacekeeping and economic development efforts, and domestic community TV and radio stations supported by the Public Broadcasting Service and National Public Radio. Nothing has changed since the funding was approved: these are simply programs (described by the Heritage Foundation as “woke and weaponised government funding”) that Trump has long opposed. The Senate must act (and gain House approval of their package) by 18 July to effect this proposal. Trump is threatening to withhold endorsements from Republican senators who don’t support his administration’s effort to claw back these congressionally approved funds.

House Speaker Mike Johnson has indicated he expects the White House to send multiple rescission packages to the Congress for action in “a multifront war against the deficit.” It looks like a concerted Republican attempt to wreak as much damage as possible on programs it dislikes in as short a time as possible, despite the evidence that these very actions could deprive them of their congressional majorities in the midterm elections in November next year. •

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His administration sees colleges and universities — particularly Harvard University and other Ivy League institutions — as hostile to conservatives, biased towards minorities, hotbeds of antisemitism, and intent on perpetuating liberal or “woke” ideologies. Trump is also attempting to impose his approach on overseas institutions that receive US research funds, including those in Australia.

Universities like Harvard are not without their faults, of course. Merit and racial diversity are endangered by admissions systems that favour the children of graduates to encourage alumni ties and, importantly, donations. But it’s also true that “legacy” admissions have declined dramatically at Harvard, from around 33 per cent in the years 2014–22 (compared to an overall acceptance rate of around 6 per cent) to 16 per cent in 2025 (when the acceptance rate was a little over 3 per cent).

These institutions are also very rich, with endowments exceeding the  gross domestic product of many countries. Harvard tops the list with an astounding US$53 billion in reserves. There are restrictions on how much of this can be spent, however, with donor terms directing 70 per cent of the annual distribution of funds. In fiscal year 2024, Harvard spent US$749 million on financial aid for students and 55 per cent of its undergraduates currently receive financial assistance.

But Trump has said nothing about the inequities of legacy admissions, and nor has he pushed universities to offer more financial aid to students: his vindictive gripes lie elsewhere. Central is his claim that American universities are rife with antisemitism and support for the Palestinian militant group Hamas.

In early March, responding to the findings of the administration’s Joint Task Force to Combat Anti-Semitism, the Department of Education threatened sixty institutions of higher education with potential enforcement actions if they do not fulfill their legislative obligation to protect Jewish students on campus.

The administration also expanded into higher education its attack on Diversity, Equity and Inclusion, or DEI, initiatives. In February the Department of Education issued a letter warning institutions to stop using “race-based preferences” in admissions, financial aid, hiring, training and other areas or risk losing federal funding. (These demands extend to Australian universities and research institutes that receive US research funds.) The department has launched investigations into fifty-two universities in forty-one states, accusing them of using “racial preferences and stereotypes in education programs and activities.” As part of its aggressive targeting of colleges and universities for allegedly flouting the president’s priorities, the department is also probing universities that allow transgender athletes to compete in women’s sports.

Trump has also taken aim at university endowments — which give universities a measure of insulation from his demands — by signing executive orders to enforce disclosure of large donations and foreign gifts. Other measures introduced by executive order would reshape the college accreditation system in line with the administration’s political priorities. Washington insiders report that the administration is planning to further up the ante by examining where endowments are invested — scrutinising them for ties to China, support for green energy and the application of environmental, social and governance criteria the White House doesn’t support.

On top of this, Trump’s One Big Beautiful Bill (yes, that’s what it’s actually called), passed by the Republican controlled House of Representatives and now in the Senate, raises taxes on university endowments. The tax rate, graduated according to the size of a university’s endowment relative to American enrolments (foreign students don’t count), would increase from the current flat rate of 1.4 per cent to a maximum of 21 per cent.

Add to that the impact on students, staff and academic visitors of antagonistic immigration policies, including the State Department’s recent announcement that it would stop interviewing applicants for student visas and “aggressively revoke” visas for Chinese students, and American universities and colleges clearly face a tough future.

Given the long history of attacks by Trump and his vice-president J.D. Vance on institutions of higher education, these hostile measures should be no surprise. In 2022, just weeks after announcing his third presidential bid, Trump announced a “free speech policy initiative” that would strip federal research dollars and student loan support from universities involved in “censorship activities or election interferences.”

Vance, a Yale graduate, now talks about his “totalitarian” alma mater’s “liberal bias.” In a 2021 speech entitled “The Universities are the Enemy” he declared that “we have to honestly and aggressively attack the universities in this country.” In 2024 he told CBS News that the United States “could learn from” decisions made by authoritarian Hungarian prime minister Viktor Orbán, including his controversial crackdowns on dissidents at universities.

In a speech to Yale University in April, Californian Democratic congressman Ro Khanna argued that Trump and Vance fear universities because they pose a threat to their consolidation of power in the executive branch. “Vance calls the university the enemy because he knows what lives here: historians, economists, law professors and scientists who threaten him not with force, but with ideas,” Khanna said.

Despite the early signals, universities and colleges have been shocked by the administration’s efforts to limit academic freedoms, the advancement and dissemination of knowledge and the ability of these institutions to support and protect students and staff from discrimination, inequities and, most recently, arrest and deportation.

Trump’s vengeance — for that is what it surely is — has been directed primarily at Columbia University (perhaps because his businesses have been engaged in a real estate battle with the university) and Harvard, the nation’s oldest university, both of which Trump and MAGA see as overrun with elites and liberals.

In contrast to the major law firms, media and IT companies and other institutions that have chosen to do deals with Trump, Harvard is taking a stand against what university president Alan Garber calls “assertions of power, unmoored from the law.” “The university will not surrender its independence or its constitutional rights,” Garber wrote. This has so far meant the loss of $2.2 billion in funding from the National Institutes of Health and $2.7 million worth of Department of Homeland Security research grants, and threats that the university will lose its ability to enrol international students unless it turns over records on visa-holders’ “illegal and violent activities.” Federal agencies have been instructed to cancel remaining contracts with the university.

“Everyone knows that Harvard has lost its way,” Trump has posted on social media. “Harvard is a JOKE, teaches Hate and Stupidity, and should no longer receive Federal Funds.” As always, he is fixated on making an example of those who push back against him. Trump says the “last thing I want to do is hurt them [Harvard]” but he maintains he has no choice, and Harvard is fighting back. “So Harvard has to behave themselves. Harvard is treating our country with great disrespect. And all they’re doing is getting in deeper and deeper and deeper. They’ve got to behave themselves,” he reiterated.

The attacks have continued. Trump has threatened Harvard’s tax-exempt status and, most recently, his administration has ordered it to stop enrolling international students. Although a federal judge has temporarily blocked the revocation of the university’s ability to enrol or keep its international students, the issue is far from resolved. Australian students and academics are among those in limbo.

Trump and his administration seem determined to undermine Harvard’s financial health and global influence regardless of the cost to the nation’s prestige and economy, to specialised knowledge and learning, and to innovation. They are using  Harvard as an example to scare other institutions into compliance.

Despite concerns about the rebellious ideas and political ideologies they might generate, institutions of higher education have occupied a special place in America from the nation’s beginning. Founding fathers Thomas Jefferson, John Adams and George Washington all saw education as a means of supporting the principles of liberty and republicanism. But the Federalists worried about colleges and universities being overcome with “seditious” ideas from the French revolution, while students aligned with Jefferson and his fellow Republicans claimed that Federalist educators were attempting to impose their own conservative dogmas.

The notorious McCarthy era brought efforts to “eradicate Socialism, Communism, and all forms of Marxism from the schools and colleges of America, and to stimulate sound American education.” A generation later, it was Republican president Richard Nixon who first said, “The professors are the enemy.” Nixon made that remark, later quoted uncritically by Vance, in a 1972 conversation with his national security adviser Henry Kissinger, towards the end of a series of campus disruptions, occupations, riots and police shootings.

But nothing has been as personally vindictive, hard-hitting on multiple fronts and lawless as the Trump attacks. “The way that the Trump administration has gone after Harvard — and higher ed in general — doesn’t really have any precedent in US history that I know about,” said influential economist and Columbia University professor Jeffrey Sachs in a recent interview with the New Republic.

Inevitably these attacks have been compared with crackdowns on universities by twentieth-century figures including Hitler, Stalin, Mussolini and Mao. In a more recent case, the Central European University (founded by George Soros) was forced out of Budapest by the increasingly authoritarian Viktor Orbán, ultimately moving to Vienna in 2018. But despite the lessons from the past, many American universities have leaned toward institutional caution and even retreat on policies like DEI.

In fighting back, the higher education sector is encumbered by two problems. The first is the longstanding and inherent reliance of tertiary education and academic research on government funding. This research is mutually beneficial, of course, with government-funded research producing an enormous variety of scientific, medical, technical and other breakthroughs.

The second is that many Americans are not supportive of higher education. Gallup polling over time shows an increasing proportion of adults say they have “little or no confidence in higher education.” Confidence has dropped particularly among Republicans, who say they are concerned that colleges push political agendas, are not teaching relevant skills and are very expensive. A 2024 Pew Research Center poll found that only a third of Republican voters (and 20 per cent of conservative Republican voters) had a positive view of colleges’ impact.

Some of this can be attributed to a network of right-wing and libertarian think tanks working closely with Republican politicians to manufacture a culture war against educators and academic institutions. (Ironically, many, if not most, of these people are graduates of elite universities.) Forgotten by many is how, after the second world war, universities became engines of social progress, with the GI Bill expanding access to college for millions of returning soldiers.

Increasingly this ill-feeling is also being generated by the White House. “A lot of Americans are wondering why their tax dollars are going to these universities when they are not only indoctrinating our nation’s students, but also allowing such egregious illegal behaviour to occur,” White House press secretary Karoline Leavitt said during a recent briefing.

For Trump, the battle itself is the whole point of this fraught and multifaceted campaign. It plays to the identity politics of his core MAGA constituency of white, non-college-educated, working-class voters. Most recently people in the administration have begun talking about the need for more people in trade schools rather than elite universities. That is merely a partisan talking point — there has been no effort to use the funds cut from Harvard or Columbia to fund vocational colleges. It’s also worth remembering that almost all of the Ivy League schools are in blue (Democratic) states.

In just a few short months Trump has inflicted serious and long-term damage on America’s higher education system. Despite their problems, these universities and research institutions have been an important source of America’s enormous economic prosperity and influence. It’s impossible to know how and where these efforts — what Vance describes as “necessary correctives” required for “basic democratic accountability” — will end. But there is one certainty: there will be long-term national and international ramifications. •

The post Trump’s war on knowledge appeared first on Inside Story.

In one sense this is not new: the big American pharmaceutical companies, mostly represented by industry group Pharmaceutical Research and Manufacturers of America, or PhRMA, have long had the PBS in its sights. It was certainly a sticking point when the Australian–US Free Trade Agreement was negotiated in 2003–04, though Australia’s negotiators managed to avoid concessions that would have raises the price of medicines. (They did, however, concede to pharmaceutical companies the right to demand a review of certain PBS decisions.)

But this time things will be very different: there will be no courteous, extended negotiations between parties. Trump will simply impose his will. And he seems unlikely to face any resistance from the two men working most closely with him on tariffs. Commerce secretary Howard Lutnick (though reportedly not thrilled with Trump’s erratic approach) has singled out Australia for dumping products on the US market; Peter Navarro, the senior White House trade and manufacturing counsellor, has made a targeted critique of Australia’s manufacturing industry.

How did we get to this seeming impasse? Trump’s tariff plan is designed to so more than simply respond to his own grievances about international trade rules. He also believes the tariffs will bring manufacturing back to the United States and make the nation “rich again.” He has even made the mathematically outlandish suggestion that tariffs could be used to replace federal income tax.

One of his first actions in January was to order the Treasury to establish an “External Revenue Service” to collect the tariff revenue he wants to use to pay down US debt and reduce taxes. Tax cuts are surely a further major driving force: the bipartisan Committee for a Responsible Federal Budget estimates that if Trump’s already-announced tariffs on China, Mexico and Canada come into effect, they’ll bring about US$120 billion a year into the US Treasury, and about US$1.3 trillion over ten years. Adding in some surprise taxes on imports from the European Union, Japan and Australia could bring the total to between US$200 billion and US$400 billion a year. Trump will need all of this and more for his tax cuts, which the committee estimates will cost somewhere between US$5 trillion and US$11.2 trillion over the decade 2026–35.

Treasury secretary Scott Bessent has laid out the key criteria the administration will use in setting its tariffs, which include what it sees as a country’s nontariff barriers, currency manipulation practices, industrial subsidies, labour conditions, and value-added taxes (like Australia’s GST). But the definitions are loose and Trump has ample room to define reciprocity in as self-interested a manner as he desires.

How is the PBS caught up in this? It’s hard to argue that Australia is “dumping” pharmaceutical products on Americans. Figures released by health minister Mark Butler show that Australia exported $2.1 billion worth of pharmaceutical products (mostly blood products and vaccines) to the United States last year against the $3.5 billion in American pharmaceuticals it imported. (The minister doesn’t say so, but presumably these figures are in Australian dollars.) Around 21 per cent of Australia’s imported pharmaceuticals come from the United States.

Some of the criteria used by the Pharmaceutical Benefits Advisory Committee for listing a subsidised medicine on the PBS — cost–benefit analyses, for example, and comparisons of new medicines with other similar products already on the PBS — could be described as non-tariff trade barriers.

But the most likely explanation is sheer opportunism on the part of PhRMA lobbyists, who see a chance to advance longstanding grievances about the tough conditions and price negotiations the US manufacturers face in getting their products — brand-name medicines, generics, biologics and biosimilars — listed on the PBS, which covers about 80 per cent of all prescription medicines for Australians. Labor’s efforts — at both the 2022 election and this year — to reduce PBS co-payments serve to make Australia a market where almost everyone with a prescription can afford to get it filled.

In an 11 March letter sent to the office of the US Trade Representative, PhRMA claimed that Australia’s “egregious and discriminatory” pricing policies undervalued American innovation. It outlined “significant unfair and non-reciprocal trade practices” encountered by PhRMA members here and in ten other major markets. It made particular criticism of the PBS process for requiring what it called “unnecessary” extra data from pharmaceutical companies, for administrative delays in listing new medicines, and for the “chilling effect” of its pricing policy.

This stands in contrast to the PhMRA submission, made in 2024, to the most recent annual review of the global state of intellectual property rights protection and enforcement. Although Australia is cited (along with Britain and countries in the European Union) as a developed market that allegedly undervalues innovative medicines, and although the submission refers to the fact that the PBS imposes automatic price cuts on medicines as soon as competing versions enter the market, Australia is barely mentioned. It doesn’t make the Priority Watch List PhRMA has drawn up for the US Trade Representative (which includes Russia, Japan, Canada and India) although it is on the Watch List (along with the European Union, Saudi Arabia, Egypt and Taiwan).

It’s hard to predict what will happen next. Trump, who is yet to speak out about this issue, hasn’t always been well-disposed towards the American pharmaceutical industry. In his first term he proposed tying the prices Medicare pays for prescription medicines to what other countries pay, but this (now somewhat ironic) proposal was never implemented. Then, having claimed credit for the Biden policy that lowered insulin prices, he couldn’t wait to undo Biden initiatives aimed at reducing prescription drug costs for Medicare and Medicaid recipients. An executive order to this effect was signed on the day of his inauguration.

Big Pharma hated Biden’s initiatives (PhRMA lost a lawsuit challenging the law that gave Medicare new powers to negotiate prescription drug prices) and so it is little wonder pharmaceutical executives now think they can work with Trump. But they may not find health secretary Robert Kennedy Jr., quite so malleable. Industry lobbyists have expressed concerns that Kennedy is bringing to the Trump administration an outright hostility towards innovative drugs, and especially vaccines.

There are a lot of contradictory positions in play, with most of the major players seemingly unaware of where their ideological stances are leading and oblivious to the fact that patients will bear the brunt of these trade wars. As health economist Luke Slawomirski pointed out recently in Crikey, if PhRMA gets its way then the proposed tariffs will make medicines even more expensive for American patients as well.

PhRMA is simultaneously lobbying the Trump administration to exempt pharmaceuticals from tariffs on the European Union, arguing that these would increase drug costs and create access barriers for patients. (The formularies American private health insurers use to restrict patient access to expensive medicines are already far more restrictive — and informed much more by cost — than the criteria used for listing these same medicines on the PBS.)

With both the Labor and the Coalition having vowed to protect Australia’s PBS, some obvious steps can be taken to protect the scheme from the accusation that it amounts to a trade barrier — and to improve Australians’ access to new medicines at the same time. After all, a central goal of the National Medicines Policy is the fostering of a “collaborative, innovative and sustainable medicines industry and research sectors with the capability, capacity and expertise to respond to current and future health needs.”

A Health Technology Assessment Review, agreed to by the Morrison government but implemented under Labor and delivered in May 2024, examined how the Pharmaceutical Benefits Advisory Committee assesses new medicines for listing on the PBS. As I discussed in Croakey Health Media last year, this was the subject of concerted lobbying by Medicines Australia, the Australian equivalent of PhRMA, among whose members are many of the American drug companies. The chief executive of Medicines Australia was a member of the review panel.

Many of the report’s recommendations have yet to be implemented. These include reducing the time taken to approve and list medicines on the PBS, greater transparency and engagement with stakeholders, and measures to tackle inequities in access to affordable medicines. Health Minister Butler has seemingly endorsed these proposals, at least in the broad sense. “The goal is faster access to the best therapies, at a cost that patients and the community can afford,” he said when the review was released. “Value for money remains paramount, because value is at the heart of patient benefit.”

An implementation group has been established but didn’t meet until 3 February. It’s time for some concerted action, sufficient (we might hope) to satisfy the more level-headed members of the Trump administration who might otherwise support punitive actions, but at the very least strengthening the PBS and making the case for its retention even stronger. •

The post Pharmaceutical warfare appeared first on Inside Story.

Trump’s decisions have far-reaching international consequences. American leadership of vaccination efforts in developing countries has evaporated, along with USAid funding for the programs. New Covid-19 variants are being discovered monthly and an array of other viruses are threatening — among them Marburg, Ebola and other haemorrhagic infections in Africa, Hendra and Nipah viruses in Southeast Asia, Japanese encephalitis in Australia and Asia, and mpox internationally. Many countries, Australia included, purchase essential vaccines from the United States, but its traditional primacy in developing and manufacturing new vaccines is threatened by major cuts to research funding.

On top of all this, misinformation about vaccine safety is pervasive, as is the growing vaccine hesitancy that has led to outbreaks of preventable diseases such as measles, polio, pertussis and hepatitis in many countries. And Trump’s withdrawal of the United States from the World Health Organization has undermined the ability to detect threats abroad and endangered negotiations over a pandemic treaty.

Public health experts in both the United States and Australians are watching with dismay as decades of global progress are put at risk. It seems pointless to expect Trump, his health secretary Robert Kennedy Jr, or his chief staff-slasher Elon Musk to reverse course. But can Australia avoid America’s backwards slide and even become a world leader in vaccines?

One clue lies in what’s happening on the ground in the United States, where the measles outbreak has spread to at least fifteen states. Despite Kennedy’s obfuscation — he has blamed poor diet for the outbreak, pushed vitamin A and other questionable treatments, and insinuated that measles infection confers a lifetime immunity that vaccination does not — many Americans, even vaccine sceptics, now realise they must get vaccinated. Shortages of the measles, mumps and rubella vaccine, or MMR, have been the inevitable result, especially in Texas.

Australians, meanwhile, have grown complacent about diseases, like measles, that are no longer common. (In recent years the only cases reported have been brought in by international visitors). The average immunisation rate among young children in Australia comes close to the goal of 95 per cent (and it’s  pleasing to see that immunisation rates for Aboriginal and Torres Strait Islander five-year-olds are higher than that). But rates have been falling overall, and parts of Australia are now vulnerable to disease outbreaks. Vaccination rates for children in the Richmond Valley, on the Gold Coast Hinterland and in Noosa, for example, are as low as 75 per cent and many adults are not fully immunised.

Australian authorities should also be cognisant of the vulnerability of Australian supplies of the MMR vaccine. The Merck and GSK vaccines approved for use in the United States are also approved in many other countries, including Australia, and shipments meant for export could be diverted for American use. The vaccine is made in Australia by Sequirus (part of CSL) but it’s not clear how much of the market they represent. An audit of local (and maybe Pacific Island) MMR vaccine supplies and potential demand would seem to be in order.

Although Kennedy has called the measles outbreak “a call to action for all of us” he has failed to make a strong case for vaccination. Whatever value might be attributed to his statement that “MMR vaccine is crucial to avoiding potentially deadly disease,” it was immediately undermined by the announcement that the Centers for Disease Control and Prevention is planning a large study looking into potential connections between vaccines and autism, despite all the research showing they are not linked.

The waste inherent in this ideologically driven exercise seems to have escaped Elon Musk’s cost-cutters. But it will revitalise the anti-vaxxers and worry vaccine sceptics globally. Already a newly elected WA upper house crossbencher, Legalise Cannabis WA leader Brian Walker, has suggested that childhood MMR vaccinations may cause autism and should be delayed.

As concerns rise about the potential for an H5N1 pandemic in humans in North America, Kennedy has interrupted efforts to increase the development and availability of bird flu vaccines, directing his department to re-evaluate a US$590 million contract with vaccine developer–manufacturer Moderna. Signed in the final days of the Biden administration, the contract would have helped Moderna develop and test mRNA vaccines, which are designed to protect against five subtypes of influenza, including H5N1, that could prompt pandemics.

The official rationale for the re-evaluation is that “four years of the Biden Administration’s failed oversight have made it necessary to review agreements for vaccine production.” But experts worry the decision could be a prelude to cancelling a contract they believe is critical to the country’s efforts to be ready for a bird flu pandemic.

The work on mRNA vaccines is especially important for bird flu. Most flu vaccines are currently made using a decades-old approach whereby viruses are grown in hen’s eggs and then inactivated. Production is slow and reliant on huge quantities of eggs, the supply of which is now threatened by outbreaks of H5N1 and other bird flu viruses.

H5N1 hasn’t so far been found in Australia, but it is already in Antarctica, where it is killing seabirds (many of which are migratory) and seals. Australian authorities need to be prepared for its arrival.

The other clue lies in Australia’s capacity to rise to the challenge. The good news is that Australia has a sterling reputation in vaccine research and development and has benefited significantly from the vaccine manufacturing capacity of CSL (once the government-owned Commonwealth Serum Laboratories), which has expanded internationally in recent years. Lessons learned from the Covid-19 pandemic and highlighted in the Halton report to the Australian government have underlined how important forward planning, vaccine readiness and self-sufficiency are in times of crisis.

The bad news is that Australia seems not to be taking an efficient, team-based approach to the threats. As the world marks the five-year anniversary of Covid-19 emergence, public health experts warn that Australia remains “grossly unprepared” for a future pandemic.

Last November Australian National Audit Office announced that it was looking into “the effectiveness of the procurement and contract management of onshore-manufactured antivenoms and vaccines” during 2020–22. This evaluation appears also to be looking at the Australian government’s $2 billion agreement with the US pharmaceutical firm Moderna to set up vaccine manufacturing in Australia. The deal was done with an overseas firm despite the fact that Seqirus, the CSL vaccine business based in Melbourne, had offered to make vaccines here more cheaply.

Using publicly available resources, it’s possible to trace how Australia’s shambolic efforts to secure adequate quantities of Covid-vaccine unfolded after health minister Greg Hunt responded to intense pressure by announcing on 13 May 2021 that the Morrison government would test the market for local manufacture. Hunt acknowledged that the government was already negotiating with Moderna about a new local facility, a fact that the company had disclosed to investors the previous day.

Despite a cheaper proposal from CSL, which already had facilities being built but didn’t yet have an approved COVID mRNA vaccine, the government announced in December 2021 that Moderna would build a manufacturing plant at Monash University capable of producing up to 100 million doses of vaccine a year. Commonwealth funding of $2 billion was included in the government’s 2022–23 Mid-Year Economic and Fiscal Outlook.

A media release from Monash University, dated 21 April 2021, had previously announced that the Victorian government would invest $50 million in mRNA Covid-vaccine manufacturing at the university. It noted that a team of Monash University researchers had  developed Australia’s first COVID-19 mRNA vaccine candidates the previous year, and had received a Medical Research Future Fund, or MRFF, grant in collaboration with the Doherty Institute to develop the vaccine. Further MRFF funding would finance a Phase 1 clinical trial.

The Department of Health and Aged Care announced the deal in these terms: “The Australian government has entered into a ten-year partnership with Moderna and the Victorian government that will see Moderna build an mRNA vaccine manufacturing facility at Monash University Victoria.” Interestingly, the statement links to a media release from prime minister Anthony Albanese, dated 14 August 2022. Labor appears to have concluded the deal initiated under Morrison.

In a 28 September 2022 interview with health minister Mark Butler, Radio National’s Patricia Karvelas enquired about vaccine contracts and negotiations underway with Moderna and Pfizer at that time. Intriguingly, Butler made no mention of the government’s efforts to develop onshore vaccine manufacture for COVID vaccines — although he did say he had met with the global head of Moderna just that week.

Making the dates align here is a challenge. My guess is that, at the height of the Coalition government’s failure to secure an adequate and timely supply of Covid-19 vaccines for Australia, Morrison and Hunt looked to link up with what Victoria was doing with Monash University and the Doherty Institute, and then Moderna was somehow invited in, pushing CSL aside. The final deal was presumably struck under the Albanese government, which came to power in May 2022.

Unknown at this point is whether Moderna stood to gain any mRNA intellectual property from ground-breaking work funded by the federal and Victorian Governments, and if so, what was paid for this. Also unknown (although this is likely to be investigated by the Audit Office) is whether the deal won the Morrison government better prices on their Moderna vaccine purchases.

Work on the vaccine manufacturing facility at Monash began in December 2022. Two years later, on 4 December last year, Butler issued a media release announcing that “the Southern Hemisphere’s only mRNA manufacturing facility has opened in Victoria.” The facility will have the capacity to produce up to 100 million vaccine doses each year for a range of respiratory diseases including Covid, influenza, and respiratory syncytial virus.

Moderna says it will supply vaccines for the Australian winter respiratory season in 2025. But one important milestone is still to be met: the facility must gain regulatory approvals from the Australia’s Therapeutic Goods Administration — and from authorities in countries like the United States if there are plans to export its vaccines overseas.

The Moderna partnership will face some serious local competition. Despite failing to win the federal–state mRNA contract, CSL/Seqirus has affirmed its commitment to accelerating its proprietary self-amplifying mRNAx vaccine program. These sa-mRNA vaccines have better immunogenicity than conventional mRNA vaccines. A sa-mRNA vaccine against the JN-1 Covid variant produced by CSL with Arcturus Therapeutics is approved in Japan for immunisation in adults eighteen years and older.

The Victorian government also has a strategic partnership with BioNTech, announced in December 2023, that will see the company establish a clinical-scale mRNA manufacturing facility and an mRNA Innovation Centre in Melbourne. BioNTech partnered with Pfizer to develop the mRNA vaccine licensed as Comirnaty, which was the first Covid vaccine to receive regulatory approval in Australia. The company is also working on mRNA platforms for cancer drugs, and this may be its major focus in Victoria.

In New South Wales the Perrottet government announced in September 2021 that it would make a $96 million investment in a pilot facility to spearhead a local RNA and mRNA manufacturing industry. The facility, in partnership with all NSW universities, will include laboratories and pre-clinical trial spaces that will enable early-stage mRNA-based drug development. Progress towards this goal has been slow: construction of the site at Macquarie University only commenced in September last year.

Universities and research institutions in other states are also moving ahead with research, testing and manufacture of mRNA vaccines and medicines. The University of Queensland and the Brisbane-based biotechnology company Vaxxas are developing a microneedle patch-based mRNA vaccine for Covid. Moderna is also a partner in this effort. (The patches deliver the vaccine to immune cells below the skin’s surface without the need for needles or a cold-chain.) Some small-scale manufacture of these patches appears to have taken place, but where will future large-scale manufacture occur? The chances are it will be one more Australian biomedical success story that moves offshore. Or will Moderna come to the rescue with their new facility in Victoria?

There is much to celebrate in this explosion of effort. The key story here is the strength of Australia research and development in this important and burgeoning new area of mRNA-based medicines and vaccines. These efforts are an important aspect of preparedness and self-sufficiency for any future pandemic. Relying on a single manufacturer and/or supplier would have its dangers, and competition might help with keeping vaccine prices low. A strong capacity could also enable Australia to help with vaccine supplies to developing nations, especially in the South Pacific.

But Australia has too often failed when it comes to commercialising research. That summary of vaccine-related research and development efforts reveals insufficient coordination and cooperation in the expensive business of scaling up manufacturing.

True, a $10 million April 2023 grant from the Albanese and Malinauskas governments will help the South Australian firm BioCina scale-up and produce mRNA vaccines in quantities sufficient for clinical trials (though not for mass production.) And the NSW government is building a large-scale manufacturing facility for mRNA vaccines targeted at animals, but vital for controlling outbreaks, because it turns out that all the other facilities being built in Australia are only for human vaccines. (It’s pertinent to note here that CSL used to make vaccines for livestock and domestic animals but sold its Animal Health business to Pfizer in a deal finalised last year.)

And you do have to ask how much vaccine capacity a nation of twenty-seven million people needs and how much it can afford. Just as there are dangers in putting all our manufacturing eggs in one basket there is also a danger of being seduced into financing state rivalries and spending valuable government funds on duplicative efforts. A national, team-based approach is needed. Is this a task for the new Australian Centre for Disease Control?

Finally, as Australian journalist Natasha Robinson points out, Australia is building an impressive vaccine capacity at a time when vaccine hesitancy is growing. Developing new vaccines for emerging infectious diseases and achieving vaccine self-sufficiency must be accompanied by transparency about how these vaccine have been tested and approved and public education programs about why they are so important. •

The post Vaccination nations appeared first on Inside Story.

Labor is always keen to play to its apparent strength as Medicare’s creator and capitalise on voters’ belief that Coalition governments are more likely to cut or privatise health services. And opposition leader Peter Dutton’s rating as Australia’s worst health minister is too tempting a campaigning point for a government seeking to blame its opponents for the 2014–15 federal budget cuts — made during his ministerial tenure — that caused much of the damage it claims to be repairing.

Labor’s Mediscare campaigns have become a familiar feature of Australian election campaigns, and they work because almost always enough evidence exists to make the claims against the opposition credible. The campaigns are often posited in the terms Albanese used at the National Press Club: that the election is all about “a choice between two fundamentally different approaches and vastly different agendas.”

Labor recognises that access to medical care is increasingly difficult and unaffordable. Treatment costs for people with ongoing health issues are a major impost and too many are missing out on needed care. When medications and primary care are forgone, pressure grows on crowded emergency departments and hospital services. The reality is that Medicare no longer offers universal healthcare.

All of the causes of this malaise are widely recognised, but so far they have been poorly tackled. The increasing burden of mental health problems and the growing number of people with multiple chronic and complex conditions, combined with increasingly difficult access to community-based specialist care, imposes a huge burden on general practices. Delivering and managing this care is not adequately rewarded by Medicare payments. Additionally, Medicare payments have not kept pace with inflation and the operational costs for doctors and other healthcare workers.

These problems were made worse by the Coalition’s decision — under Tony Abbott, Malcolm Turnbull and then Scott Morrison — to freeze the indexation of Medicare rebates between 2014 and 2020 and pocket more than a billion dollars in savings.

For many years, Medicare rebates matched costs to the extent that doctors were able to bulk-bill most patients and faced constraints on what they could charge other patients in out-of-pocket costs. That constraint no longer exists, and the average out-of-pocket amount paid by a patient who isn’t bulk-billed has risen to $43.38.

Debate about the value of bulk-billing rates as a measure of affordable access is intensifying. But falling rates do indicate increasing costs for patients, and they do provide politicians with a simple way to laud Medicare funding efforts and criticise failures to provide adequate support.

Health minister Mark Butler and his colleagues have highlighted the positive impact of the tripling of bulk-billing incentives for concession card–holders and children under sixteen, which Labor introduced in November 2023. But independent research shows that the number of GP clinics bulk-billing patients has fallen over the past two years and bulk-billing is no longer available in one-in-ten federal electorates. The Coalition has seized on this data, with shadow minister Anne Ruston claiming that “it has never been harder or more expensive to see a doctor than under the Albanese Labor government.”

The reality is that only about 48 per cent of Australians are always bulk-billed when they see a GP, with a further 24 per cent usually bulk-billed. It’s a postcode and socioeconomic lottery.

Labor’s latest announcement looks to tackle this inequity by extending the triple bulk-billing incentive — previously confined to Commonwealth concession card–holders and children under sixteen — to all Medicare cardholders. It says this will deliver another eighteen million bulk-billed GP visits each year and boldly promises that nine-in-ten GP visits will be free of out-of-pocket expenses by 2030. Importantly, the new policy also tackles the need for an expanded primary care workforce by funding 400 hundred nursing scholarships and 2000 new GP trainees a year by 2028.

This quick bandaid solution to a complicated problem has been well received by voters and most GPs. So it didn’t take the Coalition long to realise that a me-too response would avoid the election trap that Labor had set. Dutton and Ruston announced that in government they will match Labor’s $8.5 million commitment “dollar for dollar.”

In a show of one-upmanship they also boosted their package to $9 billion by adding in a previously announced $500 million to restore the number of Medicare-subsidised psychology sessions to twenty. (In a controversial move, but based on expert advice, Butler cut the number to ten in 2023.)

We might justifiably be nervous about this announcement. It’s a big step for the Coalition, which constantly alludes to its conservative economic management credentials, to adopt such an expensive policy within hours of its announcement. Did they not have their own health policy proposals under development? But perhaps it should not be a shock given that the Coalition raced to match Labor’s $573 million women’s health package before it had even been launched.

We soon learnt that the Coalition health commitments will be paid for by cutting thousands of public servant jobs — essentially all the positions created under Labor to replace the very expensive outside consultants employed by its predecessors. Dutton has been open about his quest for budget cuts but says there will be no cuts in health. Is this believable?

Still, it looks like this approach to bulk-billing will be Medicare policy regardless of who wins the election. Will it work?

One problem is that the proposed funding boost doesn’t lift rebates, which doctors say are too low to cover the cost of longer mental health consultations and other common GP visits. Among the variety of responses from the medical profession, the president of the Australian Medical Association says that the $20 bulk-billing incentive won’t cover out-of-pocket cost averaging more than $40 in some metropolitan centres and better-off suburbs.

One key problem is that we know little about the business costs of general practice and how these vary by location. The increasing corporatisation of general practice may also be a factor determining what is seen as an appropriate financial incentive to bulk-bill.

A further challenge is making sure the healthcare workforce is available where it matters. More is needed than a simple increase in the number of training places. Despite improved training and a lift in the supply of specialist rural GPs, an August 2024 report projected an overall under-supply of GPs over the next twenty-five years.

One way to tackle workforce shortages and simultaneously improving health outcomes is to look beyond general practice to primary care more broadly. When done well — as it is by Aboriginal Community Controlled Health Organisations and in community health clinics — coordinated and multidisciplinary care can very effectively meet patient needs. The primary-care workforce includes GPs, nurses, nurse practitioners, allied health professionals, midwives, pharmacists, dentists, and Aboriginal health practitioners, paediatricians and geriatricians.

This integrated approach is hindered by fee-for-service funding and medical organisations’ opposition to non-clinical members of the primary care team being given direct access to Medicare payments. But viable reforms have been proposed by a range of expert groups convened by both political parties.

In fact, every major review of the healthcare system over the past quarter-century has recommended moving away from an excessive reliance on fee-for-service. The Morrison government’s Primary Health Care 10 Year Plan and the current government’s Strengthening Medicare Taskforce Report and Review of General Practice Incentives all point to the need for more flexible blended payment models, especially for treating people with chronic and complex conditions. If GPs are mollified by increased Medicare funding and if Labor gets a second chance at governing, maybe an idealist could hope such reforms could happen?

Even assuming that an increased investment of $8.5 million improves access to GPs, or — optimistically — that efforts are made to expand access to primary care services, a huge and expensive gap remains: the availability and affordability of out-patient specialist care. Medicare now covers just 52 per cent of specialist fees, forcing Australians increasingly to dip into their own pockets. In 2022–23, out-of-pocket costs for private patients for specialist consultations amounted to $2.3 billion. Those who can’t afford private fees are left to languish on public waitlists.

New public hospital agreements with the states and territories might include sufficient funds to tackle these long waiting lists (although this would be unlikely under a Coalition government). The National Health Reform Agreements were recently extended for just one year as negotiations continue over state and territory responsibilities, especially in relation to the NDIS, with a funding increase for 2025–26 of 12 per cent and a one-off contribution of $1.7 billion.

One final plea. To improve health outcomes and eventually reducing the pressure on the healthcare system from preventable chronic conditions such as obesity, diabetes, cardiovascular conditions and now long Covid, government policy makers need to including healthiness in the healthcare system. Lip service is paid to the importance of prevention and the need to tackle the social determinates of ill-health, but these issues can’t be handled adequately within a healthcare system that is relentlessly focused on illness.

All of the necessary reforms will take time, investment, vision and bravery. The process must start with solid initial commitments that are continued, expanded, refined and supported over the decades ahead. That means a bipartisan approach that looks at Australians’ health needs well beyond the next election cycle. And that means the major political parties must drop their political ideologies and gotcha campaigning. It’s a lot to ask, but the dividends could be enormous. •

The post An unhealthy Mediconsensus appeared first on Inside Story.

As it ripped through Florida and the swing states of Georgia and North Carolina, Hurricane Helene became the deadliest North American hurricane since Katrina in 2005. Hurricane Milton followed, sweeping across much the same areas Helena had wrecked just days before. Many have been killed and millions displaced. Homes, businesses and livelihoods have been destroyed; key infrastructure and services — roads and transport, schools, water, electricity, mail, internet — are out of action.

History gives some indication of the impact these disasters, and the partisan responses, will have on voters’ decisions.

Hurricanes Katrina and Rita in 2005 created staggering problems for state and local elections in Alabama, Louisiana, Mississippi and Texas, reports a paper from the Congressional Research Services. A year after Katrina hit New Orleans in August 2005, more than half of the city’s residents had not returned in time for the city’s mayoral primary. Turnout was most affected in the hardest-hit areas, which were disproportionately poor and Black, and clearly advantaged Republicans. The federal response to Katrina, widely perceived as a politicised failure, badly damaged president George W. Bush, a fact he acknowledged in his 2010 memoir Decision Points.

Hurricane Sandy slammed into the eastern seaboard, particularly parts of New Jersey and New York, just a week before the 2012 presidential election. Republican senator Mitt Romney was looking to unseat president Barack Obama, but among those who praised Obama’s response to the storm was New Jersey’s Republican governor Chris Christie, a strong Romney supporter who had been a vocal critic of Obama. A photo of Christie and Obama shaking hands as the president arrived in New Jersey to survey the hurricane damage was later used against Christie in his 2016 run to be the Republican presidential candidate.

Hurricane Michael hit Florida’s panhandle in October 2018, just ahead of the midterm elections. A study concluded confusion about the consolidation of polling places contributed to a drop in voter turnout. Not surprisingly, and not only in this case, disaster-affected people have so many immediate concerns that investigating how to vote becomes too difficult — a barrier compounded when officials have little time to deal with voting procedures, voting machines and voting places.

Further hampering the federal government’s response to the latest hurricanes has been greater politicisation and misinformation. Republicans are seeking to use the disasters as a political tool against Kamala Harris and the Democrats. In the forefront are Donald Trump, his vice-presidential running mate J.D. Vance and Republican lawmakers who have repeatedly and falsely claimed that Federal Emergency Management Agency, or FEMA, funds are being used to help illegal immigrants rather than hurricane victims and that president Joe Biden’s administration is ignoring states’ requests for assistance.

Trump’s dissemination of these untruths is made even more egregious by the fact that he played the very games he is accusing Biden and Harris of. As president he repeatedly hesitated to help areas he considered politically hostile and ordered special treatment for pro-Trump states.

This time round, Florida’s Republican governor Ron DeSantis —whose response to major hurricanes in 2022 is credited with helping him win a second term — was playing politics even before Hurricane Milton landed. He refused to take Harris’ calls about hurricane relief, although he has spoken to Biden.

Along with the search for missing people, the distribution of emergency aid and the cleanup, the affected states are making efforts to ensure that people can vote. North Carolina, a battleground state with a Democratic governor, has already introduced emergency measures: early voting will start on 17 October, as planned, although there are fears that disruption to the US Postal Service’s operations could prevent people from receiving their mail-in ballots.

In another battleground state, Georgia, secretary of state Brad Raffensperger — who famously stood up to Trump when he sought to thwart the 2020 election results — is readying back-up plans to deliver absentee ballots and ensure that voting locations are functional, voting machines are undamaged, the election is held fairly, and election workers are not subject to threats. With Republicans preparing to contest the results in that state, the ability of all Georgians to vote is imperative.

Even DeSantis, in Florida, has signed an executive order giving election officials in affected counties greater flexibility in administering early and absentee voting.

The key question, of course, is what these voting conditions mean for the election outcome. The affected states are all crucial to the tight presidential race and even slight shifts in turnout or voting patterns could change the result. Trump’s intensified barrage of lies might well reflect Republican concerns that the latest weather events have been disproportionately felt in Republican-leaning areas.

Trump leads by two points in Georgia and less than one in North Carolina, according to the Washington Post’s polling averages. Together these states account for more than a third of the electoral votes in the seven key swing states. Florida — Trump’s home state — leans Republican; if the Harris wins there, gaining thirty electoral college votes, she will almost certainly win the presidency. Some pollsters consider Florida to be in play; even a minor shift in voting numbers or intentions could make it so.

Aside from the delivery of voting papers, access to polling stations and a fair and efficient count, the key factor in hurricane-affected areas will be voters’ perceptions of the adequacy of the Biden administration’s assistance and the contrast with what Trump would deliver. Will voters recognise and respond to Harris’s competence and compassion? With neither Trump nor Vance showing much empathy for hurricane victims (“You’ll be okay,” Trump said, even as hurricane deaths were being reported), many could agree with Biden: “Former President Trump, get a life man. Help these people!”

For the moment, FEMA is reported to have adequate funding to deliver aid, but when or if that runs out there will be problems. Republican House Speaker Mike Johnson is refusing Biden’s pleas to bring back Congress — currently in recess as members campaign — to pass a bill increasing disaster assistance. Democrats are reminding voters that many of the same Republican lawmakers who are demanding federal aid for their districts voted against the most recent authorisation of funds for FEMA. They are also pointing to the extremist Project 2025’s proposal that a Trump administration commercialise government weather forecasting and drastically scale back FEMA’s responsibilities.

It will be interesting to see if recent extreme weather events bring climate change to the fore as an issue for voters elsewhere in the United States. A recent Gallup poll had climate change well down the list of voter concerns, with just half of those polled rating it as extremely or very important. Trump dismisses climate change; Harris calls it a “global challenge.” Make America Great Again conspiracists, meanwhile, are promulgating theories that the recent hurricanes were engineered to help Democrats in next month’s election. •

The post Eye of the storm appeared first on Inside Story.

Pelosi got what she always wants — a path to a victory. She did it in the same way she has wielded so much power over the years: with careful listening and ruthless vote counting, a keen sense of what motivates her Democratic colleagues, an ability to persuade and negotiate, and an unsparing refusal to yield even when defeat seems inevitable. Her comments that morning highlighted what is often referred to as her “iron fist in a Gucci glove” approach.

In her new book The Art of Power (a cheeky jab at Trump’s The Art of the Deal?) we learn how Pelosi developed these skills and used the power they brought. Although the book is subtitled My Story as America’s First Woman Speaker of the House this is no mere outline of her path from Californian housewife and mother of five to House speaker and, as such, second in the presidential line of succession. (She was elected speaker twice, for the four years 2007–11 and for another four years 2019–23; her only predecessor to hold the position twice was Sam Rayburn in the 1950s.)

Rather, this book is for political aficionados who love the dealings essential to enact any legislative agenda; for the policy wonks who appreciate legislative acumen and the ability to keep a political party as diverse as the Democratic Party united; and for those who will cheer on an instinct for political theatre and political survival. This is a leader who also ensured her fractious caucus members had food and drink to sustain them while they hashed out political agreements and a woman who knows how to make a fashion statement even while she’s delivering an eight-hour filibuster speech on immigration rights.

The Art of Power starts out with Pelosi’s description of the horrifying October 2022 break-in at her San Francisco home. In recent years Pelosi has become a lightning rod for conservative Republicans’ anger, as exemplified when rioters broke into the Capitol demanding “where is Nancy?” on 6 January 2001, the same words used by the intruder who attacked her husband Paul. In a chapter that highlights the price politicians and their families can pay for their public roles, Pelosi makes a plea for an end to political violence, physical and verbal.

The remaining chapters are taken up with Pelosi’s accounts of the political action around the issues close to her heart that have often generated controversy and opposition, including human rights in China and Tibet, HIV/AIDS and healthcare reform, and those — the global financial crisis, the US invasion of Iraq, the two impeachments of Donald Trump, Joe Biden’s post-Covid legislation — that arose during her time as speaker.

Pelosi has for decades been an outspoken critic of human rights abuses in China; in fact, human rights in Tibet and China book-end her political career. Although she never explains the genesis of this commitment, it is clear that the people she has met and helped along the way have reinforced her resolve.

After the Tiananmen Square massacre of 1989, which came just two years after she entered Congress, Pelosi led a House resolution condemning the Chinese government’s actions. Human rights in China “are not an internal matter,” it said, but a concern for the whole world. She also sponsored a bill aimed at shielding Chinese students studying in the United States, but it was vetoed by then-president George H.W. Bush.

In 1991 she was part of a group of lawmakers who unfurled a banner in Tiananmen Square proclaiming: “To Those Who Died for Democracy in China.” In more recent years she was among the first to sound the alarm about China’s predatory trade policies and efforts to prop up authoritarian regimes.

One of the last trips she made as speaker, in August 2022, was to Taiwan. This was seen by many, especially the Chinese government, as highly provocative but Pelosi says she was determined not to let president Xi Jinping isolate Taiwan and she saw the issue as a matter of conscience.

It is this hawkishly independent streak, and her insistence on “honouring our values,” that has put her at odds over China with every administration. She disagreed with Bush the elder over his concessions to Beijing and failure to protect Chinese students; with Bill Clinton when he delinked trade and human rights in 1994; with Bush the younger when he refused to impose diplomatic boycotts on the Olympic Games held in Beijing in 2008; and with Joe Biden when he tried to prevent her Taiwan trip.

Pelosi’s account of 9/11 terrorist attacks and the war against Iraq highlights how her willingness to speak out was enabled by her long tenure on the House intelligence committee. She was drawn to the committee — not an obvious choice for a new member of Congress — by a concern about nuclear threats, but then issues of terrorism took over and she became incensed by what she saw as the misuse of 9/11 as a rationale for the war on Iraq.

In October 2002 — with Republicans in control of the House, Democrats holding a single-seat majority in the Senate, and midterm elections looming — Pelosi led a rebellion against the Iraq war resolution negotiated with George H.W. Bush’s White House by Democratic minority leader Dick Gephardt. The resolution passed, but Pelosi, as Democratic whip, had managed to persuade 126 Democrats to vote against it.

The following month’s elections were unusual. Despite a Republican occupying the White House, House Republicans gained seats. Gephardt resigned his leadership post, saying Democrats need someone to put “our party back in the majority,” and Pelosi became the first woman to lead either party in Congress.

It took her time to achieve Gephardt’s wish, but in 2006 she oversaw a midterm election campaign that swept the Democrats into majorities in both chambers. She became the House’s first female speaker, sworn in surrounded by young children, including her own grandchildren.

Pelosi plays down the magnitude of this breakthrough. She instead spends considerable time outlining how she worked to assert her core values — diversity, expansion of the leadership team, open communication. For a speaker’s actions to be strategic, respected and timely, she explains, it is vital to know what members of the caucus are thinking. “I considered myself a weaver at the loom,” she writes. “Every member is an essential thread in the tapestry our caucus is weaving.”

For those interested in policy and politics, perhaps the meatiest section of The Art of Power is the section titled Meeting Domestic Challenges. Here, Pelosi outlines efforts to deal with the global financial crisis, which overlapped with the George W. Bush and Obama presidencies, and healthcare reform. She makes it plain that she believes the GFC stemmed from the Bush administration’s regulatory failures and a lack of leadership from the White House; indeed, she claims that it was her phone call to Treasury secretary Hank Paulson that jolted Bush into action.

Her outline of the rushed and confused efforts to develop and enact the Troubled Asset Relief Program, or TARP, are frankly quite scary. The first attempt to get the enabling bill through the House failed on a 228–205 vote; it was one of the few times Pelosi lost a floor vote. Only sixty-five Republicans backed the plan despite pleas from Bush, and a significant number of Democrats also saw it as overly expensive. But the bill did pass a few days later and was signed into law on 3 October 2008.

In December, in the dying days of his presidency, Bush used his executive authority to declare that TARP funds could be spent on any program that Paulson deemed necessary to alleviate the crisis. Pelosi was further angered when the funds went primarily to stabilising banks, a move that ignored the act’s requirement for assistance to be given to homeowners facing foreclosure. Although she spends much less time discussing it, she obviously sees the American Recovery and Reinvestment Act, one of the first bills Barack Obama signed into law, as the better rescue plan.

Few major bills have a neat, linear journey, but the legislative path of the Affordable Care Act (also known as Obamacare) was among the most difficult, contested and knotty in recent times. Views clashed over the role of government, access to healthcare and abortion as a right, and how healthcare costs should be covered. Pelosi provides a long and detailed description of the process that delivered these important healthcare reforms. “I considered my role to be that of maestro,” she says.

But the tribulations of steering the legislation through Congress were as nothing compared with what followed: the need to deal with wholesale misinformation and disinformation about its effects, the problems in its implementation, and the endless Republican attempts to repeal the legislation and cut funding. Had Hillary Clinton won in 2016, says Pelosi, she might have retired from Congress; instead she stayed on, largely to protect the Affordable Care Act.

Pelosi undoubtedly deserves much credit for getting Obamacare enacted. But here I must add a personal caveat to my endorsement of this chapter: I think Pelosi does a disservice by failing to highlight the seminal work undertaken by the energy and commerce committee, its chairman Henry Waxman and his staff, and its chairman emeritus John Dingell.

My credentials for offering this (perhaps biased) opinion? I was in Washington DC during that exciting era and was a bit player in the efforts to get the Affordable Care Act written and enacted during my time at the Center for American Progress. I had previously worked on the energy and commerce committee, and during that period my husband Bruce Wolpe was on Waxman’s staff. (Indeed he later wrote a book, The Committee, about those legislative efforts.)

Of course, many readers will be attracted to this book to learn more of Pelosi’s view of Donald Trump. And it’s all there, delivered in what are, for the most part, surprisingly moderate tones. Early on, she writes about their first White House meeting with Trump, who informed her that he had won the popular vote (yes, it was an issue even then). “If we are going to work together, we must adhere to the facts,” she responded, and that set the tone for their meetings during his term in office.

Pelosi also tells the story of 6 January 2021 from her viewpoint. The House Democratic leadership team had prepared for this day — the day when Congress would certify the electoral college results — knowing that many Republicans would resist, state by state. But when the threat came it was from outside, with the invading rioters having selected her office as one of their prime targets. She was dragged from the speaker’s chair by Capitol police and taken to Fort McNair, with no time even to grab her phone.

Small wonder, then, that she wanted “a man we saw as deranged and unhinged and who was still president of the United States” to suffer consequences. Elsewhere she writes: “The theme of the Trump years might have been ‘I gave him every chance to work together and he gave me no choice but to impeach him’.” Which, in January 2021, she moved to do, for the second time.

Nancy Pelosi has not written a typical autobiography or even a feminist manifesto. What The Art of Power reveals is a woman who was not willing to endlessly wait her turn in Congress, nor to shy away from hard work. That capacity to buckle down became even more obvious when she assumed leadership positions. “A successful speaker can’t ever be surprised by anything,” she writes. (That’s clearly not a lesson the current Republican House speaker, Mike Johnson, has learned as he struggles to get his caucus to pass legislation to avert a government shutdown.)

There can hardly be a more male-dominated bastion of power or a more male-dominated pecking order than party leadership positions in the House. But Pelosi took on these challenges confidently, without doubts and without faltering (or at least none that she admits to). She increased her power by being generous — by offering more positions and more diversity, by helping with fundraising and campaigning, and by mentoring. When she arrived in Congress in 1987 just twelve Democratic women sat in the House; today there are ninety-one. She also increased her power and influence by helping to enact (or, where necessary, thwart) the legislative agendas of four presidents. And she is pragmatic: while she clearly always knows who the enemy is, she also knows that tomorrow is another day.

Finally, as The Art of Power shows, she is capable both of shaping the narrative to her benefit and creating a little drama. Her sarcastic slow clap during Trump’s 2019 State of the Union address and her theatrical shredding of Trump’s 2020 State of the Union speech will live on as political memes long after her retirement from the Congress. •

The Art of Power: My Story as America’s First Woman Speaker of the House
By Nancy Pelosi | Simon & Schuster | $34.99 | 352 pages

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The Democrats’ energy and unity (and ridicule) has left the Trump–Vance campaign floundering. Trump has abandoned speeches designed to promote policies in favour of his usual rants and personal attacks. Robert Kennedy Jr’s endorsement has served only to highlight the Republican Party’s focus on its current voter base rather than efforts to expand it.

Meanwhile, the post–Democratic convention polls are starting to come in. They show that Harris has been able to turn around the dire polling she inherited and build on her gains. Her standing has rapidly increased and her fundraising has broken records by appealing not just to traditional Democratic voters but also to independents, young voters, non-white voters and women voters.

Yesterday’s aggregate of national polls from FiveThirtyEight shows that Harris, on 47.1 per cent, led Trump by 3.4 percentage points. That’s still very close — and, more to the point, the electoral college system renders national polls almost meaningless: it’s the candidate who gets 270 or more electoral college votes who wins, not the one who wins the popular vote.

More usefully, an analysis published yesterday by National Public Radio, based not just on polling but also on historical trends and conversations with political strategists, shows all seven of the most closely watched swing states are now toss-ups. Harris has taken a consistent though narrow lead in the so-called Blue Wall states of Wisconsin, Michigan and Pennsylvania. In the Sun Belt, Trump holds an almost two-point lead in Georgia, and Harris and Trump are within one point of each other in North Carolina, Nevada and Arizona. All of which points to a very close race.

The upcoming debates between Trump and Harris and Vance and Walz may serve to further differentiate the candidates, assuming of course they take place. Trump has recently suggested he might skip the 10 September debate, a possible sign that Harris has unnerved and discomforted him.

Most of the media focus is on the presidential race — not surprisingly, given that both presidential candidates have declared (for different reasons and in different ways) that the future of the United States is at stake. But when Americans go to the polls in November they will confronted with  a range of other voting decisions.

These will certainly include the question of who should represent their congressional district in the House of Representatives (all 435 seats are up for election) and may also include choosing among candidates for the Senate (thirty-four of the one hundred Senate seats are up for election), for state governor, the state legislature and other state-level offices, and for county, city and regional offices including school boards, the sheriff and judges. There’s more: some electors will be asked to vote on abortion rights, how taxes on the sale of recreational marijuana should be spent, and other special ballot initiatives.

With the Republicans currently holding 218 seats in the House of Representatives, the minimum needed for a majority, the battles over the few seats that could deliver control will be fierce and expensive. For reasons including the advantage of incumbency and the degree of gerrymandering in each state, only about twenty-two seats are seen as genuinely competitive by pollsters like the Cook Political Report and 270ToWin.

Even in these most-competitive seats the polling is sparse. Predicting voting outcomes is further complicated by the fact that some voters will split the ticket, voting differently for president and members of Congress. When Joe Biden was still on the ticket, that trend was forecast to be quite pronounced this year. It remains to be seen if that will change under Harris.

In the absence of sufficient polls, media reports (for example, here) suggest that the Democrats are seeing new energy, better internal polling numbers and new donations under Harris and Walz. It’s said that battleground Democrats who once shied away from Biden are suddenly jumping at the chance to campaign with the top of the ticket. In the coming days, new polling should begin to show if the presidential candidates have coattails that their congressional colleagues can ride on. Candidates in more conservative areas, on the other hand, might have fared better with Biden rather than Harris as the presidential candidate.

The Senate’s fifty-one Democrats hold a small majority (including three independents who align with them). With this kind of margin, every vote counts, and the absence or defection of any members often means a bill will fail to pass.

Thirty-four Senate seats are up for election in 2024 (including a special election in Nebraska to complete the term of Ben Sasse, who resigned last year). But the Democrats have much more at risk: they hold twenty-three of those seats, with only eleven held by Republicans. Many of the seats up for re-election are either in states where Trump has done well or the contest is close.

Two senate races are currently considered toss-ups. Both are held by Democratic incumbents — Jon Tester in Montana and Sherrod Brown in Ohio — and both appear to have been boosted by Harris’s ticket. A recent poll had Tester in Montana (a state Trump won by sixteen points in 2020) finally pulling ahead of his Republican opponent by five points after having lagged for some months. Brown has also recently taken the lead in his race. The sums of money being spent here are huge; Open Secrets estimates Tester has raised US$43 million and Brown US$52 million.

Rated by 270ToWin as leaning to the Democrats are Senate races in Nevada (the Democratic incumbent is Jacky Rosen), Arizona (an open race, with Democratic candidate Ruben Gallego running against Trump-supported Kari Lake), Wisconsin (the Democratic incumbent is Tammy Baldwin), Michigan (an open race, with Elissa Slotkin as the Democratic candidate) and Pennsylvania (the Democratic incumbent is Bob Casey). Texas and Florida are rated as leaning to Republicans.

These last two races are becoming very real opportunities for the Democrats to flip. In Florida, the deep-red home state of Donald Trump, Republican governor Ron DeSantis is slipping in popularity, giving Latina Debbie Mucarsel-Powell a chance to beat incumbent Rick Scott. And in Texas, another deep-red state, African-American Colin Allred’s chances of defeating incumbent Ted Cruz are rising.

Interestingly, recent data from the Cook Political Report shows Democratic Senate candidates running strongly in every swing presidential state, leading outside the margin of error in races in Arizona, Michigan, Nevada, Pennsylvania and Wisconsin, and far outpacing Harris’s support. Perhaps, despite the prognostications above, vote-splitting will remain a feature of this election?

Harris’s performance has also given Democrats greater reason to hope they can chip away at Republican dominance at the state level than they had just a few weeks ago. Gubernatorial races are on the ballots in thirteen states. These races are important given the increasingly critical roles states play in issues like Medicaid expansion, access to abortion and transgender care, school curricula, and what books can be in school libraries.

Ultimately, as the Cook Political Report’s David Wasserman points out, the major factor in deciding who controls federal and state legislatures is the most obvious one: voter turnout, which Democrats expect will be boosted by the Harris–Walz ticket. Many voters will also be energised by abortion-related constitutional amendments on their ballots. This has been a winning issue for Democrats in the post-Roe era and could boost support for Democratic candidates in states like Montana, Florida, Nevada and Arizona.

Harris has opened up a number of paths to the 270 electoral votes she needs to secure the presidency. But it is still a very tight race, and much could change in the days ahead. There is a very real chance that the Harris–Walz ticket can help the Democrats win back the House, but as it currently stands, the Democrats’ path to holding the Senate is precarious. Hard work — or luck or fate — could change all that for both the Democrats and the Republicans. •

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One of the factors compounding household economic stresses — and an area of strength for the Democrats —  is the cost of healthcare. A tracking poll conducted for the health policy organisation KFF earlier this year showed healthcare topping the list of basic expenses Americans worry about, ahead of petrol, food and rent. Despite more than 90 per cent of the population having some form of health insurance, medical debt remains a persistent problem.

The United States spends more on healthcare than any other developed nation, yet it has lower life expectancy than in comparable countries and the highest maternal and infant mortality rates. Racial and ethnic disparities continue to influence the quality of care and access to services. With 90 per cent of the nation’s $4.5 trillion in annual healthcare spending going to people with chronic and mental health conditions, coordinated interventions to prevent and manage these diseases could have significant health and economic benefits and improve worker productivity.

And that’s not to mention the health, social and economic costs of gun violence, the opioid crisis and the conservative right’s success in reducing abortion access and women’s reproductive freedoms.

How would Democratic candidate Kamala Harris and Republican candidate Donald Trump tackle these issues? And what is driving their approaches, policies and commitments? So far, the information from both sides has focused on ideology and slogans rather than policy specifics. The KFF has pulled together a detailed comparative analysis of what is known to date about the two presidential candidates’ positions on healthcare, but more revealing is the record of both presidential tickets and what has so far been promised on the campaign trail.

Although Harris hasn’t yet laid out her policy agenda, she has said that she plans to deliver a policy platform focusing on the economy in this coming week. Specific issues seen as key to her campaign’s success are also likely be discussed during the Democratic National Convention later this month.

Harris inherits and is likely to build on Joe Biden’s healthcare agenda. Biden’s presidency was shaped by huge health-related decisions, including mass vaccinations against Covid-19 and scaled up testing; a revival of the “cancer moonshot” he spearheaded as vice president; steps to close the gender gap in medical research; executive orders to protect abortion access after the Supreme Court overturned Roe v Wade; Medicaid demonstration waivers to allow the states to expand health insurance coverage; allowing Medicare to negotiate drug prices; and limiting the cost of insulin.

Despite Republican opposition, Biden has come closer than any American president to the elusive goal of universal health coverage, building on the provisions of the Affordable Care Act — better known as Obamacare — which is now more popular and more used than ever. In 2024, 92.3 per cent of the US population, or 316 million people, have some form of insurance coverage.

Harris says her views on healthcare were shaped by her mother, cancer researcher Shyamala Gopalan, who died of colon cancer in 2009. As attorney-general of California she focused on the impact of large-scale of healthcare company mergers and clashed with major insurers, hospitals and drug companies. She isn’t afraid to aggressively use anti-trust laws to resist companies’ anti-competitive behaviour. More recently she has cemented herself as the Democrats’ foremost advocate of abortion rights.

If he’s elected vice-president, Tim Walz will undoubtedly be an active player on health, healthcare and the social determinants of health, including school food programs, schoolgirls’ access to period products, gun control, access to IVF services and gay rights. His stand on these issues is influenced by his father’s death of cancer when Walz was nineteen, leaving his mother drowning in medical debt. As governor,  he signed legislation banning medical providers from withholding medically necessary care because of unpaid debt and banned the transfer of medical debt to a patient’s spouse.

Walz was a strong supporter of veterans’ benefits legislation while he was in the House of Representatives, where he also backed legislation to regulate tobacco products. He has spoken out in favour of protecting access to fertility treatments, citing his family’s struggle with infertility.

For some health policy experts, Walz is seen as a pragmatic healthcare champion; for others — those who focus on the state laws he signed making abortion a fundamental right in Minnesota, ensuring medical care for transgender people and legalising marijuana — his record is anything but moderate. On healthcare, his policies align with Harris’s. From abortion rights to healthcare affordability to medical debt, he has sought to do at the state level what Harris aims to accomplish federally.

Pinning down the Trump–Vance healthcare goals is much harder. Of the twenty core promises on Trump’s website, the only one that directly refers to health is a pledge to “fight for and protect social security and Medicare with no cuts, including no changes to the retirement age.” Other than that, what Trump and Vance say varies from day to day, depending on whether they are talking to campaign audiences or television interviewers.

Trump seems aware that the traditional Republican opposition to surgical and medical abortion, fertility treatments, medical services for transgender people, the Affordable Care Act, and adequate spending on Medicare and Medicaid programs is seen as threatening by many voters, even his own supporters. On these, he has endlessly prevaricated, and even unilaterally changed the Republican Party platform. So far, nothing he’s said or done is likely to convince undecided voters, despite leaving him at odds with his party’s very conservative, mostly evangelical, right wing.

Trump has predicted (wrongly, most political analysts would say) that abortion is “going to be a very small issue” in this election. “I think the abortion issue has been taken down many notches,” he said during a news conference at Mar-a-Lago. “I don’t think it’s a big factor anymore.” He has refused to answer when asked if he would direct the Food and Drug Administration to revoke access to mifepristone, a medication used for abortions. And he won’t say how he will vote on a proposed Florida state constitutional amendment that would overturn the state’s six-week abortion ban, although he has predicted the vote on it would wind up in a more “liberal way.”

This is not an issue Vance has dared to bring up during his speeches in five battleground states. When asked in a TV interview about women in red states who are unable to abort non-viable pregnancies, he simply responded: “What President Trump has said is we are gonna let voters make these decisions.”

Trump has said he will not support cuts to Medicare and Medicaid, although he has said he would cut waste and fraud in those programs — a popular euphemism for funding cuts. He made a similar promise eight years ago yet his administration’s 2020 budget proposal cut Medicaid by $1.5 trillion and Medicare by $845 billion.

Rather than repealing the Affordable Care Act, Trump is now promising to make it “much better, stronger and far less expensive” if he wins in November. That’s a promise he was unable to deliver on in his previous term. The popularity of the Obama-era healthcare law makes this a fraught issue for Republicans, especially as most of the big increases in enrolments have been in red states including West Virginia, Louisiana, Ohio, Indiana and Texas.

A frequent feature of Trump’s campaign speeches is his commitment to “not to give one penny to any school that has a vaccine mandate.” This statement ignores the fact that every state in the nation has vaccination requirements for children to attend school. It also ignores a recent report from the US Centers for Disease Control and Prevention showing that routine childhood vaccinations have prevented approximately 508 million cases of illness, thirty-two million hospitalisations and more than a million deaths since 1994.

Both Trump and Vance have engaged in vicious attacks on the lesbian, gay, bisexual, transgender and queer community and those who would provide their healthcare. Human rights organisations widely criticised the Trump administration as one of the least friendly to these communities; more recently they have called out Vance for his “cruel record.” This level of discrimination and rolling back of rights would continue under a second Trump presidency.

Much has been made of the Heritage Foundation’s Project 2025 program, which includes chilling plans for the Department of Health and Human Services and its associated agencies. With this blueprint having become an effective focus of attack for Democrats, Trump has sought to distance himself from the document and its authors. His claim that he has no idea who is behind Project 2025 has been thoroughly debunked, and his efforts were further undermined when news came that Vance has written the introduction to a book by Heritage Foundation president Kevin Roberts, chief author of Project 2025.

Just over eighty days remain until the election. In that time Harris and Walz must build on their honeymoon start and define themselves and their policy priorities. The signs so far are encouraging — one poll, for the Financial Times, even has Trump trailing on the economy for the first time — but more effort will be needed to consolidate gains and win over critics, sceptics and those not currently paying attention.

Harris and Walz must overcome President Biden’s difficulty in communicating the economic and health benefits delivered by the current administration. In particular, they must deal with the economic and healthcare disparities and insecurities experienced by many communities, especially people of colour. They must explain how healthcare funding (properly targeted) is an investment in the nation’s future and the economy. Above all, they must build trust with voters that they can deliver on these commitments in a timely and equitable fashion. •

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All the Republican’s post-convention euphoria has evaporated. Trump, once the news media’s main focus, is now the irrational old man of this campaign. His vice-presidential choice, J.D. Vance, has been shown up as callow and inexperienced. The Republican National Committee and Trump’s campaign staff are racing to rework their campaign strategy.

Recent polls reflect these changes. New figures this week from the New York Times/Siena College, the Wall Street Journal and CNN  all show a tightening from the six-point lead Trump had after the debate with Biden, putting Trump’s current lead over Harris within the margin of error. A just-out poll from Bloomberg/ Morning Consult shows Harris has wiped out Trump’s lead in seven battleground states.

Importantly, Harris appears to be bringing back young voters and Black and Latino voters while holding the older and white voters who had stuck with Biden. As she shifts the electorate, Harris is creating more potential pathways to the White House and bringing states like Arizona, Georgia, Nevada and North Carolina back into play.

The continuation of Harris’s honeymoon will depend in no small part on who she chooses as her vice-presidential running mate. This announcement is expected to come ahead of the Democrats’ virtual delegate vote for their presidential candidate, which could be as soon as tomorrow. Well-placed sources indicate that Harris plans to tour battleground states next week with her vice-presidential pick.

We can be certain that Harris will not repeat Trump’s mistake when he chose Vance. By seeking to cement the future of the MAGA movement, he ignored the fact that Vance, who was poorly vetted by Trump insiders, is in no way qualified to be a heartbeat away from the Oval Office.

As a fit and energetic fifty-nine-year-old, Harris can afford to focus less on who could step into her presidential role and more on someone who has the experience to be an effective running-mate from day one while, of course, sharing her values. She also needs someone who will balance the ticket by offsetting her disadvantages (she has repeatedly been labelled a “San Francisco liberal” by Trump), building on her advantages (in tackling women’s reproductive freedom, for example) and maximising the Democratic vote in battleground states.

It’s implicitly accepted that the vice-presidential candidate should be — arguably must be — a White male. To quote Washington Post correspondents Ashley Parker and Dylan Wells, “the degree and speed with which the conventional wisdom took hold — that if she wants to win, Harris must choose a White man as her vice president — reflects, at its most cynical, that the nation will tolerate only so much deviation from its White male founding, even as the overall political world is more diverse than ever.”

The names now mentioned most often are Pennsylvania governor Josh Shapiro, Minnesota governor Tim Walz, Arizona senator Mark Kelly and Kentucky governor Andy Beshear. Others once on the list — including Michigan governor Gretchen Whitmer, California governor Gavin Newsom and North Carolina governor Roy Cooper — have withdrawn their names. There is one other possibility: secretary of transportation Pete Buttigieg, who may be the Democrats’ best communicator. Alas, as a gay man he faces that same lack of tolerance highlighted by Parker and Wells.

All the possible candidates, including Buttigieg and those who have withdrawn, have supported Harris in the days since she assumed the Democrats’ presidential mantle. They serve to highlight the party’s depth of talent — which in turn highlights how imperative it was for Biden to heed the call to make way for the next generation.

In recent days the media has focused on the sixty-year-old Walz, who served twelve years in Congress representing a Republican-leaning, mostly rural Minnesota district. According to one insider, he has “the Midwest grit, the Midwest sensibility and that appeal goes beyond the Midwest.” He speaks well to rural America while maintaining a progressive record in a state that trends Democratic.

Walz is skilled at pushing back hard against labels such as “big government liberal.” “There’s nothing extreme about feeding kids,” he told Washington Post columnist E.J. Dionne, defending his school lunch program. “There’s nothing extreme about women making their own healthcare decisions. There’s nothing extreme about saying don’t demonise these trans children. Just make a place for them. We’ll all be okay.”

In fact, plain speaking seems to be common to all the likely candidates. “You’ve got to show up everywhere, and you’ve got to speak to everyone, and you’ve got to speak in plain language and in practical terms,” Shapiro says. What has been described as the “lacerating force of Buttigieg’s relentlessly unflappable delivery” has been much in evidence as he has taken on Fox News and spoken out against Trump and Vance.

While less known for his oratory skills, Kelly — a former Navy pilot and astronaut — is seen as a strong contender on the strength of both his personal and his strategic appeal to Harris and her team. He could be vital in helping to deal with Harris’s weakness on border issues and  immigration — a weakness countered somewhat by the slew of Arizona border-town mayors, some of them Republicans, who have endorsed Harris in recent days. An added asset, and a force in her own right, is Kelly’s wife, former representative Gabby Giffords, who has been a leader of the movement to end gun violence since she survived an assassination attempt in 2011.

Regardless of who she ultimately chooses, Harris has a whole team already working on her behalf. Zoom fundraisers by Black women, White women, Latinas, gay men and even White Dudes for Harris have triggered a dormant Democratic base, galvanised volunteers and raised millions of dollars. Evidence already suggests that the Democrats’ tying of Trump’s campaign to the unpopular Project 2025 agenda has angered Trump and forced the Heritage Foundation to consider ceasing or downgrading that work.

Election day is still more than ninety days away, and much can and will happen during that time. Debates between the presidential and vice-presidential candidates are no certainty. The vitriol we have seen to date from the Trump team will continue, although clever Democratic efforts to turn criticisms into positives (such as the attacks on Harris’s laugh) seem to be having an impact and the dismissal of Trump and Vance as “weird”  is helping defang the Republicans’ campaign of fear. Inevitably, though, slip-ups, errors and maybe even disastrous moves will need to be managed by the Harris team.

Harris has a lot to do in a short time; she must build and consolidate a team, introduce herself to the country, listen to voters’ concerns and indicate how she will deal with them, push back on Trump’s MAGA agenda, and turn this election to the issues that matter to Americans and will preserve their freedoms and the nation’s democracy. First stop: her choice of running mate. •

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Although Biden’s move had been presaged in some quarters, most of the signals from the White House were that he would hang on fiercely but precariously and perhaps wrongly. There is every indication that, after several weeks of Democratic upheaval, he finally gave in to the strategic arguments put forward by former House speaker Nancy Pelosi and others.

Biden’s announcement was a shock but not a surprise. He had been under enormous pressure since his dreadful performance in the presidential debate in June, with a growing chorus of those worried not only about the Democrats’ chances of winning the White House but of gaining back the House of Representatives (once seen as a real possibility) and retaining the Senate (always going to be difficult).

The immediate response from Democrats has been a mix of relief, excitement and fear. This move resets the race for the presidency in ways that Democrats don’t yet comprehend and Republicans fear. Biden has quickly been portrayed as a patriot, as someone who has (finally) put his country first, and as a president whose substantial legacy is now, if not absolutely safe then much safer. Donald Trump now has a competitor for “hero” status.

Despite Biden’s endorsement, Harris is not yet the Democratic candidate. Others might well try to enter the race, though that would severely muddy the waters and irreparably damage Harris’s, and their own, chances. The cleanest path forward would be a consensus that Harris is the nominee. We can be certain that Pelosi and other senior Democrats are already working towards that end. It would lead to an open convention where Biden’s delegates (now released from voting for him) would vote as a block for Harris.

Any challenger faces a tough path. They would have to gain the signatures of at least 300 of the delegates who were previously committed to Biden before the start of the Democratic National Convention on 19 August in order to put their candidature forward. And if their bid is successful and they receive the Democratic National Convention nomination, time would then be taken up with negotiations over access to the funds and campaign organisational structures that currently belong to the Biden–Harris campaign. The hope is that potential candidates like governor Gavin Newsom of California and governor Gretchen Whitmer of Michigan, both of whom have previously said they will not run against Biden, will strongly stand behind Harris.

If Democrats can coalesce with enthusiasm and some very hard work around Harris, beating Donald Trump in November becomes much more likely. That, after all, is the prima facie case for Biden stepping aside.

While Harris currently polls little better than Biden nationally, she has good support from women, young people and voters of colour; she will need to make some major efforts to attract white male voters, especially those who are less well educated. She should do what she can to appeal to never-Trump voters who supported Nikki Haley.

A large part of her ability to lift the Democratic support eroded under Biden will depend on who she chooses as her running mate. That person will almost certainly be a white male, either a state governor or a senator. The names most often suggested include Pennsylvania governor Josh Shapiro, North Carolina governor Roy Cooper, and Kentucky governor Andy Beshear. Any one of these could help with votes in key states.

Of course, the elephant in the room is Harris’s sex and race. Since she was elected vice president she has constantly faced a nasty barrage of sexist, racist comments; this will now escalate to appalling levels. What impact this would have on the vote is less clear.

Trump and the Republicans had started down this road well ahead of Biden’s withdrawal. At the Republican National Convention, speaker after speaker linked her to policies on illegal immigration, calling her Biden’s “border czar.” Conservative media have declared she would be a Diversity, Equity and Inclusion president — far from a positive description. The nastiness on this issue should be held back somewhat by the very fact that J.D. Vance’s wife is of South Asian descent, though that logic is unlikely to hold throughout the MAGA camp.

It’s fascinating to imagine the response to all this is in the Republican camp. It has surely upset their current strategies. Trump is notoriously uncomfortable around strong women and people of colour, and Harris knows how to get under his skin. Within hours of the Biden announcement, the attacks had begun.

Rather than responding in the spirit of magnanimity he momentarily adopted at the party convention, Trump described Biden as “the worst president by far in the history of our country” and, true to form, issued a fundraising appeal on the basis of his new opponent. “If Joe Biden is not fit to run for president, he is not fit to serve as president,” House speaker Mike Johnston posted on social media. “He must resign the office immediately.” There will be much more along these lines in the days ahead as Republicans seek to undermine Biden as a lame duck president.

The final problem for Harris is the future campaign roles of current White House staff and powerful and respected Democrats. Will those senior staff who have been so loyal to Biden over so many years work willingly with Harris to help her campaign? Has she finally dealt with the issues that saw a substantial turnover in her own staff? And will the Obamas, the Clintons, and Biden and his family be the ardent champions across the nation that she needs?

Harris has said she is honoured by Biden’s endorsement and that she intends to “earn and win” the Democratic nomination. She has already made history as the first woman and first woman of colour to be vice-president; now she stands at the brink of another historic leap at a crucial time in American political history. •

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It was the culmination of a very different sort of Republican convention, forcibly coordinated by Trump family and aides, with the usual politics and policy issues giving way to unabashed adulation of Trump, the source of all solutions to all the problems, real and imagined, besetting the United States and its citizens. The ebullient mood was boosted by drama elsewhere about Joe Biden’s capacity to govern and ability to win.

The expectation was that this would be no ordinary acceptance speech. The bloodied hero who had chanted “Fight, fight, fight” as he was lifted from the stage at the Butler, Pennsylvania, rally was apparently a changed man, humbled by his brush with death, looking to soften his divisive and harsh rhetoric. Just the day after the shooting Trump had called for unity and a broad resistance to “Evil.”

Trump’s speech began with his sombre — if highly reworked and elaborated — description of his shooting, and the first twenty minutes gave some signs of a new political focus. “I am running to be president for all of America, not half of America, because there is no victory in winning for half of America,” he said.

But then he turned away from his prepared remarks and returned to the customary meandering attacks on his political rivals, the litany of America’s dystopian troubles, some fanciful riffs on his imagined successes as presidency and his unique ability to address current issues and, of course, diatribes against his victimisation.

Unity got the occasional mention, but now they were much more barbed. “We must not criminalise dissent or demonise political disagreement, which is what’s been happening in our country lately at a level that nobody has ever seen before,” Trump said. “In that spirit, the Democrat Party should immediately stop weaponising the justice system and labelling their political opponent as an enemy of democracy. Especially since that is not true. In fact, I am the one saving democracy for the people of our country.”

More than ninety minutes later, it was painfully obvious that the new Trump was the same old Trump. His push for unity didn’t mean abandoning his divisive politics; more likely it was a call for his opponents to stop criticising him, even a plea for sympathy. As Philip Bump wrote in the Washington Post, “The imaginary Trump ‘unity’ pivot was just another demand for fealty.”

At a time when the Democrats are in disarray — perhaps even in the throes of replacing Biden as their presidential nominee — Trump’s ego and lack of discipline seem to have again lost him the opportunity to expand his political base. There was little in this speech to woo the Never Trumpers, those who voted for Nikki Haley in the primaries even after she had withdrawn her candidacy, or the Biden doubters.

As weak as Biden (or any other Democrat) appears in the current polls, Trump can’t win in November without expanding his support beyond his rusted-on, ultra-conservative, Make America Great Again base. But he appears to have little interest in doing so.

His selection of J.D. Vance as his running mate exemplifies this mindset. He could have chosen an African American (for example, senator Tim Scott from South Carolina), a Hispanic (senator Marco Rubio was apparently being considered) or a woman (after all, he did welcome Nikki Haley’s return to the Trump camp) as a means of broadening his appeal. But he chose a young white man with virtually no experience in government.

It’s a pick that plays to the ideology of the populist right. The hope is that it will help secure Republican votes in swing states like Pennsylvania, Michigan and Wisconsin, all of which are essential for a Democratic path to presidential victory. And it could mean that the elderly Trump is looking to lock in MAGA Republicans for years to come.

As a member of the so-called “New Right,” an ideology fervent about Christian nationalism and America First anti-internationalism, Vance is in many ways more MAGA than Trump, despite his every recent conversion to the Trump side of politics. Vance, like Trump, is adept at telling people what they want to hear. For both of them, political principles are negotiable or can be couched in hazy language.

This is highlighted by the considerable efforts Trump has made to deny his strong links to those who have produced Project 2025, the conservative manifesto for a second Trump term. His staff reworked the Republican platform into Trump language — including the usual unnecessary capitalisations — that avoids all specifics on controversial issues like abortion. It was noticeable that Vance’s acceptance speech made no mention of aid to Ukraine, a divisive issue in the Republican party.

Christopher Rufo, a conservative activist at the Manhattan Institute, describes Vance as “still thinking, still learning, still positioning,” which could also mean he’s malleable to Trump’s will. As president, Trump is unlikely to hand him much responsibility, so a yes man is ideal. Vance has already indicated he would have done what vice-president Mike Pence refused to do — ignore the constitution and try to derail certification of Trump’s 2020 election loss.

But Vance has ambition and may be impatient. A possible early conflict was on show at the convention. Trump, who is courting both labour and business, seems willing to risk some corporate alienation on issues like tariffs and immigration as long as Vance can send the right messages to the blue-collar voters who are now key Republican supporters. If it gets difficult, Trump will almost certainly take the side of big business, with consequences for Vance’s blue collar vision.

Several other ominous signs suggest that a second Trump term would mean legally dubious business-as-usual, or worse. Both Paul Manafort (Trump’s 2016 campaign chairman who was jailed for financial crimes) and Peter Navarro (a former Trump advisor who was jailed for contempt of Congress) were feted at the convention.

Outside the convention, the legal cases against Trump have been dismissed (perhaps temporarily) or are proceeding at a snail’s pace.  The US Supreme Court has ruled that he has broad immunity from prosecution for any acts he may commit as president. And even if he fails to win the presidency, there is likely trouble ahead: there are reports that the Republican Party is busy laying the groundwork to contest loss in an election they claim is already being rigged against Trump.

With his legal woes fading, his control of the Republican Party complete, his deification sealed and the Democrats with no certain presidential candidate, Trump should now be facing the next few months at his zenith, unstoppable and confident in a November victory. The stars aligned to present Trump with the perfect opportunity to crush the Democrats’ chances. Instead, with a speech seen in most quarters as a squandered opportunity, he has given them hope.

For now, we are back to two old men — both unpopular — running for the most powerful political office in the United States. Increasingly, though, the signs are that one side of the equation could change very soon, with Biden leaving the race, but Trump may have lost the advantage inherent in this Democratic debacle. •

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This pivotal time in American politics — nationally and internationally — has been engulfed by the fallout from Biden’s dreadful debate performance. The oxygen has been sucked from the room by fevered discussions about Biden’s age and health and the viability of his re-election campaign, by calls from members of Congress for him to go or stay, and by the question of how deluded Biden’s family and staffers might be about his mental and physical capacities and polling numbers.

Despite the urgency of the war in Ukraine and the need to shore up NATO financing, even Biden has said that his work at the summit will be judged in the context of his continued ability to do his job.

The White House has just announced that the president, together with NATO allies, will deliver new weapons to strengthen Ukraine’s air defences to help protect their cities and civilians from Russian strikes, and Biden has just signed a bipartisan bill aimed at bolstering the nation’s nuclear power. Yet White House media briefings have become sparring matches over Biden’s health, and the media are more interested in a letter released by Kevin O’Connor, Biden’s personal physician.

This is a nightmare for the Democrats. It severely detracts from their ability to campaign against Trump, to highlight the consequences of a convicted felon — a felon granted almost complete presidential immunity by the Supreme Court — again occupying the Oval Office, and to promote the achievements of the Biden presidency.

The coverage of the presidential debate intensified this lopsided view of the American political world, with the emphasis much more on Biden’s problems than on Trump’s endless lying. The situation has only worsened since.

Just this week, ahead of next week’s Republican convention, the Republican National Committee adopted a new party platform. Lost in the focus on Biden’s health was the fact that the document was drafted by Trump staff, was approved behind closed doors, and now more closely aligns with Trump’s views, including on key issues such as a federal abortion ban, which has consistently been unpopular in public polling.

Only the more liberal media are challenging Trump’s claim that he knows nothing about the Heritage Foundation’s Project 2025, the extremist provisions of which are currently being pushed by those who see themselves as part of his second administration.

The question of who Trump will nominate next week as his vice-presidential running-mate has also been neglected. And barely anyone has noted that Trump was not seen on the campaign trail for almost a fortnight until he appeared in Florida today.

The focus on Biden’s capacity to be president now and through a second term also turns a spotlight on vice-president Kamala Harris. She is, after all, the next in line to the presidency.

Two points are worth making. The first is that Harris is very effectively assisting Biden in pitching key policy issues, including the stark contrast between Biden and Trump on reproductive health and gun control. After a rocky and much-criticised start, observers note that she has become an effective communicator and skilled advocate on these issues. Her specific campaign task is to reach out to critical Democratic constituencies, especially women and African Americans. She is also at the forefront of the party’s outreach campaign to Asian-American voters.

Second, Harris has clearly had Biden’s back during this current crisis. She routinely drags the focus back to beating Trump and away from concerns over Biden’s health. She has resisted questions about whether he should withdraw and hand the baton to her.

As calls grow louder for the president to step aside, though, some high-profile Democrats — including South Carolina Congressman Jim Clyburn, who helped Biden win in 2020 — are unifying behind Harris as the candidate to replace him. Congressman Adam Schiff of California told NBC’s Meet The Press that the imperative was beating Trump; Biden must “win overwhelmingly or he has to pass the torch to someone who can.” Harris, he added, could “very well win overwhelmingly” against Trump.

At this point that seems a very optimistic statement. Harris’s current favourability ratings are low (no better than Biden’s) and she’s a frequent target for Republicans. “Vote Joe Biden today, get Kamala Harris tomorrow,” says an advertisement from Trump’s campaign. Latino voters will play a decisive role in this election and their support for Biden is increasingly eroding; but they are not sure about Harris (or any other Democrat) either. Reports are mixed about whether Harris’s efforts to reach out to young voters are succeeding.

Still, some polls offer hope. In a CNN survey released on 2 July that found voters favour Trump over Biden by six percentage points (49 per cent to 43 per cent), Harris trailed Trump by just two points (47 per cent to 45 percent), which is within the margin of error. The same poll found that independents support Harris over Trump (43 per cent to 40 per cent) and moderate voters of both parties prefer her too (51 per cent to 39 per cent).

Only Biden can decide if he will go, and at this stage that still seems unlikely. Should “the Lord Almighty” convince Biden to quit the race at this late stage, essentially only two possible mechanisms exist for choosing his replacement. As my partner Bruce Wolpe has pointed out, they both come with huge transactional costs.

The first — and arguably the most logical — would be for Biden to step aside and direct his convention delegates to support Harris. That would look like Biden playing the kingmaker in defiance of party (and voter) wishes.

The second is that Biden could release his delegates and let the party decide whom to nominate. As proposed by Democratic advisor James Carville, this might be done in a sort of mini-primary based on a series of public events and debates. That sounds to me like a recipe for chaos, a situation that would benefit only Trump and Republicans.

If something happened to cause Biden to withdraw after his nomination at the convention, then party rules give the Democratic National Committee the power to fill the vacancy after its chair consults Democratic governors and congressional leaders. In this case, Harris would be the simple choice, but there is no guarantee. It would probably be another terrible mess that would affect Democrats down the ballot in the congressional elections.

To continue with these hypotheticals, all of which fly in the face of Biden’s commitment to stay on: it has been suggested that, if Biden does quit the race, he should resign the presidency and hand it over to Harris. This would at once relieve Biden of the problems associated with being a lame duck president and better position Harris to win from incumbency in November.

Meanwhile, who will Trump put forward on his vice-presidential ticket? The Trump campaign has sought documents from at least eight potential running-mates, but who knows how the final choice will be made when it rests with a man as volatile, narcissistic and insecure as Trump. The pundits posit that Trump is looking for someone who is a successful fundraiser and that he sees the process as the casting of a co-star (although presumably not someone who would steal his thunder).

It would make political sense to choose a woman, a person of colour and/or someone who would help Trump win votes in a swing state. Given all these factors, that might put Tim Scott, a Black senator from South Carolina who has worked hard to ingratiate himself, at the top of Trump’s list. But perhaps that’s just too logical.

In the end we must worry as much about who Trump chooses to be his vice -president as we do about Biden’s continuing candidacy and Harris’s chances. Why? Because Trump’s state of health is unknown, his mental capacity is clearly failing, he is a convicted felon with more charges awaiting adjudication — and because his choice may eventually (like his previous vice-president Mike Pence) be the ultimate decision-maker on American democracy. •

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There was also much at stake. For the Democrats, Joe Biden needed to show he was up to the task of protecting the United States (and the world) from the feared consequences of a second Trump term. For the Republicans, Trump needed to be on-point and persuasive enough to convince voters he could be trusted again with the reins of power.

But the debate had barely begun before the pundits were highlighting Biden’s obvious failings and frailty, even as they called out Trump’s continual lies.

Previous debates have shown that perceptions of performance — ahead of policy discussions and factual presentations — crown the winner, though voters generally find the debates useful rather than determinative. With his age always a strike against him, Biden’s debate performance was humiliating for him, concerning for his staff and not at all reassuring potential voters. When the fact checking is over (too little, too late) Trump should also be humiliated, but the chances are that he and the MAGA Republicans will be more than happy with the night’s performance regardless.

What now for the Democrats? Since Biden first declared he would run again, there have been those, in the party and outside, who have talked about an alternative. Biden’s claim that he is the only candidate who can beat Trump rings increasingly hollow for many, and calls to replace him are now being openly voiced.

At least three significant steps are required for this to happen, all of which should preferably happen ahead of the Democratic Convention, which begins on 19 August.

First, Biden must be persuaded to step aside. Perhaps only his wife and family and the senior advisors he trusts can broach this sensitive topic. At this late stage, primaries have been held in all fifty states and a new candidate would have no delegates. But a transfer of the candidature would only happen if Biden was happy to urge his delegates to support the proposed candidate.

Secondly, the Democrats must unite behind the alternative candidate. Ideally the decision about who would run should not take place amid the chaos of the convention floor. Who could lead the party to such a consensus?

And finally, who would be the best candidate under these difficult conditions? Linked to that question is the issue of what to do about vice-president Kamala Harris.

Harris would be the de facto pick as a Biden replacement if not for her very weak polling numbers (her approval rating currently stands at 38 per cent, according to FiveThirtyEight). Aside from California governor Gavin Newsom, who has been seen as running a “shadow campaign” for the White House, any of a raft of Democratic state governors could potentially be in contention.

Those prospects include J.B. Pritzker (Illinois), Gretchen Whitmer (Michigan), Jared Polis (Colorado) and Josh Shapiro (Pennsylvania), all of whom have been preparing the ground for a run in 2028. Whitmer is in many ways the most interesting — she was described in the Atlantic as having a “foul-mouthed irreverence, goofy humour, and ability to pound beers and disarm adversaries” that might especially disconcert Trump — but each of them has done well in recent gubernatorial races.

No doubt more than one of them would be happy to have their arm twisted if Biden stepped aside. A potential driver could be the possibility that independent candidate Robert F. Kennedy Jr could siphon off disappointed Biden voters. Of the candidates listed above, Newsom and Whitmer (and of course Harris) have the best national name recognition.

The biggest hurdle any new Democratic presidential candidate would face is that political challenges (for that is how Biden stepping aside would be seen) are always tricky and would provide extra ammunition to Trump and more grist to the mill for Republicans. One lesson from the debate is that Trump will not hold his fire and is never afraid to bend or even disregard the facts.

Biden’s saving grace may be that (1) replacing him is a fraught task with a political cost and (2) it’s a long time from this debate until the election (indeed it’s a long time from this debate to the second, scheduled for September).

In that space Trump will be sentenced in New York  on thirty-four felony counts relating to hush money paid to a porn star, the US Supreme Court will release its ruling on presidential immunity, and Trump must announce his vice-presidential pick.

Much else will distract people’s opinions and undermine their recall of a debate that Biden and the Democrats would like to forget. This is especially so if Biden can now cast this day aside and work to calm and reassure his nervous supporters and potential supporters. •

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The scale of the funding is historic, but these are bandaid-style fixes. Many Australians will benefit almost immediately, but the extra spending will do nothing to fix entrenched problems, including fragmented healthcare and prohibitive charges for specialist care. The government knows how to deal with these problems — the necessary reforms have been proposed in government-commissioned reports over the past decade — but it has so far lacked the will to act.

How health minister Mark Butler and his department tackle these recommendations during Labor’s second term will give some indication of the willingness of the government and the bureaucracy to think long-term, view healthcare spending as an investment in productivity and the economy rather than a budget impost, listen to patients, carers and the public, and override the “sharp elbows and loud voices” of the medical colleges, the pharmaceutical industry and pharmacy groups, private health insurance funds and private hospitals.

First issue off the rank is the need to renegotiate the National Health Reform Agreement that determines public hospital funding. A new agreement with the states and territories is overdue: this year’s budget merely funded it for an extra year, with a one-off top-up thrown in as an acknowledgement that more funds are needed. A new agreement with states and territories has been delayed by difficulties in reaching agreements over foundational supports for the National Disability Insurance Scheme.

The current national agreement reinforces a siloed approach to healthcare and provides no incentives or resources to encourage better coordination between community-based care and hospital care. True, national cabinet has agreed to “long-term, system-wide structural health reforms” that will “focus on the entire health system and move towards a more integrated, equitable, efficient and sustainable system.” But these are empty goals without new mechanisms for cooperation, collaboration and adequate resourcing across the jurisdictional divide. Priorities must include better access to out-patient specialist services, step-down and rehabilitative care and hospital-in-the home, and quicker access to aged care services.

There is no shortage of expert advice to guide this work, including the Grattan Institute’s recent Putting the “Reform” in the National Health Reform Agreement report and the midterm review of the current agreement, commissioned to determine if it was fit for purpose. The continuing validity of most of the recommendations of the seminal 2009 report of the National Health and Hospitals Reform Commission highlights how long the needed reforms have been dodged.

The struggles of both public and private hospitals to deliver needed services in the years since the height of the Covid pandemic highlight the need for a payment system that rewards services appropriately and boosts workforce capacity. More than that, it underlines the imperative, ignored until now, to sort out the best cooperative arrangements between the public and private hospital sectors.

The elephant in the room is the $8 billion-plus the federal government provides to the insurance industry via the private health insurance rebate. Mark Butler’s approach to the current feud between the private health insurance funds and private hospitals shows that active intervention is not on his agenda. But given the impact of the threatened collapse of private maternity and mental health services, it’s increasingly important for him to seek a resolution, and the rebate might be a cudgel he needs. Underlying these problems is a simple question: is this the best way to spend $8 billion or more in taxpayer dollars?

Central to the government’s wider challenge in healthcare is the need for a well-located workforce with the right clinical and cultural skills. Again, much of the thinking has already been done, but longstanding turf fights, union battles and Medicare arrangements are hampering implementation of the National Medical Workforce Strategy 2021–2031, the Working Better for Medicare review, the 2024 Unleashing the Potential of our Health Workforce scope-of-practice review, and the seven-point plan proposed by a unified group of peak nursing and midwifery bodies.

On top of this, graduating medical students are increasingly avoiding primary care roles, especially in underserved areas, and limited accredited speciality training places mean shortages in critical areas like psychiatry, paediatric surgery and orthopaedic surgery.

Increased investment in primary care is widely agreed to be the key to a robust healthcare system. Medicare “must rise to meet the new challenges in health and primary care,” says Anthony Albanese, but he and Mark Butler routinely fail to recognise that most of what Medicare funds is the general practice part of primary care. Primary care, more broadly, includes health promotion and prevention and better access to a wide range of healthcare and social welfare professionals (as outlined on the health department’s own website).

In his first term Butler commissioned a welter of expert reviews of general practice and Medicare, all of which highlighted the need for a more multidisciplinary model, with funding based on patients’ needs and the time taken to deal with them — in other words, a move away from fee-for-service to bundled payments that reward continued care and outcomes over activity.

Yet, as the Grattan Institute points out, the election commitment to spend $8 billion on bulk-billing incentives pushes in the opposite direction by boosting existing fee-for-service payments. Nor does this substantial package relieve the pressures on busy GPs by expanding affordable access to allied health, mental health and substance abuse services, and specialist care.

A startling omission from the government’s commitment list are the “missing middle,” those people whose needs are not well met by current health services. Often they are too unwell for primary care but not unwell enough for hospital care. While the term is most often used in mental healthcare, it also applies to the growing number of Australians who are frail and/or have multiple chronic conditions. This is a growing segment of the ageing population.

These people struggle to find affordable specialist services, have substantial out-of-pocket costs, experience fragmented care, and need help with daily life. If they’re over sixty-five they don’t qualify for NDIS services. Home-care packages are limited, and most would benefit from a healthcare coordinator. A failure to meet their needs in the right place at the right time inevitably means they end up, often inappropriately, in hospital emergency departments.

The other missing piece of the government’s healthcare policy is affordable dental care. This perennial election issue is routinely at the top of people’s healthcare needs list, and Labor backbenchers and the Greens have long pushed for more government resourcing. Butler has dismissed these calls, saying that it was not one of his priorities and declaring he was “very clearly and un­apologetically” focused on general practice. At the same time, he described oral care as a “fundamental” aspect of healthcare.

The other big gap is prevention. Almost everything funded through the health portfolio is about illness and very little is directly related to good health and wellbeing. Much lip service is paid to prevention but very few resources are devoted to keeping people fit and healthy. Preventing chronic disease was not included in the mandate of the new Australian Centre for Disease Control, despite this option being considered during the consultation on its role.

The organisational chart of the Department of Health and Aged Care shows that the Preventive Health and Food Policy section sits two levels down within Primary and Community Care. Chronic disease is a big challenge to the system and the impact of climate change on health increasingly looms as a threat, but prevention always loses out to the exigencies of clinical care.

Australia has one of the lowest rates of preventive health spending as a proportion of all health spending among OECD nations. The National Preventive Health Strategy 2021–2030 recommended that at least 5 per cent of total health spending be dedicated to preventive health by 2030, but the figure continues to hovered around 2 per cent.

Focusing more resources on prevention — to tackle problems like obesity and alcohol misuse that lead to long-term chronic disease and increased pressures on the healthcare system — and the social determinants of health — to tackle poverty, insecure and substandard housing, and a lack of health literacy — is sound economic management. It reduces healthcare costs and pressures and means a more productive and engaged society. But it does require long-term commitments; the returns on such investments are substantial but they are not seen within the three years of an electoral cycle.

There’s a lot of work to be done to deal with current health inequalities, not least to Close the Gap on Indigenous disadvantage. This requires much more than improved bulk-billing rates, more affordable prescriptions and new hospital buildings. Rather than simply parking more ambulances at the bottom of the cliff, we also need stronger fences at the top.

The groundwork for this shift in emphasis is there in the national wellbeing framework and the Measuring What Matters report, which recognise that prevention and early interventions are priorities and that changes in budget rules are needed to better justify these measures. International and Australian research has identified what’s needed, including a whole-of-government approach and a long-term focus that includes consideration of future generations

The federal government needs to ensure that the wellbeing framework is embedded into its decision-making, including budget decisions. Mark Butler must assume the role of point man on this and use the Measuring What Matters data to drive needed reforms in his portfolio. •

POSTSCRIPT, MARCH 2026

“Diagnoses In, Now for Action” is my most recent article on Australian healthcare for Inside Story, and the title sums up where the federal government finds itself in relation to the health and healthcare reforms needed for the twenty-first century, now a quarter gone.

Labor had just won a landslide victory, and prime minister Anthony Albanese had outlined his government’s “positive and ambitious agenda” at the National Press Club. Since then, despite significant new funding, none of the needed reforms have been made to the National Health Agreement, which supports public hospitals. Daily, we hear stories about the inability of many Australians to afford specialist care; toxic dynamics continue to plague the private healthcare system; the latest Closing the Gap report presents dismal data about the inequalities facing Indigenous Australians.

Since then, too, the fractured Coalition has only underlined the government’s huge parliamentary majority, providing the second-term Albanese team with a unique opportunity to secure its lasting political legacy. Albanese called it correctly when he said, “If we get this decade right, we can set Australia up for the many decades to come.” 

But can he, will he, deliver?

Healthcare reforms are needed to ensure that Medicare is truly universal, that Australians with chronic conditions can manage these effectively, that people living with disabilities and mental illness are well-supported, and that the public and private hospital systems are better integrated. Above all, though, investment is needed in health and wellbeing.

The government and the bureaucracy advising it have a very narrow understanding of health and the factors that contribute to good health. The government’s focus is primarily on a “sickcare” system: aside from secondary preventive measure like vaccines and screening, prevention is not a priority. The proportion of health expenditure allocated to public health was just 2.9 per cent in 2023–24, well below the 5 per cent target envisaged in the National Preventive Health Strategy.

What happened to the treasurer’s wellbeing budget, first proposed in 2022? Yes, a Measuring What Matters Framework exists, but it seems that no measuring is being done. According to an Australian National Audit Office review published last May, “no monitoring or evaluation arrangements [are] in place to measure the embedding of MWM across government.”

The stewardship of this work has shifted from the health department to the Australian Centre for Evaluation, which reports to assistant productivity, competition, charities and Treasury minister Andrew Leigh. A failure to embed this budget approach in the way the government as a whole does business will eventually see the initiative slip away or be dismantled — as has happened in New Zealand to Jacinda Ardern’s work in this area.

Taking on reform and the “wicked problems” in health is an undeniably huge task for the government, and particularly for health, disability and ageing minister Mark Butler. He would do well to look to the efforts of one of his Labor predecessors, Neal Blewett, who, as Bob Hawke’s health minister, knew how to use committee advice and reports’ recommendations to drive multiple agendas.

During his ministerial term Dr Blewitt led efforts to introduce Medicare and to tackle the emerging HIV/AIDS epidemic, introduced the Disability Services Act 1986, implemented a “Drug Offensive,” established the National Cervical Screening Program and the National Better Health Program, initiated the first Indigenous health and women’s health policies for Australia, and set up the Australian Institute of Health and Welfare to measure the impacts of these initiatives.

Four decades later, the Covid-19 pandemic, the pervasive influence of the Trump administration, and the insidious effects of the misinformation and disinformation undermining healthcare systems and eroding trust in government and expertise — all these serve to highlight how quickly, how easily, the government policies and healthcare rights we take for granted can be dismantled.

Australians — and especially Australian politicians — need to see the health and healthcare systems as something more than a funding impost on the budget. It is an investment in the economy, productivity and equity and a reflection of societal values. •

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Beneath this bravado he will undoubtedly be worried about his sentencing, which is scheduled for 11 July, just days before the Republican Convention. Judge Juan Merchan has wide discretion to choose between prison, probation, conditional discharge, fines, travel restrictions or house arrest. The maximum punishment would be four years in prison and a $5000 fine for each of the thirty-four charges of falsification of business records; a recent survey of similar cases brought by the Manhattan District Attorney’s Office found that roughly one in ten resulted in incarceration.

“We’re going to be appealing this scam,” said Trump. “We’re going to be appealing it on many different things.” Although he can’t do that until after the sentencing, he and allies including House speaker Mike Johnston are already pushing for his appeal to be taken up by the US Supreme Court. But that can only happen in the unlikely case that he and his lawyers raise a legitimate federal question during the appeals process.

One thing is certain: Trump’s lawyers will use whatever means they can to delay proceedings for as long as possible in the hope that by the time the appeal is heard he will have won back the presidency. That wouldn’t give him the power to pardon himself (state convictions are beyond presidential power) but he would have succeeded in regaining the White House.

Meanwhile, the former president is already seeing the political upside of criminal status. The boost to his fund-raising — a reported US$53 million haul within just one day of the guilty findings — has wiped out the lead president Joe Biden had enjoyed so far this year. How much of this money will be siphoned off for legal bills or distributed to other candidates through the Republican National Committee remains to be seen.

Trump’s trial also seems to have united the Republican Party as never before. Republicans have lined up to echo his claims of political persecution, with even long-time rivals and those who have sought to keep their distance rallying to his defence. Senate minority leader Mitch McConnell, often a Trump critic, declared that the charges shouldn’t have been brought against him and senator Susan Collins of Maine, a moderate who has pledged not to vote for him in November, denounced the case as politically motivated.

Republican figures like these clearly fear the consequences of speaking out against Trump. When former Maryland governor Larry Hogan — seen as one of the Republicans’ best chances to flip a seat and gain the majority in the Senate — declared that “we must reaffirm what has made this nation great: the rule of law” he was immediately threatened. “You just ended your campaign,” a top Trump campaign adviser responded on social media. Lara Trump, co-chair of the Republican National Committee and Trump’s daughter-in-law, said Hogan “doesn’t deserve the respect” of any Republican for his comments and refused to confirm whether he would receive any party funding for his campaign.

Trump’s mega-donors, the tycoons who defected from his camp after the 6 January riot and the Republicans’ abysmal performance in the 2022 midterm elections, have also been sidling back. No doubt they see Trump’s re-election as a real possibility and are attracted by his perceived pro-business agenda and nervous about his known capacity for vengeance.

Although last week’s conviction upends almost everything about American politics-as-usual, it might not change much in the election campaign. As a convicted felon, Trump can’t own a gun, will be denied a visa to enter a significant number of countries (including Australia) and can’t hold public office or even vote in many states. But there is nothing in the US constitution that prevents him from running for president or assuming the presidency, even if he is in prison.

In normal times the convictions would sharpen the choice between Trump and Biden. After all, no presidential candidate from a major party has ever before sought the nation’s highest office with such a badge of dishonour (although Eugene V. Debs ran from his jail cell on the Socialist Party ticket in 1920 and garnered almost a million votes, or about 3 per cent). But Trump’s pollsters are confident that voters in key states have already made up their minds.

While that is probably true of Trump’s MAGA base, it leaves up for grabs the support of independent voters and those Republicans who didn’t support him in the primaries. A Morning Consult poll shows that 54 per cent of all respondents approve of the decision to convict Trump compared to 34 per cent who disapprove. Forty-nine per cent of independents and 15 per cent of Republicans (but only 8 per cent of self-proclaimed Trump supporters) believe Trump should end his campaign because of the conviction.

And voting intentions? Fifty-six per cent of Republican respondents to a Reuters/Ipsos poll said their vote wouldn’t change, with fully 35 per cent saying they were more inclined to vote for Trump. But 10 per cent of Republicans surveyed said they were less likely to vote for Trump, and 25 per cent of independent voters said the same.

What this polling shows is that the New York trial has mostly influenced undecided voters — a sliver of the electorate that could now exert an outsized impact on a presidential election expected to be decided by a handful of votes in a handful of states. In that light, the potential loss of a tenth of his party’s voters could be much more significant for Trump than the strengthened support of just over a third of Republicans. Much can still change over the next five months, though, and for some voters the upcoming presidential debates could be decisive.

Regardless of whether Trump wins or loses, the damaging impact of his vituperative attacks on the judiciary will likely be lasting. What we have seen in recent years is a relentless attempt by Republicans, led by Trump, to undermine the judicial system. They have spoken out against the Democrats’ alleged weaponisation of the judicial process while ignoring Trump’s own attempts, in power and during the campaign, to do just that.

As president, Trump frequently called on the justice department to investigate individuals he perceived as opponents, especially Hillary Clinton, senior officials within the FBI, and special counsel Robert Mueller. He has repeatedly promised to wreak revenge on his political enemies and has specifically threatened President Biden with FBI raids, investigations, indictments and even jail time. Senators, judges, members of Biden’s family and non-governmental organisations are among his other promised targets.

There’s nothing very subtle about these threats. “I mean, if somebody — if I happen to be president and I see somebody who’s doing well and beating me very badly, I say, ‘Go down and indict them,’” he said in an interview last year. “Mostly what that would be, you know, they would be out of business. They’d be out, they’d be out of the election.”

Republicans in the House of Representatives began planning for retribution in January last year by creating a select subcommittee “on the weaponisation of the federal government.” The subcommittee is proposing to hold a hearing this month looking at “politically motivated prosecutions of federal officials, in particular the recent political prosecution of President Donald Trump by the Manhattan District Attorney’s Office.”

In the Senate, meanwhile, eight Republican senators have pledged to oppose a funding boost for the justice department and won’t vote to confirm the Biden administration’s political and judicial appointees. “Those who turned our judicial system into a political cudgel must be held accountable,” they say.

This vehemency has readily been picked up by the party’s supporters, fuelling concern that the attacks on the judicial system could lead to violence. Already prosecutors, witnesses and jurors have been targeted. Small wonder that Americans have been losing confidence in their judicial system every year since 2020, with confidence dropping to 42 per cent in 2023. Public confidence in both federal and state courts has declined significantly, with more people now viewing them unfavourably as providers of equal justice to all.

As legal scholar Paul M. Collins wrote recently in the Conversation, the judiciary depends on a widespread faith in the rule of law to ensure that the public respects and follows its decisions. In its absence, people are more likely to defy judicial decisions and less likely to cooperate with law enforcement.

The good news is that the New York district attorney’s decision to sue and the court’s finding of guilt highlight that not even Trump is above the law (at least for the moment). The not-so-good news is that those decisions also underscore the fact that the US legal system is far from perfect.

As required by the Constitution, all Supreme Court justices, court of appeals judges and district court judges are nominated by the president and confirmed by the US Senate. Today’s top courts provide a perfect example of what this can mean in practice: during his one-term presidency Trump was able forge a Republican majority not only in the US Supreme Court but also in the circuit courts.

This politicisation extends to the states, each of which has a unique set of guidelines governing how state and local judicial vacancies are filled. Where this is done by gubernatorial decisions or nominations, the usual political partisanship can come into play. In many state and local jurisdictions, officers of the court are also elected in the belief that they should be responsible to the electorate. Five states select all of their judges through elections and thirty-eight states use elections to choose some judges. These elections are  increasingly expensive, politicised and dominated by special interest groups.

Spending on these elections reached record highs in recent years. With more than US$37 million spent, April’s Wisconsin Supreme Court race was the most expensive state supreme court election in US history. While technically non-partisan, both candidates in that contest were openly aligned with, and heavily backed by, a political party.

Trump’s accusations of bias are made possible by the fact that New York district attorney Alvin Bragg, who led the Trump prosecution, is an acknowledged Democrat, and Judge Merchan, who presided over the trial, was elected in a very Democratic state. America’s acceptance and even promotion of partisanship in the judicial system, and Trump’s own thoughts about weaponising the system against his enemies, make such claims about legal persecution unsurprising. Europe provides examples of how the political temperature of these selection processes could be reduced.

The grim news could get grimmer. Politicisation and attacks on the judicial system would surely continue apace were Trump to be re-elected. As New York Times columnist Peter Baker has written, the election of a felon to the White House will have many consequences. Given that Trump has survived two impeachments, four criminal indictments, civil judgments for sexual abuse and business fraud, and a felony conviction, it is hard to imagine what institutional deterrents could check his hostility towards the judicial system. •

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The shape of the post-election Congress has another consequence, too: it will affect whether party leaders have the  ability — or even desire — to engage in the work of government and fully representing the needs and concerns of their constituents.

The current Congress, the 118th, perfectly illustrates how elected officials are failing in this task. Derided as a do-nothing Congress with elements of high-school soap opera (the fight between House Republicans Marjorie Taylor Greene and Jasmine Crockett being the latest example) it is set to be one of the least functional ever, with only thirty-four bills passed over the past twelve months. That’s the lowest number in the first year of a congressional session in nearly a century. By comparison, the 113th and 114th Congresses, during Barack Obama’s second term, passed 196 and 329 bills respectively, and the 117th Congress, during Joe Biden’s first term, passed 362.

The narrow Republican majority in the House of Representatives is at the mercy of the irascible hardline conservatives of the House Freedom Caucus, who are happy to undermine any Speaker who is willing to work  with the Democrats. Congress has consequently lurched from one stop-gap government-funding bill to another, with continuing threats of government shutdowns and disrupted services and social security payments.

“I’ve seen irresponsibility in the Congress any number of times in the past, but I’ve never seen anything like this,” says long-time congressional observer Norman Ornstein, a research fellow with the American Enterprise Institute.

Small wonder then that trust in the federal government hovers at a near-historic low and the public’s opinion of Congress has never been less positive. An April Gallup poll had just 16 per cent of respondents approving of how Congress is doing its job; it echoed a November 2023 Pew Research Center poll in which exactly the same percentage expressed trust in the government to do what is right always or most of the time. A January Gallup poll found that only 24 per cent of respondents considered most incumbent congressional representatives deserving of re-election.

What is striking is that these negative attitudes towards Congress coexist with voters’ continued belief that government should take a substantial role in many areas of their lives. On this question, the traditional split —Republicans wanting smaller government providing fewer services, Democrats looking to bigger government and more services — doesn’t hold up on closer examination.

Polling last year by State Policy Network shows that most voters, including a majority of Democrats, believe the federal government has too much control over their day-to-day lives. Yet the vast majority take a positive view of Medicaid, Medicare, Social Security, the Affordable Care Act and other big government programs. While six-in-ten Americans say the  government spends too much, majorities also say that more should be spent on education, infrastructure, assistance to the poor, border security, childcare assistance and drug rehabilitation.

Some self-interest is at play here. Among forty-five- to sixty-four-year-olds, for example — many of whom are nearing the age at which they can begin collecting government retirement benefits — 72 per cent think the government should increase benefits.

What does all this mean for voter turnout and decision-making in November?

First (and shockingly), it’s unclear how much attention the average American voter is paying to the political issues of the day. Over the past decade only around 30 per cent of survey respondents have said they pay close attention to national political news. Those that do are more likely to be older and better educated: only 9 per cent of eighteen- to twenty-nine-year-olds are following politics very closely. Independents, an important voting group in what promises to be a tight election, are generally not as aware of political issues as those aligned with a political party and report lower interest in politics overall.

The level of engagement does increase in the lead-up to a presidential election. But even as the antics of Trump and the MAGA Republicans are regular news in Australia, a PBS/Marist poll taken at the beginning of May found that 55 per cent of Americans were not following the Trump hush-money trial much or at all.

A Gallup poll in March showed that the six issues of most concern to Americans as the election looms are inflation, crime and violence, hunger and homelessness, the availability and affordability of healthcare, federal spending and budget deficits. Other issues — abortion, , for example, or gun rights, civil rights and climate change — attract less national concern though more passion.

Do Americans know where the political candidates on their ballot stand on these issues? That’s not an easy question to answer.

A 2020 study shows that about 60 per cent of voters can identify which party their current member of Congress represents and about 70 per cent know the party of their senators. Roughly the same percentages know which party has the majority in the House of Representatives and the Senate. Party manifestos rarely figure in individual campaigns, and unlike under the Westminster system, members of Congress are not required to vote the party line.

Overall, 66 per cent of adults say it is extremely or very important that candidates share their views on political issues. But the quality and depth of reporting in the American media means they must rely on sparse issue-specific information to evaluate them.

That sparsity makes personal traits more important. While just 39 per cent of Americans say these traits — living in a community like theirs, sharing their religious values, coming from a similar economic background, sharing their racial or ethnic background, sharing their gender — are extremely or very important, there are some key exceptions. People with lower incomes, Black Americans and white evangelical Protestants particularly value shared characteristics.

Importantly, these surveys fuel a sense that elected officials aren’t in touch with the people they represent and don’t advocate for the issues that matter to their constituents. Survey data from the Pew Research Center show that only about four-in-ten voters of both parties say members of Congress care about the people they represent all or most of time (compared to roughly half in 2018) and three-quarters say that members of Congress do a somewhat bad or very bad job of listening to the concerns of people in their district.

When asked by Pew in an open-ended question to identify the biggest problem with elected officials today, respondents point to a variety of issues, ranging from a lack of focus on the people they represent to negative character traits, general incompetence, and the role of partisanship in their ability to get things done. Majorities of both Republicans and Democrats think most politicians run for reasons of self-interest rather than public interest.

On several issues the gaps between politicians and voters are wide and widening. Abortion is a classic example. Some 76 per cent of moderate Republicans say abortion should be legal, as coincidentally do 76 per cent of conservative and moderate Democrats. (The figure for liberal Democrats and Democratic-leaners is 96 per cent.) Yet in March the Republican Study Committee, which represents all of the House Republican leadership and nearly 80 per cent of Republican House members, endorsed a national abortion ban with zero exceptions for rape or incest.

An analysis from 2020 shows that lawmakers voted against majority opinion in their district on one in every three high-profile roll calls in the House of Representatives. (With the growing power of the ultra-conservative House Freedom Caucus, it’s safe to assume that figure holds or is more skewed today.) As I have written previously, there is now almost no policy overlap between the two major parties despite the considerable agreement among voters even on hot-button issues like abortion and guns.

There’s one other complication. Voters’ views and preferences are often overridden by their sense of political identity: they (and presumably politicians too) will alter their policy preferences to match their partisan identities.

In general, a high degree of divergence between the political parties means less ticket-splitting, whereby a voters chooses a presidential candidate from one party and congressional representatives from the other. That trend will be heightened this year, with Republicans almost completely wedded to Trump, although a very recent set of polls sees Democratic senatorial candidates leading in four battleground states where Biden trails Trump. This suggests Black, Hispanic and younger voters may be looking to ensure their issues are taken up in the Congress, if not in the White House.

The biggest danger in November is that Americans, increasingly pessimistic about their democracy, may not turn out to vote at all. According to a survey from FiveThirtyEight, more than a quarter of voters who failed to vote in the 2020 election said they did so because nothing would change if they did. It’s hard to see how those who are disillusioned with the Trump–Biden contest will still turn out to vote for their legislative representatives (which is possible on US election ballots).

Many current predictions see a triple flip of the White House (to Trump), the Senate (to Republicans), and the House of Representatives (to Democrats) — a reverse of the current power configuration. That would make coherent legislative action and adherence to democratic norms even more difficult than it has been in recent years. •

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The climate impact of cars and trucks did figure in the debate, but the direct health benefits of the government’s plan were almost entirely absent. This was surprising: as the government’s Office of Impact Analysis put it, vehicle emissions are a major cause of air pollution and can trigger “reduced lung function, ischemic heart disease, stroke, respiratory illness and cancer.” Australia’s current regulations allow “a higher level of noxious and carbon emissions” than in comparable countries.

Faced with well-organised opposition, the government scaled back and delayed the new standard. But its near-silence on the health impacts and healthcare costs of air pollution raises an important question: was this issue fully explored during the plan’s development?

More than a quarter of the 2700 submissions received during consultations on the standard came from health, environment and social groups. Yet the potential health benefits of the proposal were virtually ignored in the subsequent consultation report, beyond a statement that the government’s preferred option would deliver $5.52 billion in health savings over the period 2025–50. No effort was made to enlist public support for the plan on the basis of its health benefits.

When ministers Chris Bowen and Catherine King announced the watered-down standards late last month, not a health expert was to be seen. Fronting the media instead were representatives of automobile manufacturers and vehicle traders, one of whom, Tesla’s Sam McLean, welcomed the government’s backdown as a “compromise between all the folks you see up here on stage.”

The health effects of traffic pollution have been recognised for decades. But recent evidence shows them to be far more serious than previously known, causing premature deaths, cardiovascular and respiratory diseases, childhood asthma, adverse birth outcomes, diabetes and even dementia.

Yet there’s a shocking dearth of Australian-specific research. I was able to find only a handful of studies, the results of which vary widely because they use different mechanisms of analysis. The absence of robust data makes it much harder for governments to resist heavy lobbying by industry groups and businesses. Nevertheless, the studies that do exist highlight the imperative for action.

A 2005 study from the Bureau of Transport and Regional Economics found that motor vehicle-related air pollution accounted for between 900 and 2000 early deaths in 2000. The economic costs were assessed as between $0.4 billion and $1.2 billion for morbidity and between $1.1 billion and $2.6 billion for mortality, with most of the burden born by the elderly and the very young living in capital cities.

In 2018 the Australian Burden of Disease Study found that 3236 deaths were attributable to air pollution from particulate matter. Most of these deaths were from cardiovascular disease, stroke, respiratory diseases, lung cancer and type-2 diabetes.

A recent paper from Centre for Safe Air conservatively estimated the annual deaths from air pollution to exceed 3200, with a cost greater than $6.2 billion from years of life lost and an acknowledgement of other, more extensive, health and social impacts.

A paper published in January 2024 using data from 2018 indicated that transport emissions caused between 1000 and 2550 premature deaths and roughly 26,700 cardiovascular hospitalisations, asthma attacks and chronic obstructive pulmonary disease episodes in that year, at a total cost of $910 million.

But arguably the most up-to-date and definitive analysis is an expert position statement on the health impact of traffic emissions from the University of Melbourne, endorsed by the Australian Chronic Disease Prevention Alliance. It finds an annual toll of 11,105 premature deaths, 12,210 hospitalisations for cardiovascular disease, 6840 hospitalisations for respiratory disease, and 66,000 cases of asthma in children aged up to eighteen.

Much of the sizeable variation in these studies reflects the fact that they are measuring contributors to air pollution differently — in some cases by including more than just traffic pollution, in other cases by factoring in different-sized particulate matter (it’s usually PM2.5, the smallest, or PM10) or by including or excluding the effects of nitrogen oxide compounds.

The University of Melbourne paper cites a New Zealand study that took in both PM2.5 and nitrogen dioxide. It found that in 2016 some 3300 premature deaths could be traced to air pollution, with more than two-thirds of them attributable to motor vehicles. Air pollution contributed to more than 13,100 hospital admissions for respiratory and cardiac illnesses, including 845 asthma hospitalisations for children and approximately 1.745 million days on which people were prevented from doing the things they might have done if air pollution had not been present. The cost to the New Zealand economy in that year was estimated at NZ$15.5 billion. (The population of New Zealand in 2016 was 4.7 million.)

In Australia, as elsewhere, the burden of motor vehicle emissions falls disproportionately on people who live in urban areas or belong to certain population groups. Unborn and young children, the elderly, ethnic minorities, and those with underlying chronic disease conditions are most vulnerable.

And — as is so often the case — the greatest impact is on those who are most disadvantaged, who are more likely to live in air pollution hotspots and who are already dealing with inequalities in health and access to healthcare. Data from the Australian Institute of Health and Welfare shows that the total disease burden attributable to air pollution is 2.2 times greater in the most disadvantaged socioeconomic group than among the most advantaged.

Recent findings highlight one further reason why air pollution should be treated as an urgent public health issue. Researchers have identified it as one of the three main modifiable risk factors — along with alcohol and diabetes — for Alzheimer’s Disease. People with higher exposure to traffic-related air pollution have been found to be more likely to have the elevated amyloid plaques in their brains associated with Alzheimer’s.

The fine particulate matter, PM2.5, in air pollution is hypothesised to cause inflammation and oxidative stress in the brain, contributing to pathology changes. A University of Michigan study that examined the links between different types of PM2.5 air pollution and dementia found that higher exposure to PM2.5 particles from agriculture, road traffic, coal burning, industry and wildfires was linked to an increased risk of dementia.

These studies are observational in nature, but given that fewer than 1 per cent of Alzheimer’s cases are inherited, environment and lifestyle are likely to play a key role in the development of the disease. Moreover, the adverse health effects of air pollution from road traffic should be seen in conjunction with the impact of bushfire smoke, which is an increasingly common threat in Australia.

One more finding should serve to keep the focus on policy rather than politics: there is growing evidence that pollution makes it easier for Covid-19 to spread through the air. An international study has reported that long-term exposure to nitrogen oxide compounds and particulates could have contributed to up to 15 per cent of Covid-related deaths internationally, and up to 3 per cent of deaths in Australia.

In other words, the federal government’s decision to pull back on the new standard was clearly not based on all the available evidence. The loudest voices got the most attention. For whatever reason, Labor also appears to have been influenced by the Biden administration’s concurrent decision to ignore health impacts and cave in to business objections to new air pollution standards developed by the US Environmental Protection Agency.

Even though he is keen to reverse Donald Trump’s rollback of regulations, Biden is obviously looking to ensure he doesn’t face headwinds from powerful business sectors, transport unions and the governors of Republican states in a tough election year. And — importantly — the revised standards he announced this week still place the United States well ahead of Australia.

In polling last month by Resolve Political Monitor, only 22 per cent of respondents supported the vehicle emissions plan in its original form and a whopping 78 per cent either opposed the plan or were unsure. That’s not surprising, especially given that only 38 per cent of voters were aware of the plan. But it also shows that the government didn’t communicate the full benefits of a tougher standard.

Support for new policies — even those that increase fuel efficiency, make electric vehicles more affordable, and improve public health — won’t come if voters don’t know how they will benefit. And when a government fails to communicate effectively it’s no surprise if everything voters know about a proposal comes from the interest groups that oppose it. •

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Many Americans, and many of those watching around the world, see American democracy cracking, freedoms being eroded and the political system breaking. Much of the blame is sheeted home to Donald Trump and his Make America Great Again followers, and the case against them can clearly and forcibly be made.

But the United States has faced such crises before: in the 1790s, with the intense standoff between Federalists and Republicans; before, during and after the Civil War; in the Jim Crow period of the 1890s, which also saw five consecutive presidents elected with a minority of the popular vote; and after the Watergate revelations. The problems inherent in the American political system are thus compounded by problems and leaders unique to each era.

Trump’s presidency clearly damaged American democracy. Just how damaged and how long-lasting the effect is up for debate (a detailed 2023 report from Brookings discusses the issues well). During his term the United States was labelled a “backsliding democracy” by International IDEA, a European democracy think tank, and for some years the Economist’s Democracy Index has ranked the United States among “flawed democracies” including Greece, Poland and Brazil.

In a recent interview for the Democracy Project at Johns Hopkins University, political scientist Robert Lieberman stressed that democracy exists on a continuum. The United States started out as a constrained democracy, with citizenship limited to white men and only property-owners entitled to vote. For Lieberman, the key question is not “whether we are a democracy, but in which direction are we headed. Are we moving forward or are we moving backward?”

The current situation is arguably more serious than previous democratic crises because there are so many concomitant threats. There’s the pervasive partisan divide; conflicts over racism, immigration and nativism; growing socio-economic inequalities; the erosion of voting rights, particularly those of minorities; lawmakers’ attempts to undermine reproductive health, the rights of LGBTQI+ people, school curricula and library books; and the endless promulgation of lies and distortions that quickly come to be treated as facts.

Some of these threats have been decades in the making. Americans have long been sceptical of the power of the federal government: trust in Washington, which began to decline during the Vietnam war and continued to decline amid the Watergate scandal in the early 1970s, is at an historic low. Fewer than one-in-five Americans said they trusted the federal government to do what is right “just about always” (1 per cent) or “most of the time” (15 per cent) in 2023 Pew Research Center polls.

Individual institutions have suffered as well. The US Supreme Court’s  reputation has been damaged by recent rulings contrary to popular opinion, and trust in federal agencies like the Justice Department, the Centres for Disease Control and Prevention and the Federal Reserve has eroded. It’s shocking to also see declining trust in the military, police and the medical system.

These troubles pile on top of problems intrinsic to American democracy: the unusual mechanism, an electoral college, for electing the president; equal representation for the states in the Senate regardless of vastly different populations; lifetime appointments for US Supreme Court justices; and the lack of a national system for overseeing elections.

Because of their distrust of the popular vote, the Founding Fathers created the electoral college and other structural protections against what they saw as the uninformed masses. Patently, this system no longer works. Twice this century the person elected president by the electoral college had lost the popular vote (George W. Bush in 2000 and Trump in 2016), and it could happen again in 2024.

Because small, less-populous and mostly White states like Wyoming, Montana and North and South Dakota have the same number of senators as populous and diverse states like Texas, New York and California, Republican majorities in the Senate this century have never represented a majority of the population. The impact on confirmations of judicial nominees and senior executive branch appointees has been profound.

Finally, there is the deepening polarisation of the American political system. This began post-Watergate, was boosted by Newt Gingrich and the Tea Party, and is today exemplified by the House Freedom Caucus, the MAGA movement and the Congressional Progressive Caucus. This deepening polarisation has been marked by an intensifying shift rightwards among each new cohort of Republican legislators, echoing the widening differences between red and blue states and the growing urban–rural political divide.

Bring an ambitious, narcissistic, embittered and malevolent Trump back into this setting and the weaknesses of both the political system and the guard rails of democracy will become very apparent. Trump has schemed to overturn legitimate election results (and is likely to do so again), encouraged violence and discrimination, attacked the media and government institutions, undermined the staff and bureaucrats who worked for him, courted dictators and appeared beholden to foreign interests, lied and denied, and profited from his public office. Most egregiously, he encouraged the 6 January 2021 attack on the Capitol.

Three years on, amazingly, a majority of Republicans believe Biden was not legitimately elected. Despite Trump’s multiple indictments and legal jeopardy, they are willing to vote for him yet again. Republicans in the Congress increasingly follow his wishes on key pieces of legislation, and even those lawmakers he has belittled and besmirched end up endorsing him.

If Trump is re-elected he will be much less constrained and much more able to get his way than in his previous term. His rhetoric on the 2024 campaign trail — dark, violent, authoritarian and vengeful — has generated alarm. We have been warned about a Trump kleptocracy.

Some observers think the worst cannot and will not happen (see, for example, this article by Elaine Karmack). But a Brookings Institution report, Understanding Democratic Decline in the United States, warns that “the electoral road to breakdown is dangerously deceptive”:

People still vote. Elected autocrats maintain a veneer of democracy while eviscerating its substance. Many government efforts to subvert democracy are “legal,” in the sense that they are approved by the legislature or accepted by the courts.

The most obvious preventive measure lies at the ballot box — though that can only get rid of Trump, not Trumpism. And American voters themselves display some worrying tendencies. The Public Religion Research Institute and the Brookings Institution found that 75 per cent of Americans believe that “the future of American democracy is at risk in the 2024 presidential election” and the Democracy Fund found that more than 80 per cent of Americans see democracy as a “fairly good” or “very good” political system; but the latter study highlighted that only about 27 per cent of Americans consistently and uniformly support democratic norms across multiple survey waves. Perhaps not surprisingly, this response differs by political allegiance: 45 per cent of Democrats consistently support democratic norms but only 18 per cent of Independents and 13 per cent of Republicans.

Many voters acknowledge Trump’s true character but rationalise their actions as support for conservative judges, anti-abortion legislation, overturning unfair trade agreements, retaining tax benefits or protecting the Second Amendment. Yes, there are Republicans who consider Trump a “grotesque threat to democracy” and won’t vote for him again, but there are also former Obama voters who see Trump as “our last shot at restoring America.”

Even with Trump gone from the political stage (and that endpoint may result in further efforts to upset democratic processes), considerable effort will be required to restore individual rights and freedoms and deliver the blessings of democracy to all Americans. Ending Trumpism will require a massive effort by the Republican Party to reconfigure its base and operations and find leaders who will promote a different kind of conservatism. For their part, Biden and the Democrats must work to understand the anger and despair that has driven Trump’s MAGA supporters to adopt his bleak and autocratic views. •

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But behind the hyperbolic headlines — “Trump Racks Up Massive Wins in Super Tuesday GOP Races,” “How Trump Steamrolled His Way to the GOP Nomination” or “How a Fighting Biden Took on the State of the Union” — are the many twists and turns that will determine the campaign’s eight-month trajectory and its outcome in November.

The only thing the two putative candidates agree on is the significance and consequences of this year’s vote. Trump says, rightly for once, that the 2024 election will be the “single most important day in the history of our country.” Biden says the election is “all about whether America’s democracy will survive.”

In the days since Biden’s State of the Union speech, duelling campaigns in Georgia and other swing states have offered glimpses of the two candidates’ strategies for courting an electorate less than enthused by another Biden–Trump showdown. It’s clear that this re-run of the 2020 faceoff will test the limits of campaign financing and political decorum.

The endgame is the pattern of voting in the general election — and, more particularly, in the swing states like Georgia, Michigan, Arizona, Pennsylvania and Wisconsin. Using polling to make forecasts is complicated by the fact that the winner is the candidate who racks up the most electoral college votes, not the most votes.

Polls offer little in the way of accurate insight at this point in the election cycle. But as their current base of support stands, neither Trump nor Biden can win. The polling averages from FiveThirtyEight and 270toWin have them neck and neck, with their favourability ratings languishing in the mid-fifties.

The votes that will make the difference must be won from independent voters and those party voters who are not strongly committed to either Trump or Biden. Here, despite his age and the general lack of enthusiasm for a second term, Biden seems to have the edge. But he faces problems with some segments of the population: the Democrats’ longstanding advantage with Black, Latino and Asian American voters has shrunk to its lowest point in more than sixty years; his administration’s failure to end the Israel–Gaza conflict has upset young voters and especially Arab Americans and Muslims; and many young people are simply lukewarm about Biden. Nevertheless, the president has consistently gained more than 90 per cent of the Democratic vote in the primaries to date, and even in Michigan, where Gaza war sentiment led many to vote “uncommitted,” he scored more than 80 per cent.

Trump’s base is more galvanised, more rusted on, and smaller. His party’s “Never Trump” contingent remains strong, as seen by the support Haley attracted. On Super Tuesday she received more than two million votes across fifteen states. She pulled 37 per cent of the Republican vote in Massachusetts, 33 per cent in Colorado, 29 per cent in Minnesota, and a surprise victory in Vermont. A week later, after she suspended her campaign, she drew more than 77,000 votes in Georgia (a state Trump lost to Biden in 2020 by fewer than 12,000 votes).

What is rarely pointed out is that Republican state primaries are increasingly a winner-take-all proposition for the convention delegates (a situation cleverly engineered by Trump campaign staff). On Super Tuesday Trump reaped 93 per cent of Republican delegates while winning only around 70 per cent of the vote.

Haley’s continuing support shows that Trump hasn’t been able to defuse his long-term problems with suburban voters (especially women), moderates and independents. These are the voters who cost him a second term in 2020 and could potentially cost him again in 2024.

A key issue for the Trump campaign is where the Republicans who voted for Haley will go in November. Quinnipiac University polling found that 37 per cent of Haley voters would vote for Biden and 12 per cent would stay home. Emerson College polling found 63 per cent of Haley primary voters would vote for Biden in the general election with 10 per cent undecided. Some exit polls have delivered even higher numbers of voters reluctant to commit to Trump.

Trump, who has derided Haley using sexist and racist language, has shown little interest in reaching out to her voters. In January he seemed to reject them outright, declaring that anyone who made a donation to Haley “will be permanently barred from the MAGA camp. We don’t want them and will not accept them.” No surprise then that many of her supporters wonder whether they still have a place in the Republican Party, a perception that will only deepen as Trump, his campaign and his family take control of the Republican National Committee.

Trump’s efforts to appeal to independents have been desultory at best; he seems incapable of moving beyond the rhetoric of stolen elections, woke liberals, the deep state, threats from illegal immigrants and asylum seekers, and his own perceived victimisation. His speeches offer little more than a dark vision for his second term. His embrace of Russian president Vladimir Putin, Hungarian president Viktor Orbán and other authoritarians, his suggestion that he was open to making cuts to Social Security and Medicare, and the persistent efforts of conservative Republicans to undermine women’s reproductive rights won’t win over these independents.

This inability to broaden his support is the biggest threat to Trump’s efforts to reclaim the presidency. But that doesn’t necessarily mean Biden will have an easier time sweeping up the independents and undecideds. Will those concerned about the Israel–Gaza crisis who opted for “uncommitted” in the primaries vote for Biden in the general election, or will they simply stay home? (Given Trump’s vilification of Muslims they are unlikely to vote for him.) That will largely depend on what happens in Gaza between now and November. And can Biden and the Democrats reverse their declining support among minority groups and young voters?

The changing demographics of the United States has seen a decline in the White, non-college educated voters who have been the mainstay of the Trump Republican Party, an increase in politically active young voters, many of whom don’t see either party as dealing with the issues that matter to them, and an increase in racial and ethnic diversity at a time when race is a central political issue.

The Pew Research Center has reported that Biden received more 90 per cent of the Black vote in 2020 while Trump received just 8 per cent. But this year these voters are frustrated with Biden over a range of issues, including the lack of progress on racial justice and the economic impact of soaring inflation.

Latino voters, who make up some 15 per cent of the electorate, are a heterogeneous group politically, with divergent opinions on issues like immigration. A recent poll from the New York Times and Siena College shows 46 per cent of Latino voters supporting Trump and 40 per cent supporting Biden (albeit with a large margin of error).

Recently Trump has touted his support among the Black community, though not always in flattering terms. He does have a growing contingent of Black hip-hop artists among his vocal supporters and most recently resorted to using AI-generated pictures to build his credentials with the African-American community. But there’s little evidence of a major shift in support; a December poll showed only 25 per cent of Black adults had a favourable view of Trump.

Jaime Harrison, the African American chair of the Democratic National Committee, has accused Republicans of promoting “fairy tales about their plan to win over Black voters.” He made particular note of the fact that Trump “pals around with white supremacists.” Just days after the Trump campaign began its overhaul of the  Republican National Committee came the announcement that the party is closing all of the community centres it established for minority outreach in California, New York, North Carolina and Texas.

Ideology aside, the issues that will drive voters to the polling booths in November are common to all Americans: the economy and its impact on family budgets, healthcare costs, immigration, gun control and abortion. America’s role in supporting Ukraine and as a potential peacemaker in Gaza will also be important. These issues often play out very differently for Democrats and Trump Republicans: abortion and reproductive rights, immigration policies and gun control are classic examples. Perceptions of other issues, including the economy, interest rates and the outcomes of Biden’s national security and foreign policy efforts, will change — perhaps dramatically — between now and voting day.

For many Trump supporters, policies (or lack thereof) are of little consequence; like Trump, they are not interested in a united country or a bipartisan approach to legislation. They share Trump’s story, described by Biden in his State of the Union speech as one of resentment, revenge and retribution, and, shockingly, many of them embrace his authoritarianism. As one supporter posted on social media, “I’m not voting Republican, I’m voting Trump.”

For Democrats, kitchen table issues also include the erosion of freedoms and the future of democracy in the United States. Historian and presidential biographer Jon Meacham makes this stark statement about America today: “Historically speaking, the forces now in control of the Republican Party represent the most significant threat to basic constitutionalism we’ve experienced since the Civil war. That’s not a partisan point; it’s just the fact of the matter. And I’m not talking about particular policies, about which we can and should disagree. I’m talking about the self-evident willingness of a once-noble party to embrace lies and the will to power over essential democratic norms.”

The months ahead will be some of the most consequential in the nation’s history, with no guarantee this tense situation be overturned or resolved by the vote in November. •

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By the beginning of 2024 a record-breaking 21.3 million Americans had signed up for health coverage through Obamacare’s health insurance exchanges — five million more than a record high at the same time last year. Intriguingly, the largest increases have come in Republican-dominated states. In Florida, one in four people under the age of sixty-five are enrolled in an exchange plan; in Georgia, Texas, Utah and South Carolina the figure is more than one in ten.

Much of the recent increase can be attributed to the unwinding of Covid-era rules that made it easier to gain access to Medicaid, the healthcare scheme for people on low incomes. Under Biden, marketplace subsidies for health insurance premiums have been increased and eligibility widened, although this enhanced assistance will expire after 2025 without an extension from Congress. The administration has also boosted publicity about how the insurance exchanges work — publicity substantially reduced under Donald Trump — and removed a glitch that deprived some families of subsidies.

Fourteen years on, the data show that Obamacare is increasingly doing what Obama and the Democrats wanted — not just providing the security of health insurance but also reducing income inequality and racial disparities in healthcare. It has reduced the out-of-pocket costs of preventive healthcare for all Americans and the burden of medical spending on families, particularly those on low and middle incomes. America still doesn’t have the universal coverage standard in other wealthy nations, but some states, including Massachusetts and New York, are getting close.

Trump and Republicans in Congress couldn’t repeal Obamacare in 2017 largely because it had become too popular. It’s even more popular now. Around 60 per cent of Americans support the healthcare law and the figure is even higher for some of Obamacare’s specific provisions, including protections for pre-existing health conditions.

When Trump vowed late last year to “never give up” his call for Obamacare’s repeal — claiming it is “too expensive, and otherwise, not good healthcare” and promising to come up with “a much better, and less expensive, alternative!” — he was offering a campaign gift to Democrats. The promise, which Trump has made frequently since his 2016 campaign without ever detailing a replacement, has contributed significantly to Republican electoral defeats since then. On this issue he has failed to attract a groundswell of support even among Republicans: polling last December by independent healthcare analysts KFF showed that only 32 per cent of self-identified Republican voters considered it very important for candidates to talk about the future of Obamacare, compared with 70 per cent of Democrats.

But that same polling indicates voters are eager to hear the presidential candidates discuss healthcare affordability. Eight in ten voters describe this topic, and the future of Medicare (the federal insurance program for older people) and Medicaid, as “very important.” They regard access to mental healthcare as a healthcare priority too, along with prescription drug costs, gun violence, the opioid crisis, abortion and climate change. (The pandemic barely makes it to the list — only 22 per cent of those surveyed said it was very important.) All these issues and more show up among Biden’s election commitments, whereas Trump’s election statements are vague or absent. (A recent article from KFF Health News outlines what a second Trump presidency could look like for healthcare based on Trump’s previous record.)

Abortion, gun control, immigration, LGBTQ rights and climate change — all issues relating to health — are now seen as “litmus test” issues that drive voting choices. Ironically, though, the most potent policy decisions in these areas in recent years have been made not by elected politicians but by the courts, with the US Supreme Court, now dominated by conservative Trump appointees, as the final arbiter.

This sort of policy rule-making has not always worked well for Trump, Republicans or voters. A classic example is the US Supreme Court decision to overturn Roe v. Wade, the federal guarantee of abortion rights. This ruling delivered Trump and Republicans one of their most significant victories and one of their biggest political vulnerabilities.

Americans’ support for abortion is now at a record high; 69 per cent believe abortion should be legal in the first three months of pregnancy and 61 per cent think that overturning Roe v. Wade was a “bad thing.” Voter anger over abortion restrictions was widely credited with Democrats’ wins in the 2022 midterm elections. This is expected to be the case again in 2024, with abortion on the ballot in many states, even those where abortion rights are legally enshrined.

When asked which party best represents their views on abortion, more people say the Democratic Party (42 per cent) than the Republican Party (26 per cent). Women of reproductive age and young voters see abortion as a factor galvanising them to vote — and American women consistently vote more often than men. Some analysts believe angry Republican women could spell trouble for the party vote in 2024.

Litigation over abortion restrictions and access to reproductive health services is nevertheless proceeding in many Republican-controlled states, and the US Supreme Court is set to rule before November 2024 on two cases involving reproductive rights and healthcare: one on access to mifepristone, the pill used in more than half of US abortions, and another on emergency, life-saving abortions in hospital emergency departments.

Both Trump and his surviving rival in the primaries, Nikki Haley, struggle to articulate a coherent position on abortion that is acceptable to both conservative Republican Party officials and voters. Biden, by contrast, has put reproductive rights squarely in the middle of his re-election campaign. He has committed to enshrining abortion rights in federal law and has issued an executive order aimed at strengthening access to contraception.

The Affordable Care Act and its regulations guarantee coverage of preventive services, including birth control and contraceptive counselling, at no cost for women with health insurance. In 2020 the US Supreme Court upheld a Trump administration regulation that allowed employers with religious or moral objections to limit the birth control cover provided by Obamacare. Last month the Biden administration released proposed rules that would remove the moral exemption but retain the religious exemption, potentially restoring free contraception coverage to 126,000 women.

Abortion and contraception in the United States — a country where maternal and infant mortality rates and healthcare and pharmaceutical costs are shamefully high — are often economic decisions rather than moral or ideological ones. Even in some of the most conservative states with very few abortion services, rates of legal abortions are high. Access to reproductive healthcare services is crucial for many women, regardless of political affiliation, and especially those who are poor. Reproductive health researchers at the Guttmacher Institute say 75 per cent of American women seeking an abortion are either in poverty or just above the poverty line.

It’s worth noting that over the past forty years the sharpest drops in abortion rates have been under Democratic presidents, presumably because of their greater focus on delivering comprehensive healthcare services.

A study released in September 2023 by the Carnegie Endowment for International Peace provides an interesting insight into partisanship more broadly in the United States. Since the Tea Party era there has been almost no policy overlap between the two major parties in Congress (and the situation grows more partisan by the day). Among voters, by contrast, considerable agreement exists even on hot-button issues like abortion and guns.

But voters’ policy views are not strongly held and the American political system doesn’t easily allow them to express their policy preferences. What is strongly held is a sense of identity: what is referred to as emotional or affective polarisation. Voters don’t like people from the other political party — largely based on misbeliefs, misinformation and misperceptions — and will alter their policy preferences to match their partisan identities. In this respect, media like Fox News and Newsmax are seen as having a bigger impact than social media and political campaigns.

The fate of the Affordable Care Act sees two key issues — rising economic pressures and the polarisation of politicians and voters — come together. The act was initially very unpopular because of poor messaging from Democrats and misinformation and disinformation from Republicans and the conservative media. Confusion about a complicated law that took years to come into effect was widespread. And many Americans didn’t realise that the Affordable Care Act (which they liked) was the same as Obamacare (which they despised and/or feared), though those who benefited soon became supporters.

The situation in Florida (an increasingly Republican state) exemplifies the split. Florida has far more people enrolled in Obamacare’s federal health insurance marketplace than any other state. Floridians, bombarded with misinformation from then governor Rick Scott (“everyone now realises that Obamacare was a terrible notion”) and from current governor Ron DeSantis (who wants a healthcare plan that would “supersede” Obamacare), were initially loathe to take up government-subsidised health insurance, deriding it as “socialism.”

But Medicaid has never been expanded in Florida, which ranks among the five most expensive states for healthcare, many local employers don’t offer health insurance, and many retirees are younger than sixty-five and not yet eligible for Medicare. Obamacare offers affordable options for all these groups. Its increasing uptake and popularity has been driven by Republican-leaning Hispanics in the Miami area, where it’s described as “ingrained in the community” and the Obama campaign logo is routinely used to promote insurance.

Despite all this, a November poll showed Florida’s Hispanic voters backing Trump. While only 30 per cent of those surveyed indicated they would “definitely” or “probably” vote for Biden, 36 per cent opted for Trump. Results like these suggest that emotional polarisation will continue to drive voting patterns in November, even if this risks the loss of healthcare insurance and associated benefits.

On the upside, the Affordable Care Act no longer faces quite the same existential threat that once loomed. Despite Trump’s renewed threats, the scheme’s popularity continues to increase and Republican hostility is fading. It has become deeply embedded in the US healthcare system. (It would be no easy task to untangle its provisions from Medicare.) And it will be hard to sell voters a promise to take away the health insurance they know and value — even if there is a replacement, with all its own complicated and time-consuming details. •

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Of course, DeSantis and Newsom would each willingly take up residency in the White House in January 2025. But DeSantis’s chances of victory in November next year appear sufficiently marginal that his presidential aspirations must now be deferred until 2028 — and that’s assuming his current campaign hasn’t already undermined that postponed effort, or will do so in coming months.

The consequences of a primary challenger to a sitting president are ingrained into the Democrats’ psyche. (The most recent, Ted Kennedy’s challenging of Jimmy Carter in 1980, was widely believed to have opened the way for Ronald Reagan’s win.) And Joe Biden has long cast himself as uniquely positioned to defeat Trump. Precedent and decorum require Newsom and anyone else with presidential ambitions to wait until Biden has concluded his presidency before they announce their aspiration to replace him.

There are, however, at least two elephants in the room that could upset the status quo, both in the upcoming election and in four years’ time. The first is the possibility that Trump will come under such legal duress that he is replaced as Republican nominee. Admittedly, a party so much in his thrall is unlikely to act in even those circumstances. And if Trump is elected in 2024, it isn’t far-fetched to assume he will subsequently refuse to leave the White House, try to declare himself president for life and/or undermine the 2028 elections. Former Representative Liz Cheney has warned of this threat.

The second, much larger elephant, is Biden’s age, which creates the possibility that an unforeseen health crisis could end his candidacy before November 2024 or his second term before 2028. Health issues aside, it’s just possible — perhaps after a family intervention over the Christmas break — that Biden will be persuaded not to run and instead declare that he will focus on managing current, pressing domestic and foreign policy issues to the end — as Lyndon Johnston did in March 1968. But it’s late in the election cycle to change candidates and doing so would raise fraught questions. Would Biden endorse his vice-president Kamala Harris? If so, would the kingmakers in the Democratic Party follow his lead?

Yet another elephant — for whatever reason dismissed by the media and the pundits — is that an unexpected health event is just as likely for Trump, only three years younger, visibly overweight and under severe stress as his business prospects falter in New York.

Trump’s departure from the scene before election day would most likely see Nikki Haley become the Republican nominee, although it’s not clear she could bring along the rusted-on, Make America Great Again gang she would need to win. Recent polling shows Haley leading Biden in a hypothetical head-to-head race by four points, but Trump leads Biden by a seven-point margin in the same poll.

If Biden dies or steps down in office during his second term, Kamala Harris automatically becomes president. Her nominee for vice-president would need to be confirmed by a majority vote of both Houses of Congress. (The last time this happened was after Richard Nixon’s resignation in 1974, when Gerald Ford nominated Nelson Rockefeller to serve as his vice-president.) If Biden serves out his term then the 2028 race for the Democratic nomination is wide open and Harris must join the field.

The line-up of Democrats eager for the presidential candidacy highlights both a recognition that any one of them could have the chance to step up ahead of 2028 — an incentive to strengthen their national profiles — and the fact that there’s a wealth of well-credentialled candidates. “So many people, it’s breathtaking,” says veteran Democratic strategist James Carville. “The level of talent in the Democratic Party in 2023 — and I say this with great confidence — is as high as any political party has ever had in my lifetime.”

Carville goes on to list party figures including state governors Josh Shapiro (Pennsylvania), Andy Beshear (Kentucky), Gretchen Whitmer (Michigan), Jared Polis (Colorado) and Roy Cooper (North Carolina), senators Raphael Warnock (Georgia) and Mark Kelly (Arizona) and former New Orleans mayor Mitch Landrieu. Other names can be added to that list: New Jersey senator Cory Booker, Minnesota senator Amy Klobuchar and transportation secretary Pete Buttigieg, who all ran in 2020, along with Illinois governor J.B. Pritzker and, of course, Newsom. Still others are likely to emerge, some with real chances and some who would be very long shots.

It’s impossible to predict four years ahead of time who will win a presidential race. Barack Obama, for example, was just a first-term senator when he first came to prominence courtesy of his speech at the 2004 Democratic Convention. As 2007 ended, his chances against Hillary Clinton, the early frontrunner, were considered slim. But in January 2008 he won the surprise victory in the Iowa primary that began to alter the contours of the campaign. Then African Americans, having previously looked to Clinton and hesitant about Obama, delivered him a stunning victory in South Carolina. After that he began to break away, gaining delegates and undermining Clinton’s claims of superior electability.

Conventional wisdom holds that the Senate — which has been called the “presidential incubator” and the “presidential nursery” — is a major launching pad for presidential contenders. In recent generations it propelled John F. Kennedy, Obama and Biden into the White House (but didn’t guarantee the success of the Bob Dole/Jack Kemp team in 1996). These days senators risk being tagged with the unfavourability ratings voters from both parties assign to Congress as a whole, now the highest in nearly four decades. Those voter sentiments might not bode well for Klobuchar (who has been in the Senate since 2007) and Booker (since 2013); both Kelly and Warnock are relative newcomers, having taken up their seats in 2020 and 2021 respectively.

State governors, especially those from the larger states, bring to presidential races their governing records. Seventeen of forty-five American presidents (counting two-timer Grover Cleveland only once) had been state governors. In the fifty-nine quadrennial elections held to date, governors have captured a total of fifty-five presidential nominations; the most recent are Ronald Reagan, Jimmy Carter, Bill Clinton and George W. Bush, who all ran hard and successfully on their records in that job.

Once you factor in other key determinants of a viable presidential candidature like personality, ideology, fundraising capabilities, and the ability to gain early momentum by doing well in early primaries (Iowa, New Hampshire, South Carolina) and then win in the states with large numbers of electoral college delegates (California, Texas, Florida), and then add — dare we say it — appearance, sexual orientation, race and religion, the potential winners’ list among the governors looking to run becomes much shorter.

Three people stand out: Shapiro, Beshear and Whitmer. Newsom could be added to this list — there is no denying his name recognition, donor base and political talent — but he comes with more baggage than the other three. California is troubled by an economic malaise; Newsom has pursued a salacious love life; his popularity in the state is falling. Regardless, and despite his claims to be campaigning for Biden, Newsom almost certainly sees himself as the leading candidate, and he has been busy playing that role by making official trips, with photo opportunities, to China, Israel and a series of prominent events in red states.

Having only taken office this year, Shapiro is still in the honeymoon phase of his gubernatorial stint. It remains to be seen whether the fifty-year-old moderate has staying power. Previously state attorney-general, he gained prominence by handily beating far-right Trump-backed Republican Doug Mastriano in the governor’s race by a fifteen-point margin, becoming the first Pennsylvania Democrat to succeed a Democratic incumbent in sixty-four years.

Pennsylvania’s status as a critical swing state has only enhanced Shapiro’s profile in national circles. He is seen as an ambitious politician with a history of playing the long game, as evidenced by the fact that he was a keynote speaker at the New Hampshire Democratic Party Convention in September.

Beshear became a Democratic hero in November when he won a second term as governor of Kentucky, defying the usual political leaning of his red state. The forty-five-year-old, who was first elected as governor in 2019, has emulated his father, also a two-time Kentucky governor. In his first term Beshear was credited with having responded well to a series of natural disasters — the devastating tornadoes and horrific floods that ravaged parts of Eastern Kentucky — and the pandemic.

Beshear’s opponent, Daniel Cameron, the first African American to be elected attorney-general of Kentucky, was backed by Trump. Beshear blunted Cameron’s strategy by painting himself as above the partisan fray, touting an “economy on fire” and his commitment to “Team Kentucky” and public education, and warning about the future of abortion rights under the Republicans. These messages resonated well with voters; it’s an approach that should also work well on the national stage.

Whitmer, fifty-two, has been governor of Michigan, an important swing state that voted Trump in 2016 and 2020, since 2019. She was re-elected in 2022, winning by nearly eleven points over her Republican opponent. Her signature causes are infrastructure, healthcare and abortion access. With Democrats in control of the governor’s office and both the state’s legislative chambers following last year’s election, Whitmer has pushed through tax cuts, gun control measures and protections for abortion and gay rights. She has served as one of the vice-chairs of the Democratic National Committee since January 2021.

Whitmer was recently described in the Atlantic as having a “foul-mouthed irreverence, goofy humour, and ability to pound beers and disarm adversaries.” That may not play in Peoria or Washington, DC, but one thing is clear: she knows how to deal with Trump and his ilk. As a target of his nasty rhetoric, she has accused Trump of helping to incite, and later condoning, an October 2020 plot to abduct her. The planned kidnap by a group of men associated with the Wolverine Watchmen, a Michigan-based militia group furious over tough Covid-19 rules and perceived threats to gun ownership, was thwarted by the FBI and undercover agents — something for which Trump took credit, while simultaneously downplaying the threat to Whitmer.

Biden’s campaign team vetted her as a possible running mate in 2020 and Biden confirmed she was on his shortlist in March that year. According to reports, Whitmer removed herself from consideration, urging Biden to choose a Black woman instead — a smart and thoughtful move at a time when the nation was still in the midst of a reckoning over race and inequality following the death of George Floyd at the hands of white police.

Whitmer might be the best of the three, but she faces one clear obstacle — she’s a woman. On that basis alone she would be ruled out of consideration as Harris’ vice-presidential nominee if one were needed.

Is America finally ready for a woman as president? A paper published on the website of the distinguished political scientist Larry Sabato offers an in-depth analysis of the obstacles female candidates face on their paths to the White House. On balance, it finds, Democrats are more likely to support female candidates than are Republicans. A PRRI poll found in 2016 that more than two-thirds of Donald Trump supporters believe society as a whole has become “too soft and feminine.” And Trump has used the worst aspects of masculinity as a political strategy.

With each of the potential Democratic candidates already receiving donor support, it’s useful to look at where the money is going. Whitmer, Newsom and Pritzker have all recently launched national political groups. Whitmer has created a federal political action committee called “Fight Like Hell” to boost abortion rights as a plus for Biden and congressional candidates next year, giving her a visible role in the 2024 campaign. Newsom has “Campaign for Democracy,” which is focused on gun control; Pritzker’s “Think Big America” aims to protect reproductive rights and fight extremism.

For the moment, all of the Democrats who harbour presidential ambitions (hidden and not so hidden) must focus on the task at hand — getting Biden elected next year. Everyone’s political ambitions will end up in the dustbin if Trump is re-elected.

An opinion piece for CNN Politics artfully describes the current low-key jockeying as a “delicate and sometimes uncomfortable dance.” For the next eleven months, it goes on, “they are stuck being intriguing but not enticing, stoking flames but not fanning them. That task has been made more fraught when their very existence reminds voters — who have made consistently clear that they want another alternative to an eighty-one-year-old president — about what could have been.” •

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“There’s something dangerous happening in America now,” said Biden. “There’s an extremist movement that does not share the basic beliefs in our democracy. I don’t think anyone today doubts democracy is at stake in 2024.”

If we’ve learned anything in the last seven years, it’s that democracy can’t be taken for granted. A 2021 report, Democracy Under Siege, listed the United States among twenty-five countries that have experienced a massive deterioration in freedoms fuelled by political corruption, conflicts of interest and lack of government transparency. The report describes the final weeks of the Trump presidency — as the incumbent strove to illegally overturn his election loss — as an illustration of the parlous state of American democracy.

New York Times columnist David Leonhardt has identified twin threats facing the nation’s democratic status. The first (acute) threat is the growing movement inside the Republican Party to refuse to accept defeat in an election. In 2022, more than 300 Republican candidates for state and national offices either denied or questioned the outcome of the presidential election. This, says the Ash Center for Democratic Governance and Innovation at Harvard University, is unprecedented in American history and seemingly unique in the history of mature democracies around the world.

The second (chronic) threat is that the power to set government policy is increasingly disconnected from public opinion. Just a few examples highlight the trend. The US Supreme Court, dominated by Republican appointees, seems poised to shape American politics for many years with decisions on issues like abortion and gun rights that don’t reflect the views of anywhere near a majority of the population. Polls routinely show most Americans are alarmed or concerned about climate change, but its causes and impacts are denied by Republican lawmakers. A supermajority of Americans support voting rights with equal access for all eligible adults, but many states are working to limit voting access and some Republicans, led by Trump, have admitted that expanding voting hurts their party’s election prospects.

Other, equally disturbing, threats exist: the rise of political violence and intimidation; the erosion of rights for LGBTQI+ people, asylum seekers and other minority groups; book bans and political intrusions into educational institutions and curricula; increasing division along racial, religious, socioeconomic and political lines. It’s easy to see the long reach of Trump and Trumpism in every one of these threats.

Most recently, Congress was brought to a halt for three weeks because House Republicans caved in to MAGA extremists. They threw out House speaker Kevin McCarthy but then couldn’t agree on who should replace him. Trump’s social media criticisms of successive nominees and his loyalty tests carried more sway with House Republicans than a new speaker’s ability to oversee the House’s work.

Representative Mike Johnson from Louisiana was finally elected speaker after three others had been nominated but then withdrawn. Known as MAGA Mike and active in efforts to overturn the 2020 election, he is a self-described evangelical Christian who is staunchly anti-abortion, anti-LGBTQI+ rights, anti-union and anti-immigration. He has embraced the far right’s culture wars and backed the House Republicans’ inquiry aimed at impeaching Biden.

Elected to Congress just seven years ago and having never held a committee chair, Johnson is the least-experienced speaker in more than a century. Senate Republicans openly admitted they didn’t know who he was. But experience and expertise are scorned and devalued by Trump and his cohort. As the Nation’s John Nichols wrote, Mike Johnson’s main qualification for the job was that he’s neither a Democrat nor a democrat.

In fact, Johnson has insisted the United States isn’t a democracy — a system he defines as “two wolves and a lamb deciding what is for dinner” — but rather a constitutional republic based by its founders on a “biblical admonition.” He shares this view with a number of his lawmaker colleagues who are eager to stress the republic’s restraints on democracy. “Democracy isn’t the objective; liberty, peace, and prosperity are,” posted Utah Senator Mike Lee in 2020. “We want the human condition to flourish. Rank democracy can thwart that.”

Johnson’s role in attempting to overturn the 2020 elections and his position as speaker, which places him second in line to the presidency behind the vice-president, has raised concerns about how he might seek to influence the outcome of the next presidential election (assuming he is still in that position in January 2025) should Trump (almost certain to be the Republican candidate) lose again. No wonder Trump is happy to claim credit for his election to the speakership.

Much has been written about the extent of Trump’s influence over the Republican Party. (Perhaps takeover is a better description.) That he played such a pivotal role in determining who was finally elected as speaker and was endorsing candidates for upcoming primaries even while campaigning on his own behalf and attending to his legal troubles explains why he is courted, feared and rarely out of the news.

Merging his campaigning with his courthouse appearances seems to be working. Legal woes that would distract or destroy most candidates are now marketed as a feature of his 2024 presidential run. So too is his ostentatious disrespect for legal processes and precedents. He has been castigated by several judges and fined twice for verbal attacks on courthouse staff. Judge Arthur Engoron even threatened to lock him up. “Why should there not be severe sanctions for this blatant, dangerous disobeyal [sic] of a clear court order?” he asked.

Trump’s brand of authoritarianism, demagoguery and populism has deep roots in American history, but his spin on the tradition is amplified by his wily command of the media and fears among a segment of voters (primarily white, religious and without a college education) who see themselves and their values left behind in a racially and ethnically diverse economy and nation. Trump plays off what they see as an existential threat to their way of life.

In the aftermath of the 2022 elections, when the Republicans’ lacklustre performance could be read as a repudiation of Trump, the New Yorker’s Jelani Cobb argued — correctly — that Trump is not solely responsible for the current levels of intolerance, racism, nativism, belligerence and anti-democratic behaviour in the Republican Party, and there is no reason to believe his absence would cause these to evaporate.

Presidential candidates like Ron DeSantis and Vivek Ramaswamy might be lagging forty or more points behind Trump in the polls, but they are promulgating the same ideology and are keen to be seen as equally fierce cultural warriors. Those Republican candidates who aren’t toeing the Trump line — namely Nikki Haley and Chris Christie — are lagging even further behind.

Republican states, meanwhile, have mounted a frightening series of anti-democratic efforts. They are manipulating election administration by controlling secretaries of state and other executive offices. They are giving partisan state legislatures greater control over elections. They are reducing ballot drop box access for early voting. Several states, among them North Carolina and Louisiana, have resisted court decisions based on the Voting Rights Act that aim to make congressional district maps more accurately reflect the makeup of their population.

There is no such loss of the right to own guns. Nationally, thirty-five mass gun killings — incidents in which four or more people died, not including the perpetrator/s — have been recorded so far this year. More and more people are using guns to harass and intimidate others, including lawmakers, elected officials, school board members, voters and election workers. Although a significant majority of Americans support universal background checks, an assault-weapons ban and other priorities of gun-control advocates, stronger state and federal controls are elusive.

Links can be made between gun violence, democracy and trust. Research shows how eroded democratic institutions and declining trust in social structures lead to more lethal violence and increases in gun ownership. The Pew Research Center has shown that many Americans think the public’s trust in the federal government and in their fellow citizens has declined and that the interplay between the lack of trust in the public and the interpersonal spheres has made it harder to solve some of the country’s problems.

The latest Pew polling figures put trust in the federal government at almost its lowest in nearly seven decades of polling. Just 1 per cent of Americans say they trust the government in Washington to do what is right “just about always” and only 15 per cent trust the government “most of the time.” Writing in Politico, Max Stier and Tom Freedman argue that this statistic is more concerning than the rise of anti-democratic movements or efforts to steal an election: it reflects very poorly on the nation’s primary democratic institution, Congress, and its ability to deal with social, economic and foreign policy challenges.

Reviving American democracy means reversing the decline in political rights and civil liberties, improving public discourse, and reforming political institutions and practices to persuade Americans that politicians are representing them fairly and governments are working to solve pressing problems. Key among the essential reforms is a remaking of the Republican Party — or at least a rejection of its Trump-cult elements. That brand of right-wing populism may not be the only threat to democracy in the United States, but it is the biggest. •

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It’s almost a decade since I wrote those words in the Medical Journal of Australia — and yet, despite a succession of papers, reports and policy proposals, surprisingly little progress has been made. The consequences, and the dollar costs, of poor oral and dental health, often preventable, continue to drag on the community.

It’s well recognised that dental decay and tooth loss can cause pain, problems eating and speaking, and loss of self-esteem. But poor oral health is also linked to heart disease, diabetes, stroke, pneumonia, autoimmune diseases like rheumatoid arthritis, chronic kidney disease, dementia, low-birthweight babies and more. In older people it is associated with a greater risk of all-cause mortality.

Apart from poor dental hygiene, oral ill-health can be brought on by certain medical conditions and treatments, including diabetes, HIV/AIDS, osteoporosis, lupus, Sjögren’s syndrome (dry mouth), chemotherapy and radiotherapy, and a range of medications.

Dentists play a key role in screening for oral cancers. While these cancers are more common in older smokers, recent research shows an increase in diagnoses among young Australians without identifiable risk factors. In particular, the number of women under forty-five diagnosed with tongue cancer is rising significantly faster than for women over forty-five and men.

For those reasons alone, better integration of dental and medical care should be a priority. Many patients with coexisting medical and dental issues require multidisciplinary care plans involving doctors and dentists. Collaboration of this kind improves the quality of care and its results, including patients’ quality of life.

Given the costs (to both the healthcare system and patients) and the consequences of a failure to better integrate dental and medical care, increased access to affordable dental services should be a particular priority. This need could and should be considered separately from the provision of universal dental care: it goes beyond the preventive and early-intervention measures that ensure a healthy smile to the health of the body as a whole.

The current system’s failures are especially pronounced for two categories of patients: those with congenital heart disease, or CHD, and those with cancer, especially cancers of the head and neck. Patients with CHD and gum disease are particularly at risk. The bacteria that cause gum disease can cross into the blood stream, enter the heart chamber and directly infect the valves. These patients need special care for even the simplest dental procedures, and additional screening and safeguards before any surgery.

A German study published in 2022 found that children and teenagers with CHD were significantly more likely to experience dental decay and inadequate dental hygiene. This may be because their regular hospitalisation is interfering with normal dental check-ups, a deficiency exacerbated by a shortage of experienced paediatric dentists.

There’s no reason to believe the situation is any different in Australia. While national data are lacking, the paediatric dental team at Westmead Children’s Hospital found that about 27 per cent of children with CHD had a history of dental infections. The cost of extractions (the majority of services) and restorations under anaesthesia for these children is substantial: the mean number of days in hospital was 1.43 and the mean cost was  $4395 per child treated. The paper makes the point that clear referral pathways to dental care are a key need for children with CHD.

Richard Widmer, the leader of the team, told me that he and his colleagues often spend many hours and thousands of dollars on dental care before Westmead’s patients, often from regional and rural New South Wales, can get the operations they need. This is a potentially avoidable burden on the public health system and obviously distressing for the children.

A witness at the current parliamentary inquiry into dental services described how a patient at St Vincent’s Hospital in Sydney had a left-ventricular assist device implanted at a cost of more than $150,000. This life-saving work was almost undone because his poor oral health, which was not assessed before the operation, caused a life-threatening infection. The patient needed costly intensive care and further surgery.

Cancer patients — especially patients with head and neck cancers — also need special attention. They often have poor dentition to start with, have faced surgery, chemotherapy and radiation therapy, and must then manage chronic dental problems that frequently worsen over time.

Nectarios Andrews, a dentist who works with multidisciplinary head and neck teams at several Sydney hospitals, describes the people he works with as the “most vulnerable of patients” who have “already battled a cancer diagnosis [and] are too often doomed to a life of devastating dental pathology with crippling functional and emotional outcomes.”

New technologies and techniques are delivering remarkable results for these patients. Jonathan Clark’s team at Chris O’Brien Lifehouse in Sydney has a dedicated craniomaxillofacial reconstruction program that combines advanced reconstructive surgical techniques (using dental prosthetics produced by 3D printers) with virtual surgical planning (where the surgery is digitally simulated to increase the accuracy of reconstructive surgery). Evidence suggests these procedures deliver clinical benefits and increased rates of dental rehabilitation, leading to improvements in key health-related quality-of-life outcomes, including speech, aesthetics, swallowing and eating.

Too often, though, the amazing multidisciplinary treatment and care delivered to these patients in (mostly public) hospitals can’t be completed because specialised dental services are lacking. Hospital-based dental services are only available for low-income healthcare card holders and most patients with head and neck cancers can’t afford private dental care that can cost as much as $100,000 beyond what is covered by health insurance. Some patients have very complex requirements for which general dentists are neither trained nor equipped.

As impressive and affordable as the work is at Chris O’Brien Lifehouse, only one-in-ten patients are dentally rehabilitated following oral cancer surgery. New public and private funding options are needed to improve patients’ access to these services. As it currently stands, many patients come through extensive surgery and treatment for oral cancers only to face poor quality of life because they can’t get access to dental prostheses and ongoing dental care.

Better links between oncology, hospital-based dental services and private dentistry are also needed. Dental information is shared in some but not all cases to assist dentists looking after these patients in the community, but dental records are excluded from My Health Record. This information is crucial: cancer patients who have had, for example, extensive radiation to their jaw are at risk of poor healing after dental extractions.

Australia’s National Oral Health Plan 2015–2024 identifies four priority population groups with relatively poor oral health and inadequate access to care. These include people with additional and/or specialised healthcare needs, a category that covers most of the patients described above.

The parliamentary committee’s interim report makes mention of the need for greater coordination between medical and dental services. It quotes one witness stating that “preventing (oral) infection is a medically necessary service and therefore essential health care” (emphasis in the report).

Peter Foltyn, a consultant dentist at Sydney’s St Vincent’s Hospital, is quoted as recommending that any oral and dental health services needed before medical treatment should urgently be integrated into the Medicare Benefits Schedule, or MBS, and that medical undergraduate training should include education on the important relationship of oral health to systemic health.

If they meet certain requirements, dentists already have access to a number of MBS items. These include items for multidisciplinary case conferencing and the preparation of treatment plans for cancer patients; consultations (including telehealth) for oral and maxillofacial patients; and assistance at operations. But no analysis of the use of these items is publicly available, and they apply only to services delivered either in the community or to private patients.

Even if new Medicare items and increased funding for public services were provided tomorrow, little will change for patients unless and until medical and dental cultures change and professional siloes are broken down. This has been done successfully in other medical settings — mostly in multidisciplinary cancer teams — but this kind of integration needs to be universal.

The key barrier is medicine’s and dentistry’s distinct education systems, clinical networks, records, and funding and insurance arrangements. Necessary changes would include interdisciplinary education, shared training, and a recognition that dental services are an integral part of primary care and essential for the treatment of some medical conditions.

An article published  several years ago in the Australian Journal of General Practice did an excellent job of exploring the history of the medicine–dentistry divide and the challenges it creates, and suggested how these might be tackled. Its authors made a strong case that education is the place to start.

A 2018 study of the hours dedicated to oral health education in medical schools in Australia highlighted that imperative. It showed that Australian medical school graduates have little if any foundational knowledge of oral health, including dental caries, oral cancer, dental emergencies, and the relationship between diabetes and periodontal disease. Only a few hours in multi-year programs were dedicated to teaching these topics, and no medical school reported hands-on training in an oral health setting.

We can hope that things have changed since that study was published, but only an optimist would believe that the shift has been sufficient to overcome the current siloes.

It’s time for the federal government to make the system changes and introduce the financial incentives across both the public and private sectors that will push medicine and dentistry into a partnership to improve health and health outcomes for all Australians, starting with those most affected by poor dental and oral health. •

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In government just a year later and in power for almost a decade, the Coalition made frequent promises to lift the uptake of private health insurance even as doubts intensified about its value and cost. Along the way, private hospitals labelled private insurance as the health system’s “weakest link” and the private health funds themselves worried about an exodus of customers.

With analysts increasingly predicting what the Grattan Institute calls a health insurance “death spiral,” the Morrison government made moves over several years to — as officials described it — “improve the value proposition of private health insurance for all Australians.” In reality, that was code for the government’s efforts to rescue the funds from what industry insiders have called “the jaws of death.”

The changes enacted by the Coalition were mostly ineffective. Efforts to make health insurance policies easier to understand were undermined by industry lobbying, leaving the system as confusing as it ever was. Discounts for younger members appear not to have lifted the participation rate for hospital cover. A deal to keep premiums lower was undermined by the failure to achieve savings on the prostheses list, a government-maintained register of medical devices for which insurers are required to pay a benefit. A costs-finder website designed to reveal out-of-pocket costs for specialist medical services has done nothing to increase the affordability and uptake of private insurance.

Through those years the means-tested rebate remained untouched. Never a government to take on difficult issues, the Coalition was confronted with the reality that meaningful options were risky, controversial or both.

Labor’s current consultations on private health insurance had their genesis in Coalition health minister Greg Hunt’s review of the sector, which he launched in July 2019. “I’ve already been meeting with private hospitals, insurers and medical leaders on the next stage in terms of private health insurance reforms,” he said at the time. A few months later he reported that he was working on ways to enable health funds to cover hospital-in-the-home and specialist treatment delivered outside hospitals at a lower cost, starting with mental health and orthopaedics.

This work appears to have stalled. The 2020–21 budget papers announced that the Morrison government would begin consulting the private funds about expanding community-based mental health and rehabilitative care in October 2020, with the changes to take effect on 1 April the following year. I can find no evidence that progress was made towards this goal.

The following year’s budget papers proposed a review of the Medicare levy surcharge (a penalty payable by higher earners who don’t have hospital health cover) and the private health insurance rebate (the means-tested government subsidy to help offset the cost of private insurance). They said that the prostheses list needed modernising and its administration improved, and foreshadowed scrutiny of private hospital default benefit arrangements (the benefits insurers pay to private hospitals if they have no standing financial agreement).

The need for reform has only intensified since Labor took office. Housing and cost-of-living pressures mean that many people, especially if they’re young, can’t afford an expensive discretionary purchase like private insurance. Out-of-pocket costs for private healthcare services continue to rise. The ageing of private fund members is threatening the funds’ sustainability. The cost to government of the private insurance rebate is expected to be around $28 billion over the four years from 2021–22.

But private insurance reform is not a topic health minister Mark Butler is talking about, at least in public. In his media releases and statements this year I can find only one passing reference to the government’s reform program: a mention of reducing private health prostheses prices and enhancing the Medical Costs Finder. The work on major reforms appears to be happening under the radar.

Given the impact any changes could have on all Australians, it’s surprising the health minister isn’t keeping the public informed. We can be sure the other stakeholders — the health insurance industry, the private hospitals and the doctors’ groups — are being kept in the loop.

Labor’s work draws on commitments made by the Coalition in recent years, and reports commissioned by its last health minister, Greg Hunt. But tracking the efforts of both governments is hindered by a lack of transparency and a dearth of publicly accessible documents. Complicating the task is the fact that many of the proposals currently up for analysis and discussion are highly technical, demanding expertise in insurance, taxation and risk management that most health policy experts — let alone the general public — lack.

An online search for official information on private insurance reform reveals a single page on the health department’s website — and despite being dated July 2023 it is clearly a relic of the Morrison era. An invitation to find out more about the reforms it mentions takes the visitor to a budget 2021–2022 fact sheet.

The government’s consultation hub is more forthcoming. It includes a report from consultancy firm EY on hospital default benefits and reports from Finity Consulting on lifetime health cover (May 2022), risk equalisation (September 2022) and a mix of other insurance issues (2023).

This is where the story gets complicated. The latest Finity report recommends retaining the Medicare levy surcharge, the insurance rebate and lifetime health cover (no surprises there), and offers options for optimising both the surcharge and the rebate by targeting incentives more effectively. It offers no options for reforming lifetime cover, with the implication that this is inextricably linked to changes in the surcharge and the rebate.

In its earlier lifetime cover report, Finity found evidence that the penalties for delaying the purchase of private insurance, or for purchasing it only when it was felt to be needed, were having a weaker effect and/or becoming less relevant for younger Australians faced with financial constraints.

A single-page departmental consultation paper requests feedback on these studies’ recommendations and how they might be implemented. It also seeks views on a number of policy and regulatory issues not canvassed in the consultants’ reports and wants to hear back about “the readiness of participants in the private health sector to work constructively together to the benefit of policyholders and the performance of Australia’s private healthcare system, and whole of sector mechanisms that can facilitate this outcome.”

The consultation period was open from 6 June to 15 August. The consultation paper had mysteriously disappeared from the consultation hub when I looked for it on 20 August but was reposted after my email enquiry. No submissions have yet been posted on the website. While we can assume that Private Healthcare Australia (the industry’s peak representative body), the Australian Private Hospitals Association, medical organisations and, it’s to be hoped, consumer and patient groups are keenly interested in the outcomes, to date only the Australian Medical Association and the Australian Private Hospitals Association have made their submissions public.

A separate consultation process on EY’s recommended changes to hospital default benefits arrangements took place in August–September 2022, but despite the release of a consultation strategy the recommendations appear to have gone no further. Without changes to the current default policy, patients using smaller hospitals and hospitals in under-serviced areas will be increasingly out-of-pocket, or those hospitals will receive increasingly inadequate compensation.

Thankfully, a paper by several academics who worked with Finity Consulting helps navigate through this welter of studies. According to its authors, the studies have produced three key findings: that financial incentives for consumers to purchase private health insurance are effective overall but inefficient in achieving their desired objectives, including reducing pressure on public spending; that options for reforming those incentives have been designed only as short-term solutions; and that price changes have little effect on insurance uptake.

Reduced to these three key points, the consultants’ work can justly be regarded as unnecessary. A succession of recent analyses and reports from universities and elsewhere have shown how incentives to take out private insurance do and don’t work and what might be done to improve its value for those who purchase it.

A 2021 paper from ANU’s Tax and Transfer Policy Institute looked at the effectiveness of various sticks and carrots used to encourage private insurance, in particular the changes made by the Gillard government in 2012. It found that the Medicare levy surcharge had a greater bearing than the premium rebate on decisions to purchase insurance.

Research by economists Yuting Zhang and Nathan Kettlewell, on the other hand, showed that increasing the levy surcharge wouldn’t meaningfully increase take-up of private insurance because higher-income people who aren’t already buying insurance appear to be highly resistant to financial incentives and disincentives.

A four-step plan to fix the private health insurance system released by the Grattan Institute called for restraints on price-gouging specialists, measures to stop insurers increasing premiums if they can’t demonstrate value for money, and market competition to control the costs of prostheses.

Amid these reports, what messages have the insurers and providers of private healthcare been pushing in their communications with government, the media and the public?

Private Healthcare Australia, the funds’ lobby group, is strongly focused on two issues: restoring the full private insurance rebate — removing the means test, in other words — and cutting back the costs of medical devices, which are much more expensive in private hospitals than in public hospitals. It recently called for a review of the Morrison government’s prostheses changes, which it described as an “inflationary medical device deal.” Tackling both these issues, says the group, will lower premium costs and increase the uptake of private insurance. (Mark Butler announced a series of changes to the prostheses list in January 2023, but they won’t be fully implemented until July next year.)

The Australian Private Hospitals Association argues that the appeal of private insurance will decline if private hospitals aren’t viable. It accuses the funds of profit-taking at the expense of the long-term viability of private hospitals. The association objects in particular to the default funding arrangements for the treatment of private patients in public hospitals.

The Australian Medical Association deserves some credit for recognising the impact of high-priced health insurance premiums on patients. Its submission to the consultation pushes reforms the AMA first put forward in 2020, including the creation of a Private Health System Authority charged with protecting patients, instilling confidence in this highly complex system and driving reform. The AMA has also called for the private health sector to adopt (and fund) more innovative and efficient models of care, including home- and community-based care.

The loud voices of these well-resourced organisations are not easily ignored by governments. The needs, concerns and growing dissatisfaction of the general public, meanwhile, aren’t readily marshalled, presented and heard. While the biggest concern in the community is that insurance should deliver value for money and be accessible when needed, the evidence shows that many Australians value public hospitals more, especially in a crisis. One in four patients who hold private insurance choose to use public hospitals.

What’s glaringly absent from the current consultations are several basic questions that deserve to be taken seriously. Chief among these is whether the government should withdraw its financial support for private insurance altogether and invest the billions of dollars it would save in Medicare and public hospitals (or cut out the funds and directly support private healthcare).

Which of course raises the question of whether private insurance actually does reduce the burden on public hospitals — a belief challenged by recent research from the Melbourne Institute (summarised in the Conversation) that found it doesn’t make much difference to hospital admissions and waiting-list times.

In debating the public–private divide, it’s important to separate the delivery of private healthcare from private insurers, which are simply financial intermediaries — and surprisingly small ones at that. Australia’s total health budget in 2020–21 was $220.9 billion, of which governments contributed $156 billion, individuals $33.2 billion and private insurance $18 billion. Moreover, to quote insurance industry expert Ian McAuley, there isn’t any aspect of private insurance that isn’t done more efficiently and more equitably by Medicare.

The debate on these issues has always been hindered by the fact that Medicare was introduced without planning for how two health insurance systems, Medicare and private insurance, would coexist. Now might be the time to face the problem squarely.

I have yet to see any response from health stakeholders to the government’s plea for signs of a willingness to cooperate constructively for the benefit of health consumers — but that is surely what is needed if the necessary reforms are to be made. A new openness with the public about the existing consultations would be a good place for both the health minister and his department to start. •

The post The weakest link appeared first on Inside Story.

This is just one strange, chillingly undemocratic, dimension to what promises to be a very strange election. The two oldest men ever to run for president are recontesting an election Trump believes was stolen from him in 2020 — a claim he will certainly propagate again if he loses again. Where he is burdened by historic indictments and a raft of legal probes, Biden’s ability to claim a successful term has been hampered by an intractable, do-nothing Congress and a series of US Supreme Court decisions that have rolled back federally enshrined rights.

Republican-controlled states, meanwhile, continue their efforts to gerrymander electoral districts and undermine voting rights. And the same polls that show Americans want neither Trump nor Biden also show they don’t know who they do want to see on the presidential ticket.

Into this scene emerges a little known, putatively bipartisan group enigmatically called No Labels, which claims to have an “insurance policy in the event both major parties put forth presidential candidates the vast majority of Americans don’t want.” The policy? It will put forward a yet-to-be-named bipartisan presidential/vice-presidential ticket. To this end the group is promoting a US$70 million effort to get its ticket on general election ballots across the nation.

Democrats and Never Trumpers are especially fearful that No Labels’s actions will divert support from voters who might otherwise back Biden. (Trump holds on to disaffected Republican voters more tightly than Biden holds disaffected Democratic voters.) Under the first-past-the-post system used in presidential elections, this would increase Trump’s chances of winning.

But Republicans have reason to worry, too. In a poll conducted for No Labels earlier this year, 59 per cent of respondents said they would consider a moderate independent ticket if faced with a Trump–Biden rematch. But, as others have pointed out, without names on the ticket these numbers demonstrate only a yearning for an alternative. To translate that desire into votes, No Labels needs candidates who can win real support from voters of both parties and independents.

Third-party candidates aren’t uncommon in US presidential elections. In some cases they are barely noticed; in others the evidence shows they affected the outcome. Ralph Nader’s candidature in 2000 is often seen as ensuring that George W. Bush won Florida, and hence the election. Jill Stein, the Greens candidate in 2016, received 49,941 votes in Pennsylvania, a state Hillary Clinton lost to Trump by 44,292 votes.

Perhaps the best-known of all, Ross Perot, received 18.9 per cent of the popular vote (the highest percentage of any third-party candidate ever). But he was seen to have pulled votes equally from George H.W. Bush and Bill Clinton.

Founded in 2010 by former Democratic operative Nancy Jacobson, No Labels was a response to the rising Tea Party’s attacks on Barack Obama’s legislative agenda. It describes itself as a bipartisan movement for Americans who are “tired of the extremes on the left and the right.” Rather than help Obama, its aim was to support lawmakers willing to meet in the middle, irrespective of their party affiliation. Current co-chairs are former Democratic senator Joe Lieberman, former NAACP executive director Benjamin Chavis, and Larry Hogan, the Republican former governor of Maryland.

Because No Labels is a non-profit organisation rather than a registered political party it needn’t declare its sources of funding. Most donors appear to be wealthy individuals working primarily in the finance sector who have also made big donations to the major parties. No Labels also oversees a number of political action committees, or PACs. Experts in campaign finance law say the organisation has reached the limits of what is permissible under electoral law.

Until recently, No Labels has mostly advocated procedural reforms aimed at limiting the power of the majority party in Congress. In 2017 it helped start the bipartisan Problem Solvers Caucus and later it launched fundraising efforts to support candidates who backed the caucus’s agenda. That agenda is more centre-right than centrist: on healthcare, for example, it has pushed to compensate health insurance companies for the rising costs imposed by the pre-existing conditions that Obamacare requires them to cover, and for the elimination of a medical device tax that was also part of Obamacare.

Notably, the lifespans of No Labels and the Problem Solvers Caucus encompass the very period when Washington politics has become increasingly partisan and nihilistic. But whatever No Label once was, it is now clearly an organisation in transition, intent on a new agenda that would make it a player in the national political arena. Suddenly the “national movement of commonsense Americans pushing our leaders together to solve our country’s biggest problems” is in the business of proposing who voters might choose to be the president and vice-president.

Americans got a glimpse of what this might mean a few days ago, at a town hall meeting in Manchester, New Hampshire, when No Labels launched the group’s policy agenda, “Common Sense.” Headlining the event were West Virginia senator and rogue Democrat Joe Manchin, who has hinted at a presidential tilt, and Utah’s former Republican governor Jon Huntsman, who ran for president in 2012.

One think tank has described the policy plan as timid and vague. It is a mish-mash of middle-of-the-road pabulum, dodges tough issues like abortion (it urges “a sustainable abortion compromise most Americans can live with”) and provides no definitive solutions to the problems confronting the nation. Manchin and Huntsman, presumably there as exemplars of the proposed presidential ticket, were equally obtuse on how a bipartisan team might govern. The memo on the No Labels website laying out a third-party presidential plan also dodges crucial issues, including whether and how the campaign would avoid handing the election to Trump.

It is no easy matter to compete against the two major political parties in a presidential election. Just getting names on the ballot papers requires complicated efforts to meet a variety of state-specific filing requirements and timelines. Typically, petitions must have a requisite number of approved signatories.

The group has already gained ballot access in Arizona, Colorado, Alaska and Oregon and signature-gathering efforts are under way in other states. No Labels is providing the names of “placeholder” candidates who will be replaced by the actual presidential and vice-presidential candidates when they are selected. As part of this effort, the organisation has established a number of state affiliates, some with deep Republican roots, which have declared themselves political parties.

Presidential and vice-presidential candidates will be selected between Super Tuesday (5 March) and the No Labels convention, scheduled for April in Dallas, where the candidates will be endorsed. But who will make these decisions and endorsements is never stated.

Realistically, this push for political action is likely to be driven from the top of No Labels by Jacobson and Lieberman, with sidelines support from those, like Manchin, who may see personal opportunities looming — especially as he apparently faces a tough race to retain his senate seat, and buoyed by favourable polling. (No Label’s pollster is HarrisX, owned by Mark Penn, a former adviser to Hillary Clinton who has distanced himself from the Democratic Party and who is married to Jacobsen.)

Perhaps not surprisingly, splits have emerged inside the organisation and reports indicate a toxic work environment. One of the founders, William Galston, has resigned over the presidential push and the Democratic members of the Problem Solvers Caucus are described as being in open revolt.

There does seem to be an element of outsiders’ revenge to what has been characterised as a spoiler intervention that will strengthen Trump’s chances. When challenged on this, Jacobsen has said that No Labels will nominate a ticket only if polling shows a viable path to victory (“if our rigorously gathered data and polling suggest an independent unity ticket can’t win, we will not nominate a ticket”) and that the ticket will be pulled from the ballot if the campaign tilts the race to a competitor, especially to Trump. “We will not spoil for either side. The only reason to do this is to win.” Lieberman told the Atlantic. “The last thing I’d ever want to be part of is bringing Donald Trump back to the Oval Office.”

But these statements only raise more questions. Can Jacobson and Lieberman be trusted to make these decisions? What is the metric they will use? Where do they think the votes to deliver a third-party win will come from?

Only the latter question can be answered here. At a time of hyperpartisanship, centrist and independent voters are, at least theoretically, up for grabs. Biden already occupies much of the centre and Republicans like Trump, Ron DeSantis and Mike Pence are preoccupied with the right. Pew polling shows that while 38 per cent of Americans describe themselves as independents, only 7 per cent identify as an independent leaning towards neither of the two major political parties.

What distinguishes the small share of Americans who are truly independent is their low level of interest in politics, and that makes them hard to engage in the swell of support No Labels needs. Most analysts (including at Third Way and in Politico) agree that No Labels’s hopes of any electoral college votes, let alone the 270 mentioned on their website, are based on flawed premises.

For the time being, though, Democrats and Never Trumpers must worry about No Labels’s intent. Some small reassurance comes in Aaron Blake’s Washington Post analysis of polling by Monmouth. The pollster found that Biden leads Trump by seven points (47–40) in a head-to-head among those who will “definitely” or “probably” vote for either candidate. In contrast to other polls (including HarrisX’s), Monmouth’s shows no significant shift when a third-party ticket is introduced. With a generic third-party ticket, Biden edges ahead by nine points; with Manchin and Huntsman named as candidates, Biden still has a six-point edge.

As Blake observes, while Americans generally like the idea of an independent candidate, what No Labels is offering is not an independent or a third-party ticket but a fusion Republican–Democrat ticket. And he reminds us that third-party tickets almost always poll better than they perform on election day because voters ultimately want to choose between candidates who have a chance of winning. •

The post Is No Labels heading off-label? appeared first on Inside Story.

Thanks to three Trump-era appointments, the nine-member court is dominated by six conservative justices. While it has repudiated aggressive conservative litigation on immigration, tribal rights and the ability of states to control elections, in each case with the three Democratic appointees as part of the majority, it has also responded to the conservative agenda in decisions on affirmative action, gay rights and student loans. Divided along partisan lines — with the court’s three Democratic appointees in strong dissent — those decisions will have a significant impact on the rights of protected population groups in the United States.

The dominant news, and a cause for progressive celebration, is the court’s decision to reject the radical independent state legislature theory in Moore v. Harper, a case brought by a group of Republican lawmakers from North Carolina. The theory rests on a relatively recent interpretation of the US constitution’s elections clause, which says that state legislatures can set the rules for national congressional elections in their states.

According to proponents of the strongest form of the theory, no other organs of state government — courts, governors, election administrators or independent commissions — can alter a legislature’s decisions about how federal elections are run. Trump lawyers used this theory in 2020 to argue, unsuccessfully, that Joe Biden’s victories in key states were illegitimate and that state legislatures could unilaterally reverse the outcome.

In the latest case, the court ruled that state legislatures can’t make decisions that ignore their state’s supreme court or violate their state’s constitution. This six–three judgement, which applies to all states, is being hailed as a major win for democracy and voting rights.

But the tireless efforts of hardline conservatives will mean further attempts to challenge the court’s ruling and invoke the independent state legislature theory are likely in 2024. And the decision will not change the commitment of the Republican-dominated North Carolina legislature to the undermining of federal election processes and voting rights.

The genesis of the case was a gerrymandered electoral map drawn by the Republican-dominated North Carolina legislature after the 2020 census. After it was rejected by the state’s supreme court, Republicans passed an emergency application in February 2022 asking the US Supreme Court to intervene. That court rejected the request for immediate intervention, and the election last November was conducted under a map drawn by experts appointed by a state court.

The result was a fourteen-member congressional delegation evenly split between Republicans and Democrats — a reasonable result in a state where 34 per cent of voters are registered Democrat, 30 per cent are registered Republican and 36 per cent are unaffiliated.

But the 2022 election changed the composition of the North Carolina supreme court, which is now dominated by Republicans with a five-to-two margin. The new court’s majority reversed course, saying the legislature is free to draw gerrymandered voting districts as it sees fit — as it is already doing. A political fight is developing in North Carolina over voting rights and what has been described as “headline-grabbing confrontations over nearly every lever of the electoral apparatus.”

Moreover, the US Supreme Court’s decision contains what some see as a time bomb. In his majority opinion, chief justice John Roberts reaffirmed his court’s capacity to overrule state courts when it so chooses. Importantly, he persuaded the three liberal justices, Elena Kagan, Sonia Sotomayor and Ketanji Brown Jackson, to go along with a version of judicial review that some experts fear could allow the court to meddle in future elections.

It is interesting to note that the justices pointed to Bush v. Gore, the 2000 Supreme Court opinion that stopped Florida’s recount and confirmed George W. Bush’s presidential victory, as a template for resolving election disputes, despite the fact that the court’s opinion in Bush v. Gore explicitly stated that it was not intended to create precedent.

A series of other just-released decisions reflect the court’s conservative leanings and seem part of a broader effort to overthrow long-supported rights and benefits for minority groups. Two decisions saw the six conservative members of the court invalidate admissions programs at Harvard and the University of North Carolina that use race as a criterion, effectively ended race-oriented affirmative action admissions programs at public and private colleges and universities across the country and tossing aside yet another well-established federal right.

It is ironic that the justices ruled that the admissions policies violated the equal protection clause of the fourteenth amendment to the constitution — an amendment that was ratified in 1868 to enable the federal government to deal with the profound racial discrimination against Black Americans that continued after the Civil war.

The majority decision was written by Roberts, a long-time critic of affirmative action programs. At both Harvard and the University of North Carolina, he wrote, the programs “lack sufficiently focused and measurable objectives warranting the use of race, unavoidably employ race in a negative manner, involve racial stereotyping, and lack meaningful end points.”

As if to acknowledge these programs’ importance to ensuring greater diversity, though, Roberts stressed in a footnote that military academies are exempted from the decision. “No military academy is a party to these cases, however, and none of the courts below addressed the propriety of race-based admissions systems in that context,” he wrote. “This opinion also does not address the issue, in light of the potentially distinct interests that military academies may present.”

The only two Black members of the Supreme Court — Clarence Thomas and Ketanji Brown Jackson — openly traded barbs in their widely divergent opinions.

“As [Jackson] sees things, we are all inexorably trapped in a fundamentally racist society, with the original sin of slavery and the historical subjugation of black Americans still determining our lives today,” wrote Thomas, himself a beneficiary of academic affirmative action. “The panacea, she counsels, is to unquestioningly accede to the view of elite experts and reallocate society’s riches by racial means as necessary to ‘level the playing field,’ all as judged by racial metrics. I strongly disagree.”

Thomas also accused Brown Jackson of ignoring the oppression of other groups, including Asian Americans and “white communities that have faced historic barriers.” (It’s worth noting that Thomas and his conservative colleagues don’t take issue with the legacy programs that perpetuate elite access to Ivy League universities.)

Justice Brown Jackson, who led the liberal dissent, didn’t mince words either, calling the decision “a tragedy for us all.” She defended the use of race-conscious programs to ameliorate the pervasive, present-day effects of America’s history of state-sponsored racism. “Gulf-sized race-based gaps exist with respect to the health, wealth, and wellbeing of American citizens,” her dissent began, and went on to argue that allowing colleges to consider applicants’ race has “universal benefits” because it helps to close those gaps and thereby promotes equality.

Not surprisingly, these US Supreme Court decisions have generated strong condemnation. Critics are concerned about the impact on Black Americans and on the diversity that is so needed in the healthcare workforce.

More is at stake than affirmative action in university admissions, including the central question of whether the law can be used to fix longstanding racial inequalities. As Justice Sotomayor wrote in her strong dissent, “The Equal Protection Clause of the Fourteenth Amendment enshrines a guarantee of racial equality. The court long ago concluded that this guarantee can be enforced through race-conscious means in a society that is not, and has never been, colorblind.”

Conservatives, long wary of race-based programs designed to benefit minorities, will be emboldened to leverage these decisions into attacks on affirmative action programs in other areas such as corporate diversity. “In the broadest sense,” wrote political analyst Ron Brownstein in the Atlantic, “the Republican-appointed justices have moved to buttress the affluence and status that allow white people to wield the most influence in society, and to diminish the possibility that accelerating demographic change will force a renegotiation of that balance of power.”

Disadvantaged students will also be affected by the court’s decision, in Nebraska v. Biden, to strike down President Biden’s student debt relief plan. This was a 2020 election campaign promise to deliver financial relief to up to forty-three million student loan-holders, including cancelling the full remaining balance for roughly twenty million, with these relief dollars targeted to low- and middle-income borrowers. Advocates argue that both student loan forgiveness and affirmative action are racial justice issues.

In a major win for Republicans, who had vehemently opposed the plan, the court’s six conservatives ruled that the Biden administration lacked the power to forgive loans for more than forty million borrowers. Facing Republican opposition to legislation to implement this commitment, Biden had used the HEROES Act, which was authorised in 2003 after the 9/11 attacks as a means of giving loan relief during times of war and other emergencies.

The plan’s hefty price tag also meant it had major economic implications. In striking down the plan the court thus relied on the “major questions doctrine,” which says that Congress must give direct authorisation for the executive branch to implement a policy that has major economic and political impacts on the country. The doctrine was first invoked in 2022 in a decision about the extent to which the Environmental Protection Agency could regulate greenhouse gas emissions.

Republicans and advocates of limiting the power of the federal bureaucracy cheered this most recent court decision, but the liberal justices and many legal experts are concerned it could prevent the government from taking decisive action on climate change, healthcare and other urgent problems.

“The Court, by deciding this case, exercises authority it does not have,” Justice Kagan wrote in her dissent. “It violates the Constitution.” Norman Ornstein of the American Enterprise Institute was even blunter: “They created out of whole cloth a bogus, major questions doctrine. They made a mockery of standing. They rewrite laws to fit their radical ideological preferences. They have unilaterally blown up the legitimacy of the Court.”

Another recent decision puts a question mark over the court’s decade-old judgement establishing the constitutional right to same-sex marriage. In this latest case, the court decided that Colorado’s anti-discrimination law violated a web designer’s free speech rights under the first amendment, raising fears that the right of LGBTQI+ Americans to non-discrimination (including the right to marry) is being eroded.

The case, 303 Creative v. Elenis, rests on several hypotheticals. Web designer 303 Creative is owned by Lorie Smith, who opposes same-sex marriage on religious grounds. But the company has never been asked to create a website for a same-sex wedding, and Colorado has never tried to force it to design such a website. In fact, Smith didn’t design wedding websites for anyone at all when the suit was filed.

Justice Neil Gorsuch, who wrote the majority opinion for the conservative justices, called the message conveyed by any websites Ms Smith designs “pure speech,” as if no services were being provided and the primary point of the websites would be to express the designer’s views on matrimony. The court’s three liberal justices disagreed. “Today,” Justice Sotomayor wrote, “the court, for the first time in its history, grants a business open to the public a constitutional right to refuse to serve members of a protected class.”

The decision came at a time when Republican legislators in many conservative-leaning states are targeting the rights of transgender and other LGBTQI+ people. In strongly criticising the decision, President Biden expressed a fear that the ruling could invite more discrimination. “In America, no person should face discrimination simply because of who they are or who they love,” he said in a media statement. “More broadly, today’s decision weakens long-standing laws that protect all Americans against discrimination in public accommodations — including people of color, people with disabilities, people of faith, and women.”

Not only do these recent decisions highlight the impact of the three conservative justices appointed by Donald Trump; the majority and minority opinions also highlight how divided the US Supreme Court has become. Observers have detected a new contentiousness during oral arguments and within justices’ opinions. The highly personal attacks in the affirmative action rulings are a far cry from the expected dispassionate legal interpretation.

In dissenting from the decision to strike down the student debt plan, for instance, Justice Kagan wrote that “in every respect, the court today exceeds its proper, limited role in our nation’s governance.” Chief Justice Roberts retorted: “It has become a disturbing feature of some recent opinions to criticise the decisions with which they disagree as going beyond the proper role of the judiciary.”

Moreover, when court decisions continually divide along the same lines as the divergence of political opinions — as has happened in most of these big cases — it is very hard for the public to see the distinction between law and politics.

A growing number of critics worry the court is losing its legitimacy by overturning abortion rights and using disingenuous legal reasoning to advance a reactionary political agenda. At the same time, public revelations of the close ties between Justices Samuel Alito, Gorsuch and Thomas and wealthy benefactors with business before the court have met with official indifference from the chief justice. Small wonder the court’s popularity has plunged to record lows as the public increasingly sees the court as a political body.

Biden is facing increasing pressure from Democrats to embrace far-reaching reforms to the nation’s highest court, including expanding the number of justices and imposing term limits and mandatory retirement. While he has harshly criticised the court’s sharp pivot to the right, calling it “not a normal court,” he has declined to endorse any of proposed reforms.

Together with abortion, these most recent decisions will be an ideological divide along which Republicans and Democrats — and voters — will line up for next year’s elections. The conservative push to erode rights for women and minority groups will galvanise both those who agree and those affected.

Biden is signalling he will run against the court and Republican lawmakers on a host of judgements, including abortions rights and student loans, hoping to appeal to women, people of colour and young voters. For this to be a winning strategy, he must get voters who are disappointed by the lack of action on these and other issues — including stricter gun rights and more liberal immigration laws — to see that their only hope of remedy lies with him and the Democrats.

Trump will certainly tout his success in stacking the US Supreme Court, and his Republican presidential rivals will presumably claim they will do more. This approach has deep appeal for the rusted-on Make America Great Again base but is unlikely to garner sufficient votes to gain a victory in the general election.

It is no accident that Trump, even as he takes credit for the decision to abolish legal abortion, has been dodging questions about whether he would sign a federal abortion bill into law — something many within the conservative movement see as the next frontier in this fight. Florida governor Ron DeSantis, his chief rival in the Republican presidential primary, has sought to outflank him on the issue by embracing it as a key feature of his campaign, as has former vice-president Mike Pence.

What the United States is seeing in 2023 — in Supreme Court decisions, state actions and the failure of Congress to enact any meaningful legislation — is a clawing back of the rights of Americans, especially those in minority groups, in a way previously unseen in modern times. This must surely be a key election driver next year. •

The post One step forward, three steps back appeared first on Inside Story.

One reason Trump was an early entrant is his insatiable desire for media attention (good or bad, it’s all publicity, he obviously believes). But a strategy was at work too: his efforts to garner media attention, control the Republican Party, dominate discussions within the chattering classes, and hoover up donations were designed to intimidate rivals and leave little room for those brave enough to consider a challenge.

Florida governor Ron DeSantis, South Carolina senator Tim Scott, former vice-president Mike Pence, former New Jersey governor Chris Christie and several others are loitering hesitantly on the sidelines. Former South Carolina governor Nikki Haley, former Arkansas governor Asa Hutchinson and entrepreneur Vivek Ramaswamy have declared their candidature but remain largely unknown to most voters. (National Public Radio has compiled a longer catalogue of declared and possible candidates.)

When Republicans are provided with a list of potential presidential candidates and asked who they would vote for, Trump is still the clear winner. The most recent FiveThirtyEight analysis shows Trump on 49.3 per cent and DeSantis on 26.2 per cent, with Pence (5.8 per cent) and Haley (4.3 per cent) lagging, though ahead of several others who barely register. The RealClearPolitics poll average has similar results. History suggests these very early polls say a lot: candidates polling more than 30 per cent have a decent chance of becoming the nominee; those polling below 10 percent are usually doomed.

Trump’s margin over DeSantis (his only viable competitor for the moment, despite not having declared his candidature) varies from thirteen to thirty-seven percentage points. The gap was narrowing until news broke of Trump’s recent indictment in New York. Since then his lead has surged, as has his fundraising.

Polls taken since the indictment, and with several other more serious indictments likely, reflect Trump’s two key strengths — his rusted-on Make America Great Again base and his control over the wider Republican Party, whose members are fearful of breaking with him.

Many Republicans seem to have been energised by the looming cases. Eighty per cent of self-identified Republicans told a national Marist poll that the investigations are a “witch hunt”; just 18 per cent said they were fair. By contrast, a majority of all Americans (56 per cent) say the investigations into Trump are fair and a significant majority (75 per cent) say Trump has behaved illegally and/or unethically.

Despite these apparent portents of success, though, there are growing signs that key support groups (primarily older, white Republican voters), senior members of Congress (including Senate minority leader Mitch McConnell) and the Republican establishment (wealthy donors, the Murdoch empire and some right-wing commentators) are finally deserting Trump, or at least considering that possibility.

The evidence suggests Trump is losing older white Christian voters, key to his 2016 win, who have soured on his coarse and divisive language and his undignified persona. The six-point fall in their support for Trump between 2016 and 2020 may have been critical in the key battleground states that decided the 2020 election.

Support from this group continues to erode. The recent Marist poll, for example, found white conservative seniors were not as enthusiastic as other Republicans, with only 61 per cent calling the threats of indictment a “witch hunt” and 37 per cent saying they were fair. A March poll among Republicans in Iowa, a state with a significant older white Christian demographic, indicated that 74 per cent would “likely” vote for Trump if he were the party’s nominee in 2024 but only 47 percent would “definitely” vote for him.

As it stands, Trump’s support among Republicans is almost certainly enough to win him the presidential primary, regardless of who else enters the race. But it will not be enough to win him the general election. Even the New York Post, a News Corp publication well-recognised as favouring conservative candidates, finds Trump’s unfavourability ratings a huge hurdle. Closer to home, the Murdoch-owned Australian recently worried that “Tarnished Trump May Hand Biden a New Term.”

But Trump and his staff seem unable to crunch the numbers. Their focus is on his adoring MAGA base, and they have shown little interest in appealing to Republicans whose support is wavering, or to the independent voters essential for a win in 2024.

Trump narrowly won independents in 2016, but they swung to Biden in 2020 by a nine-point margin. Today, only 37 per cent of independents approve of Trump, and fully 64 per cent don’t want him to be president. They are appalled by his refusal to preside over a peaceful transition and his role in the violence at the Capitol on 6 January 2020; they are tired of his endless election denial and his focus on perceived slights; they reject his relentless campaign of political revenge against those who refused to stand with him.

This erosion of support from crucial voters in key battleground states like Pennsylvania has rightly been described as a self-inflicted wound. Trump believes that his capture of MAGA Republicans has made him the most powerful force in the Republican Party: he basks in their uncritical admiration and sees no reason to change or to compromise his campaign strategy. He has reportedly told advisers that he must “run as himself” in order to pull off a 2016-style victory.

Meanwhile dissent continues to grow inside the Republican tent and within a growing Never Trump movement. Mostly this sentiment reflects anger that Trump’s interventions in the 2022 midterm elections cost Republicans seats in the House and control of the Senate and that further losses are likely in 2024. These dissidents, too, are increasingly disgusted by his behaviour and concerned that his legal troubles will engulf him at the very time he needs to be focused on the 2024 election.

Georgia governor Brian Kemp is among those making the case for “anyone but Trump.” He has challenged Republicans to seek out a presidential nominee who gives voters a “reason to like us” and offers a vision for the future rather than an obsession with the past.

A potential rival for the Republican nomination, Chris Christie, was more forceful: “[Trump] is losing. And if he doesn’t change course, both in terms of the substance of what he is discussing and the way that he approaches the American people, then he will lose.” Even Mike Pence has suggested that he won’t support Trump again, saying “I think we’ll have better choices.”

Just as significantly, big-name Republican donors and fundraisers are looking to back alternatives to Trump. Both the Koch–affiliated Americans For Prosperity and the anti-tax Club for Growth have signalled they are seeking another candidate. “He is a metastasising cancer who if he is not stopped is going to destroy the party,” Republican fundraiser Eric Levine told Politico. “He is the first president since Hoover to lose the House, the Senate and the presidency in a single term. Because of him Chuck Schumer is the Leader Schumer, and the progressive agenda is threatening to take over the country. And he is probably the only Republican in the country, if not the only person in the country, who can’t beat Joe Biden.”

We should note that a Never Trump movement existed in 2016, and at one point a key figure was senator Lindsey Graham, now a fully paid-up member of the suck-up-to-Trump camp. That first anti-Trump drive fell apart when he won the presidency, and today, if its members calculate that Trump could win, the movement may well do so again.

Trump’s ability to raise millions of dollars from his base means he doesn’t care that major donors are looking elsewhere. His campaign says he has raised more than US$34 million for his 2024 run since the start of the year, boosted by a big bump in donations (US$15.4 million) since the announcement of the New York criminal charges.

(It’s worth noting that these are not the figures reported to the Federal Election Commission. Trump’s April filing reports US$14.5 million raised during the first three months of this year, with at least US$2.7 million raised from individual donors in the two weeks after 18 March. This puts him well ahead of his rivals but lags behind the pace set in his earlier campaigns.)

Trump’s campaign is increasingly funded by hundreds of thousands of individual donations, the vast majority under US$200. It is estimated that Trump and his close allies have raised more than US$390 million since election day in 2020 through aggressive fund-raising solicitations to his MAGA crowds. A significant proportion appears to be being spent on the legal expenses of Trump and his cohorts.

Trump’s unwavering campaign formula faces one further set of risk factors: the changing political and demographic landscape of the United States.

Voter support has moved to the left on issues like guns, abortion and race. The rulings of the Supreme Court, dominated by Trump appointees, have gone against public opinion on abortion and guns and will soon encroach on key social policy areas like marriage equality, healthcare and protections for transgender people and immigrants.

For decades, Republicans relied on abortion to rally their conservative base, vowing to undo Roe v Wade and outlaw the procedure. But since last June’s Supreme Court ruling denying the federal right to a surgical abortion, and since a judge in Texas sought to ban the drug used for medical abortions, voters have been galvanised and abortion has emerged as a potent issue.

Although Trump boasted about his anti-abortion Supreme Court nominees and took credit for their Roe v Wade ruling, he has begun to uncharacteristically tiptoe around this issue, even in the face of Florida’s action to deny abortions after six weeks.

But Trump has grasped one issue with both hands, and that’s gun rights, a core issue for his MAGA base that will be a tough sell in a general election. At the recent National Rifle Association convention, he promised that, as president, he would make sure “no one will lay a finger on your firearms.”

A February Gallup poll showed Americans’ dissatisfaction with existing gun laws has risen to 63 per cent, the highest since Gallup started asking the question twenty-three years ago, and an increase of seven points in just a year. Many more mass shootings have occurred since then — thirty in the first seventeen days of April alone — and many more people have died from gun-related causes.

Voter demographics are also changing — a fact that has driven much of the Republican efforts to limit voting rights. The Brookings Institute sees younger voters, with their preference for Democratic candidates, as upending politics. Youthful racial minorities are seen as the primary demographic engine of the nation’s future growth, countering an ageing, slow-growing and soon to be declining white population.

Donald Trump long seemed immune to the rules of political life and the consequences of even the most outrageous conduct and the most obnoxious language. Now, perhaps, that is changing. In recent focus groups, most “persuadable” Republican voters stood by their past support of Trump but some — feeling “overwhelmed” and “fatigued” — are looking beyond Trump for the 2024 primaries.

Their exhaustion with Trump doesn’t mean they are looking for a break with Trumpist policies, of course. They aren’t necessarily seeking more moderate policies, or even more moderate messaging; they are looking for someone less divisive — and perhaps less self-centred.

“I and a lot of other Republicans who were supportive of President Trump are becoming less and less supportive,” said one Republican voter. “Not because I’m a ‘Never Trumper.’ I just don’t believe Trump is the best person to move this party forward.” •

The post Is Donald Trump losing his grip? appeared first on Inside Story.

Together with his companies and a number of his senior White House staff, Trump is facing an unprecedented array of state and federal legal investigations and lawsuits. He will have to navigate every one of them, and associated financial and reputational costs, during his campaign to secure the Republican presidential nomination for 2024.

Perhaps the most serious charges are those likely to emerge from special counsel Jack Smith’s investigation of Trump’s role in inciting the 6 January riots and attempting to overturn the 2020 election result, and his obstruction of efforts to locate classified documents at his Mar-a-Lago resort.

In the case of the Mar-a-Lago documents, the improper handling of federal records and obstruction of a federal investigation could be the basis of charges under the Espionage Act. The 6 January case is more complex: it is looking at how Trump spent money raised purportedly to help pay for legal challenges to the election; at efforts to have his own slates of state electors file fraudulent official certificates; and at who organised and funded the 6 January rallies. It could result in charges that Trump and others engaged in a conspiracy to defraud the United States and/or obstruct official government proceedings.

In Georgia, a criminal investigation is looking at Trump’s attempt to persuade state officials to overturn Joe Biden’s win in their state. In a post-election call, Trump told Georgia’s Republican secretary of state, Brad Raffensperger, that he wanted “to find 11,780 votes” (Biden won the state by 11,779 votes). It is a federal felony to knowingly attempt “to deprive or defraud the residents of a state of a fair and impartially conducted election process” through “the procurement, casting, or tabulation of ballots that are known by the person to be materially false, fictitious, or fraudulent under the laws of the State in which the election is held.”

A grand jury convened to make a preliminary investigation has concluded that multiple indictments are warranted for Trump’s alleged efforts to overturn the Georgia results. The decision whether to proceed will be made by the Fulton County’s district attorney, Fani Willis.

Trump also faces a raft of civil charges. These include a joint lawsuit from a number of members of Congress and Capitol police officers contending that Trump’s fiery speech incited the 6 January attack on the Capitol, and claiming damages, and two separate New York investigations into the Trump Organization and Trump’s web of related businesses. Both the New York probes are examining allegations that Trump misrepresented his companies’ finances in order to obtain bank loans or to reduce taxes.

This brings us back to the Manhattan District Attorney’s investigation into the money paid to Stormy Daniels to keep quiet about a tryst with Trump. Daniels was given US$130,000 in the closing days of the 2016 campaign by Trump lawyer and long-time “fixer” Michael Cohen, who was later reimbursed by Trump. Cohen confessed to violating New York State election law and served jail time in 2018.

In January this year, district attorney Alvin Bragg empanelled a grand jury to hear evidence about Trump’s role in the payment. Kellyanne Conway, who held a senior advisory position on the Trump presidential campaign and later became a White House counsellor, has given evidence, though it’s not clear whether she appeared before the grand jury or simply met with prosecutors. It was Conway who Cohen notified when the payment had been made, and who presumably then notified Trump.

To make this case a felony (a more serious crime punishable by a prison sentence of more than a year), prosecutors will have to show that Trump was involved in the falsification of business records. (The Trump Organization labelled the US$130,000 as legal expenses.)

As the shape of the 2024 presidential campaign starts to emerge, these proceedings will become political dynamite. Special Counsel Smith’s pace has quickened in recent weeks, signifying to observers that he is working to present his charges before the presidential primary debate season begins in August. Charging decisions in the Georgia inquiry are expected in the (northern) spring or summer.

These unusual and complex probes have turned some of Trump’s many current and former lawyers and senior presidential aides into witnesses or even potential targets of investigation. In recent weeks the special counsel has issued a flurry of grand jury subpoenas to high-profile witnesses including former vice-president Mike Pence and Trump’s former chief of staff, Mark Meadows, with strict deadlines for responses. These have triggered multiple, closed-door legal battles that could delay proceedings for some months and may well be part of Trump’s management strategy.

Trump lawyers have asked a federal judge to block the subpoena for Pence to testify, citing executive privilege. Pence himself has said he is prepared to fight his subpoena “as far as it needs to go.” While he is obviously looking to protect himself and his own possible presidential bid, this might also be a feint to protect himself against attacks from Trump, who has already accused him of disloyalty.

Trump’s push for all-encompassing executive privilege is an ongoing attempt to enable him (and by extension his aides) to withhold information from the Congress, the courts and the public. But this presidential power may not reach as far as he hopes: the constitution gives presidents immunity from being sued only over their official actions, and the US Supreme Court has never held that presidents are immune from criminal prosecution. The question, then, is whether Trump’s 6 January speech and efforts to overturn the election result fell within his official job responsibilities.

A judge of the Federal District Court for the District of Columbia ruled last year that the case brought by the members of Congress and the Capitol Police could proceed because Trump’s various communications before and on 6 January amounted to a “call to action.” Trump’s lawyers appealed that ruling to the District of Columbia Circuit Court, which then asked for the justice department’s opinion.

In a friend-of-the-court brief, the civil division of the justice department said that if Trump’s speech incited the 6 January riot — the contention found credible by the District Court — then he was not shielded by immunity. Urging the appeals court to allow the suit to proceed, the department’s lawyers wrote that the “traditional function [of public speaking] is one of public communication. It does not include incitement of imminent private violence of the sort the District Court found that the plaintiffs’ complaints have plausibly alleged here.” If the justice department says this about a civil case, it should hold the same position in a criminal case.

This is not the only pending case that tests the limits of when Trump was acting in his capacity as president. A separate District of Columbia Court is weighing whether he was acting in his official capacity when he spoke disparagingly of writer E. Jean Carroll, who has accused him of raping her in the 1990s and is suing him for defamation. In this case the justice department agreed with Trump’s lawyers that he made these remarks while answering reporters’ questions and was acting in his official capacity. This case against Trump looks likely to be dismissed.

Some of Trump’s lawyers are using another blocking tactic, asserting lawyer–client privilege. This argument can be overcome under the “crime–fraud exception” if prosecutors can show that Trump’s lawyers’ actions are part of a criminal scheme. Federal prosecutors are attempting to use the exception to compel further testimony in relation to the advice from lawyer Evan Corcoran used by Trump to obstruct the Mar-a-Lago documents investigation.

Legal jousting has been a way of doing business for Trump for decades. A USATODAY analysis in 2016 found that he and his businesses had been involved in at least 3500 legal actions in federal and state courts during the previous three decades. Even as he claimed the Oval Office he faced seventy-five active lawsuits.

Trump adopted his litigious nature early, after his family company was sued by the justice department in 1973 on grounds that its rental housing policy violated the Fair Housing Act. He and his father used the notorious and famously combative lawyer Roy Cohn to counter-sue, claiming defamation. There was no real victory, but his biographers see this episode as driving home the key lessons he learned from Cohn: deny, deflect, delay and don’t put anything in writing. Perhaps this last dictate explains why Trump doesn’t use email.

Trump has carried these lessons through five decades of lawsuits, tax challenges and business failures, two impeachments and more legal investigations than any other president. As one biographer, a former federal prosecutor, wrote, “[Trump] sued at the drop of a hat. He sued for sport; he sued to achieve control; and he sued to make a point. He sued as a means of destroying or silencing those who crossed him. He became a plaintiff in chief.”

Trump might often threaten to sue, but he rarely follows through and almost always loses when he does. This is partly a result of poor legal advice: infighting has always been rife in a legal team whose personnel has changed dramatically over the years.

More recently he has used many curiously incompetent, and sometimes fraudulent, legal advisers. These include Rudy Giuliani (now in legal jeopardy over his false claims about the 2020 election), Sidney Powell (the subject of a petition brought by the State Bar of Texas Commission for Lawyer Discipline alleging that she violated legal ethics rules in working to overturn the 2020 election) and Jenna Ellis (who recently admitted to making false statements about the 2020 election).

Guided by these figures, Trump’s legal failures accumulated in the months immediately after November 2020. He and his allies filed more than sixty lawsuits seeking to overturn the election results, all of which — including direct petitions to the US Supreme Court, which includes three Trump-appointed justices — failed for lack of evidence. Some were dismissed because of errors in filings and other procedural lapses.

Trump has a reputation for not paying his lawyers, and these days he is increasingly conducting his legal nastiness using other people’s money. The Republican Party has paid millions for Trump’s legal bills. Recently the chair of the Republican National Committee announced that the committee will no longer do so because Trump is running for the party’s presidential nomination. During 2021 and 2022, when many Republican candidates struggled with election finances, Trump spent more than US$16 million from his political action committee, Save America, on legal payments, including US$10 million on his own legal fees.

The House select committee that investigated the 6 January insurrection found that much of the money accumulated by Save America came from a Trump fundraising drive that took US$250 million in donations from supporters specifically to cover legal challenges to the 2020 presidential election results. The fund was never actually created, and the money was instead used mostly to cover Trump’s own legal fees and for payments to several pro-Trump organisations headed by former Trump administration officials.

Trump could be defending himself in as many as four criminal cases as he runs for the Republican presidential candidature next year. He believes, perhaps accurately, that an indictment would increase his poll numbers. He insists that he is a victim of political enmity and corrupt prosecutors, and that the investigations are an effort to silence his supporters. He refuses to acknowledge that his legal problems are entirely a result of his own actions.

When asked if he would stay in the 2024 race if indicted, he responded that he “wouldn’t even think about dropping out of the race.” It was a bold declamation, but one that may not be his to make. No president or former president has ever been indicted. (Richard Nixon was pardoned by his successor, Gerald Ford, “for all offenses against the United States” that he “committed or may have committed” during his presidency.) But Donald Trump is in growing legal and political peril. •

The post Before the deluge appeared first on Inside Story.

When Anthony Albanese promised to create an Australian Centre for Disease Control back in October 2020, partly inspired by the CDC, he was responding to Australia’s underpreparedness in the face of the Covid-19 pandemic. But Labor’s proposal reflects a much longer debate: since as far back as 1987 Australian public health experts have been calling for a dedicated body to advise government not just about threats from infectious diseases but also about preventive health measures.

Labor’s 2020 pledge focused on improving Australia’s response to future pandemics (and, indeed, better managing Covid’s ongoing effects). Its announcement highlighted the need for improved disease surveillance, better management of the National Medical Stockpile, regular preparedness drills, and close cooperation with state and territory governments and with other countries.

The ACDC is expected to take a key role in preventing, monitoring and managing infectious diseases, including unexpected contagions generated by climate change and resumed international travel. But every bit as vital will be its efforts to prevent the chronic diseases caused by lifestyle and environmental contaminants. Treasurer Jim Chalmers’s first budget provided $3.2 million in 2022–23 for design and consultations for this new agency.

In a discussion paper released last month, health minister Mark Butler says the ACDC will take “an ‘all-hazards’ approach to strengthening Australia’s ability to respond to a range of public health threats — both natural and those created by humankind.” Given the range of complex capabilities the ACDC could be expected to meet, it seems likely to be established in several phases.

As Butler envisages it, the first phase would include rebuilding the National Medical Stockpile, undertaking communicable disease surveillance, prevention and response, and ensuring greater data-sharing and data linkage. Other more controversial or more difficult elements will be incorporated in later years.

Butler and the Department of Health and Ageing are being inundated with advice and instructions. Writing for Croakey Health Media, public health specialist Terry Slevin outlined twenty-eight questions he believes the government’s discussion paper raises that must be addressed. VicHealth chief executive Sandro Demaio has listed six principles an ACDC must follow in order to be successful.

Two imperatives in particular are clear already from submissions and consultations. The ACDC shouldn’t duplicate existing functions but instead play a coordinating role. It must be given the necessary resources, key among them being an expert workforce and sustained, long-term funding.

While the public health sector is pushing for quick action and certainty, careful planning is critical and a staged rollout will help ensure there are no gaps and oversights. A commitment to boost the public health workforce and ensure a steady supply of needed expertise will be essential. The Public Health Association of Australia has called for a standardised national public health training program for all jurisdictions and for a more effective workforce distributed more equitably.

Australia has a reliable set of health statistics collected by a variety of government agencies, but it does a poor job of using this data for policy development and evaluation. Links between different datasets are limited, and little effort has been made to understand health disparities and inequalities. In many cases — as the most recent Closing the Gap report highlights — essential data for assessing health and social interventions is simply not available. The ACDC will need to tackle these gaps.

The general assumption is that the ACDC will also have health promotion and prevention responsibilities, although their scope is yet to be determined. The potential gains are enormous: chronic disease could be reduced by two-thirds by targeting lifestyle‐related risk factors, including tobacco use, obesity, alcohol misuse, physical inactivity and high blood pressure. Yet Australia lacks “a sustained, comprehensive and strategic approach to prevention, together with adequate funding, coordination and monitoring.”

Australia’s erratic “roller coaster” of preventive health efforts has been driven largely by ideology. Tony Abbott’s government, for example, abolished the Australian National Preventive Health Agency and ceased the National Partnership Agreement on Preventive Health in the 2014–15 federal budget.

But the Morrison government launched a National Preventive Health Strategy 2021–2030 in December last year and provided $30.1 million for its implementation. That strategy could very effectively be incorporated into the mandate of the ACDC. The newly established National Health Sustainability and Climate Unit might also sit well within the agency.

The ACDC’s effectiveness will depend heavily on its ability to communicate advice to political and policy decision-makers and guidance to the community. The pandemic has highlighted how trust, respect and appropriate targeting are essential for successful public health communication — and how this is rarely successfully contracted out to external consultancies.

All these issues are covered, at least to some extent, in the discussion paper’s seven design principles. But many stakeholders will need to be involved in the discussions and negotiations ahead. Key among them are the states, the territories and other federal agencies that may be reluctant to cede aspects of their current responsibilities.

These potential problems highlight the fact that this crucial new agency is being developed against the background of complex, under-resourced public health systems, state and federal, alongside a multiplicity of committees and advisory groups. The pandemic has also highlighted how, at times of national crisis, political decision-makers override expert advice and bodies designed to facilitate cooperation.

The ACDC will need the power to collect consistent national data (by contrast with how the states and territories all collected Covid-19 data differently) and to act when required (and perhaps even overrule local and state government decisions). It will also — drawing on the lessons of its American counterpart — need to be independent of both the federal health department and political interference.

The government would do well to make every effort to bulletproof this new agency against potential political attacks and efforts to claw back allocated funding. One way to safeguard the agency’s financial future would be to establish a “future fund” to ensure funding and remove funding decisions from the short-term political vagaries of the federal budget process.

The Medical Research Future Fund, established in the 2014–15 budget with funds taken from the health and Indigenous affairs budgets (including the National Preventive Health Agency and the National Partnership Agreement on Preventive Health) now has some $2 billion more in funds than the $20 billion goal: using some of these funds for an ACDC would be entirely appropriate.

The fact that Australia is the only country in the OECD without a Centre for Disease Control or equivalent should be turned to our advantage by assessing the best features of international exemplars. The discussion paper examines six — in Canada, Europe, France, Switzerland, Britain and the United States — and provides more detailed case studies for Canada and the United States. Canada is presumably singled out because, with both provincial and federal governments, it most closely resembles Australia.

An ACDC won’t solve all of Australia’s public health problems, and it would be a serious mistake to focus on the delivery of a new agency at the expense of other aspects of the public health systems. But it can play an important role in coordinating and reorienting Australia’s healthcare system. Whether all the stakeholders can be brought into agreement will ultimately depend on the leadership of health minister Butler and the investment foresight of treasurer Jim Chalmers. •

The post An ounce of prevention… appeared first on Inside Story.

Midterm elections — treated by many voters as a referendum on the sitting president’s agenda — are always fraught with danger for the party in the White House. This year the Republicans ran on issues like crime and the economy, seen as their bailiwick, and hoped to capitalise on lingering resentments over Trump’s 2020 election loss and the partisan divide opened up by the Democrats’ probing of the 6 January invasion of the Capitol. But Trump changed the dynamics fundamentally when he inserted his candidates, his policies and indeed himself into the campaign.

The expected Republican wave failed to eventuate not just federally but also in the states. Democrats lost fewer House seats than in any midterm election under a Democratic president in forty years. They retained the Senate and performed better in midterm elections for state governors than at any time since 1986.

With angry Republicans blaming Trump, the former president’s role as party kingmaker is under challenge from Florida governor Ron DeSantis, who emerged as the big Republican winner.

The election results have immediate consequences for the remainder of Joe Biden’s first term. They will help shape the 2024 elections, and provide important clues as to how changing demographics will influence the future of American voting.

In Biden’s view, the results showed that “the overwhelming majority of the American people” support his economic agenda. He might well be right: exit polling shows that voters see the economy and jobs as the most important issue facing the nation, and inflation as the most important issue in determining their vote.

Those polls also revealed other factors driving support for Democrats: anger at limits on abortions, concerns about healthcare costs and gun control, and a high turnout among young voters. As Biden had warned in a prime-time address ahead of the elections, the very future of the nation was on the line in the face of election denial, voter intimidation and political violence. His concern was no doubt driven by the large slate of extremist candidates for federal and state offices endorsed (and largely handpicked) by Trump on the basis of their loyalty to him and their support for his grievances.

Voters in crucial battleground states, perhaps tiring of the endless rhetoric about a lost presidency during a period of high inflation, rejected Trump’s election-denying candidates. Voting was peaceful, with few technical glitches and only muted Republican claims of election fraud. Biden summarised election day thus: “It was a good day, I think, for democracy.”

That optimism overlooks the fact that the president will have to deal with a Republican-controlled House of Representatives less interested in working cooperatively than in investigating and probably impeaching him, his family and Democratic leaders like Nancy Pelosi. Biden must push hard to get key elements of his agenda — and legislation essential for the operation of government, including a lift in the debt ceiling — enacted by the lame-duck Congress that lasts only until new members take their places in January.

The House promises to be a can of worms for both sides of politics. For all that Trump’s election slate has been deemed a failure, at least 145 of the Republicans elected to the House are election deniers. Importantly, they will constitute the majority of the GOP caucus.

This means that current House minority leader Kevin McCarthy might not have sufficient support to realise his ambition of becoming speaker; the position could instead be taken by someone as contentious as Representative Jim Jordan, a founding member of the House Freedom Caucus and the top Republican on the House judiciary committee. With a slim majority, Marjorie Taylor Greene and other so-called MAGA Republicans will make electorally unpopular demands of the leadership. But perhaps the chaos that is almost certain to ensue will work in the Democrats’ favour in 2024.

In the Senate there is a very real possibility that the Democrats can win fifty-one seats, but this is dependent on incumbent senator Raphael Warnock winning a run-off against Herschel Walker in Georgia. With a Republican-controlled House, Democratic control of the Senate is essential if Biden is to win confirmation of any future appointments. A one-seat majority on the relevant committees will help, and will also provide a buffer during difficult negotiations with senators Joe Manchin and Kyrsten Sinema, who often resist toeing the Democrats’ line.

In the states, meanwhile, Democrat victories will provide a bulwark against the erosion of electoral rights. Democrats won important gubernatorial races in Arizona, Wisconsin and Pennsylvania, along with secretary of state positions (responsible for overseeing elections) in Minnesota and New Mexico. They also took the majority in state houses in Minnesota and Pennsylvania, long controlled by Republicans. For the first time in modern history, Democrats were elected to all twenty-six statewide and federal offices in Rhode Island and Massachusetts.

In Michigan, governor Gretchen Whitmer, who has been heavily targeted by Trump, made abortion rights central to her winning campaign and Democrats won control of the state legislature for the first time since 1984. Michigan’s election lines have been determined since 2018 by an independent, nonpartisan panel.

In Florida, by contrast, incumbent governor DeSantis had made sure new electoral districts were heavily gerrymandered in his party’s favour He defeated his Democrat opponent Charlie Crist by nearly twenty percentage points and delivered four more Republican seats in the House of Representatives.

DeSantis, who contends that his state has become a (Republican) “promised land,” has positioned Florida in the vanguard of many of the nation’s most polarising culture war fights. His election success sets him up for a fascinating presidential primary battle — and simmering warfare — with Trump.

While DeSantis may not emerge as the Republican saviour, Trump’s status as party kingmaker is no longer secure. Republican leaders are openly blaming election losses on his poor-quality candidates and failure to financially support their efforts. Trump has responded with his usual denial of responsibility, lashing out at his advisers. Many wealthy potential donors are looking at other potential presidential contenders, including former secretary of state Mike Pompeo, Virginia’s governor Glenn Youngkin, South Carolina’s senator Tim Scott and even former vice-president Mike Pence.

Where the money goes will be an important factor for the Republican presidential primaries. Trump’s early entrance into the field is as much about getting first access to donors as it is about trying to fend off other contenders — and is perhaps also an attempt to avoid prosecutions.

In a few short weeks (or sooner if Trump has his way) the United States will be plunged into the maelstrom of presidential primaries, and political operatives will start strategising for 2024. Far-thinking Republicans must recognise that rusted-on Trump supporters — mostly older, white and without a college education — are a diminishing demographic. On the other hand, Democrats can’t take for granted the longstanding support of Black voters or ignore evidence that Hispanic support is slipping.

Across the nation, the share of non-Hispanic white voters is declining. America’s youngest voters, millennials and generation X, are more racially and ethnically diverse than older generations. At the same time, the increasing proportion of voters aged sixty-five and over (19 per cent by 2024) will force a focus on social security and Medicare, programs Republicans have said they will cut.

The fevered gerrymandering and vote-suppressing efforts of Republican governors and legislators reveal their understanding that only these forms of election-rigging stand between their party — at least in its present form — and oblivion. Even the Republican-dominated US Supreme Court has pitched in, allowing states to use unlawfully gerrymandered congressional maps for last week’s elections and currently hearing a case that would undermine the Voting Rights Act.

The midterm results have delivered a sense of relief to many, including leaders in other democracies, but they also highlight the work still needed to protect American democracy and America’s place in the world. The new balance in Congress is hardly a prescription for the national unity that Biden seeks to promulgate, and the looming internecine warfare between Trump, DeSantis and the Republican leadership will work against any efforts to bridge the party divide. •

The post Game changers appeared first on Inside Story.

Colorado has also done almost everything election experts recommend to protect its electoral system from hacking. County clerks are combating disinformation about the security and reliability of the system and refuting false claims of potential fraud in the wake of last year’s presidential election.

A large majority of Colorado voters have opted to be placed on a permanent mail-ballot list maintained by the state. As an overseas voter, I received an email link to the ballot papers from the office of the clerk and recorder of  Summit County (my district of residence) at the beginning of October. I needed some personal details to unlock these papers and a little tech savvy to fill them out and submit them. I returned my completed voting paper, along with an affidavit attesting my eligibility to vote, by email a few days later.

I have since received an email from Colorado BallotTrax to inform me that my ballot was received. A phone number and an email address are given for any questions I might have, and a link to the GoVoteColorado.gov website operated by Colorado’s secretary of state. Another email will let me know when my vote has been counted.

I voted in the same way in the Democratic primary races earlier this year (the results are here) and in every presidential and midterm election since I became an American citizen. A highlight was voting for the 2020 presidential primaries, in person this time, at the old County Courthouse in Breckenridge, using an unwieldy electronic voting machine. But it wasn’t very celebratory; although “I Voted” stickers were available, democracy sausages were nowhere to be seen.

In this election I could vote for one of the state’s two federal senators (incumbent Democrat Michael Bennet or Republican Joe O’Dea); for the representative for the second congressional district (incumbent Democrat representative Joe Neguse or Republican Marshall Dawson); for a state senator and a state House of Representatives member; and for thirteen state-wide offices, including governor and lieutenant governor (with Democrat incumbents Jared Polis and Dianne Primavera seeking re-election), attorney-general, secretary of state, treasurer, and four representatives each for the State Board of Education and the State Board of Regents, which oversee state spending in schools and universities respectively.

Voters who hadn’t run out of energy by that point could also say yes or no to eleven state ballot measures on public school funding, alcohol licencing and other matters. No judicial positions were on the ballot, but I could register whether or not I wanted those in current elected judicial positions to remain. (Full details of what was on the ballot are here.)

Colorado is a blue state with pockets of more conservative voters, including ranchers concerned about gun rights, petrol prices and more. (One rancher is currently spending US$11 million on anti-Polis billboards.) It also has five military bases, home to some 60,000 people, as well as military retirees and evangelical church members. But the political demographics are changing, with young, college-educated suburbanites making up a rising percentage of the population. After voting primarily Republican from 1920 to 2004, the state has voted with the Democrats in the last four presidential elections; Biden won in 2020 with a 13.5 per cent margin.

The Democrats hope that the 2022 midterms will defy historical precedent and enable them to retain control of the Senate and perhaps even hold the House. In Colorado, Senator Michael Bennet holds a comfortable lead over his Republican opponent and has done well in fundraising, but it is critical that this low-key senator is able to stave off his Republican opponent, Joe O’Dea. O’Dea’s moderate positions on issues like abortion, his rejection of former president Donald Trump and his endorsement by former president George W. Bush make him a very real threat.

Controversial Republican Lauren Boebert, who represents Colorado’s third congressional district in the House of Representatives, is backed by Trump and has earned notoriety for her inflammatory remarks. She has positioned herself as one of the most far-right members of Congress. One poll has her in a statistical tie with her Democrat challenger Adam Frisch, and there are hopes that he has the momentum to make this a competitive race.

Boebert won in 2020 with just 51 per cent of the vote, in a district that includes the wealthy ski centres around Aspen and the middle-class cities of Glenwood Springs and Pueblo, and where 43 per cent of voters are unaffiliated. But the nonpartisan election handicapper Cook Political Report rates this district as solidly Republican. This race matters, not just because it contributes to controlling the House of Representatives but also because more wins for Trump-endorsed candidates will boost his kingmaker status and increase the likelihood he will run for president in 2024.

In contrast to Boebert’s high-profile contest, the second congressional district where I vote remains a solidly Democratic seat. Our local congressman, Joe Neguse, who is running for a third term, is the son of Eritrean refugees (a significant number of whom have settled in Summit County) and the first African-American man elected to the US Congress from Colorado.  His Republican opponent Marshall Dawson is so low-profile I had to research him on the internet, and I still don’t know much about him.

Neguse, who is on House leader Nancy Pelosi’s leadership team, is one of the co-chairs of the House Democratic Policy and Communications Committee. He was also chosen as an impeachment manager for Trump’s second impeachment trial. In recent years, this seat has been a strong jumping off point for politicians seeking higher office: of the last four to hold it, two went on to the US Senate and one (Polis) to the governorship.

Neguse has already marked himself as a man to watch, and he is expected to play an enhanced role in the House leadership as old hands like Nancy Pelosi and Steny Hoyer step aside.

State elections are an increasingly important feature of the American political landscape. State governors and legislatures oversee the drawing of electoral boundaries, determine voting rights, decide who is eligible for Medicaid, and now— after the recent decision of the US Supreme Court — make decisions about abortion access.

In this, too, Colorado is in a better position than most other states. Since 2020, the state’s legislative and congressional districts have been drawn up by two separate independent redistricting commissions created after the state’s voters resoundingly approved ballot provisions in the 2018 elections.

The state has also set up an insurance marketplace (as outlined in the Affordable Care Act) to help make health insurance more accessible, and more than half a million Coloradans are covered under Medicaid Medicaid expansion. Low-income undocumented pregnant people and children will gain eligibility by 2025. It is ranked in the top ten states for healthcare.

In April, Governor Polis signed into law the Reproductive Health Equity Act, which codifies protections to ensure that abortion and choice remain legal in Colorado; in July he signed an executive order further protecting reproductive health rights and clarifying that Colorado won’t cooperate with other states’ criminal or civil investigations of health decisions that are legal in Colorado.

Polis has a good track record: he has provided full-day kindergarten and universal preschool and he is entitled to tout his management of the pandemic. FiveThirtyEight’s poll average has him ahead of his Republican rival Heidi Ganahl by a widening margin of 14.3 percentage points.

The political climate has seen secretaries of state — who oversee elections and maintain voter registration files — become increasingly important. Colorado incumbent, Democrat Jena Griswold, made a name for herself in 2020 when she pushed back on national television against election disinformation and challenged Trump’s assertions that mail ballots are less secure. She has subsequently faced death threats from Trump allies.

Griswold successfully went to court to bar Mesa county clerk Tina Peters, who faced criminal charges for allegedly compromising voting equipment and election security, from overseeing both the 2021 election and this year’s midterms. Undeterred, Peters ran in the Republican primary but was beaten by Pam Anderson, a former head of the Clerk’s Association who has made standing up for the state’s election model central to her campaign. No polls are available for this race, but Griswold has to be seen as the frontrunner, although Anderson is a plausible opponent.

Voter turnout — always a problem in the United States and especially so in midterm elections — will be crucial for Democrats if they are to retain the seats they need to hold power in Congress. Campaign staff aim to keep the spotlight on abortion and women’s anger over the Republicans’ curtailing of their rights to reproductive health. Colorado’s progressive stance on abortion issues might turn out to be a two-edged sword, though, if voters don’t feel their reproductive health rights are under threat and aren’t motivated to vote.

Polling suggests the key issues for the state’s voters include inflation and the cost of living; housing shortages and homelessness; climate change, with the state exposed to wildfires and drought; and the cost of childcare. Still, protecting abortion rights and addressing racism and discrimination are in the top ten.

As voting begins around the nation, the FiveThirtyEight forecast has Democrats slightly favoured to win the Senate and Republicans slightly favoured to win the House — and the evidence is that all the races are tightening. Ten states in particular will play a significant role in deciding the balance of the US House and Senate and shaping the map of governorships: Arizona, Florida, Georgia, Nevada, Pennsylvania, Kansas, New Hampshire, Ohio, Wisconsin and North Carolina.

While Colorado doesn’t appear on that list, every race is important, never more so than this year. The United States is facing rising threats from domestic extremists and those who would undermine the sanctity of the right to vote. As vice-president Kamala Harris says, “everything is on the line in these elections.” •

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Biden’s speech in front of Philadelphia’s Independence Hall last Thursday may well come to be seen (in Biden’s words) as “one of those moments that determine the shape of everything that’s to come.” Biden castigated Trump and the Make America Great Again, or MAGA, wing of the Republican Party for pursuing an anti-democratic agenda and fomenting civil unrest, and underlined how the extremism of Trump and Trumpism threatens the very foundations of the nation.

That the current president was warning the nation of the dangers posed by the former president on the steps of the building where both the Declaration of Independence and the US Constitution were debated, written and signed underlined the significance of Biden’s words.

He went on to remind Americans that they are “not powerless in the face of these threats — we are not bystanders in this ongoing attack on democracy” — and concluded with a call to “Vote, vote, vote.”

Biden didn’t come lately to this theme. He says he was driven to run for the presidency again after the white supremacist march in Charlottesville, Virginia, in 2017. Amid fears that the forces that drove the 6 January attack on the Capitol aren’t fading away, he recently convened private meetings with leading historians and political analysists to discuss growing dangers to American democracy.

Even as Biden’s speech was being written, Trump was urging his followers to attack the FBI and the justice department and demanding yet again that he be declared the rightful winner of the 2020 election or that the election be re-run. Trump ally, Senator Lindsey Graham, was threatening civil violence if Trump was prosecuted for illegally possessing government documents.

The key Republican responses to Biden’s speech were also delivered in Pennsylvania. House minority leader Kevin McCarthy — the man who looks to be Speaker after the midterm elections — used a speech in Scranton to align himself with Trump’s efforts to undercut federal law enforcement over the search of Mar-a-Lago. He delivered a point-by-point condemnation of Biden’s policies and, in words that presaged Biden’s later that day, accused the president of launching “an assault on our democracy” with policies that had “severely wounded America’s soul.”

Two days later, at what was billed as a rally for Republican candidates in Wilkes-Barre, Trump delivered his own explosive, aggrieved response. He called Biden “an enemy of the state” and the FBI and the justice department “vicious monsters,” escalating the attacks he has made on his social media website. Dialling up the rhetoric, he called Biden’s words at Independence Hall “the most vicious, hateful, and divisive speech ever delivered by an American president.”

It’s no coincidence that Biden and Trump converged on Pennsylvania: with several high stakes, competitive races, the state is emerging as the nation’s centre of political gravity. The outcome of the open race for governor between Democrat Josh Shapiro, the former state attorney general, and Republican Doug Mastriano, a former state senator backed by Trump, may determine the future of abortion rights and free and fair elections in a state that has a Republican-led legislature.

Meanwhile, lieutenant-governor John Fetterman, recovering from a stroke, and Trump-endorsed celebrity TV physician, Mehmet Oz, are engaged in an ugly contest over who will replace retiring Republican senator Pat Toomey. The battle has included unedifying clashes over the price of the vegetables needed for crudités and concerns that Oz has spread misinformation and spruiked unproven medical treatments.

Trump narrowly lost Pennsylvania to Hillary Clinton in 2016 (by around 50,000 votes) and to Biden in 2020 (by just over 81,000 votes) but polled well in predominantly suburban and rural counties. The question for 2022 is whether this political alignment will hold or whether moderate suburban voters and the white rural and working-class voters who once embraced Trump will now reject the candidates he backs. And if that’s the case in Pennsylvania, what of the rest of the United States?

The conventional wisdom in American politics is that the president’s party loses ground in midterm elections. Midterms are referendums on incumbents and almost no president has escaped a tough critique: in the nineteen midterm elections between 1946 and 2018, the president’s party only once improved its share of the popular vote for the House of Representatives. Only twice in the past 100 years has the president’s party gained seats in both the House and Senate.

The Democrats hold razor-thin margins in both the House and the Senate. House Democrats have a mere six-seat advantage, and Republicans are helped by partisan redistricting in Republican-controlled states and the fact that more Democrats (thirty-one) than Republicans (nineteen) are retiring. Republicans need to win only one seat to take control of the Senate, a victory that would kill any chance of Biden implementing his agenda during the second half of his term.

But political pundits are now seeing 2022 as a year in which precedents might be broken and assumptions cast aside, not just in Pennsylvania but across the nation. Democrats have a new sense of optimism about the possibility of blunting predicted Republican gains.

Just a few months ago, the discussion was about how big the “red wave” was going to be. (Confusingly, Republicans are labelled red and Democrats blue in the United States.) On 2 June the respected Cook Political Report declared that things looked ominous for the Democrats; on 30 August it concluded that Republican control of the House was no longer a foregone conclusion.

Last weekend, Race to the White House gave the Democrats a 61.34 per cent chance of retaining the Senate. FiveThirtyEight, which gives the Democrats a 68 per cent chance, attributed the surprise figure to poor candidates in battleground states. Other political analyses are more cautious, but it’s reasonable to postulate that the Democrats might gain one or more Senate seats.

It still takes a lot of optimism to believe the House will stay under Democratic control, but the twenty-to-thirty-seat gains once predicted for the Republicans have narrowed to ten to twenty. (The 270ToWin consensus forecast is here.) Under the circumstances, holding the Republicans to less than ten extra seats could be viewed by Democrats as a victory of sorts.

Several issues have brought the pollsters and the pundits to envisage what one Republican strategist described as “more like a shallow red puddle” than the red tsunami predicted earlier.

The first is that women, especially Democrats and Independents, have been fired up by the US Supreme Court’s decision to reverse the constitutional right to abortion, and subsequent state efforts to limit women’s access to abortions and reproductive healthcare. American women are engaging politically in a way that has not been seen before.

The number of women registering to vote has surged, especially in deep-red states like Kansas, Idaho and Louisiana, where abortion rights have already been severely curtailed, and in key battleground states like Pennsylvania, Michigan, Wisconsin and Ohio, where the electoral stakes for abortion rights are highest.

“In my twenty-eight years analysing elections, I’ve never seen anything like what’s happening in the past two months in American politics,” wrote political strategist and pollster Tom Bonier on Friday. “Women are registering to vote in numbers I’ve never witnessed.”

In August, Kansas — a red state that hasn’t backed a Democrat for president in nearly sixty years — voted overwhelmingly to keep abortion rights in the state constitution. An estimated 69 per cent of new voter registrations ahead of the ballot were women.

In a string of recent House special elections, Democrats have out-performed expectations. Again, abortion has been a key driver. A surge in women voters helped Democrat Pat Ryan prevail over Republican Marc Molinaro in the special election last month in New York’s 19th congressional district, a swing district in the Hudson Valley that Biden won in 2020 by just two percentage points. After the race turned into a clearcut battle over abortion rights, Ryan exceeded the vote of the Democrat in 2020 and ran 1.3 per cent ahead of Biden in 2020.

Despite the prognostications — and evidence — that abortion could be a winning issue for Democrats, all but a very few Republicans are not listening. But it’s telling that Republican candidates in critical races in states like Pennsylvania, Michigan, Colorado, Arizona and North Carolina are scrubbing abortion language from campaign websites and adjusting their rhetoric on the hustings.

An election centred on the removal of a constitutional right has no precedent. And while the focus is on abortion rights, other minorities — LGBTQ and Trans groups, for example — are concerned that their hard-won rights will also be taken away by the Trump-appointed conservative majority on the US Supreme Court.

Also changing the election dynamics is Trump’s involvement in divisive primaries. He has hand-picked his acolytes for House and Senate races and for offices responsible for counting and certifying the votes in Arizona, Georgia, Michigan and Wisconsin, the states that denied him victory in 2020.

The candidates he has backed have had mixed success in often-bitter Republican primaries and beyond, which might signal that his influence on his party has waned. But the Democrats’ prospects in the Senate are undeniably enhanced by his pick of inexperienced (to put it politely) Republican candidates including Mehmet Oz in Pennsylvania, J.D. Vance in Ohio, Hershel Walker in Georgia and Blake Masters in Arizona, all of whom have underperformed in polls despite Trump’s backing.

Trump’s support didn’t help Sarah Palin either; she lost the Alaska special election to replace Republican Representative Don Young, who died in March. Democrat Mary Peltola, who won under the state’s new ranked-choice voting system (which operates like Australia’s preferential system), becomes the first Alaska Native to serve in Congress. She will face re-election in November, again against Palin and Nick Begich, a more moderate Republican. It will be interesting to see if Palin’s rhetoric changes after her unexpected loss.

Trump and his allies’ aggressive midterm strategy is seen in the Republican party as a double-edged sword. Republicans don’t win if they don’t turn out the Trump voters, and the former president can boost excitement among that group, but he can also turn off moderates and independents — and Republicans can’t win with Trump voters alone. Republican candidates also fear that his capacity to dominate the political news will undermine the task of making the election all about Biden and the Democrats.

This problem for Republicans has an upside for Democrats (and America). If Trump’s role in the campaign delivers losses rather than victories then his 2024 presidential candidacy will be less likely.

More trouble for Republicans comes from a slowdown in fundraising, a strong sign of flagging electoral support. With small donors pulling back, online fundraising has slowed across much of the party. Some Republicans suspect Trump’s relentless fundraising pitches and cash hoarding has exhausted a donor base also affected by cost of living pressures. Worryingly for Republicans, Democratic contributions have meanwhile surged.

Republican Senate candidates who spent big on bruising primary campaigns are now finding that the National Republican Senatorial Campaign, or NRSC, is pulling advertising, even in critical states like Pennsylvania, Wisconsin and Arizona. The conflict has intensified between Senate minority leader Mitch McConnell and the NRSC’s chairman, Senator Rick Scott of Florida. McConnell has argued that huge sums of money (some US$150 million so far this election cycle) have been spent on poor quality candidates; Scott has retorted that “trash talking” Republican candidates is “treasonous to the conservative cause.”

Despite his (justifiable) concerns, McConnell is investing millions of dollars from his Senate Leadership Fund to support J.D. Vance in Ohio and Oz in Pennsylvania, both of whom have been running poor campaigns. He has also pushed Trump ally Peter Thiel, who has been bankrolling MAGA candidates, to continue to fund Masters in Arizona and Vance in Ohio, but has reportedly been rebuffed.

McConnell’s preoccupation with ensuring he resumes the Senate leadership is also hindered by his increasingly bitter feud with Trump, which the former president revived after McConnell criticised the quality of Trump-backed candidates. “Mitch McConnell is not an opposition leader, he is a pawn for the Democrats to get whatever they want,” Trump said, calling for a new Republican leader in the Senate to be picked “immediately.”

Trump’s gripe is no doubt partly driven by the fact that Biden and the Democrats can lay claim to a significant list of recent legislative achievements. These include the Inflation Reduction Act, with its major climate change, healthcare and tax reforms, the CHIPS and Science Act, and the PACT Act, which expands medical benefits for veterans exposed to toxic fumes at military bases.

These bills have helped counter public perceptions of a do-nothing Congress. Biden has also used his presidential powers to tackle issues like student debt, gun control and access to abortion that would have been blocked in Congress.

At a time when American voters are worried about cost-of-living pressures and pessimistic about where the country is headed, will these achievements — along with historically low unemployment and gas prices finally going down — be enough to influence their votes in November?

Maybe, but to strengthen their argument that midterm defeats will bring dark times, Biden and the Democrats are also forcing the Republicans to play defence on issues like the rule of law and public safety (on which Trump’s vendetta against the FBI is no help). Biden has also moved to put democracy and political violence on the agenda. These are issues the polls indicate voters of both parties care about (although perhaps in different ways for different reasons) and polling shows they are beginning to affect voters’ intentions. FiveThirtyEight’s generic congressional ballot has the two parties basically even, with the Democrats leading by a little less than a point, on average, but trending up since the beginning of August.

After hitting a low of 37.5 per cent in July, Biden’s approval rating has risen by more than five percentage points on FiveThirtyEight’s presidential approval tracker. When presidential approval ratings are less that 45 per cent their party tends to lose a lot of seats in Congress. Trump, though, with an approval rating of 39.8 per cent, is even less popular than Biden.

Neither Biden nor Trump is on the ballot in November, but their influence is important. A recent Wall Street Journal poll shows that Biden would defeat Trump by six percentage points in a hypothetical rematch this month. The more Trump is on people’s minds, says a CNN analysis, the better Democrats are doing.

While the non-MAGA Republicans want to ensure that the 2022 election cycle is a referendum on Biden not Trump, it is clear that Trump will do everything possible to stay in the news cycle and thus muddy the message. He brazenly demonstrated this by delivering what David Frum called “a protracted display of narcissistic injury” in Pennsylvania. Nothing could more perfectly have amplified Biden’s message. Can Democrats now widen the new but narrow path to winning in November? •

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As of 9 September, only 2 per cent of the population of low-income countries had received at least one vaccine dose. In lower-middle-income countries the figure was 30 per cent, in upper-middle-income countries a slightly more respectable 54 per cent, and among high-income countries 65 per cent. Not one low-income country had met the World Health Organization’s target of vaccinating at least 10 per cent of their people.

The averages hide more shocking disparities. While more than 80 per cent of Australians, Portuguese and South Koreans are fully vaccinated, many governments are struggling to get first doses to even half of their population. In the poorest nations — countries like Haiti, Yemen, Sudan and the Democratic Republic of Congo — less than 1 per cent of the population have had even one dose.

Despite these obvious shortfalls, the British healthcare research company Airfinity calculated in September that rich countries had surplus supplies of more than 500 million shots, even taking account of their planned booster programs, and that the figure is likely to rise to 1.2 billion by the end of the year.

An analysis by the Financial Times shows that rich countries have given out more booster shots in the last three months than poor countries have administered in total doses all year. If those surplus vaccines aren’t sent to the countries most in need, as many as 2.8 million lives could be lost this year.

Epidemiologists are concerned that the current vaccination pattern will prolong the pandemic and create an opening for more dangerous and transmissible variants. The OECD sees inequalities within and between countries escalating, recovery of the global economy slowing, and international travel and tourism continuing to be affected.

An International Chamber of Commerce study found that the global economy stands to lose as much as US$9.2 trillion if governments fail to ensure low-income countries have access to vaccines. Up to half that impact would fall on advanced economies themselves. Even the US intelligence agencies are worried: their latest annual threat assessment concludes that the financial and humanitarian crises experienced by some hard-hit developing countries will increase the risk of internal conflict, government collapses and migration.

How did we get to this point? The course of the pandemic provides part of the answer. It initially fell hardest on high-income countries, which very quickly made early purchase bids for vaccines at prices largely governed by the market. Some countries (the United States, Britain, Canada and eventually Australia) purchased enough vaccines to cover their populations several times over. The G7 countries as a whole, home to just 13 per cent of the world’s population, have purchased more than a third of the world’s vaccine supply — including almost all the current mRNA production from Moderna and Pfizer/BioNTech.

In response to the demand, vaccine manufacturers set their official prices in a variety of ways. Larger, established companies like Janssen (the vaccine manufacturing arm of Johnson & Johnson) and AstraZeneca pledged to market vaccines at no profit during the pandemic. Pfizer’s CEO said the company planned to price for a marginal profit. Novavax plans to make an appropriate return. Newcomer Moderna priced to generate a profit.

In reality, vaccine prices are a movable feast, deeply dependent on quantity, negotiating capacity and demand. UNICEF, the UN children’s fund, has found that many middle-income countries are paying as much as high-income countries, if not more. Researchers at Oxfam calculated that Pfizer/BioNTech and Moderna received US$100 billion of taxpayers’ money to fund research, development and early purchases of their vaccines, but are charging up to twenty-four times the cost of production, and rising.

The AstraZeneca jab is seen as the cheapest of the main Covid-19 vaccines. That might be true in Europe, where the company’s contract with the European Union specifies just US$2.15 a dose, but not elsewhere: the British Medical Journal reported earlier this year that South Africa had paid AstraZeneca US$5.25 per dose for 1.5 million doses to be administered to healthcare workers.

We might all agree that being vaccinated during a pandemic is a humanitarian entitlement, but international action so far has been driven just as much by a concern among Western powers that Russia and China have more successfully pursued vaccine diplomacy with vulnerable nations.

China boldly declared its Sinovac and Sinopharm vaccines to be a “global public good”— as opposed to a commercial product — and has supplied them to some sixty countries, in many cases at no cost. This effort seems intended, at least partly, to undercut purchases already made from Western suppliers but not yet delivered.

But now, with the Chinese vaccines displaying lower efficacy, many of the countries that have used them face a public health dilemma.

COVAX, a global hub for buying and distributing vaccines created by the World Health Organization, the Coalition for Epidemic Preparedness, UNICEF and Gavi, is designed to help countries that would otherwise struggle to negotiate affordable vaccine purchases. It uses funding from governments and donors such as the Gates Foundation to make its own contracts with vaccine manufacturers and deliver supplies where they are needed.

Despite the grand vision, COVAX is 500 million doses short of its vaccine distribution goals. Its aim was to distribute at least two billion doses, two-thirds of them to lower-income nations, by the end of 2021. But only 16 per cent of contracted doses have been delivered, and the two billion doses target has been pushed out a year.

COVAX has struggled for several reasons. Prime among these is the “vaccine nationalism” of high-income nations, which have been slow to meet their commitments to the hub. Though billions of doses have been promised, actual contributions have been paltry, and too often they are small donations of soon-to-expire doses made at the last minute.

Australia is a case in point. The federal government promised A$130 million to COVAX, of which only A$44 million has so far been provided. It promised forty million vaccine doses from the national stockpile and a further twenty million doses for countries in Southeast Asia and the Pacific by the end of 2022. To date, fewer than five million doses have been supplied to developing nations.

In fact, Australia seems to be taking as much as it is giving. The Nine newspapers have revealed that the federal government has bought at least 500,000 Pfizer doses from COVAX to boost local supplies, and the government’s own figures show that it has a A$123 million option to purchase a total of twenty-five million doses for Australian use.

COVAX had hoped that the Serum Institute of India, the world’s biggest vaccine manufacturer, would boost its stockpile, but when Delta infections grew in March this year the Indian government limited exports in order to supply the domestic market.

Around eleven billion doses are needed to fully vaccinate 70 per cent of the world’s population. More than six billion doses will have been administered by the end of this year, leaving a deficit of about five billion doses. A majority of people in the lowest-income countries will wait another two years before they are fully vaccinated.

The problems with COVAX have led policymakers to consider other approaches. Longstanding calls to increase vaccine manufacturing within less well-off countries — extending back to well before the pandemic — have grown louder, with a variety of approaches under discussion. Global health advocates argue that vaccine production must spread beyond the current concentration in the United States, Europe, India and China, not just to tackle this pandemic but also to be ready for future viruses.

A group of countries led by South Africa and India called last year for the World Trade Organization to issue a waiver of intellectual property protections for Covid vaccines. More than one hundred Nobel laureates and seventy-five former heads of state added their support in April, calling on US president Joe Biden to suspend vaccine patents in order to “expand global manufacturing capacity unhindered by industry monopolies that are driving the dire supply shortages blocking vaccine access.”

Despite Biden’s support, the proposal has encountered fiery opposition from the pharmaceutical industry. Vaccine companies say they are already expanding production and the move would have little if any practical effect. Even if they had the formulas, few countries have the trained personnel needed to produce Covid-19 vaccines, and supplies are already stretched.

The World Health Organization has asked innovating firms to contribute their intellectual property to the UN’s Medicines Patent Pool, and proposes a role for itself to coordinate technology transfers, facilitate training, help countries organise the necessary investments in factories, and assist with regulatory approvals and agreements on royalties.

In April the African Union’s Centres for Disease Control and Prevention announced an ambitious plan to establish new vaccine factories with the aim of reducing the continent’s reliance on vaccine imports in general. A push is also being made for an mRNA vaccine manufacturing hub in South Africa. Moderna has indicated it is opposed to patent waivers; now it seems that South African researchers, with WHO support, will attempt to create their own mRNA vaccine using reverse-engineering techniques.

In a recent article in the New York Times, experts in vaccine development and production say that manufacturing mRNA vaccines in developing countries is feasible. Despite resource and timing issues, this approach would give countries the capacity to vaccinate against not just Covid-19 but a whole range of other infectious diseases endemic to low-income countries.

American economist Alex Tabarrok is among those who have argued that patents are not the major obstacle to the current vaccine supply problems. A patent waiver might be largely cost-free for rich countries, he says, but would do little to relieve supply shortages or make distribution fairer. “Sorry, there is no quick and cheap solution,” he writes. “We must spend… Bottom line is that producing more takes real resources not waving magic patent wands.”

Regardless of the force of that argument, two examples highlight why local manufacturing will be vital in the medium to long term. First, the cost of the WHO-recommended vaccine program for children under two years of age — which was set before the pandemic and currently includes eleven vaccines — has been skyrocketing. By 2020 the cost was estimated at between US$37 and US$101 per fully vaccinated child. These important childhood vaccination programs could become unaffordable, especially with the economic fallout of the pandemic.

Second, important newer vaccines — the vaccine against the human papillomavirus, the causative agent of cervical cancer, for example — are already out of reach for many low-income countries. Every year, more than 300,000 women die from cervical cancer, mainly in low- and middle-income countries; nearly all those deaths are preventable by vaccination.

Although the pharmaceutical industry is frequently — and often justifiably — portrayed as purely profit-oriented, the major companies have made efforts over the past decade to support “open source” models of production. These schemes have generally focused on the neglected tropical diseases that receive little research and development funding despite affecting a significant proportion of the world’s population. Could more be done to encourage this approach?

That such hopes are not overly optimistic is indicated by last week’s announcement that US-based pharmaceutical giant Merck has reached an agreement with the UN Medicines Patent Pool to license the international manufacture of its potentially lifesaving antiviral drug molnupiravir for treatment of Covid-19 in adults. This move is expected to create broad access for its use in more than one hundred low- and middle-income countries.

According to the announcement, the three patent holders, Merck, Ridgeback Biotherapeutics and Emory University, “will not receive royalties for sales of molnupiravir under this agreement for as long as Covid-19 remains classified as a Public Health Emergency of International Concern by the World Health Organization.” Many will be watching for signs of other companies following Merck’s lead.

Back in Australia, meanwhile, the End Covid For All campaign last month released a report urging the federal government to lift its commitment to the global vaccination effort by A$250 million in funding and twenty million extra vaccine doses. The group’s Tim Costello urged Australia to “become a vaccine factory for the region.” Help is needed with testing, supplies, transportation and vaccination efforts to ensure these donations deliver benefits effectively and efficiently.

Covid-19 vaccines are a precious resource. Australia needs a plan to ensure it plays its role internationally in making sure vaccinations are managed fairly, without unnecessary price spikes, hoarding or wastage, in recognition that no country is safe until every country is safe. •

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Nor are his problems caused exclusively by a unified and implacable Republican opposition; they’re also a result of bitter divisions and competing demands within his own party. Thanks to political stand-offs between Democratic factions, the two bills to implement Biden’s domestic policy agenda — the bipartisan infrastructure bill (so-called because it garnered some Republican votes when it was passed by the Senate in August) and the social policy measures of the US$3.5 trillion Build Back Better bill — are stalled in the House.

For several days last week, obstreperous congressional Republicans looked like bringing the United States to the brink of financial collapse and a government shutdown. The last day of September marked the end of the financial year in the United States and, with that, the expiry of funds for federal government activities. Failure to reauthorise funding would mean all the chaos and costs of a government shutdown.

On top of this, the debt ceiling — an entirely artificial limit on how much money the US government can borrow — will be reached within days. A failure to increase the government’s borrowing authority would see the United States defaulting on its debt for the first time in history, putting at risk some six million military and government jobs, and threatening social security and child tax benefit payments. As Treasury secretary Janet Yellen has warned, the consequences would be “a self-inflicted wound of enormous proportions,” with both national and international consequences.

Those twin threats — a debt default and a government shutdown — aren’t new, but now Mitch McConnell, Republican leader in the Senate, is doubling down on a Republican campaign to undermine Biden’s broader economic agenda.

Republicans have previously had no problems voting to raise the debt ceiling — indeed, more than a quarter of the country’s US$28.4 trillion federal debt was accumulated during the Trump presidency. But McConnell says no Republican will vote to raise the debt limit and the Democrats must shoulder the entire political burden of such a move. No principle is involved; this is pure politics.

Last Monday Senate Republicans blocked a bill already passed by the House that would fund the government until 3 December (by which time appropriations legislation for fiscal year 2022 would ideally be enacted). The bill would have provided billions of dollars in natural disaster relief and help for Afghan refugees, and would have avoided a default on the national debt. The Senate Republicans also blocked the Democrats’ procedural motion to allow a simple majority vote to raise the debt ceiling.

The brinkmanship partially collapsed on Thursday, probably because congressional leaders recognised that no politician or political party benefits from a government shutdown. The provision to raise the debt ceiling was stripped from the continuing resolution which then passed the Senate (65–35), having survived a Republican attempt to limit benefits for Afghan refugees. Back in the House, it was passed 254–175; then, just hours ahead of the shutdown deadline, it was signed by President Biden.

For the moment, the debt ceiling is a can that has been kicked a small way down the road; it’s calculated that it will be breached around 18 October. Failure to deal with it more comprehensively will cause a lot of pain and could trigger a recession and financial crisis. Already the financial markets are nervous.

Republicans are presumably looking to portray the Democrats as ineffective financial managers, but it’s a dangerous game. In the end, the debt ceiling must be, and will be, raised (even if none of Biden’s new policies are enacted).

It might also be a pointless game. In the midst of a pandemic, public concern about the budget deficit is down. Gallup polling shows Americans are less worried about the deficit than a decade ago (only 49 per cent worry about it “a great deal” in 2021, compared with 64 per cent in 2011). A recent Morning Consult/Politico poll found that a plurality of voters would hold both political parties equally responsible for a default, although more voters would assign blame to Democrats (31 per cent) than Republicans (20 per cent).

House Speaker Nancy Pelosi, meanwhile, is being kept busy wrangling with her Democratic colleagues over how to proceed with both the infrastructure bill and the Build Back Better bill. She and her lieutenants have so far done an amazing job of shepherding the provisions and funding for the US$3.5 trillion Build Back Better package through thirteen House committees. The bill is proceeding under the budget reconciliation process, which means only a simple majority of votes is required in the Senate.

But it’s there in the Senate — where the Democrats can’t afford to lose a single vote — that two Democrat senators, Joe Manchin from West Virginia and Kyrsten Sinema from Arizona, are holding out. The progressive Democratic caucus in the House, with nearly one hundred members, has vowed to defeat the infrastructure bill unless the Senate is certain to ensure passage of the Build Back Better bill. The progressives rightly fear that the scope of the bigger bill will inevitably be whittled down as Biden and the White House endlessly negotiate with Manchin and Sinema, and more moderate House Democrats push for action.

Both senators are pushing for a smaller package. But while Manchin has publicly outlined his concerns, Sinema has been far more enigmatic and has largely declined to make her fears public.

Manchin, a centrist Democrat from a Republican-leaning state relishing the power he is wielding, has said he could support a US$1.5 trillion package and indicated his willingness to negotiate. He insists that the legislation must also include the Hyde Amendment (a legislative provision barring the use of federal funds to pay for abortion). He seems to be running his own agenda here: Biden’s domestic spending proposals are immensely popular in the poor, coalmining state Manchin represents, even among those who voted for Trump.

Sinema, a first-term senator, might also be enjoying the spotlight. She too has baulked at the legislative price tag — and at some of Build Back Better’s tax-raising provisions — but she hasn’t been willing to discuss these concerns with the White House. Among Democrats in Arizona she is increasingly seen as an obstructionist; indeed, she was recently censored by the state party for her stance on the bill.

As progress on an agreement stalled on Friday, the president went to Capitol Hill for a closed-door meeting with House Democrats. Afterwards. his message was that the timeline is secondary to the content of the bill. “It doesn’t matter whether it’s in six minutes, six days, or six weeks,” he said. “We’re going to get it done.” Later reports revealed that he had indicated he would put the infrastructure vote on hold until Democrats pass his social policy and climate change package. Even though the infrastructure bill’s delay has already had consequences, he seems willing for it to continue for some time. Only emergency legislative action on Saturday to reauthorise the expiring transport programs in the bill prevented the furloughing of thousands of transportation department employees.

Weekend rumours suggest that Biden, Pelosi and Senate leader Chuck Schumer are telling Democrats that the final Build Back Better outlay will be US$2 trillion, on top of the US$1 trillion in infrastructure. That will require compromises on what can be funded. Underpinning such compromise is the fervent hope that Democrats across the ideological spectrum will recognise that a failure to agree will not only undermine the president and the party’s midterm election prospects, but also limit the opportunity for future legislative wins on gun control, voting rights, access to abortions, immigration and other important issues.

As E.J. Dionne, Bruce Wolpe and other commentators have pointed out, the drawn-out fight over Obamacare offers lessons for Democrats today. The protracted and ugly legislative saga that finally led to Obamacare’s enactment tainted what Americans thought about the bill and what it meant for them. Soon after, Democrats lost the House in the 2010 midterm rout.

What Biden is proposing is a massive across-the-board investment in the workforce, infrastructure, social programs, education and the environment that will make a significant difference in most Americans’ lives. Not only that: it is viewed quite positively even among Republican voters.

The fallout from 2010 shows why the Democrats must unite on a realistic compromise and get these provisions enacted quickly so that the results are already apparent in 2022. That offers the real possibility of overturning the killer history of midterm losses for the incumbent party in the White House. •

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Back in March Biden signed into law the US$1.9 trillion American Rescue Plan Act, and since then approximately 171 million payments of up to US$1400 per person have gone out to households. Democrats touted the plan as a godsend for the middle class, but perhaps its greatest achievement will be to lift more than five million children out of poverty this year. Although the bill passed without a single Republican vote, many Republican lawmakers have proclaimed its benefits to their constituents.

Biden’s sweeping plans for infrastructure, jobs and families go well beyond tackling the impact of the pandemic. In size and ambition, his US$4 trillion in domestic policy commitments rivals Lyndon Johnson’s Great Society programs in the 1960s and Franklin Roosevelt’s New Deal in the 1930s.

In a move that was both astute and characteristic, he chose to split the key legislation into two parts for congressional action. With infrastructure and jobs first up, the White House and congressional Democrat leaders took a gamble that they could get Republican votes. It took months of negotiations, but the US$1.2 trillion Infrastructure Investment and Jobs Act passed the Senate last Wednesday with nineteen Republican votes, including the vote of Senate minority leader Mitch McConnell, who has declared stopping the Biden agenda to be his priority.

The bill will fund the largest upgrade of roads, bridges, transport systems, ports, power generation and broadband in decades. Fully US$550 billion — mostly from unspent coronavirus relief funding and tighter monitoring of gains by cryptocurrency investors — will fund new investments, including electric car charging stations, zero-emission school buses, better water infrastructure and environmental remediation.

With the passing of that bill, Biden has achieved something that eluded both of his Democrat predecessors, Bill Clinton and Barack Obama: winning sizeable bipartisan support for a top legislative priority. And he did it despite noisy opposition and threats from former president Donald Trump.

Why Biden’s gamble paid off better than anyone could have predicted can be explained by several factors. He used a centrist coalition of senators to lead the negotiations. He did the hard work needed to get the deal over the line, including making significant concessions. (The Senate bill is about US$1 trillion less than that initially proposed.) And he recognised how difficult it would be for Republicans to explain to their constituents why they had refused to support funding to improve the obvious failings of the nation’s infrastructure.

“Today, we proved that democracy can still work,” he proclaimed after the Senate passed the bill. It was a vindication of his election commitment to work with lawmakers across the political aisle.

That was never going to happen with the more expensive remainder of his 2021 legislative agenda. Even getting the more moderate Democrats to support a US$3.5 trillion expansion of federal safety net programs — paid for by winding back Trump-era tax cuts for corporations and wealthy families — will be challenge enough.

But Biden’s wins continued all the same. Just before leaving for the summer recess, the Senate passed a budget resolution that will provide the blueprint for legislation to implement this agenda. The vote was 50–49, the narrowest of margins, but the vital fact is that Biden didn’t lose a single Democrat senator.

Important as they are, these victories are only stepping stones towards enacting the Building Back Better plan. The path will quickly become harder, rockier and dramatically more partisan when Congress returns for the autumn session, when the House must pass its versions of the infrastructure bill and the budget resolution, to be agreed with the Senate in conference. Only then can the infrastructure bill be signed into law and work begin on translating the budget resolution into legislative language that must be passed by the House and the Senate. This package will be brought forward as a budget reconciliation bill, avoiding the Senate filibuster and requiring only a simple majority vote to pass.

The arcane legislative processes are further complicated by the Byrd rule, which limits what can be considered in a reconciliation package, and looming disagreements among House Democrats over the order in which the bills will be considered.

House leader Nancy Pelosi has said that the House will take up the budget resolution as soon as it returns on 23 August but won’t deal with the infrastructure bill until the Senate has passed the reconciliation bill. She is intent on ensuring the Senate includes all the major programs in this bill and is tying the two packages together to keep her whole caucus on board, as moderates grow wary of additional spending and progressives look for more.

The budget reconciliation bill will include a range of measures that will divide Democrats and Republicans on the basis of ideology, not least because of the significant roles (revived if not new) it gives the federal government. Its investments in families, education, healthcare, climate change and immigration include universal preschool for three- to four-year-olds; two free years of community college; the addition of dental, vision and hearing benefits to Medicare coverage; lower prices for prescription drugs; a new Civilian Climate Corps along with many of the climate provisions that didn’t make it into the infrastructure bill; historic levels of investment in affordable housing; and permanent residency for millions of immigrants.

The Republicans have no interest in supporting measures they have derided as “radical Democrat tax-and-spend.” McConnell and House minority leader Kevin McCarthy have been divided on many issues — including the infrastructure bill — but are united in opposing the budget reconciliation proposals.

Daunting as the task might seem, Biden has reason to believe the wind is at his back. Above all, these measures are very popular among voters. Sixty-five per cent of respondents to a recent Quinnipiac poll supported the bipartisan infrastructure proposal, and 62 per cent are in favour of the Democrats’ reconciliation plan. These levels of support are echoed in other polls, even including a Fox News poll.

The reason is simple. Most Americans see Biden’s policies as benefiting the rich, poor and middle class alike, so he is avoiding the divisions that Trump traded on. Employment is up, unemployment is down, and hourly rates in low-wage industries are finally starting to climb.

Biden can also rely on the expertise of Pelosi, Senate majority leader Chuck Schumer and his own White House aides to wrangle and cajole congressional Democrats, and juggle their concerns and needs against those of the president.

At the same time, though, other urgent and contentious issues are looming. Unless legislation to fund public agencies is enacted in a timely fashion, a government shutdown is on the cards after the end of the government’s financial year on 30 September. The federal debt limit, already extended by extraordinary measures, must be extended by November.

Important constituencies are eager to see action on voting rights, gun control and social justice reforms. And the pandemic is far from beaten. The partisan divide on issues like masks and social isolation, combined with the conspiracy theories, misinformation and hesitancy, means this is now a pandemic of the unvaccinated. The momentum of the vaccinations has slowed and the Biden administration is struggling to revive it in the states and counties where resistance is high.

Biden’s approval ratings have taken a small hit as a result, although his handling of the pandemic still attracts 55 per cent approval. The most recent Reuters/Ipsos poll found 51 per cent of those surveyed approved of his overall performance and 45 per cent disapproved. (At the same point in his presidency, Trump’s approval rating was 37 per cent.) The same polling found that public health was the key issue for both Democrats and Republicans, ahead of the economy, the environment, healthcare and immigration.

Biden knows his window of opportunity is closing. What doesn’t get legislated by Christmas won’t get done once next year’s midterm elections are looming — a key argument that should work to keep congressional Democrats aligned on the votes ahead. The enactment of these two legislative packages is imperative both for the perceived success of Biden’s first term and for Democrats to have any chance of overturning precedent and keeping their (already razor-thin) majorities in the House and the Senate.

The elephant lurking in the room is Trump. He has a war chest and is intervening in Republican primaries, determined to punish enemies, keep his agenda at the centre of the party and keep himself in the media spotlight. Some fear that the 2022 elections, at least in part, will be a referendum on Trump rather than Biden, particularly if Trump makes them a form of revenge for his 2020 loss.

Biden’s response is to reach out to disaffected Republicans and independents, and his legislative efforts are helping to garner their support. The early success of his infrastructure deal has helped loosen Trump’s grip on Republicans’ decision-making, vindicated the president’s faith in bipartisanship, and affirmed the rationale for his presidency. As he said following Senate passage of his infrastructure bill, “This is what I call governing.” •

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What went wrong? How did a country with an internationally envied record of managing the pandemic and a history of successful vaccination programs come to lag so dreadfully? And what can be done before more Australians die unnecessarily and more lockdowns damage the economy and erode wellbeing?

The evidence shows that the blame rests squarely with the Morrison government and its advisers (assuming their advice is being followed). Only a substantial change in their attitudes, policies and communication efforts will reverse the vaccination trends and enable Australia to open its state and international borders permanently.

Efforts to develop a vaccine against the SARS-CoV-2 coronavirus began early and have been spectacularly successful. By July 2020, when I looked at progress in international vaccine development, 139 vaccines were in development and twenty-six undergoing human trials. Omitting Chinese efforts, at least six vaccines from major pharmaceutical companies were in either phase 2 or phase 3 clinical trials.

By then, the United States, Canada, Britain and other countries were making deals to ensure access to a range of vaccines. The Australian government’s approach was much more cautious; rather than “back every horse in the race,” bets were made on just two vaccines and the new mRNA vaccines were totally ignored.

Scott Morrison’s claim in August that Australians were at the head of the vaccine queue was based on a letter of intent for the purchase of thirty million doses of AstraZeneca vaccine, with CSL to manufacture at least some of these, and a big bet on the University of Queensland vaccine, with a heads of agreement signed with CSL for the production of fifty-one million doses.

There is every reason to believe that these purchasing decisions were based as much on cost considerations as on a need for national self-reliance, and that they ignored advice to ensure access to a full range of vaccine types. The AstraZeneca vaccine costs about US$4 per dose, considerably less than the mRNA vaccines made by Pfizer (US$20) and Moderna (US$32–37), which have more challenging storage and transport requirements. While local production is an admirable goal, it is not clear how CSL could simultaneously manufacture two different vaccines at the same facility given the large-scale production requirements.

It is public knowledge that negotiations between the Department of Health and Pfizer in July 2020 didn’t result in a purchase agreement at that time (that didn’t come until November, with a purchase of ten million doses). Persistent rumours suggested that Australia turned down the possibility of forty million Pfizer doses, to be delivered early in 2021, after haggling over costs and intellectual property.

By the end of February this year Australia was watching with great interest as US president Joe Biden and his team successfully turned around the Trump vaccine rollout fiasco and as Britain and Israel were implementing effective national vaccination campaigns.

Australians were initially happy to wait, even as Biden and Johnson went into overdrive — after all, the situation Down Under was very different, with infections under control and time available for full regulatory approval (rather than emergency authorisation) and planning a gold-standard vaccine rollout.

By this stage Australia had orders for twenty million Pfizer doses to arrive in 2021 and for 3.8 million AstraZeneca doses to be manufactured offshore (300,000 had already arrived), with fifty million more to be manufactured by CSL in Australia. After problems with the molecular clamp technology using HIV-derived proteins, though, there was to be no University of Queensland vaccine. As a result, Australia was now looking for more vaccines but faced a long queue for the Pfizer and Moderna mRNA vaccines, with perhaps as many as a billion doses already spoken for by other nations.

A few lucky Australians, the prime minister among them, had received their first jab. Morrison and Hunt heroically announced a target of four million vaccinations by the end of March and full vaccination by October. With a potential arsenal of seventy million jabs, enough for thirty-five million people, these goals seemed realistic.

But things started to go wrong very quickly. By the beginning of April it was clear that the Morrison government had over-promised and underdelivered. The European Union blocked exports of AstraZeneca vaccine, citing its own needs, and expected supplies were not arriving at vaccination centres. CSL production was under way but not in full swing. The government had already walked back the “all Australians vaccinated by October” pledge on 11 March.

And then, on 8 April, the government announced it had accepted the Australian Technical Advisory Group on Immunisation’s advice that Pfizer should now be the preferred vaccine for people aged under fifty because of the risk of blood clots from the AstraZeneca vaccine.

Since then, the vaccination program has spiralled further out of control, fuelling anger and frustration among state and territory leaders, despair among healthcare providers, and increasing vaccine hesitancy in the population.

The litany of failures is long and growing: unjustifiable delays in vaccinating population groups at highest risk (such as people in aged and disability care and their carers, and remote Indigenous communities); the inability to commit to vaccine deliveries in terms of both timing and quantities; the absence of effective communications and public education campaigns; and, most critically, a lack of transparency in government actions and decisions. All this has been aggravated by failures in hotel quarantine — yet another area of federal government responsibility that has been botched or, more accurately, ignored.

Many of the problems stem from the fact that the federal government (in contrast to state and territory governments) has little or no experience or expertise in delivering health services. Large sums have been spent on contractors and subcontractors to deliver vaccines and consultancy firms to advise on how to do this, often without first going to public tender and with no public scrutiny.

Unable or unwilling to admit to problems and tackle them promptly, the Morrison government has lost all the advantages that accrued from earlier lockdowns. Under its original goal, some twenty-two million doses would have been delivered by now and everyone in the top priority groups would be fully vaccinated. Even under the revised goal, more than ten million doses would be in Australians’ arms. That would have gone a considerable way towards blunting the impact of the Delta variant.

According to this week’s figures, the current vaccination gap is 4.7 million doses. Based on the current seven-day rolling average of 111,600 doses, it will take eleven more months to vaccinate all Australians (including children).

Some efforts have been made to deal with the problems. At the beginning of June, Lieutenant General John Frewen was announced as the head of the National Covid-19 Vaccination Task Force, a step described by one commentator as the federal government defaulting to the one implement it completely controls. Morrison chose to describe this as a “completely new organisational structure for getting a whole-of-government effect on a very big problem” and highlighted this by renaming the taskforce Operation Covid Shield.

Frewen has since released week-by-week vaccine allocations through to the end of the year, which should assist planning in the states and territories. But vaccine supplies will be constrained at least until the end of August, depending on how many people refuse the AstraZeneca vaccine. Supplies may also be affected by continuing outbreaks of infection that increase demand by states and territories over that allocated.

By mid September the supply of some 2.2 million doses each week is expected to be totally made up of mRNA vaccines, both Pfizer and Moderna. Australia’s initial twenty million Pfizer doses have apparently been brought forward a little and an extra twenty million have been ordered, to arrive before December. An agreement to secure twenty-five million doses of Moderna was announced in May, but the vaccine is yet to be approved by the Therapeutic Goods Administration. An agreement to purchase Novavax (a protein-based vaccine) also apparently exists; but phase 3 clinical trials have yet to conclude, so hopes for its availability in 2021 are very optimistic.

The rollout is now heavily reliant on state vaccination centres, general practitioners and Commonwealth-funded GP respiratory clinics. The case has been made that significantly more GPs need to be recruited to the Pfizer program, that more pharmacies should be involved, and that urgent attention must be given to vaccinating remote Indigenous communities.

The government’s medical experts have done a terrible job of allaying fears about the risks of vaccination and stressing the urgency of getting completely vaccinated, leaving opportunities for misunderstandings and false anti-vaccine claims. Scott Morrison’s “it’s not a race” rhetoric further clouded the message.

Until now, the federal government has made a virtue of following expert advice, even if that advice has not been well-communicated. But Morrison’s recent statement that people under forty could access AstraZeneca vaccine after consultation with their doctor — made in defiance of expert advice, without any input from national cabinet, and ahead of any consultation with the medical community — represents a major departure, worsening vaccine confusion and hesitancy and blindsiding GPs.

Meanwhile, Morrison and his ministers misrepresent the situation in Britain, for instance, by claiming that high rates of vaccination have not prevented infections and hospitalisations from the Delta virus. This ignores the reality that, while Delta infections are increasing, only 7.8 per cent of new Delta cases are among double-vaccinated Britons. Only very small numbers of vaccinated people are hospitalised and dying in the United States, too.

Further evidence about what vaccination can achieve can be found much closer to home in the results of NSW tracking and tracing. After a party in Western Sydney — described as a superspreader event — twenty-four of the thirty attendees tested positive for Covid-19. The remaining six were all vaccinated.

Any delay in getting Australians fully vaccinated inevitably hinders our ability to provide excess vaccines to countries in the Pacific and Southeast Asia. Morrison has said he remains committed to ensuring early vaccine access for these neighbouring nations through commitments at the G7 and through COVAX, the international scheme to ensure equitable access to Covid-19 vaccines.

In his press conference after this week’s national cabinet meeting, Scott Morrison said he was “very confident that Australians won’t give in to the frustration, that they will continue to show the great application and effort and patience that we know is required of all of us… We’ve got to keep going Australia.” The surest way to have Australians “keep going” is for the government to get going. At the moment it is mired in a mess of its own making. •

The publication of this article was supported by a grant from the Judith Neilson Institute for Journalism and Ideas.

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The case the court has agreed to hear, Jackson Women’s Health Organization v Dobbs, challenges the constitutionality of a 2018 Mississippi law that bans almost all abortions after fifteen weeks of pregnancy, with narrow exceptions for medical emergencies or foetal abnormalities. A federal district judge and a panel of the US Court of Appeals for the Fifth Circuit have both upheld an appeal against the law launched by the women’s health organisation that runs the only abortion clinic in Mississippi.

The case effectively reopens both Roe v Wade and the US Supreme Court’s 1992 decision in Planned Parenthood v Casey, which held that “the state’s interests” in relation to a foetus that isn’t yet viable “are not strong enough to support a prohibition of abortion or substantial obstacle to the woman’s effective right to elect the procedure.” In accepting the Mississippi case, the court says it will examine whether “all pre-viability prohibitions on elective abortions are unconstitutional.” The state’s attorney-general will argue that the capacity to survive outside the womb is the wrong place to draw the line.

Among developed nations, the longstanding and increasingly partisan political battle over women’s reproductive rights is uniquely American. Continual challenges to legal guarantees encapsulated in Roe v Wade and elsewhere not only undermine women’s freedoms but are also likely to be contributing to the appalling rates of maternal and infant mortality in the world’s richest nation.

A quick history lesson highlights how precarious the legal right to abortion is for American women. While Roe v Wade is commonly seen as guaranteeing a right to abortion, it secures only the right to privacy when seeking access to an abortion, thus protecting a woman’s autonomy in the decision to have an abortion.

Even this is mitigated by what the distinguished legal journalist Linda Greenhouse calls “a physician-centric framework.” To a remarkable degree, indeed, Roe v Wade is about doctors’ rights. The majority opinion, written by Justice Harry Blackmun, actually says that “the attending physician, in consultation with his [sic] patient, is free to determine, without regulation by the State, that, in his medical judgment, the patient’s pregnancy should be terminated.” This doctor-knows-best rhetoric could well have helped enable the limitations since placed on American women’s reproductive rights.

It is important to note that Roe v Wade is essentially superseded by the 1992 decision. When this case reached the US Supreme Court, only Justice Blackmun remained of Roe’s seven-member majority, and a majority of the justices had been appointed by presidents who openly sought its reversal. Even so, the court surprised everyone by reaffirming Roe’s central tenet of the right to an abortion; but it also instituted an “undue burden” standard that permitted the state to regulate abortion to protect unborn life from the beginning of pregnancy, so long as women’s authority to decide whether to give birth was protected. In taking this approach, the court created opportunities for restrictions on abortion that Roe itself never sanctioned.

In the wake of the Roe v Wade decision, anti- and pro-abortion groups were galvanised. At the same time, Republican strategists were staking out anti-abortion positions as part of a strategy to appeal to Catholic and evangelical voters. This was the beginning of a growing partisan divide on the issue, which has become almost a litmus test for aspiring Republican lawmakers.

Efforts to limit abortion soon turned to focusing on funding for reproductive services. The Hyde amendment, introduced in 1976 and enacted by every Congress since, bans the use of federal Medicaid funds for abortion services, with exceptions for pregnancies resulting from rape or incest and pregnancies that would endanger the mother’s life. It is particularly harmful to women of colour and those with low incomes, who disproportionately rely on Medicaid for their healthcare coverage. (Note that the Hyde amendment does not block states from using their own Medicaid funds; currently fifteen states pay for more abortions than those permitted under the amendment.)

Gallup polls report that around 50 per cent of Americans agree abortion should be legal “under certain circumstances” and another 29 per cent “under all circumstances.” This level of public support makes the federal political fight difficult, leading anti-abortion activists to be more relentless in their use of the courts and to target Republican-dominated state legislatures.

Donald Trump oversaw a major effort to curtail abortion. The “gag rule” was applied to recipients of US global health aid (a hard line that was particularly punitive for female victims of sexual violence during conflicts), access to contraception was restricted, and insurers and healthcare professionals were given more latitude to deny reproductive health services. He also made good on his promise to load up the Supreme Court with justices who would overturn Roe v Wade by appointing Neil Gorsuch, Brett Kavanaugh and Amy Coney Barrett.

Joe Biden has been reticent about speaking out on abortion. His election campaign didn’t highlight the issue, and he hasn’t taken it up since moving into the Oval Office. Perhaps his Catholicism has played a role, but more likely his silence reflects the many other important issues that need to be tackled.

But he has made a good start on rolling back Trump’s undermining of women’s health. He has reversed the restrictions on funding Planned Parenthood and overseas groups that provide abortion referrals; reversed restrictions on the supply of medical abortion drugs; and removed hurdles to medical research that uses foetal tissue derived from abortions. He has appointed vocal advocates of abortion rights to key federal posts, including Xavier Becerra as health and human services secretary.

The mere fact that the Supreme Court agreed to take up this case indicates it is likely to overturn or severely limit the judicial basis of abortion rights. None of the usual criteria for accepting a case were satisfied — there was no split in the circuit decisions and no unsettled question of federal law — and the case had languished on the court’s docket since before the death of Justice Ruth Ginsburg, an ardent support of Roe v Wade. Moreover, the newer, more conservative justices have already shown their willingness to overturn longstanding precedents and expand the scope of decisions.

Biden will be under enormous pressure to do more to protect abortion rights, not just because of fears about the outcome of Jackson Women’s Health Organization v Dobbs but also because of even more draconian state-level anti-abortion provisions. Sixteen states have attempted to ban abortion before viability, mostly with “heartbeat” bills, which seek to ban the procedure from the time a foetal heartbeat can first be heard. (This is six weeks from conception, at which time many women are still unaware they are pregnant.)

The anti-abortion legislation recently passed by the Texas legislature highlights what the future could look like without Roe v Wade (which originated in Texas). It not only bans abortions after six weeks but also allows private citizens the right to sue anyone who aids or abets an abortion — including healthcare workers and facilities, insurance companies, counsellors, families, the person who drives the patient to the clinic, and even those who donate funds to support abortion services. As lawyers opposing the legislation have argued, it enables anti-abortion groups to “weaponise the judicial system” to paralyse women’s healthcare services, isolate women who need abortions, and intimidate these women’s supportive networks.

All of these bills have been blocked by court orders, and await the undoing of constraints imposed by Roe v Wade. Many more bills are coming: since January, 549 abortion restrictions, including 165 abortion bans, have been introduced across forty-seven states; sixty-nine of these, including nine bans, have been enacted.

Biden made an election commitment to codify Roe v Wade into federal law and abolish the long-time ban on federal funding for abortions via the Hyde amendment. Vice-president Kamala Harris campaigned on a proposal to create a “preclearance” system, analogous to that in the Voting Rights Act, whereby states that want to change abortion access must seek approval from the justice department. In a first step, Biden’s fiscal 2022 budget request, just released, omits the Hyde language.

To enact any or all of these provisions, Biden must determine how much pressure he wants to put on the Democrats in Congress to tackle these fraught issues ahead of the 2022 elections. And there is an additional problem: all of these measures can only be passed if the Senate filibuster (a requirement for sixty votes rather than a simple majority) is abolished.

A more contentious way to tackle this issue — one that is already on the table for some Democrats —is to expand the number of justices on the Supreme Court (there is precedent, although not recent). A group of Democrats has introduced a bill to do this in the House of Representatives; and, not surprisingly, Republicans have been scathing in their opposition. But the bill has a doubtful future even without Republican opposition: House speaker Nancy Pelosi has said she has no plans to bring it up for a vote.

Although the court’s composition is clearly on Biden’s mind, he has been in no hurry to make a decision. In April he signed an executive order setting up a bipartisan commission to examine the court’s size, the justices’ lifetime appointments and other court-related matters, thus fulfilling a campaign commitment.

The key issue that may drive Biden and his administration to apply more effort to abortion rights specifically and women’s reproductive health more generally is his strong commitment to improving access to healthcare and creating a more equitable society. “We are deeply committed to making sure everyone has access to care — including reproductive health care — regardless of income, race, zip code, health insurance status, or immigration status,” Biden said in a joint statement with Harris on the forty-eighth anniversary of Roe v Wade in January.

The hard line against abortion rights that is so prevalent in American politics puts women’s lives, livelihoods and health at risk and widens the disparities between rich and poor that are already a feature of US healthcare. More importantly, the current battles ignore the real-life complexity — ethical and financial — of ending a pregnancy. That is not likely to change any time soon. •

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Despite its flaws, and despite a decade of attacks by congressional Republicans, the ACA — or Obamacare, as it is often called — is more popular than ever. A February poll showed support at 54 per cent, with many of those saying they oppose Obamacare supporting its provisions when they are spelt out. But that popularity seems only to have hardened Republicans’ resolve to fight its expansion.

On his first day in office Biden use presidential authority to rescind an array of healthcare-related executive orders made by his predecessor and implement his own policies. He appointed a new Covid-19 response coordination team. He withdrew Donald Trump’s Medicaid waiver, which allowed states to restrict eligibility using work requirements. He rolled back restrictions on reproductive health and the use of foetal tissue n research. He revived US membership of the World Health Organization and the Paris climate accord.

Biden also restored science and scientific expertise’s central role in health-related policymaking, reinstated workplace and environmental protections, and reversing the Trump administration’s hostile stance on gay rights and racial justice — all decisions just as important for Americans’ health as expanded health insurance coverage and improved access to healthcare services. (Kaiser Health News keeps a list, aptly titled The Great Undoing, of his ongoing efforts to undo Trump’s health policies.)

But the real work of restoring and expanding Obamacare involves writing the detailed legislation that must then pass Congress. With a Democratic majority of only six votes in the House of Representatives and just one (the vice-president’s) in the Senate, and with little or no chance of Republican support, that will be an enormous challenge.

Biden signalled where he was heading early. The US$1.9 trillion American Rescue Plan Act, the first of three bills that make up the Build Back Better plan, was made public before he took the oath of office. It focuses on pandemic relief, rescuing the American economy, opening schools, scaling up vaccination, and in other ways controlling the pandemic.

Aside from one-off payments to all Americans and increases in tax credits — measures that will temporarily lift many children out of poverty — short-term funding was also provided to lower the cost of health insurance premiums and pay the private health insurance of laid-off workers. Unemployment, nutritional assistance, rental and mortgage assistance benefits were boosted; Native American communities received US$8.3 billion for health, housing and education programs; and new financial incentives were introduced to encourage the twelve remaining states (led by Republicans, mainly southern and poor) to take up Obamacare’s expansion of Medicaid.

Biden’s time in the Obama administration had brought home to him the hazards of endless and ultimately fruitless negotiations with Republicans. He knew that bill must be passed in full, and quickly.

The American Rescue Plan Act was signed into law on 11 March, having passed through Congress without attracting a single Republican vote. As a result, Biden could mark his first hundred days in office with most Americans having received their promised relief payments, some 200 million Covid-19 vaccinations having been carried, out and many other achievements. The economy is roaring back, if unevenly, and the White House is characterised by action, transparency and an air of normality. Polling shows Americans are the most optimistic they’ve been about the nation’s direction in nearly fifteen years.

This gives the president the political capital to proceed with the two other parts of his Build Back Better agenda — US$2.3 trillion over the next eight years for the American Jobs Plan and $1.8 trillion for the American Families Plan — both of which include health and healthcare provisions.

Although the American Jobs Plan is primarily about rebuilding America’s rundown infrastructure, investing in green energy and creating jobs, it will also provide funding for the social supports that advance equity and aid access to healthcare. These include investments in broadband access, public transport, affordable housing and safe drinking water, all of which will especially benefit low-income and minority communities.

One of the package’s ground-breaking initiatives is the US$400 billion allocated to expand and upgrade community-based care for the elderly and people with disabilities, and an almost doubling of current spending under Medicaid. Although these funds seem unlikely to meet demand — especially given fears about the safety of residential care in the wake of Covid-19’s toll — they could dramatically improve the lives of those in home care and their carers. The latter are mainly immigrant women, often living below the poverty line without health insurance, whose median hourly wage is only US$12.60. During his election campaign, Biden spoke out about the need for this important part of the healthcare workforce to be given pay raises, workplace protections, paid family and medical leave, job training programs and collective bargaining rights.

The third component of Build Back Better, the American Families Plan, covers education, childcare, paid family leave and healthcare. It expands the American Rescue Plan’s premium tax credits for health insurance and provides US$2 billion to train skilled healthcare workers. It also tackles the social determinants of health by providing free meals to children in areas of high poverty and creating a healthy foods incentive program.

Education is directly linked to self-rated health, infant mortality, life expectancy and compliance with medical advice. Programs that close gaps in educational outcomes between low-income or racial and ethnic minority populations and higher-income or majority populations are essential to achieving health equity.

Congressional Republicans are predictably outraged by these US$6 trillion spending plans. They have accused Biden of pursuing a radical agenda that will turn the United States into a failed socialist state, and reject even job creation and infrastructure initiatives they (and Trump) once supported. They don’t see broadband or the removal of lead pipes carrying drinking water as infrastructure, and they claim that home care services were “shoehorned” into the plan.

Senate minority leader Mitch McConnell declared that the Biden administration “wants to jack up taxes in order to nudge families toward the kinds of jobs Democrats want them to have, in the kinds of industries Democrats want to exist, with the kinds of cars Democrats want them to drive, using the kinds of childcare arrangements that Democrats want them to pursue.”

Just as anathema to the Republicans are the increases in corporate taxes and taxes on individuals earning more than US$400,000 needed to pay for these bills, measures designed to avoid boosting an already huge federal deficit. Unsurprisingly, the Republicans’ appetite for remaking the economy is small, as evidenced by their US$568 billion infrastructure counter-proposal, which deals narrowly with roads, bridges and other transport infrastructure and ignores the economic possibilities of green jobs and clean energy.

Biden recognises that he has a unique opportunity to make what he has called a “once in a generation series of federal investments in our nation’s future.” With the pandemic having highlighted the consequences of relying on the market to deliver affordable and accessible services, a majority of Americans now supports a single-payer health insurance system and 69 per cent favour a public option that would compete with private health insurance.

Recognition is also growing that the much-touted American exceptionalism involves lower life expectancy, higher suicide rates and higher rates of avoidable deaths than in comparable countries. Many Americans now see the consequences of what happens when healthcare is neither universal nor affordable and paid family leave isn’t guaranteed.

Joe Biden is acutely aware of the Democrats’ narrow majorities in the current House and Senate and the distinct possibility these could be overturned in the next election cycle. His response is to go big, go fast and go partisan to get his plans in place before the 2022 elections.

The president has found considerable bipartisan support for his proposals in the community. Indeed, his ideas are often more popular than he is (his approval rating is currently around 54 per cent) and in most polls that support also comes from many Republicans. An ABC News/Washington Post poll conducted on 18–21 April found that 65 per cent of Americans support the now-enacted coronavirus relief package. Several different polls indicate that a majority of voters want Congress to pass the American Jobs Plan, and the more people know about it the more they approve. Polling also shows strong approval of the care-giving provisions, with a Morning Consult/Politico poll showing 76 per cent support (including 64 per cent among Republican voters). A Monmouth poll shows widespread enthusiasm for the American Families Plan, with 64 per cent support and 34 per cent opposition.

Nor are American voters particularly fazed by the price tag, or the increased taxes needed to pay it. A CBS News/YouGov poll, for example, found that Americans support raising taxes — on individuals earning more than US$400,000 a year and on corporations — by the same wide margin of 71 per cent to 29 per cent. A Monmouth poll found support for higher corporate taxes at 64 per cent and for raising taxes on those earning more than US$400,000 at 65 per cent. Some Republican lawmakers have even been touting the benefits Biden’s Covid-19 relief plan has delivered to their districts.

The president’s problems with Congress are not confined to managing the Republicans; there is obstinacy and dissent among the Democrats, especially those on the left who want more, and want it quicker. Biden campaigned on giving Americans universal healthcare coverage, and that is still a long way off. Estimates put the percentage of uninsured Americans at 12.5 (rising to an average of 15.5 per cent in states that have not expanded Medicaid): that’s twenty-nine million people, mostly low-income and people of colour, with another 21.3 per cent under-insured.

To reduce those figures significantly, two things need to happen: the cost of health insurance purchased privately and through the Obamacare exchanges needs to fall, and the recalcitrant states need to expand Medicaid. Biden is already tackling these issues, but more needs to be done. The new supplements for purchasing health insurance run for only for two years, and twelve states (with some four million eligible people) have yet to expand Medicaid.

In the absence of universal healthcare, Medicaid is an important, if shaky and uncertain, safety net. It provides mental health and substance abuse treatment for millions and covers almost half of all births. The states holding out against expansion are losing money they can ill afford, especially as coronavirus infections continue. Just last month, the Texas State House rejected Medicaid expansion because of continuing opposition from Republicans. Expansion would have enabled some 954,000 adults to receive healthcare coverage (about 75 per cent of whom are people of colour) and brought the state US$5.4 billion in federal dollars to pay for it.

Rather than funding expanded health insurance coverage through private insurers, progressive Democrats and some policy experts argue for a public option (as originally proposed in Obamacare) and/or for people aged fifty-five or sixty qualify for Medicare (an idea that was championed by Hillary Clinton in her 2016 presidential race).

Congressional Democrats led by Senator Bernie Sanders and the Congressional Progressive Caucus are pushing to have Medicare expansion included in the American Families Plan. They see this as a precursor to an eventual Medicare-for-All program. A broader group of Democrats is pushing for the American Families Plan to allow Medicare to negotiate prescription drug prices. Biden has endorsed these, and the public option, in the past.

In his speech to the Congress Biden promised that he would strive “this year” to lower insurance premiums, reduce drug costs and pursue other reforms to Obamacare. Presumably he feels that including these provisions in the American Families Plan would draw fire from the powerful health insurance, hospital and pharmaceutical corporations, making its passage through Congress even more difficult.

Sometime between now and 1 October the administration and Democrats must also confront the decision of the US Supreme Court in the California v Texas, a case brought by Republican state attorneys- general and supported by the Trump administration. The decision will essentially decide the fate of Obamacare and the survival of the entire Affordable Care Act. Analysis shows that it would adversely affect the lives of almost all Americans.

Should the worst happen, re-enacting a version of the Affordable Care Act in today’s political climate would be almost impossible, even as more Americans than ever are signing up for the health insurance coverage provided by the federal Obamacare exchange. It would be a dreadful irony if Trump’s legacy, delivered after he left office, was — finally — the end of Obamacare.

For this reason alone, but for so many others besides, Biden’s efforts to provide the United States with the kinds of government services that other wealthy, democracies already take for granted and to build voter support for a stronger social safety net are a national imperative. •

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The report deals with four possible ways the SARS-CoV-2 virus might have emerged and infected people in Wuhan. Its “likely to very likely” scenario is that the virus was transmitted to humans from an original source (almost certainly bats) by an intermediate animal host. Direct transmission from the primary animal source (referred to as zoonotic spillover) is “possible to likely.” A “possible” route would have involved transmission via frozen foods — viable viruses can be carried long distances on frozen food packaging — but an escape of the virus after a laboratory incident is seen as “extremely unlikely.”

While political sensitivities help explain the report’s tentative language, scientists, epidemiologists and public health officials weren’t surprised by its inconclusive findings. Making definitive judgements on this sort of question is never easy. AIDS, for instance, was first identified in the 1980s in the United States but it was not until 1999 that researchers could say for certain that the causative virus, HIV, originated from the simian immunodeficiency virus in monkeys, with chimpanzees as the intermediate hosts.

Even with advances in genomics since then, it would be unusual for a report twelve months into a pandemic to provide answers to all the key scientific questions. The team that produced the WHO report describe it as “a first start” and “not a static product but a dynamic one.”

The report’s first scenario reflects the generally shared view of infectious disease experts. The same route was followed by the coronavirus that caused SARS in 2002 (from bats to human, probably via raccoon dogs or civets) and Middle East respiratory syndrome in 2012 (where the likely intermediary was camels).

Although the first official case of what came to be called Covid-19 was recorded in Wuhan on 8 December 2020, it wasn’t until 21 January that Chinese authorities conceded the disease could spread by human-to-human transmission. The standard international response to an emerging public health problem, under the auspices of the WHO, was perhaps slow to get under way, but by late February 2020 the organisation had issued the report of a joint mission with China. Its goal was to underpin pandemic planning in China and internationally. The following month a brief report summarised what was then known about the origins of SARS-CoV-2 from an ongoing global study coordinated by the WHO, and the WHO also made recommendations to reduce the risk of other pathogens emerging from animals to humans in markets like Wuhan’s.

Then Donald Trump intervened, and everything became much more chaotic and increasingly driven by politics rather than science.

With a tweet on 16 March, Trump began referring to the coronavirus as the “Chinese virus.” His initial attack reportedly came after a Chinese foreign ministry spokesperson speculated that the American military personnel who attended the Military World Games in Wuhan in October 2019 could have introduced the virus.

The rhetoric quickly escalated. Soon Trump and the American right-wing media were repeatedly blaming China for the contagion, stating that it could have done more to prevent the disease spreading and proposing that the source of the virus might be a Wuhan research laboratory. As a counter, China suggested that the virus existed abroad before it was discovered in Wuhan and may have been imported into the country on or in frozen foods.

Trump also conflated blaming China with his hostility towards the WHO. He had already acted to withdraw the United States from the organisation and he now claimed the organisation had an “alarming lack of independence” from China.

Australia was drawn into the political fray in April when prime minister Scott Morrison put forward a three-point plan for overhauling the WHO: redefining its formal powers; recruiting independent investigators who would determine the source of major outbreaks like the current pandemic; and creating an independent review body to examine the performance of the WHO during such crises. Predictably outraged, the Chinese government accused Australia of launching a political attack on China and “pandering” to the United States. The furious backlash included a series of attacks on Australian exports.

Morrison wasn’t necessarily doing Trump’s bidding, but his efforts implicitly acknowledged that broad international support for a US-led inquiry was highly unlikely. As it turned out, Australia’s chances weren’t much better, although Morrison has sold the outcome as a win. Despite some heavy lobbying by Morrison, foreign minister Marise Payne, and Australia’s WHO representative Lisa Studdert, Australia’s plans were ultimately watered down considerably by the World Health Assembly, the WHO’s decision-making body.

The compromise was found in a motion from the European Union that called only for an “evaluation” of the outbreak by one of the WHO’s internal independent review committees. The motion — passed in May by the World Health Assembly with 137 votes, including from China, the United States and Australia — made no specific mention of China and provided no new powers for the WHO.

Enter the WHO origins study, whose delayed report was released last week. This is a separate process from the arm’s-length independent evaluation panel, chaired by former New Zealand prime minister Helen Clark and former Liberian president Ellen Johnson Sirleaf, which will report to the World Health Assembly, the WHO’s governing body, at its May session.

It wasn’t until November that Beijing and the WHO agreed on a series of scientific studies to be carried out in China. (These, together with the composition of the study team, were promptly rejected by the Trump administration.) The two primary aims were to determine exactly when the outbreak started and to learn how it emerged and jumped into the human population. Three types of data would be vital: genetic sequences of the virus, tests on animals, and epidemiological research into the earliest cases.

When the foreign members of the investigative team visited Wuhan in January through February, it was to help in a joint assessment of the evidence that China had found, not to scour the city for new facts. Indeed, the foreigners weren’t free to wander. While they were able to visit all the places they had requested, each visit was carefully managed. One WHO team member called the Wuhan trip a “highly chaperoned, highly curated study tour.”

Partly as a result, the report leaves unanswered a number of questions — some of them contentious — and raises other issues that need to be tackled. Where, for instance, are the bat population that harboured the progenitor of the SARS-CoV-2 virus and the intermediate host/s and what was the conduit of the virus to Wuhan? A coronavirus very similar to SARS-CoV-2 is found in the horseshoe bats that live in caves hundreds of kilometres from Wuhan, but these bat viruses don’t have a specific binding domain that would enable the spike protein to attach to a receptor on human cells, thus initiating the disease process. The important binding domain is believed to have emerged in the intermediate host. Scientists have so far tested more than 50,000 samples from domestic, farm and wild animals in the Wuhan region looking for potential intermediate hosts, and have found no trace of the virus that causes Covid-19.

Much more work is needed to explore the possibility that animal-breeding farms in southern China may be disease reservoirs. Once heavily promoted by the government, many or most of the wildlife farms appear to have been shut down in February 2020 — a strong signal that Chinese authorities considered them a probable pathway for a coronavirus to reach humans. While SARS-CoV-2 has been found in domestic cats, dogs and ferrets, in captive lions and tigers, and in farmed mink in Europe, this is a result of transmission from humans, known as reverse zoonosis. But mink, fox and raccoon dog are raised for fur in China and have not yet been eliminated as intermediate hosts.

The investigative team called for more studies of the possible role of frozen wildlife in viral transmission, and whether and how people can be infected through this route. It also recommended broadening the search for the virus’s origin beyond China. Recent reports of coronaviruses closely related to SARS-CoV-2 being found in bats in Japan, Cambodia and Thailand would justify this move, according to scientists.

The Chinese members of the team appeared to strongly favour the hypothesis that the virus could have reached Wuhan on a frozen food shipment — the third of the WHO report’s scenarios — especially if this indicated that the virus came from outside China. China has tested 1.5 million frozen samples and found the virus thirty times, so this scenario can’t yet be ruled out.

Of course, where a disease is first reported isn’t necessarily where it started. Recent evidence suggests that the first case of Covid-19 in Hubei province can be tracked back to 17 November 2019, and that by 20 December sixty cases had been confirmed. If this is correct, then either those cases were not detected or recognised at the time, or they were detected and recognised but reporting was suppressed.

Genetic evidence supports this timeline. Using molecular dating tools and epidemiological modelling, scientists estimate that the virus was circulating for about two months prior to December 2019. Add to that the growing evidence that the Wuhan market, while it may have harboured a viral “superspreader,” was not the source of infection.

Efforts in Wuhan and nearby areas to track down the earliest cases should continue, the WHO team said, to help researchers understand how the pandemic started. It recommended analysing older samples from blood banks in the province, though it isn’t clear who would provide the required technology, staffing and funding to undertake this effort.

The fourth of the WHO scenarios — a laboratory release, accidental or deliberate — may be unlikely but is still being propagated by the likes of former US secretary of state Mike Pompeo and, surprisingly, even the former head of the US Centers for Disease Control and Prevention. Until this possibility can be definitively dismissed, it will continue to undermine relations between China and countries like Australia and the United States.

The Wuhan Institute of Virology has certainly analysed bat viruses, and it does possess gene information about coronaviruses that it has not released publicly. China has a history of disinformation and delays in reporting about SARS-CoV-2 that serve to heighten suspicions. And laboratory accidents and safety lapses do happen. In an open letter published in the Wall Street Journal and Le Monde in March, a group of scientists argued that flaws in the joint WHO–China inquiry meant it couldn’t adequately explore the possibility the virus leaked from a laboratory.

Ironically, the Trump administration last May pulled the funding provided through the National Institutes of Health for a decade-old joint research alliance between American scientists and Chinese scientists at the Wuhan Institute of Virology, which was studying coronaviruses in bats and their spillover into humans. The consequent loss of trust and access was surely a hindrance to the WHO inquiry just a few months later.

Almost immediately after the report’s release, a number of countries expressed deep concerns about the adequacy of the findings. In a joint statement, Australia, the United States and twelve other countries said that the WHO team hadn’t had access to all the information it needed in China. White House press secretary Jen Psaki said that President Biden believes Americans “deserve better information” about the origin of Covid-19. The WHO report “doesn’t lead us to any closer of an understanding or greater knowledge than we had six to nine months ago about the origin,” she added. “It also doesn’t provide us guidelines or steps on how we should prevent this from happening in the future.”

Perhaps it was these concerns that prompted the WHO director-general Tedros Adhanom to remark during a briefing to member states that the report hadn’t made an “extensive enough” assessment of the possibility the virus was introduced to humans through a laboratory incident. Further data and studies will be needed to reach more robust conclusions, he said, adding that he expected “future collaborative studies to include more timely and comprehensive data sharing.”

The key participants must ultimately acknowledge that the point of these investigations is not geopolitical advantage but a better understanding of how the SARS-CoV-2 virus came to be so damaging. Despite what Trump and perhaps other leaders think, the aim of such investigations is not to apportion blame; if this becomes the key driver, they will never succeed.

Dominic Dwyer, an Australian infectious diseases expert who was part of the team that went to Wuhan, made the point well when he said, “Rather than blaming governments, we need to foster cooperation and trust between investigators, between and within countries. This not only helps us during this pandemic; it’s the key to managing future pandemics. The more cooperative we are, the more likely we are to get the best results. We have to make sure politics doesn’t muck that up.” •

Funding for this article from the Copyright Agency’s Cultural Fund is gratefully acknowledged.

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The extent of what’s being called vaccine nationalism is clear in the figures. As of early February, more than three-quarters of all vaccinations had been administered in the ten countries that together account for almost 60 per cent of global GDP, leaving some 130 countries, with 2.5 billion people, yet to receive a single dose.

Even before many of the vaccines had completed clinical trials or regulatory approval, the governments of the wealthiest countries had signed agreements with pharmaceutical manufacturers. As a British Medical Journal paper published in December revealed, some 3.76 billion courses (or 7.48 billion doses) of the projected manufacturing capacity of 5.96 billion courses by the end of 2021 were already committed by November 2020.

Of these, a shade over half were allocated to the high-income countries that account for only 14 per cent of the world’s population. Australia, Japan and Canada — countries with relatively small populations and few coronavirus cases — had collectively reserved more than a billion doses. Perhaps 2.34 billion courses would be left for low- and middle-income countries, the authors calculated. By 30 January, Britain had reportedly secured enough vaccines to give each of its citizens five doses, while Canada has ordered enough to give everyone nine doses.

The situation is reminiscent of the 2009 H1N1 influenza outbreak, when a handful of wealthy countries secured most of the vaccine supplies and relatively few of the populations who would have benefited most from the vaccine got it in time to make a difference.

Vaccine nationalism is rarely beneficial in the long run. Modelling by the International Chamber of Commerce shows that the economic benefits of funding equitable access to vaccines dwarf the costs. Advanced economies stand to lose as much as US$4.5 trillion if they fail to give developing economies access to coronavirus vaccines.

That didn’t stop EU health commissioner Stella Kyriakides from threatening to require companies making coronavirus vaccines in the bloc to “provide early notification whenever they want to export vaccines to third countries.” The statement contrasted with pleas for vaccine sharing from French president Emmanuel Macron, German chancellor Angela Merkel and other leaders.

The main international effort to secure equitable and affordable vaccine supplies for all countries, especially the poorest, falls under the auspices of COVAX, a joint initiative of Gavi (a public–private global health partnership dedicated to increasing access to immunisation in poor countries), the Coalition for Epidemic Preparedness Innovations (an Oslo-based fund supporting the development of vaccines against Covid-19) and the WHO.

COVAX aims to build manufacturing capabilities and secure two billion vaccine doses for distribution by the end of 2021. The plan is for more than a billion of these doses to be provided free or at a low cost to ninety-two low- and middle-income countries. The remainder will go to wealthier countries, which will pay for them.

Australia joined COVAX last September with a A$123.3 million commitment to its purchasing mechanism, which will enable Australia to purchase vaccines as they become available. This option may never be taken up, though: it comes on top of the agreements Australia has struck with Oxford–AstraZeneca, Pfizer and Novavax, which together will provide some 120 million doses.

COVAX’s work was initially hindered by the Trump administration’s refusal to participate. That was last September, after it had withdrawn the United States from the WHO, citing the agency’s “China-centric” response to the pandemic. It’s probably no coincidence that China announced its participation in COVAX the following month. In some diplomatic circles its motives for doing so are suspect. Russia, although a major vaccine developer and manufacturer, stayed on the sidelines.

All that changed with the election of Joe Biden, who acted quickly to rejoin the WHO and provide funding for COVAX. He has announced an initial US$2 billion and will release a further US$2 billion over two years once other donors have made good their pledges.

The US funds were appropriated by a bipartisan congressional vote in December — after Biden was elected but when Trump was still in office — and they provided a much-needed boost to the program. Indeed, the decision has been described as a “game changer” that will help mobilise other governments to start contributing to COVAX. The current funding shortfall for coronavirus testing, drugs and vaccines, and the resources to deliver them is estimated at US$27 billion for 2021.

Suddenly Russia, too, is interested in working with COVAX, although it has indicated it will not be substituting COVAX for its supplying of Sputnik V vaccine directly to other countries. China has taken this approach as well, offering priority access to its own vaccines to countries in Africa, the Middle East and Southeast Asia. While less is known about their efficacy, the Russian and Chinese vaccines are considerably cheaper than those produced in the West. These two jousting world powers clearly see their vaccines as a form of soft diplomacy, with more opportunities for this created by Trump’s weakening of America’s international standing and involvement. It is unlikely that the Biden administration will so readily cede this field.

Despite the boost from US involvement and recent pledges for increased support from G7 nations, COVAX faces a huge task in getting the leaders of wealthy countries to deliver their full funding commitments and to match their actions to their rhetoric.

Macron’s rhetoric is a case in point. Supported by Merkel, he called for 3 to 5 per cent of the European and US vaccine supply to be sent to developing countries. Diverting a small percentage of doses would not dramatically affect vaccine rollouts, he said, and would deal with the fear that Moscow and Beijing plan to wage what he called “a war of influence over vaccines.” Direct donations of vaccines, he argued at the Munich Security Conference last month, would be quicker than donating money to COVAX. But it isn’t clear when or even if these donations will happen. The British government said it will “share the majority of any future surplus coronavirus vaccines from our supply” with COVAX but gave no time frame.

Despite the problems, the good news is that vaccines are starting to arrive in Africa. This past week 600,000 doses of the Oxford/AstraZeneca coronavirus vaccine — developed in Britain, manufactured in India, with needles sourced from Dubai and funded by COVAX — arrived at the airport in Accra. This means that Ghana, a lower-middle-income country with a population of thirty-one million, can begin vaccinations this week.

African countries like Ghana have not been hit as hard by the virus as wealthier nations. So far, Ghana has recorded some 82,000 cases and nearly 600 deaths; but now, like many others in Africa, it is experiencing a second wave of infections. Managing the pandemic in Guinea and the Democratic Republic of the Congo has also been complicated by new outbreaks of Ebola.

Experts believe that the emergence of new coronavirus variants has contributed to a new wave of infections in many countries in southern Africa. They are concerned that unequal vaccine supplies and delays in vaccination programs will not only prolong the pandemic but also increase the possibility of hardier, more lethal variants. With more than 130 countries yet to vaccinate a single person, this is yet another reason for concerted international vaccination efforts.

COVAX has no power to compel states to share their surpluses. Some countries, Norway and Canada among them, have committed to sending their excess vaccines to COVAX. Others have used vaccines to advance foreign policy goals (Israel) or placate near neighbours (Spain).

And Australia? Prime minister Scott Morrison initially made a fairly tepid commitment to distributing coronavirus vaccines to the Pacific and some Southeast Asian countries “if Australia develops a supply.” Already, Australia has secured dramatically more vaccine than needed — and is also investing in increased local vaccine manufacturing capabilities — so Morrison should be able to ensure that “we’re doing our bit in this part of the world,” as he said in early February.

International availability of vaccines may also be boosted by cooperative initiatives to lift manufacturing capacity. French pharmaceutical giant Sanofi recently announced it would make its manufacturing infrastructure available to produce the Pfizer vaccine, and US company Merck, whose own vaccine candidates were not successful, has said it is in talks with governments and companies to potentially help manufacture already-approved vaccines. Brazil, China and India all have vaccine industries with enough capacity to manufacture supplies for their own use and for export.

The WHO has called on companies with vaccines to issue non-exclusive licences to allow other producers to manufacture their products, a mechanism that has been used before to expand access to treatments for HIV and hepatitis C.

As countries like the United States, Britain and now Australia are learning, successful vaccination programs require much more than simply getting the vaccines safely to vaccination centres. Trained personnel, technical assistance and equipment are needed, as are careful record-keeping and surveillance, transport and refrigeration. All this is considerably more costly and often more difficult to arrange than the vaccines themselves.

Last May the Australian government redirected A$280 million from overseas aid and humanitarian programs to the international Covid-19 response. Most of these funds (A$205 million) went to the Pacific region for technical assistance and supplies, laboratory diagnosis, personnel and surveillance. The Australian Council for International Development welcomed the decision but decried the repurposing of already-stringent aid funds. Additional resources are required.

The elephant in the room, especially where new vaccines are involved, is who bears the risk of any adverse side effects or injury to patients. Countries funding their own vaccine procurement must also undertake their own liability programs.

In the United States the Trump administration granted companies like Pfizer and Moderna immunity from liability for unintentional problems with their vaccines. It isn’t possible to sue the government or the Food and Drug Administration over side effects either. This rare blanket immunity deal, which extends until 2024, involved invoking the 2005 Public Readiness and Emergency Preparedness Act, which provides legal protection to companies making or distributing critical medical supplies, such as vaccines and treatments, unless there is wilful misconduct by the company. 

The Australian government’s 2020–21 budget included a commitment to provide the suppliers of coronavirus vaccines with indemnity against liability for rare side effects. But experts have pointed out that it isn’t clear what this means in practice, and the government has not released any further details, citing “commercial in confidence” considerations.

The WHO, in what it describes as the “first and only” international vaccine injury compensation scheme, has agreed a no-fault compensation plan for claims of serious side effects in the ninety-two poorest countries due to get coronavirus vaccines via the COVAX scheme. This relieves recipient governments of a potentially serious financial and judicial burden.

Coronavirus vaccines have arrived in record time, and they will have a critical role in bringing the pandemic under control. But population immunity is required to end the pandemic, and this must be achieved internationally if the world and travel and open borders are to return to something like pre-pandemic times.

Achieving that level of immunity will take time and efforts well beyond vaccination programs; it will involve politics as much as science, political will as much as vaccination expertise, and recognition that a global pandemic requires a global response.

To return to the words of the WHO director-general: “Vaccine nationalism is not just morally indefensible. It is epidemiologically self-defeating and clinically counterproductive… Allowing the majority of the world’s population to go unvaccinated will not only perpetuate needless illness and deaths and the pain of ongoing lockdowns, but also spawn new virus mutations as COVID-19 continues to spread among unprotected populations.” •

The publication of this article was supported by a grant from the Judith Neilson Institute for Journalism and Ideas.

The post Vaccinating the world appeared first on Inside Story.

The United States is the stand-out failure. For decades, enormous spending on healthcare has failed to produce better health and longer lives than in many other countries that spend less. Covid-19 has added hugely to the mortality toll, with a disproportionate number of deaths among already-lagging minority populations. But even before the pandemic, average life expectancy in the United States, and in Britain, had fallen in recent years.

Life expectancy is the traditional broadbrush measure of population health. It gauges the effectiveness of the healthcare system and the effectiveness of healthcare spending. But it also gauges the impact of the social determinants of health — poverty, housing, education, discrimination and other non-medical factors that play a major role in health and wellbeing. Because life expectancy figures are an average across the population, some groups could actually experience decreases in a particular period while the population as a whole is going forward.

On the basis of the 275,000 US deaths attributed to Covid-19 by early December (the figure is now more than 470,000), University of California researcher Patrick Heuveline estimated average life expectancy for American babies born in 2020 to be lower by more than a year, the biggest fall since the end of the second world war. Heuveline compared the expected mortality rate in 2020 with the actual rate, which included deaths from Covid-19 and the “excess” deaths among people who didn’t get necessary medical care. The more young people are affected, the worse the impact on life expectancy. By comparison, the HIV epidemic reduced the US life expectancy at birth by 0.3 years at its peak in 1992. Covid-19’s impact on US mortality can be expected to cancel a decade of reductions in all other causes of mortality combined.

These findings are confirmed and extended in a study published just this month. American researchers Theresa Andrasfay and Noreen Goldman estimate that US life expectancy at birth has fallen by 1.13 years, to 77.48 years, lower than any year since 2003, and they project a 0.87-year reduction in life expectancy at sixty-five. The African-American and Latino populations, which have experienced a disproportionate burden of Covid-19 morbidity and mortality, are estimated to experience declines in life expectancy at birth of 2.10 and 3.05 years respectively.

This has the effect of increasing the Black–white life expectancy gap from 3.6 years to more than five years, eliminating the progress made in closing the gap since 2006. Latinos, whose mortality rates are consistently lower than white Americans’ (a phenomenon known as the Hispanic paradox), will see their three-year-plus survival advantage reduced to less than one year.

The picture is almost certain to look bleaker in 2021. Further reductions in life expectancy can be expected beyond 2020 because of continued Covid-19 mortality and the long-term health, social and economic impacts of the pandemic. Moreover, most epidemiologists consider that the number of infections in the United States has been severely underestimated and that excess mortality (deaths from causes other than Covid-19) will be higher with hospitals and healthcare systems operating under pressure.

The United States is not the only country to have suffered such a setback. Life expectancy will fall in any country or region that has experienced a coronavirus infection rate higher than 1 per cent, especially if the mortality rate in younger patients is high. A 10 per cent Covid-19 prevalence rate in North America and Europe means a loss of at least one year of life expectancy at birth.

In Bergamo in Italy’s Lombardy region, where serological tests have shown a 50 per cent infection prevalence rate, a group of European researchers has estimated a loss of life expectancy of 4.1 years for men and 2.6 years for women. (In this case the measure is average life expectancy for the population as a whole, so direct comparisons with US findings are not possible.) Demographers at Oxford University’s Leverhulme Centre calculate that life expectancy for both men and women in England and Wales was reduced in 2020 by more than a year (one year for women and 1.3 years for men) as of December 2020, wiping out gains made on life expectancy in the past decade. Australia has escaped this trend, thanks to low infection rates and a high concentration of deaths in the oldest age groups.

For Americans, this dismal news comes on top of several decades’ evidence that life expectancy at birth is lagging, the existence of a large and rising “mortality gap” between Americans aged fifty and older and their international peers, and data showing that even highly advantaged Americans are in worse health than their international peers.

In 2013 the US National Academies of Science (then the National Research Council and the Institute of Medicine) issued a report, Shorter Lives, Poorer Health, that ranked the United States last in life expectancy for men and second-last for women among high-income countries. Edward Alden of the Council on Foreign Relations described the report’s findings as “a catalogue of horrors.” (I was commissioned by the Institute of Medicine to write a discussion paper, Reducing Disparities in Life Expectancy: What Factors Matter?, for the report.)

The research team that produced Shorter Lives, Poorer Health aimed to elucidate why the United States suffers the health disadvantages it documented. Common explanations — obesity, lack of access to healthcare, health disparities between population groups — were all at play, but the exact cause, or combination of causes, wasn’t clear.

Despite the glaring deficiencies this report exposed, the situation has only worsened. The United States now ranks forty-third out of 195 countries for life expectancy at birth (Australia is fifth). In the absence of significant action, is expected to rank sixty-fourth by 2040. The figures are worse for African Americans, Native Americans, and people in poor and rural areas. The US maternal mortality rate ranks last among similarly wealthy countries and its infant mortality rate thirty-third out of thirty-six OECD countries. Many Americans are not living to see old age; the United States has consistently had the lowest or second-lowest probability of surviving to fifty.

The overall pace of mortality improvement has slowed in a number of European countries, and even in Australia, over the past decade. Dementia is the major contributor, along with rising obesity and diabetes and adverse trends in inequalities. The distinguished epidemiologist Michael Marmot succinctly outlined the challenges for Britain — but generally applicable in other developed countries — in his Marmot Review 10 Years On last February.

While access to healthcare is important, it contributes only modestly to longevity. Between a third and a half of these life expectancy gaps are explained by differences in the social determinants of health, including rates of poverty and educational disadvantage.

Poverty has a major impact on health and premature death. The longer people live in disadvantaged circumstances, the greater the risk of ill health. People who are unemployed, and the families of those who are unemployed, experience a much greater risk of premature death. Education is also key. Highly educated adults in the United States have lower yearly mortality rates than less-educated people in every age, gender and racial/ethnic subgroup of the population. These differences are somewhat wider among men than women.

The United States is also confronted with rising mortality rates caused by alcohol, drug overdoses, the opioid epidemic, gun violence and suicide. These “deaths of despair” are exacting an increasing toll on middle-aged, non-Hispanic white Americans, especially those without a college education. Indeed, the most meaningful risk factor for such a death is not having a university degree.

It’s not hard to see how these risk factors were all in play during the pandemic, with access to healthcare and social services more important than ever, employment and income at risk, and the demoralisation and grief brought on by the loss of jobs, social contacts and loved ones. The Trump administration must obviously be blamed for the pandemic’s disastrous impact in the United States, but the foundations for failure were decades in the making. The Shorter Lives report’s catalogue of horrors was a harbinger of things to come.

In the search for answers about inequalities, the report contains a final chapter (regarded by the research team as almost an afterthought) that discusses whether values seen as typically American — individual freedom, free enterprise, self-reliance, a major role for religion, federalism — influence the development of policy and its enactment in ways that are detrimental to Americans’ health.

Recent analysis of state politics and policies has found that American states with more progressive policies have longer life expectancy rates than those with more conservative policies. On this measure, American states have increasingly diverged since the early 1980s, shortly after the federal government began transferring policymaking authority for Medicaid and welfare programs to them. In 1959 Connecticut and Oklahoma had the same life expectancy; by 2017, Connecticut had gained 9.6 years while the more conservative Oklahoma had gained just 4.7.

The researchers estimate that if all states adopted policies similar to those of Hawaii (which has strong laws on labour rights, prohibiting tobacco and environmental protection, and a healthcare system that acknowledges the Native Hawaiian culture), US life expectancy would be on par with those of other high-income countries. These findings are partially countered by an analysis that found even if everyone achieved the health outcomes of white Americans living in the richest counties, health indicators would still lag behind those in many other countries.

The relationship between politics and health is also reflected in voting patterns. In 2016, counties with stagnating or falling life expectancies were more likely to vote Republican. This aligns with the strong support for Trump and Republicans among white Americans without a college education. Many of these Republican-voting areas are now also those with the highest infection and mortality rates from coronavirus.

For president Joe Biden and his team, these data highlight the size of the task ahead. Primacy, of course, must be given to controlling Covid-19, getting everyone vaccinated, and tackling the pandemic’s economic fallout ahead of boosting access to healthcare (including mental health and substance abuse services), housing, employment and education. But if these efforts are not targeted at the most needy communities they will simply widen existing socioeconomic gaps.

There are lessons in these figures for Australia, too. The pandemic has highlighted the inadequacy of the social services safety net — hence the large but temporary lift in the JobSeeker rate — along with the fragmentation of the healthcare system and the widening health disparities. For too many Australians life expectancy is a postcode lottery. For Indigenous Australians the life expectancy gap has not narrowed since 2006.

Better health is undoubtedly related to social expenditure, and social protection may be more important for health outcomes in more unequal societies. In a recent edition of the Medical Journal of Australia, Shane Kavanagh, Anthony LaMontagne and Sharon Brennan‐Olsen warn of the likely impact of calls to prioritise rapid reductions in government debt through cuts to health and social services. Government spending on health, education and social supports has the potential to increase economic growth, they argue, and “avoiding austerity measures will better serve the health of Australia’s population, and indeed the health of the nation.”

The political preference is too often for policy solutions that are readily to hand and simple. A medicine that allows patients to live with diabetes is seen as a more desirable announcement for the health minister than the grinding job of changing food and exercise policies so that fewer people are overweight and prone to the disease. Evidence from the United States suggests that policies on tobacco, labour, immigration, civil rights and the environment appear to be particularly influential for life expectancy.

It is shocking how quickly the hard work of improving life expectancy can be overturned. But there is also evidence that better policies can turn things around relatively quickly. Within four years of the introduction of mandatory health insurance, known as Romneycare, in Massachusetts in 2006 the death rate had fallen by 3 per cent, with the steepest declines seen in counties with the highest proportions of poor and previously uninsured people.

Joe Biden has committed to tackling the social inequalities and inequities in the United States. He quickly appointed a White House health equity task force headed by physician Marcella Nunez-Smith, which will make recommendations on mitigating and preventing health disparities. The task force’s initial focus will be on the equitable allocation of resources, vaccines and relief funds to deal with the pandemic.

The new president has also signed executive orders aimed at improving racial equity across the nation. These include measures to strengthen the anti-discrimination housing policies weakened under Trump and to enhance the sovereignty of Native American tribes. More far-reaching changes are expected in the months ahead.

Biden says he plans to infuse a focus on equity into everything the federal government does. All Australians — but especially those whose lives are shortened and diminished by the lack of an adequate income, housing, education, healthcare and employment — would benefit from a comparable commitment from Scott Morrison and his government. •

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Plenty of blame can be sheeted home to different government agencies and jurisdictions and some specifically American risk factors, but just one individual stands at the apex of the pyramid of failures.

Donald Trump leaves office with a legacy and under circumstances that will engage historians and political and social analysts for decades. He is one of only three presidents to be impeached, he sought to overturn the results of a presidential election that he clearly lost, and he refuses to acknowledge his rightfully elected successor, Joe Biden. But these strikes against him will be secondary to the swathe of illness and death he knowingly failed to prevent.

He will forever be known as the man under whose presidency the richest and most powerful country in the world, a country that abounds in scientific and medical innovation, was brought to its knees by a viral foe. Trump’s “America First” slogan and his oft-touted American exceptionalism are being measured in daily death numbers that surpass those of the bombing of Pearl Harbor and the terrorist acts of 11 September 2001.

Other countries much less well-endowed with the means to deal with a pandemic — countries like Vietnam, Mongolia, Malawi and Fiji — have shown how a shrewd combination of public health measures can control this virus. How and why did the United States fail so badly?

The seeds were planted long before the arrival of the pandemic by what Christine Todd Whitman, who headed the Environmental Protection Agency during George W. Bush’s presidency, calls “an orchestrated war on science.” Trump and his administration rolled back public health regulations, dismantled the agency charged with tracking and preparing for pandemic threats, undermined other scientific institutions, and suppressed and censored government scientists.

For reasons that remain obscure but probably relate to concerns about the economy, and hence the November election, Trump lied about the dangers posed by the virus and undermined efforts to contain it. Too many Americans — including state governors and mayors, who must take a share of the responsibility — joined in with his belittling of masks and his encouragement of public protests against lockdowns.

His appointees made political pawns of key agencies including the Centers for Disease Control and Prevention and the Food and Drug Administration, ordering them to issue inaccurate information and ill-advised health guidance, and tout potentially harmful treatments. This was “not just ineptitude,” as one epidemiologist remarked, it was an effort to “sabotage” the quest to keep people safe.

The damage has been compounded by the socioeconomic and racial inequalities that riddle the nation, the prevalence of risk factors such as obesity, diabetes and heart disease, poor access to healthcare services for many (aggravated by Trump’s efforts to destroy Obamacare), and little in the way of safety nets to protect those who lose jobs or must quarantine. Meanwhile, Trump and those members of his circle who tested positive to coronavirus used their privileged access to the best, most expensive treatments to drive home their message that the infection was inconsequential.

Trump has revelled in his ability to bestow (or withhold) needed funds, equipment and therapeutics. Too often this has been done in accordance with political ideologies and favouritism, if not wilful carelessness. Figuring prominently in the growing revelations about mismanagement is the president’s son-in-law, Jared Kushner, whose Project Airbridge, set up to deliver testing supplies and protective equipment, operated outside the standard federal channels for competitive bidding, disclosure and transparency. How the products were sold has gone undocumented, as have the way prices were determined and which facilities received supplies. Kushner hired his college roommate over credentialed medical experts to develop a national testing plan that never eventuated.

The list goes on. The administration mismanaged a contract for the manufacture of ventilators and ended up paying US$500 million more than necessary for 43,000 breathing machines. It’s not clear how many of these were received and distributed. Trump claimed he had inherited a Strategic National Stockpile with “bare” cupboards, but we now know the stockpile had 16,660 ventilators available in March but the administration had distributed considerably fewer than this by June. Reports suggest that ventilators were being sent overseas to countries that didn’t need or couldn’t use them.

Just as disturbing, the former head of the Biomedical Advanced Research and Development Authority, Rick Bright, made a detailed whistleblower complaint about how he was pressured to approve unproven chloroquine drugs and award contracts to friends of the administration.

Meanwhile, most of the US$525 billion from the Paycheck Protection Program, designed to help small businesses retain their employees, instead went to larger businesses. The Brookings Institution has detailed how Trump family businesses, Trump associates and Trump allies benefited from these funds. Numerous other reports have revealed cronyism, corruption and conflicts of interest, extending as far as the White House coronavirus task force and Operation Warp Speed, set up to deliver coronavirus vaccines.

This shocking litany serves not just to highlight Trump’s mendacity and his administration’s criminal negligence, but also to underline the task ahead for Joe Biden and his team.

Faced with the policy vacuum around the pandemic and the erosion of trust in government and scientific experts, Biden is running an active transition. His overarching election commitments on the coronavirus were to listen to science, ensure public health decisions are informed by public health professionals, and restore trust, transparency, common purpose and accountability to government. Within a week of election day he announced a bipartisan coronavirus task force. Later, speaking immediately after the electoral college sealed his victory, he highlighted that his attention remained firmly on the pandemic.

Biden comes to the presidency with more inside knowledge of the presidency and its interactions with other federal and state jurisdictions than perhaps any of his predecessors. His selection of key staff is reinforcing that advantage: Ron Klain as chief of staff, Xavier Becerra as health and human services secretary, Dr Vivek Murthy to an expanded role as US surgeon-general, Dr Rochelle Walensky as head of the Centers for Disease Control and Prevention and, of course, Dr Anthony Fauci as his chief medical adviser.

Recognising the need to heal the divisions exacerbated by Trump and the coronavirus, he has pledged to tackle the pandemic’s impact on minorities, to deal with the socioeconomic divides that mean many Americans must risk infection or lose their jobs, and to acknowledge and reward the work of carers. His planned structural reforms depend on reining in the pandemic and delivering immediate relief.

Biden’s economic team includes Neera Tanden as head of the Office of Management and Budget, Janet Yellen as secretary of the Treasury, and Jared Bernstein and Heather Boushey as members of the Council of Economic Advisers. Each has the background and commitment to carry out Biden’s program with skill and dispatch.

Those who charge that Biden is attempting to recreate the Obama years fail to recognise the value of having an experienced team made up of people who know how the systems and levers of government work, and who know each other. Biden is choosing a team that is ready to go from day one — indeed, a team that is already at work.

These people will bring their own histories and conflicts of interest to their positions, but the vetting and ethical and legal concerns will undoubtedly be better managed than under the Trump administration. Lawyers for the presidential transition are drafting new rules for White House staff that are likely to be more restrictive than those that governed the Obama administration.

Despite all the planning, two key external issues will shape how Biden’s agenda is implemented.

The first is whether the Democrats can win control of the Senate. If not, they will face the continuing obstinance of Senate majority leader Mitch McConnell and his conservative caucus. Winning both of the Georgia run-off races will be an enormous challenge for the Democrats, but a bigger task might be persuading McConnell not to cripple the Biden presidency by disrupting his legislative agenda and blocking his nominees for positions that need Senate approval.

The second is the enormous challenge of getting the coronavirus vaccine out across the nation in an equitable manner. Biden has called vaccine distribution a “huge, huge undertaking.” Fretting when his team was initially denied access to the Trump administration’s distribution plan, he commissioned his own plan in consultation with state governors.

To date Trump has been the loudest cheerleader for his administration’s role in getting vaccines developed through what he correctly proclaims to be “one of the miracles of modern medicine.” But he has shown much less interest in getting the vaccines where they are most needed. In the final days of his presidency, a focus on this effort, which currently lacks a detailed national plan and any sort of communication and education strategy, could have helped buff his legacy. Instead, he has chosen to undermine public trust in the vaccine by ordering Food and Drug Administration officials to approve it or be fired.

Trump was not present at the first vaccinations in Washington, DC, and issued no statement beyond a tweet saying “First Vaccine Administered. Congratulations USA! Congratulations WORLD!” His inner circle and officials are looking to jump the vaccine queue, regardless of their vulnerability.

In this vacuum, Biden has assumed the mantle of chief vaccine communicator. He has pledged “one hundred million shots in the first one hundred days” of his presidency, promising that this will change the course of the disease, and has emphasised the vaccine’s safety. But he also acknowledges that his first hundred days will not end Covid-19 and continues to plead with Americans to wear masks and obey public health guidelines.

Will Americans, now so cynical, weary and divided, listen to the very different message Biden is sending? Will they start to follow the example set by Biden, Harris and their people and wear masks, practise social distancing and limit gatherings? While the president-elect lacks the authority to mandate such measures, recent research offers some reassurance that communicating the importance of social distancing is only marginally less effective than imposing distancing measures by law.

The release of the first vaccine (with more likely to be approved) has signalled to Americans that there will be an end to the pandemic. If the rollout falters — because supplies are limited, because required services are not available, because there are disagreements over priority groups, or (disastrously) because of unanticipated side effects — then public confidence will be shattered.

Managing these challenges will require Biden and his team to communicate clearly and with one voice. Trying to persuade those who believe in conspiracy theories is generally a wasted effort, but strategies exist for limiting the spread of misinformation in the first place.

Joe Biden laid out the central task (and the primary burden) of his presidency in his acceptance speech given on 7 November: “I believe it is this: Americans have called on us to marshal the forces of decency and the forces of fairness. To marshal the forces of science and the forces of hope in the great battles of our time.” America will be waiting and the world will be watching. •

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With the president refusing to concede defeat, it’s unclear how closely the process will resemble the usual orderly handover of powers. There’s every chance that the disregard for niceties, precedents and laws so evident over the past four years will continue until — and even on — Inauguration Day.

Normally, the General Services Administration acts quickly once the result is known. Even before the electoral college meets to finalise the results, the GSA provides the transition team with funding, access to government services and space for headquarters. Concurrently, the president-elect begins receiving classified briefings from the CIA and other security agencies, and exchanging information and background papers with all government agencies.

The Biden–Harris transition team has been gearing up since June and is expected to number some 350 people. Funds of more than US$7 million have been raised to cover costs, including the expense of shepherding nominees through the Senate approval process. Unusually, the GSA’s administrator, a Trump appointee, has yet to sign off on the provision of the agency’s assistance.

Presidential transitions can be fraught, but George W. Bush’s handover to Barack Obama in 2008–09 is seen as the gold standard. At the height of the global financial crisis, with the nation’s economy on the verge of collapse, their interactions were smoothed by the two teams’ knowledge of each other from briefings, group crisis training and a series of one‐on‐one meetings between senior Bush and Obama staff. A terrorism threat in Washington on Inauguration Day was dealt with by national security personnel from both the Bush and Obama teams.

The White House reportedly has a transition team headed by Chris Liddell, assistant to the president and deputy chief of staff for policy coordination. Much needs to be done, including providing security clearances to enable key Biden advisers to access classified briefings during the transition period. But this work — mostly hidden from Trump amid fears he would try to derail it — appears to have ground to a halt since election day. Reports suggest that the mood is dark and chaotic, and that staff are disheartened and already leaving, a situation not helped by another outbreak of Covid-19 in the White House.

Rumours suggest that Trump might signal his lack of engagement by decamping to Mar-a-Lago in Florida (presumably at taxpayers’ expense). Alternatively, he might take to campaigning again, making his case about a “stolen” election. He is also expected to deliver a series of pardons, perhaps even for himself and his family — an act whose legality is yet to be tested. The Republican National Committee and Trump’s campaign organisation are fundraising to support his legal tactics and retire his campaign debts; they need some US$60 million to fund his legal challenges alone.

Fortunately, Joe Biden has little need for a formal handover. He has already been part of a well-executed transition, and he and his family know their way around the White House.

A new Biden–Harris transition website lays out the five key policy areas already outlined by the president-elect: the pandemic, rebuilding the economy and jobs, healthcare, climate change, and racial justice.

The first order of business will be to tackle the health and economic impacts of a pandemic whose reach has grown exponentially during the election campaign. Hospitals in many states have been overwhelmed, the economy disrupted, and families and communities left in grief and crisis. Experts now consider Covid-19 to be out of control nationally.

The urgency of the problem is highlighted by forecasts released last week by the Centers for Disease Control and Prevention. They predict that the week ending 28 November will see between 450,000 and 960,000 new coronavirus infections and between 4600 and 11,000 deaths. These estimates might even be overly conservative: 6 November saw 132,797 new cases and 1147 deaths across the United States. More than ten million Americans have been infected and significant numbers remain disabled by long-lasting side effects. Without effective interventions, the toll by Inauguration Day will be crippling and intolerable — yet the Trump administration seems unconcerned that this will be its lasting legacy.

Biden has announced a bipartisan coronavirus taskforce headed by three physicians — former US surgeon general Vivek Murthy, former Food and Drug Administration commissioner David Kessler, and Marcella Nunez-Smith, who is recognised for her work promoting health and healthcare equity among marginalised populations. All are well known in public health, science and political circles. Murthy and Kessler have been outspoken about the need to avoid any perception of political interference in pandemic decision-making and have signalled they will approach pandemic control far differently from the Trump administration.

The taskforce will build on consultations and planning in recent months, echoing work on Obama’s healthcare reforms by former senator Tom Daschle’s team throughout December 2008. The taskforce will need to reach out to red and blue states alike, whose cooperation will be vital to implementing the Biden plan’s federal initiatives (including possible mask mandates) and improved supply chains for personal protective equipment, testing supplies, therapeutics, vaccines and supplemental healthcare services.

This work is unlikely to step on the toes of the White House coronavirus advisory group, which has largely ceased to function. Trump has threatened to fire Dr Tony Fauci, and former chief spokesperson Dr Deborah Birx has been reduced to issuing an urgent plea for more aggressive action, which was leaked to the Washington Post. Trump now listens only to Dr Scott Atlas, whose views on the pandemic are decidedly renegade.

The administration’s approach to the pandemic in recent months was succinctly summed up by Mark Meadows’s proclamation (so ironic in light of his own infection last week) that “we are not going to control the pandemic.” By contrast, a coronavirus briefing was the first order of business for Biden and Harris, followed by a public statement on plans to tackle the pandemic and rebuild the economy. Biden’s statement coincided with encouraging news from Pfizer about its coronavirus vaccine.

In 2008, the lame-duck Bush administration was willing to take advice and guidance from the Obama transition team on tackling the global financial crisis. Most notably, Bush agreed to Obama’s request to ask Congress to release more funds for the economic bailout. Biden will now push the lame-duck Senate to pass the coronavirus relief bill that is so urgently needed.

House speaker Nancy Pelosi and Senate majority leader Mitch McConnell have both indicated their interest in passing such a measure, but their last attempt failed when they were unable to agree on the scope of legislation. Can Biden’s input now help them find common ground? Complicating this push, Congress will be distracted by the looming 11 December government funding deadline. Failure to reach a deal on that issue will result in a government shutdown. And there’s another possible obstacle: Trump would need to sign any new spending bill.

Covid-19 and its economic impacts are challenging enough, but the Biden–Harris team will also need to work simultaneously on a range of other difficult issues. In quick order, Biden must announce his cabinet members and get them working on their agendas; assess which of Trump’s actions need to be undone (including his withdrawal from the World Health Organization and the Paris Agreement on climate change); develop legislation and, if he can’t get the Senate to cooperate, issue executive orders; and develop a contingency plan in case the US Supreme Court overturns Obamacare in 2021.

Dramatic policy changes have been promised in areas such as climate change, environmental protections, immigration and education. Here Biden will have to balance different policy positions and concerns inside the Democratic caucus (especially those from the left) and the reluctance of Republicans to work cooperatively. One way to tackle ambitious agendas is to work stepwise, in a planned series of bills, but that requires a firm hand and strong control of the levers of government and policy implementation.

Unless Biden can work with the Senate, he will be forced to resort to executive orders. McConnell was the enabler-in-chief to Trump and he will look to play a controlling role with Biden. But Biden has worked with McConnell over many years and is arguably every bit as familiar with Senate procedures. It will be interesting to see whether Republican allegiances to Trump remain strong during the upcoming lame-duck session, or whether Biden can use his longstanding relationships to persuade at least some Republicans to moderate their positions.

Whether McConnell retains his role as majority leader in the new Congress depends on the outcome of two run-off Senate races in Georgia in early January. The Democrats need to win both of them to control the Senate with vice-president Harris in the chair. (Harris will resign her ordinary Senate seat, and the Democrat governor of California will replace her with another Democrat.) If that doesn’t happen, McConnell is once again in the catbird seat. Whether Trumpism will remain rampant in the Republican caucus once Trump is off the scene is unknown.

Democratic control of the Senate would make a big difference to Biden’s appointees and agenda. As incoming president, he will appoint more than 4000 people to his administration, a quarter of whom will require Senate approval. The media are already compiling lists of likely cabinet appointees and White House advisers. Biden has a surfeit of well-qualified people to choose from, many of whom have served in previous administrations. He will face a balancing act between experience and new faces, and has promised an administration that “looks like America.”

Axios reports that a Republican Senate would work with Biden on centrist nominees but block any “radical progressives” or other figures who are controversial among conservatives. This could result in Biden’s having a more centrist cabinet and a more centrist legislative agenda than anticipated.

While work must proceed apace in Washington, Biden must also look beyond America’s borders and begin the long and difficult task of restoring relationships and trust around the world. He has committed to end Trump’s America First approach but is expected to move carefully, providing international reassurance that the United States is re-engaged with the world with a few big, symbolic acts.

It is tricky to do this sort of work when the outgoing president still remains in charge. This time around, concerns have been voiced about the unscripted actions Trump might take in the remaining weeks of his tenure and how these could damage national security.

Biden’s choice of a secretary of state will send a clear message nationally and internationally. Former UN ambassador Susan Rice is a leading candidate, but her unpopularity among Republicans might mean that the position goes to William Burns, deputy secretary of state under Obama. Placing someone with substantial state department experience at the head of that agency would restore morale there, which is reportedly at an all-time low, and provide a strong pair of hands to take on this important work while Biden is consumed with domestic issues.

The most important task for Biden in the days ahead is to project calm and order. He must continue as he has begun: turning away from harsh rhetoric and divisive language; seizing the momentum and turning it into decisive action; listening to those who didn’t vote for him — people fearful of the future thanks largely to Trump’s rhetoric — and offering them hope and substantive change. Biden has set out the vision, saying, “Let us be the nation that we know we can be. A nation united. A nation strengthened. A nation healed.” Now he and his administration must work to deliver it. •

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This might be the most important election in our lifetimes, a critical moment for a nation in crisis and a world facing complex challenges. The size of the turnout (both early and on the day) attests to voters’ awareness of that fact.

As I write this, Joe Biden is ahead in the popular and electoral college votes, but key states including Pennsylvania, Wisconsin and Michigan can’t yet be called. Although he appears to have lost some states he was hopeful of winning, he is still more likely than Trump to gain the 270 electoral college votes necessary to take office.

Whether Democrats will win back the Senate is also unclear. A failure to do so would hamstring Biden’s capacity to make key appointments and pursue his legislative program. Whatever the final outcome, this isn’t the result Democrats hoped for; but neither is it the one Trump touted.

Trump voters see his return for four more years as the nation’s safeguard against internal threats from socialism, anarchy and violence, and external threats from nuclear attack and biased trade deals. They are worried about the erosion of their freedoms and fearful of “big government.”

Biden voters primarily want a return to normalcy. That means bringing the pandemic under control, creating the conditions for people to go to work or school, and seeing Congress and an administration focused on dealing with their needs and concerns, including high-quality affordable healthcare, education, climate change and racial justice. They abhor Trump’s language and behaviour and their impact locally and internationally.

Essentially, though, the election was a referendum on Trump’s management of the coronavirus pandemic. But even that issue played out in a highly partisan way, with CNN exit polls showing that about seven in ten Trump voters say the economy should have priority over containing the coronavirus, while nearly eight in ten Biden voters see managing the pandemic as more important than rebuilding the economy. Trump supporters view law and order as important; Biden supporters rank racial equity higher.

For Australians, it is shocking to see the Trump administration, despite the pandemic’s huge toll and impact on the healthcare system, still pressing the US Supreme Court to abolish Obamacare. Yet, with local economies in ruins and job losses climbing, people still came out to vote in such substantial numbers for Trump and the Republicans.

On the other hand, despite the Biden campaign’s efforts not to repeat the recognised failures of Hillary Clinton’s 2016 campaign, and despite Biden’s commitment to the Black Lives Matter cause, it is clear that there was a failure to pay sufficient attention to the concerns of African Americans and Latinos, perhaps because their support was taken for granted.

The behaviour of the candidates late on election night was typical of the way the campaign was conducted. Biden made a public statement saying “it ain’t over yet” and calling on people to be patient. Trump tweeted that Democrats are trying to steal the election, then gave a speech that derided current counts as “a fraud on the nation,” prematurely declared victory, and pledged to ask the US Supreme Court to stop further counting of votes. This was incendiary stuff, the like of which has not been seen before on election night in the United States. As anticipated, Trump is trying to delegitimise the election process.

As reported by Jonathan Swan of Axios, Trump and his White House have long planned to ensure that election night didn’t end with a concession speech. He apparently talked through in some detail plans to declare victory if it looks like he’s “ahead,” even if large numbers of votes were still uncounted in Pennsylvania and other key states.

While he denied he would do this, he then went on to state that ballots should not be collected and counted after election day. “I think it’s terrible that we can’t know the results of an election the night of the election… We’re going to go in the night of, as soon as that election’s over, we’re going in with our lawyers… [I]f people wanted to get their ballots in, they should have gotten their ballots in long before that.”

Typically, this kind of wrangling has been pre-empted when news outlets have declared winners on the night of the election using partial counts and exit polls, which allow them to see how much of the vote is going to which candidate and calculate whether a candidate has a path to victory.

What happens now is that the electoral process proceeds as it has always done, slowed a little because of the enormous numbers of early ballots to be counted under rules that differ from state to state. Each state has its own laws governing when it needs to certify the election’s results, and none stipulate election day itself. (Biden’s home state of Delaware, in fact, is the only state that will certify its results within the same week as election day.) Most states will certify their results in the last two weeks of November, with some extending until the second week of December. The winner should be clear well before then, however.

In the lead-up to the election, American voters described their fundamental unease about America’s future. The delay in a clear result will test whether the American people can at least unite in exhibiting patience with the process, and whether the nation’s institutions are strong enough to withstand authoritarian efforts to override due process. •

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A CNN Instant Poll showed that 53 per cent of voters who watched the debate saw the Democratic candidate as the winner and 39 per cent gave it to Trump. Nearly three-quarters saw Biden’s criticisms of Trump as largely fair, and respondents were split evenly over whether Trump’s attacks on Biden were fair.

Trump, forced to be better behaved, still avoided substantive responses in favour of innuendos about the Biden family, distortions of Biden’s political legacy, and lies about Biden’s election policies. He spent much time highlighting what Biden didn’t do during his eight years as vice-president — and some of those blows may well have landed, especially as Biden missed a few chances to highlight Trump’s own failures.

This debate revealed yet again the limits of Trump’s interest in and commitment to the issues that concern most voters, his lack of understanding of their daily lives, his inability to move beyond his campaign-style messaging, and his hyper-partisan view of the United States and the world beyond.

Biden showed up as the same candidate from the first debate. He didn’t always succeed in demonstrating the depth and breadth of his election policies and their relevance to voters. But he generally managed to communicate effectively using lines that carried zing and showed an understanding of voters’ needs, while displaying his character and humanity.

The debate is likely to have only reinforced the choices of already committed voters. It certainly had no practical impact on the forty-seven million who have already cast their ballots. Trailing in the national polls and with much of the early voting appearing to favour his opponent, Trump needed to throw the debating equivalent of a Hail Mary pass. He didn’t. And Biden needed only to avoid dropping the ball and to run out the clock, which he did.

On the pandemic, Trump wanted to blame everyone but himself for what he continues to see as a China-instigated blow to his raison d’être and best campaign plank, the economy. Biden didn’t hit Trump hard enough on this: though he pointed out that the Senate Republicans’ refusal to pass the US$3 trillion economic recovery package means that people and businesses are going without essential financial support, he failed to highlight the fact that commercial enterprises, cities, states and the country can’t open for business while the virus remains essentially uncontrolled.

More than 7.7 million workers (with 6.9 million dependants) have lost not only their jobs but also their employer-provided health insurance at a time when they most need it. Trump has stopped saying he wants to abolish Obamacare and now claims he has essentially killed off Obamacare by getting rid of the tax penalties for individuals and businesses that don’t have or provide insurance cover. If the US Supreme Court strikes down the law, he says, there will be “brand new, beautiful healthcare.” Careful listeners will have caught his intriguing statement that “the Democrats might do this, unless we control the House” — yet another sign that he has no idea how to create a “beautiful” system.

When the debate turned to national security, Trump resorted to vindictive points about Hunter Biden’s business dealings with the Ukraine, to which Biden responded by attacking the president’s dealings with Russia and China. Biden did score the winning point with a succinct statement to camera — “This is not about his family or my family; it’s about your family” — but that was a segue from an important topic. The answers to questions on North Korea and nuclear armaments also went nowhere, and that was it for foreign policy and defence.

Biden’s strengths came to the fore on immigration and race. Trump is pathologically unable to express any support for Black Lives Matter, instead slamming Biden’s position on criminal justice reform way back in 1994. Biden’s policies on improving racial justice are comprehensive and therefore worthy of respect: he sees the importance of tackling the social determinants of disadvantage, including not just social justice but also housing, education and the ability to borrow money to start a business. He reiterated commitments on immigration and on delivering a path to citizenship for “Dreamers,” the undocumented immigrants who arrived in the United States at a very young age. Combined with Trump’s comment that it was “good” that young children were taken from their parents at the US border and kept in cages, this may help give a needed boost to Biden’s standing with Latino voters.

The final topic of the debate, climate change, is probably the most divisive among voters. Trump made it plain that jobs and the economy would beat out environmental protections every time (as exemplified by his administration’s push to undo a raft of Obama-era regulations), which might help him in states like Texas, Pennsylvania and Michigan.

For his part, Biden has negotiated a set of national and international environmental policies designed to balance the concerns of his party’s left (the likes of Alexandria Ocasio-Cortez and Bernie Sanders) and the more moderate Democrats. His blueprint inextricably links climate action and environmental justice with the needed economic revival, an approach that has received wide support and has been shown to deliver more jobs, faster economic growth, and more financial benefits for workers than Trump’s economic revival plan.

But most Americans are not across the fine details of Biden’s wide-ranging suite of policies, which made it easier for Trump to undermine his claims, as he did with casual references to Biden being a puppet of “AOC plus three” (conservative code for Ocasio-Cortez and her colleagues in the House) and more pointed comments about Biden limiting his support for fracking and the oil industry.

At the end of the debate, as they have done from the beginning, the two candidates stood in stark contrast. Their differences were highlighted when they were invited to preview their inauguration speeches. Trump remained transactional, wedded to “making America great again” with economic and taxation measures; reminiscent of the dark tones of his 2017 inaugural speech, he warned of “sad days” ahead if his aims were thwarted. Biden offered themes of unity, hope over fear, and opportunity for all. •

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But this was never guaranteed to be the case in 2020. Nothing involving President Donald Trump and politics is subject to prevailing wisdom, and, with this being a contest between the two oldest-ever candidates, the odds that their running mates will have to step up are higher than usual. Add to this the fact that Trump’s unknown Covid-19 prognosis might make this the last debate of the campaign, and the stakes couldn’t be higher.

Vice-president Mike Pence came to the debate with his record as a Trump collaborator and sycophant squarely on the table. He touts his credentials as “a Christian, a conservative, and a Republican, in that order” and he has willingly shored up Trump’s suspect credentials with all those groups.

He has done this ably. Initially the philosophical differences between the two were substantial, but over the past four years Pence has very effectively masked the divisions. Now he is tied to Trump, his policies and his unpopularity; and as a result, as several recent polls show, his favourability rating, a positive in 2016, is under water.

Joe Biden made his choice of running mate based on several key considerations that likely never entered Trump’s mind when he chose Pence. Biden has the experience of serving as vice-president — and as a real partner and source of wise counsel — to Barack Obama, and he clearly wanted to echo that dynamic in his own administration. He also realised the significance of choosing both a woman and a person of colour. And he was not intimidated by someone who is strong and forthright in her own right, a woman who came to today’s debate with positive favourability ratings and a perception that she would emerge the winner.

The central topic was inescapable: as head of the White House coronavirus taskforce, Pence must be held accountable for the many disastrous failings of the Trump administration in dealing with the pandemic. On this question, Pence’s dismal response tried to make a virtue of the Trump administration’s failure to tell the American people the truth about the pandemic at the outset and acknowledge the suffering they have experienced as a consequence.

Pence was always going to be on the back foot on this issue — most obviously because his advisers objected to the use of protective plexiglass screens during the debate, and because Pence himself, who has been in close contact with people known to have tested positive for the coronavirus, should have been in isolation.

But, like Trump, he is more than willing to ignore expert advice and prioritise image over his own and others’ safety. Public health experts have called his participation in the debate after the recent flare-up of cases at the White House, and the presence of his staff members who have also been exposed to the possibility of infection, grossly negligent.

It quickly became apparent that Pence had a single mode of response to the array of questions raised during the debate — questions about the role of a vice-president when the president is disabled in any way, about the economy and tax cuts, about climate change, about China, about the Supreme Court and about racial justice. In each case he evaded the questions in favour of a set of Trump-light talking points riddled with inaccuracies and gaslighting and accompanied by pained expressions. Many of his statements — on issues such as the adequacy of the response to the pandemic, climate change, whether the Trump administration has a healthcare plan, and the push to swear in a new Supreme Court judge — served only to highlight how out of touch he and Trump are with mainstream America.

Harris was much more forthcoming about substantive policy issues. She used her recognised prosecutorial and verbal combat skills to good effect, especially when discussing how Trump’s isolationism has made America less respected and weakened national security, how women’s reproductive rights are under threat, and the implications of Trump’s refusal to condemn white nationalism.

This debate was never going to repeat the nasty argy-bargy of last week’s presidential encounter. Pence is much more focused and controlled than Trump. But he used Trump’s debate playbook anyway, rarely allowing Harris to finish her sentences and consistently disregarding the timeframes set by the moderator. Like Trump, he is a practised and shameless liar.

Many women watching the debate would have sympathised with Harris and known exactly how she felt while a rude, older man stole her time and spoke over her. Her performance was not as sharp as might have been expected, but she showed herself to be capably across the issues, poised in the face of constant interruptions, and willing to push back on outrageous statements.

Did the debaters fulfil their mission? Can either team claim a political victory? The pundits will make their decisions over the next twenty-four hours and the voters’ thoughts will be known with the next round of polling.

Pence’s key task was to reassure jittery Republican voters reeling from several weeks of disastrous news for their ticket. Biden has significant and consistent leads in both national and swing-state polls, and Trump’s Covid-19 diagnosis has taken the momentum out of his already-struggling campaign.

Harris’s job was to walk the fine line of attracting support from both white and minority Americans without coming off as an “angry Black woman,” while simultaneously calling out the racism and sexism of the Trump administration.

In the end, despite predictions that the encounter might change the campaign dynamic, it seems only to have reinforced the fact that the election is a referendum on President Trump, his vice-president and his administration. It did nothing to upset the positions in the race that Biden and Harris currently hold. •

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Its members are more ethnically diverse and more progressive than older generations. In their relatively short lifetimes they have experienced the 9/11 terrorist attack, the global financial crisis, a series of extreme weather events and the impact of global warming, and now a global pandemic and a nation rent by racial, civic and hyper-partisan divisions.

They also turn out to vote in consistently lower numbers than older generations. In 2018, though, fired up by gun control, immigration, student debt, climate change and other issues they took personally, and supercharged by their opposition to president Donald Trump, their turnout increased substantially at the midterm elections. The figure is variously given as 36 per cent by the US Census Bureau, 42 per cent by Pew Research, and 46 per cent by the Harvard Institute of Politics: the differences appear to lie in the fact that data are only available from forty-two states so the national figure must be estimated.

Two-thirds of them supported the Democratic candidate for Congress, the widest partisan gap in this group for the past twenty-five years.

With this year’s presidential election widely seen as a pivotal point for both American democracy and international politics, experts say young voters could have a significant impact on the result. Is that accurate? Will their concerns and the candidates’ responses get them out to vote this time around?

The United States has one of the lowest rates of youth voter turnout.

Despite the boost in 2018, the early evidence from the 2020 presidential primaries suggested that figure wouldn’t rise this year. Fewer than one in five young people cast ballots in the Super Tuesday states.

These young people aren’t turned off by politics — in fact, they are surprisingly engaged. During the 2016 campaign, three-quarters of Americans aged under thirty professed an interest in politics, and a survey conducted in 2019 by the Kennedy School at Harvard found that 43 per cent of eighteen- to twenty-nine-year-olds said they were likely to vote in their party’s primary.

To date, though, those intentions haven’t translated into actions. Key among the reasons is the fact that first-time voters are often confused by complex and unclear voter-registration rules.

Voting is a fraught process in the United States, even in the best of circumstances, and young people are less likely to know where they should vote and more likely to be negatively affected when polling places get moved. It is particularly difficult for those from families that don’t see voting as a priority, for those whose parents may not themselves be eligible to vote, and for those who are moving from home to college or work. Young Americans are also less likely to have the necessary driver’s licence, passport or other voter identification.

Young people often miss the deadlines to register to vote, which is required in every state except North Dakota. Four million teenagers turn eighteen in 2020 and each state has varying laws about when they can register. Eighteen states and the District of Columbia allow pre-registration for seventeen-year-olds, and sometimes even sixteen-year-olds, but some states require people to be eighteen. Same-day registration is available in twenty-one states and the District of Columbia, and several states, including California and Oregon, have some form of automatic voter registration. In states that have implemented these types of reforms the turnout gap between older and younger voters has closed by about a third.

College and university campuses would normally be expected to help students vote, although this year many campuses are closed because of Covid-19. Between 2014 and 2018, the rate of student voting more than doubled, from 19.3 per cent to 40.3 per cent. In 2018 that was some 7.5 million students whose voting preferences leant strongly to Democrats. Female students, especially those who were Black or Latina, voted at the highest rates.

Students have a right (protected under a 1979 US Supreme Court decision) to register and vote where they attend college. Colleges and universities are also obliged by the federal Higher Education Act to make voter registration and voting available to all their students. That hasn’t stopped legislatures in several swing states, including Texas, Wisconsin, Florida and New Hampshire, from imposing rules that make it harder for college students to register and vote.

Campus closures combined with active suppression efforts are creating the “perfect storm,” especially with the alternative, mail-in voting, itself under threat. A recent poll found that more than half of young voters feel they don’t have the resources or knowledge they need to vote by mail in November.

On the other side of the ledger, a plethora of action groups is seeking to engage young people in the political processes. Those with a progressive focus include the Alliance for Youth Action, Kids Voting USA, NextGen America and Young Invincibles. Conservative group Turning Point USA, meanwhile — which aims to “educate, train and organise students to promote freedom” — is closely linked to the Trump family, and founder Charlie Kirk has acknowledged its focus on waging political warfare on campuses, in particular those in swing states.

Young voters care about a range of issues, including college debt, affordable healthcare, expanding voter rights, gun violence, immigration, climate change, and jobs and the economy. Polling shows they are less likely to approve of President Trump’s performance, more likely to think government has a role in solving society’s problems, more likely to think African Americans are treated less fairly than white Americans, and more likely to attribute climate change to human activity. College students cite Covid-19 and race relations as the two most important issues facing the nation.

The pandemic will most heavily affect the future prospects of young Americans, who are bearing the brunt of job losses in those businesses — restaurants, bars and retail — that typically employ younger people and seldom provide benefits, or who have had their education interrupted. For older millennials, the economic disruption is especially difficult because many have never fully recovered from the global financial crisis. The pandemic also makes access to affordable health insurance top of mind, especially with the Trump administration supporting the current attempt to have the US Supreme Court strike down the Affordable Care Act.

But while millennials and generation Z agree on many issues, this age group is by no means a liberal monolith. In particular, the voting patterns of young white men stand out. In 2018, more than a third of voters under age thirty were white men; in some key states like Iowa, Ohio and New Hampshire they make up a sizeable share of the electorate. They are the only subgroup of young voters to consistently vote Republican, although this support fell significantly over the first two years of Trump’s presidency.

In 2016 young white men preferred Donald Trump to Hillary Clinton by twenty-two percentage points while young white women and young women and men of colour preferred Clinton by margins ranging from fifteen to sixty percentage points. Two years later young white men still preferred the Republicans, but by only seven percentage points. By contrast, young white women and young men of colour voted for Democratic candidates by a margin of thirty percentage points and young women of colour by a margin of over eighty.

Tufts University’s Center for Information and Research on Civic Learning and Engagement, or CIRCLE, classifies this group of young white men as potential swing voters in 2020. Its research found that nearly one in five young voters who backed Republicans in 2018 plan to support Democratic presidential nominee Joe Biden this year.

Who speaks to and for this generation of young voters? Many millennials cast their first votes for Barack Obama, and members of generation Z began entering the electorate just as his term was ending. For them, his administration is a reference point for who is electable and what is achievable. Small wonder that many in 2020 don’t see anyone offering what they want.

A series of polls taken in the run-up to the primary elections this year show that it isn’t necessarily the age of the candidates that matter — rather, young people are attracted by the ideas they put forward. That is why Elizabeth Warren, Bernie Sanders and Pete Buttigieg ranked so well, although Biden has always been in consideration.

Young Republicans are also speaking out, concerned that the party and its leaders are failing to speak to people like them. In his rants against illegal immigrants, voter fraud and crime, Trump has undoubtedly preyed on the fears of older white voters and dismissed the more socially aware concerns of younger voters. At the same time, more than a quarter of the country’s eighteen- to twenty-nine-year-olds (29 per cent) say that their lives are worse because of Trump and only 15 per cent say their lives are better.

It is no surprise, then, that this election will be a referendum on Trump and his administration and policies for this age group.

A Harvard Institute of Politics poll in April found that 54 per cent of young voters (69 per cent of Democrats, 64 per cent of Republicans and 31 per cent of independents) intended to vote in November’s general election. This is up from the 50 per cent who, in the spring of 2016, told the same pollster they would vote — although the actual turnout in November that year was lower. (The poll cites 46 per cent and, as previously discussed, it is likely even lower.)

This poll also found that young Americans preferred Biden (then only the presumptive nominee) over Trump by twenty-three percentage points, an advantage that extended to thirty percentage points among those most likely to vote.

More recent polling shows that Biden, as the official Democratic candidate, has kept this level of support among millennials and generation Z, who strongly reject Trump’s management of the coronavirus pandemic and his responses to the Black Lives Matter protests. Differences based on race and education remain, but they are diminishing.

A July Brookings Institute survey of voting intentions among white working-class Americans — those without a college education who are seen as Trump’s key supporters — shows younger voters in this group are more likely than their elders to question Trump’s competence and character. The survey found 45 per cent of these potential 2020 voters aged under forty were leaning to Biden. It can be assumed that this trend is more pronounced in voters under thirty (and has perhaps become even more dramatic with the passage of time and the impact of the pandemic).

An August survey of college students by the Knight Foundation showed Democratic nominee Joe Biden to be their clearly preferred candidate; around 70 per cent said they’d vote for the Democratic nominee, compared with only 18 per cent for Trump. But respondents were not enthusiastic about Biden, and their voting intentions appear to be driven by a dislike of Trump (of whom 81 per cent had an unfavourable view).

Motivated by their social sensibilities and their experience of life in Trump’s America, it is clear that young voters will make efforts to have their voices heard in the November election, even in the face of voting barriers. Seventy-one per cent of the 4000 full-time college students who responded to one survey were “absolutely certain” they would vote in the general election this year. Such a participation rate would be unprecedented for young voters (that’s the level seen in voters aged sixty-five and over), but then the 2020 election will have many unprecedented aspects.

While turnout will be important in determining the outcomes of the November election, the exigencies of the electoral college system mean that where the turnout occurs will be even more important. CIRCLE’s analysis sees youth votes as particularly important for the presidential outcome in a number of states, including Wisconsin, North Carolina, Florida, Pennsylvania and Arizona.

These voters will actually have two important roles in 2020. The first is to follow up on the commitments they have expressed so strongly to date by casting their votes. The second is to spearhead a movement that engages their peers and family in the political process.

Projections show that millennials and generation Z will make up more than half of the population by 2030, and more than half of all eligible voters. If they turn out in 2020 at the same rate as older citizens and then stay politically engaged, they can get their elected representatives to pay attention to the policy issues that matter to them and begin the task of uniting a nation bowed down by a pandemic, racial injustice, social inequalities, ultra-partisan politics and the Trump kakistocracy. •

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Former president Barack Obama was quick to tweet his support. “Joe Biden nailed this decision,” he wrote. “By choosing Senator Kamala Harris as America’s next vice president, he’s underscored his own judgements and character.”

Biden declared back in March that he would choose a woman as his running mate, and the rise of the Black Lives Matter movement and growing support for racial justice strengthened the push for a person of colour. He had a rich selection to choose from: former ambassador Susan Rice, representative Val Demings, mayor Keisha Lance Bottoms, senator Tammy Duckworth, representative Karen Bass, and Georgia Democrat Stacey Abrams, as well as Harris herself. Although Harris was an obvious match, she faced strong competition from well-qualified women, many of whom would surely find roles in a future Biden administration.

Harris, whose parents are from Jamaica and India and who identifies as Black, will become the first woman of colour on a major-party presidential ticket, and only the fourth woman. But she is running more in the footsteps of Shirley Chisholm (who made a landmark presidential bid in 1972) than of Geraldine Ferraro (the first woman nominated for the vice-presidential position in 1984).

Biden’s choice has been described as one that “will literally make history and change the trajectory of history.” It makes a series of proudly unequivocal statements: that women of colour have a critical role to play in national politics; that America’s diversity should be represented in the White House; and that Biden is not afraid to be associated with an ambitious, powerful woman.

Biden’s eight years as vice-president and his decades of political service mean he is acutely aware of what is needed in a running mate: trust and compatibility are key, along with strengths that complement and extend his own, and experience in reaching out and working with others, especially in the congressional legislative arm of government. The ability to galvanise the electorate and get out the vote is more important than delivering a single state.

On the personal level, the candidate must pass a vetting process that ensures no nasty surprises will be uncovered by the opposition and the media. And — especially for a woman — stoicism and strength is needed to withstand excruciating scrutiny, scorn and even lies.

Harris ticks all these boxes. In particular, she has had a longstanding relationship with Biden and his family, built when she and Biden’s son Beau (who died of a brain tumour in 2015) were attorneys-general in California and Delaware respectively. As vice-president, Biden swore Harris in as senator in 2017. And it is not unimportant that Harris also has an excellent relationship with Obama, dating back to her early support for his 2008 presidential run.

But it isn’t just that Harris meets Biden’s need for a relationship that is “simpatico”; they are also aligned in their generally centrist approaches to policy. Her run in the presidential primaries means her personal and political past have already been exposed and she is well aware of the tough times ahead, as foreshadowed by comments on her pantsuits and pearls and those who ask “is she Black enough?”

Two further issues count here. Harris has a far more vigorous campaign style than Biden and is effective in debates. Her experience as a prosecutor is excellent preparation for the attack-dog role she will need to play to enable Biden to remain, presidentially, above the fray. Trump and Pence will run a scurrilous campaign loaded with falsehoods and dissembling. Harris, like no previous vice-presidential candidate, will need to bait, fact check and condemn them and their surrogates.

Arguably her most important attribute is that she has the experience to step into the presidential role. In the days ahead it will be crucial to the Democratic campaign for Americans to see this clearly. Given that Biden would be the oldest person to take the office, much has been made of the need for a vice-president who can step up.

Biden has referred to himself as a “transition candidate,” acting as a bridge to a younger generation of leadership. This is often taken to indicate that he will only serve one term. Harris would have a strong prospect of becoming president in her own right should Biden not run for re-election in 2024, so the longer-term future of the Democrats is at stake.

Harris has downsides, of course. Although generally well recognised and well liked among many demographics aligned with the Democrats, she did not do as well as expected in her presidential primary race. Her time as a prosecutor and California’s attorney-general is a cause for concern among progressives. The fact that she and Biden share similar centrist positions means that they will have to work hard to drive enthusiasm for the ticket from the left and younger voters. That said, there have already been positive messages of support from Bernie Sanders and Elizabeth Warren. It’s to be hoped that Harris’s partnership with Alexandria Ocasio-Cortez on a climate equity bill is also a sign of party unity.

So far, President Trump’s reaction has been somewhat low-key, though that is unlikely to last. After news of Harris’s selection broke, he told reporters that she was “my number one draft pick” as a potential Biden running mate. He cast his criticisms of her in typical Republican tones (she’s for raising taxes and slashing military spending, against fracking and petroleum products, and in favour of socialised medicine) and then resorted to typical personal tones. He called her “nasty” and “horrible” and said that she was “very disrespectful” to Biden when she attacked him in the Democratic primary debates for his support for busing.

The Trump campaign is currently struggling to find its way, not helped by a president who is reportedly angry and unwilling to take advice. The malaise is reflected in the polls, with a survey out just hours ahead of Biden’s announcement giving him a ten-point lead over Trump nationally. There are even rumours that Trump could dump Pence as his vice-president if the Democratic ticket generates lots of voter support.

The adage is that vice-presidents don’t win elections but they may help lose them. Its truth will be tested in a campaign held against the backdrop of the coronavirus pandemic, economic hardship, social unrest, striking partisan divides and threats from inside and outside the nation to undermine the voting process. •

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But president Donald Trump eschewed unity and empathy. Instead, in two speeches — at Mt Rushmore National Park on 3 July and then at the White House official celebration on 4 July — he advanced a view of the nation that was even darker, more disruptive and more dystopian than in his chilling inauguration speech.

From the moment it was announced, Trump’s Mt Rushmore speech was clearly going to be more about self-aggrandisement than acknowledging the impact of the pandemic. His campaign staff chose to flout recommendations to protect crowds from coronavirus (masks were optional and social distancing ignored) or to protect against the possibility of fires caused by fireworks.

Trump has long shown a fascination with the monument and has even mused about having his own face carved into the mountain alongside presidents George Washington, Thomas Jefferson, Abraham Lincoln and Theodore Roosevelt. He seems unaware or unconcerned that the monument, designed by a white supremacist, is built on land that is sacred to, and was stolen from, the Sioux Nation. Peaceful protests by First Nations people were, of course, ignored.

From a stage set beneath those stone presidential faces, Trump read woodenly from a speech that sought to engender fear and loathing of those who have protested at racial injustice and symbols of white power and slavery. He excoriated them as “evil” representatives of a “new far-left fascism,” and part of a “left-wing cultural revolution” whose ultimate goal is “the end of America.”

“Our nation is witnessing a merciless campaign to wipe out our history, defame our heroes, erase our values, and indoctrinate our children,” Trump proclaimed. “Angry mobs are trying to tear down statues of our founders, deface our most sacred memorials, and unleash a wave of violent crime in our cities.”

He doubled down the next day in his “Salute to America” address in Washington. He assured his supporters that he was “defeating the radical left, the Marxists, the anarchists, the agitators, the looters, and people who, in many instances, have absolutely no clue what they are doing,” while he pledged to “safeguard our values.”

He spoke out against a “cancel culture” he charged with attempting to close down the economy and intimidate dissenters (presumably a reference to pandemic lockdown efforts), against schools that are “teaching children to hate America,” against newsrooms and even corporate boardrooms, and against the “years of extreme indoctrination and bias in education, journalism, and other cultural institutions.”

What became clear over these two days was the character of the president’s campaign for a second term. In this beefed-up version of his 2016 campaign, the threats to his supporters no longer come from rapists and drug dealers flocking across the border (the coronavirus has halted that flow) but from other Americans. (In this he follows a tradition that goes back at least as far as the McCarthy witch-hunts of the 1950s.) Of what he calls “far-left fascism,” he said: “If you do not speak its language, perform its rituals, recite its mantras and follow its commandments, then you will be censored, banished, blacklisted, persecuted and punished.”

As if to convince those who were shocked by his tone that these speeches do truly presage his re-election strategy, Trump has continued his attacks in the days since. He criticised the Washington Redskins and Cleveland Indians sports teams as “politically correct” for reviewing the Native American element of their respective names, criticised the National Association for Stock Car Auto Racing’s decision to ban the Confederate flag from its races and events, and made a baseless attack on the only Black driver on the NASCAR circuit.

This is red meat for Trump’s rusted-on supporters, signalling to them that they are “the true victims of discrimination.” But for most other Americans it evokes scenes from The Plot Against America and other dystopian literature.

An obvious contrast came in the 4 July message from Trump’s Democratic challenger. Former vice-president Joe Biden also focused on racial justice, in his case highlighting the fact that the United States has not lived up to its founding principle that “all men are created equal.” But Biden offered hope. “We have a chance to rip the roots of systemic racism out of this country,” he said, and “live up to the words that founded this nation.” He went further in an op-ed piece, writing that “Independence Day is a celebration of our persistent march toward greater justice.”

Polling and surveys indicate that Biden is in tune with majority opinion. In fact, Trump appears increasingly out of touch not only with mainstream sentiments on race and racial justice, but also with public concerns about the coronavirus pandemic, where the country is heading, and other issues important to voters. Concern about Trump’s suitability for the highest office is also intensifying, not least among those who have worked most closely with him.

Race has been a defining issue in US politics since the Continental Congress adopted the Declaration of Independence on 4 July 1776. Now the issue is once again at the centre of a national debate made more urgent by the disproportionate impact of the coronavirus pandemic and its economic consequences on Black Americans, and the brutal killing of George Floyd by Minneapolis police.

Almost 75 per cent of Americans (including 53 per cent of Republicans) say they support the Black Lives Matter protests. Most don’t buy into the picture of anti-American chaos that Trump paints; even among those who think the protests are violent, 53 per cent are supportive. The seismic shift in the politics of race is leaving Trump and his followers on the losing side of the culture wars he is attempting to stoke.

George Floyd’s death has been pivotal in changing public opinion in a way that so many other Black deaths have not. Many thousands of Americans of all races and ages have marched in the streets of not only big cities but also small towns, and fully two-thirds of Americans (including 47 per cent of Republicans) now think their country has a race and law-enforcement problem.

The National Football League has reversed its position on players’ kneeling during the national anthem; Mississippi and other parts of the country are acting to remove Confederate symbols and statues; sports teams are changing their racist monikers and mascots; and the military and universities are looking to remove Confederate names from their bases and facilities.

While the daily lives of many Americans are consumed by the worsening consequences of the coronavirus, Trump’s focus is elsewhere. His rare references to the pandemic — entirely without empathy for individuals and communities — are taken up with falsehoods and fallacies.

An average of this week’s polls reveals that 56 per cent of Americans disapprove of the president’s response to the pandemic, the highest level so far. This figure is even higher among Independent voters (65.3 per cent) and dramatically so among Democrats (89.6 per cent).

As the epicentres of infection move from the blue states of the northeast and west coasts to the red states of the south and Midwest, his disapproval among Republicans is likely to grow. Republican-led states like Florida, Arizona and South Carolina now have the highest daily reported cases per capita, and officials in Texas and Florida have warned that hospitals are increasingly overwhelmed.

The Pew Research Center recently found that 87 per cent of Americans say they are dissatisfied with the direction of the country, 71 per cent say they are angry, 66 per cent say they’re fearful, and just 17 per cent are proud of the way things are going. As the country’s economic performance — which was to have been Trump’s key election card — declines, so too does Trump’s approval rating for managing the economy, which has fallen sixteen points to 47 per cent since January.

It all adds up to intense opposition to the president. The latest NPR/PBS NewsHour/Marist poll found that his overall disapproval rating was 58 per cent, and that an extraordinary 49 per cent of voters “strongly” disapprove of the job he’s doing.

The corollary of that is Joe Biden’s clear and consistent lead, sometimes edging into double digits. The RealClearPolitics average of the polls at the end of June had Biden up by 8.7 points and ahead in the battleground states of Wisconsin, Florida, Michigan and Pennsylvania. Pew polling gave Biden an eleven-point advantage (52 per cent to 41 per cent) on who can best handle the public health impact of the pandemic.

Particularly worrying for the president’s circle is the 29 per cent swing against Trump among suburban voters. Once-loyal older white voters are also defecting. Not all of them will vote for Biden, of course, but those who will say they trust the former vice-president to do a better job of unifying America and handling race relations. Interestingly, this shows up as a bigger positive in their view of Biden than the fact that they think he will also do a better job handling the coronavirus pandemic.

A series of polls shows that healthcare, the economy and jobs are consistently the top issues for all voters. As lay-offs continue, millions of people are also losing their job-linked health insurance — up to forty-three million of them, according to one report. Many will look to obtain insurance through the Obamacare exchanges and Medicaid expansion programs, although this will be difficult in many Republican-led states.

Enrolments in the federal Obamacare exchange were up 46 per cent in April–May over the same period last year, and enrolments in state-based marketplaces are up even more. This increased reliance on Obamacare comes even as the Trump administration has asked the US Supreme Court to strike down the law in its entirety, with nothing to replace it or to ensure that Trump’s promises of protections for pre-existing conditions are kept. In the midst of a pandemic that will compound a whole range of pre-existing conditions, this move alone highlights the extraordinary disconnect between the president and voters.

With a little over one hundred days to election day, it’s still possible that Trump’s current dismal position could turn around. But that seems unlikely in the absence of any sign of a second-term agenda and with reports that Trump is dismissing advice from his campaign staff in favour of following his own instincts to victory.

Trump’s flailing on policy issues and failing in the polls have consequences for those who had hoped to ride into, or back into, public office on his coat-tails. Despite their muted response to the president’s Independence Day rhetoric, reports indicate that Republicans are unnerved, to say the least.

Not only are the Democrats predicted to hold the House of Representatives but their chances of taking over the Senate are also rising. Incumbent senators from Arizona, Colorado and Iowa look increasingly vulnerable, and seats in Maine, North Carolina, Montana and Georgia are competitive, too.

Republican lawmakers reportedly fret that Trump’s positions on social issues and lack of a second-term agenda leave their party running against the currents of change and open to charges of ignoring voters’ concerns. “He’s got us on the wrong side of every emerging demographic,” said one anonymous senior congressional Republican. What is noticeable, though, is that most of those speaking out about the behaviour that Republicans have pandered to for the past three and a half years are doing so anonymously.

One indicator of Republican lawmakers’ concerns is the substantial number of retirements: in all, twenty-six of the party’s House members and four senators are forgoing re-election this year without declaring their candidacy for another office, while just seven Democrats in the House and one in the Senate are retiring outright. Trump’s grip on the party remains so strong that it’s easier to withdraw from politics than be an anti-Trump Republican.

In the absence of policies that can win votes, the only visible election strategy from Trump and Republicans is to prevent as many people as possible from voting. This is an effort that has engaged the Republican Party for some time (I wrote about it for Inside Story in 2016) and has now reached fever pitch. Efforts obviously designed to stop likely Democratic voters from enrolling and getting access to voting stations, early voting and mail voting (these last two increasingly important in these pandemic times) are being justified as measures against non-existent voter fraud.

Trump rails against mail voting despite the fact that it has always been used by overseas Americans (including State Department and military families) and has been used for over a decade in states like Colorado, and despite using it regularly himself. He has openly admitted, “If you ever agreed to [mail voting] you’d never have a Republican elected in this country again.”

It seems clear that his belligerent attacks are also designed to undermine confidence in the election process. In a recent article in Newsweek, former senator Tim Wirth and former senior congressional aide Tom Rogers postulate a Plot Against America–type scenario in which Trump loses the election but refuses to step down on the basis that the vote was rigged (he has already laid the groundwork for this) or that there was foreign interference (again, he has already outlined how this could be done — presumably by China rather than Russia — using false ballots).

This scenario might seem far-fetched, but it is raised disturbingly frequently by level-headed observers. It is a sad indictment of where some people fear Trump has taken America. •

The post Trump’s plot against America appeared first on Inside Story.

The situation is likely to worsen. As restaurants reopen, and with much of the population expecting a return to normal, food shortages and rationing could provoke civil unrest. Yet the Trump administration has no evident plan — indeed few ideas of any kind — for tackling food supply pressures that are hitting the president’s own red state constituencies hardest.

The problems began emerging in April among the unsanitary and often unsafe meat and poultry processing plants in rural towns, especially in the Midwest and Great Plains. Two of the ten US facilities with the highest rates of coronavirus infection are the meat processing works in Sioux Falls, South Dakota and Waterloo, Iowa (seven of the other eight are prisons).

With meat processing companies reluctant to release their data and not legally required to do so, up-to-date official statistics are hard to come by. The most recent report from the Centers for Disease Control and Prevention, dated 8 May, covers outbreaks in processing plants during April, by which time Covid-19 cases had been reported in 115 plants in nineteen states. Many of these plants were shutting down.

Not surprisingly, meat and chicken supplies quickly ran short on supermarket shelves. The consequent panic buying was aggravated on 26 April when Tyson Foods, one of the country’s largest meat producers, placed a full-page advertisement in major Sunday newspapers warning that “the food supply chain is breaking” and “millions of pounds of meat will disappear from the supply chain.”

The Trump administration responded with uncharacteristic speed. Just two days later, the president invoked the Defense Production Act and signed an executive order declaring meat and poultry processing an essential industry and forcing plants to remain open “to ensure a continued supply of protein for Americans.” The companies were happy to comply — the executive order shields them from any health or safety liability — and most workers were unable to resist demands to return to what is often the only work available, despite a continuing lack of protective equipment and health safeguards.

Just three companies (Smithfield, Tyson and JBS) account for two-thirds of the US beef market. This degree of consolidation is also evident at plant level: most processing facilities employ thousands of workers, and closing just one of them can result in more than ten million fewer beef servings a day.

Working in a processing plant is one of the most dangerous of American jobs, and the plants have a history of exploiting and abusing workers in the rural areas where they are major employers. Facilitating the exploitation is the fact that many of the workers are immigrants, often undocumented.

The pandemic seems to have opened another chapter in this nasty history. The Guardian recently revealed how negligence, secrecy and mismanagement at poultry processing facilities in Georgia, Arkansas and Mississippi operated by some of the largest food manufacturers have allowed the coronavirus to spread.

Since Trump’s order to reopen, and despite improved infection control procedures in some but not all workplaces, the number of cases tied to the plants has increased dramatically. Local health authorities are often reluctant to push major employers by mandating testing and isolation procedures. The governor of Nebraska has said his state will not disclose the numbers of coronavirus infections in specific meat plants without the consent of the companies.

Data collection by the Midwest Center for Investigative Reporting shows that 20,400 infections had been recorded across 216 plants in thirty-three states by 8 June, and at least seventy-four workers had died. In April, only five of Tyson Foods’ facilities had infections; now, twenty-four have reported outbreaks, with more than 7000 workers infected. The problem extends beyond meat and poultry to processed-food facilities and farms and ranches. According to data collected by the Food and Environment Reporting Network, by 8 June at least 282 meat packing and food processing plants, and thirty-nine farms and production facilities had confirmed cases of Covid-19.

It’s easy to see how a very infectious virus can spread under the conditions at these plants, and it’s easy to see how this affects the communities in which these plants are located. Counties with or near meat processing plants have almost twice the rate of known coronavirus infections as the national average. In some cases the figures are much worse: the Tyson Foods plant in Dakota City, Nebraska, has 786 positive cases (about 17.5 per cent of the 4500 workers and contractors it employs), and surrounding counties in Nebraska, Iowa and South Dakota together average 1000 cases per 100,000 population compared with the national average of 199 cases per 100,000.

These cases fit into a surge of coronavirus infections in rural areas since May. Now, the counties with the highest numbers of cases on a population basis are in Tennessee, Nebraska, Minnesota, Iowa, Kansas and Oklahoma, as well as in the rural areas of southern states like Georgia, Mississippi and Texas. All are areas that rank highly on the CDC’s social vulnerability index. Outbreaks have been further fuelled by the decision of many Republican jurisdictions not to close down public activities, and the failure of people in conservative farming communities to use preventive measures.

Around sixty million people live in rural America, including as many as 2.7 million hired farm workers. They are older and poorer than their urban counterparts and have higher rates of diabetes, obesity and other health problems. In many places the local healthcare system is already stretched thin, and even a minor surge in patients is enough to overwhelm small hospitals that often lack intensive care units and ventilators.

The coronavirus infection has arrived just as the summer harvest season is starting. Fruits and vegetables are still largely picked by hand, an undesirable job that is generally taken on by immigrant workers, roughly half of whom lack legal immigration status. These transient workers live in crowded and substandard housing and often speak little English. Time off for illness means lost pay. The Trump administration’s public charge rule means that even legal migrants are unable to access healthcare and other government benefits.

Bloomberg News reported on 30 May that all the 200 workers on one Tennessee farm tested positive for coronavirus and that Washington’s Yakima County (which produces apples, cherries, pears and hops) had the highest per capita infection rate of any county on the west coast. More than one hundred migrant workers at two large produce operations in New Jersey had contracted the virus.

No concerted government reporting or prevention effort is apparent, despite these workers being essential to America’s food supply. The Covid-19 outbreaks are creating labour shortages at the worst possible time, and many fruit and vegetable crops are being left to rot in the fields.

Those shortages compound the pandemic’s impact on the food supply chain. With cafes, restaurants, hotels and schools shut down, and many people reluctant to shop in supermarkets and farmers’ markets, many producers lost their markets. Dairy producers have been dumping large quantities of milk, and growers have been unable to get fresh produce delivered. Now, just as venues are reopening, further supply interruptions are likely to lead to shortages and increased prices.

All this means that the rate of food insecurity in the United States, especially among households with children, is unprecedented in modern times. A Brookings Institution study drawing on two national surveys in late April found that more than one in five households, and two in five of those with children under twelve years of age, were experiencing food insecurity. The incidence of hardship — as measured by respondents who reported children not eating enough because the household lacked the means to buy food — has increased more than fourfold since 2018.

In New York City an estimated two million people face food insecurity. City officials are planning to begin delivering more than a million free meals a day under the supervision of a “food czar” appointed by mayor Bill de Blasio.

The Trump administration and a number of Republican-governed states have made things worse by trying to limit access to the Supplemental Nutrition Assistance Program (SNAP, formerly the Food Stamps Program), depriving many children of free or inexpensive school meals. With cars and people queuing for miles, food banks are under extraordinary pressure. According to the hunger relief organisation Feeding America, the number of people served at food banks is up by more than half on a year ago and about two in every five people are seeking foodbank help for the first time.

There are no simple solutions to the waste and the need. Growers already reeling from huge losses in sales say they need help to meet the costs of harvesting, packing and transporting their crops to food banks. And the food banks aren’t set up to be warehouses for such vast quantities of perishable food.

The US$2 trillion coronavirus stimulus package provides for US$23.5 billion in assistance for farmers, to be allocated by agriculture secretary Sonny Perdue. Concerns that the administration will use this money to shore up Trump’s support among farmers in electorally pivotal Midwestern states seem justified by the skewed distribution of US$28 billion in aid to farmers to offset Trump’s trade war with China.

The stimulus package also provides the agriculture department with a further US$25.1 billion for food aid programs for poor families, including US$850 million for food banks. To date, despite the unprecedented demand, less than US$300 million has been sent out.

Together, these problems encapsulate all that the United States has become as a result of Donald Trump’s mismanagement of the pandemic: essential workers are infected and dying in unacceptable conditions; food is wasted while American children go hungry and city supermarkets ration purchasing; and some rural livelihoods and lives are wrecked while others benefit from pork-barrelling. •

The post How not to feed America appeared first on Inside Story.

Australia’s mental healthcare system has long been fragmented and under-resourced. Despite increasing rates of mental illness, and despite the impact on individuals, families and society, services fall well short of demand. The coronavirus made the problem worse, and has highlighted how much needs to be done to provide adequate care.

To their credit, Australian governments have recognised the need to act. But so far they haven’t done enough. A bigger investment is needed to ensure that Australians in distress — whether they’ve had direct exposure as patients or healthcare staff, are elderly, disabled or isolated, or are suffering from joblessness or anxiety — get help in a timely fashion, and to prevent suicides from outstripping the coronavirus’s toll to date. Given that the economic adversity may have yet to peak, the damage to mental health and wellbeing could well intensify.

Studies of the impact of other pandemics — SARS, Middle East respiratory syndrome, influenza and Ebola — have shown how these engender fear, anxiety, emotional distress, and post-traumatic stress symptoms. Other studies have shown how global economic crises can affect mental health and lead to an increase in suicides.

Recent Australian surveys highlight the nature and extent of the mental health problems caused by the coronavirus pandemic and the economic downturn. Significant numbers of respondents to a survey in April by YouGov feared they would be unable to pay their bills (60 per cent), they would lose their job (49 per cent), they would not be able to feed their family (48 per cent) or they might lose their home (38 per cent). Home schooling and caring for children in isolation for longer periods is adding to the stress. The survey found a large increase in the number of Australians drinking alone, and one in four relationships under strain.

Researchers at the Australian National University came up with similar findings. But while two-thirds of respondents reported feeling anxious or worried, the survey also picked up an increase in social trust and cohesion.

A study by UNICEF Australia looked specifically at how the coronavirus pandemic and the associated lockdown is affecting teenagers. Almost half of young people surveyed reported an increase in stress and anxiety, with higher rates for girls than boys. Much of this is attributable to the uprooting of their lives, with nearly nine out of ten having had to stop seeing their friends and most having had their education and extracurricular activities disrupted or stopped entirely.

In the weeks since these surveys were conducted conditions have almost certainly worsened, especially for adults, as the economic impacts of the coronavirus shutdown become more apparent.

Mental stress, which ranges in intensity from mild anxiety to severe post-traumatic stress disorder, disrupts normal brain function and causes impairments in learning and memory. Chronic stress influences the onset and severity of depression and cognitive decline, and it affects the body even at the genetic level. The physiological consequences of stress depend on the intensity and duration of the stress factors, and different people will perceive and react to these differently depending on their resilience. These differences help explain why some people are struggling while others are finding they are productive and content during this period of social isolation.

The increase in mental stress is reflected in requests for help. Lifeline, for example, was hit by a 25 per cent increase in calls in March, bringing the national total to around 90,000 calls, the highest in the organisation’s fifty-six-year history. Google reported a 75 per cent increase in searches for advice on domestic violence, and Beyond Blue has seen a 60 per cent increase in contacts compared with this time last year.

Healthcare workers on the front line of the pandemic are probably under the greatest stress of all. Doctors, nurses and emergency workers already have high rates of burnout, and doctors in particular have high rates of suicide and depression. With these health professionals providing care to very ill patients and also worrying about their own safety and that of their families, Covid-19 has created new pressures.

Alerted to these increasing mental health needs, the Australian government allocated $74 million (over two years) for mental health services in the $1.1 billion package of coronavirus health funding introduced on 28 March. This included $14 million to existing help services, including Lifeline and Kids Helpline, $10 million to Beyond Blue for a dedicated coronavirus wellbeing helpline (with Medibank Private providing a further $5 million), and funds for a range of support services and communication campaigns covering frontline health workers, people receiving aged care support, young people, Indigenous Australians, pregnant women and new parents.

Another $150 million was allocated for counselling services for families caught up in, or at risk of, domestic violence. Medicare subsidies for telehealth services were expanded significantly to allow GPs, psychiatrists, psychologists and other eligible health professionals to consult with patients using telephone and video conferencing.

Despite their obvious advantages in medically underserved areas, telehealth services had not previously been widely deployed or accessed in Australia. Of the 2.4 million visits to psychiatrists in 2018–19, only 66,000 involved telehealth. Doctors and patients have responded very positively to the new arrangements. They will continue until 30 September, when a review will determine whether conditions warrant an extension. The government will be under pressure to maintain the telehealth option as part of needed mental health reforms.

Several recent studies have provided additional information about the long-term mental health impact of the coronavirus and the isolation measures. Orygen modelling commissioned by the Victorian government shows that, without action, an extra 370,000 people in the state will seek mental health treatment or be hospitalised over the next three years as a result of the pandemic, with young people disproportionately affected, and hundreds more suicides will occur.

Work by the Brain and Mind Institute, or BMI, at the University of Sydney indicates a suicide surge that could take many more lives than Covid-19. Annual suicide rates could rise dramatically — from 3000 to as many as 4500 over each of the next five years, assuming unemployment rates go as high as 15 per cent. Youth suicides will make up almost­ half of the projected increase. Hospitalisations and emergency department visits for self-harm could rise by as much as 20 per cent.

Unchecked, this would mean a generational mental health crisis in some hard-hit regions, including those affected by the collapse of tourism. Over the next five years in one such area on the NSW north coast, an estimated half a billion dollars could be lost because of a fall in productivity directly attributable to coronavirus-generated increases in mental health disorders and suicide.

To prevent this disastrous outcome, the BMI team propose an increase in specialised mental health services, to be provided by mental health GPs, psychiatrists, allied health services and community mental health services, along with technology-enabled coordinated care and outreach and enhanced contact with and support for survivors of suicide attempts. Implemented nationwide, these services would mean an estimated 2650 fewer deaths, 33,450 fewer suicide attempts and 225,800 fewer presentations to emergency departments over the next five years.

Orygen’s Patrick McGorry, the BMI’s Ian Hickie and the Australian Medical Association’s Tony Bartone sent this research to the national cabinet with a letter calling for action. “The duration and depth of the disruption to our lives [from the pandemic] is not yet known,” they wrote. “However, we do know that people living in outer urban areas, rural and regional Australians, casual workers, those recently unemployed, and older workers will most likely be affected by the social and economic impacts. We must act quickly to increase key capabilities before the surge in demand for mental health services becomes evident.”

The national cabinet and the federal government responded on 15 May with $48 million for a National Mental Health and Wellbeing Pandemic Response Plan. Of this, $2.6 million will go to the National Suicide and Self-harm Monitoring System, which was announced in the 2019–20 federal budget at a cost of $15 million over three years. Sharing a further $4.7 million will be the National Suicide Prevention Research Fund, administered by Suicide Prevention Australia, and the National Suicide Prevention Taskforce.

For outreach, $19 million will go to Primary Health Networks to deliver readily accessible services by mental health nurses, and $3.5 million to Carers Australia and Carers Gateway to provide targeted assistance and information. Another $3.5 million was allocated for health information in languages other than English, and $3.5 million for Primary Health Networks to work with Indigenous Australians. Just $10.4 million was allocated for a national mental health communication campaign, which suggests that communication is not a key priority.

For Ian Hickie, these measures don’t “seem to reach the scale or the immediacy really required now to be ready for the really significant mental health problems that we will face over the next two years.” According to Patrick McGorry, “This is a very big wall we’re trying to build and we saw a couple of bricks put in the wall [on 15 May], but when is the rest of the wall going to be built?”

The government’s plan says little about integrating mental health and substance abuse services, and provides no funding for the latter, despite polls showing that 20 per cent of Australians say they are purchasing more alcohol and 70 per cent of that group report they are consuming more alcohol than previously. The already overburdened rehabilitation system is being pushed to breaking point.

The government has also appointed its first deputy chief medical officer for mental health, Ruth Vine, to steer the federal response to the mental health implications of the coronavirus crisis. It is not clear how she will interact with the chief executive of the National Mental Health Commission, Christine Morgan. Chief medical officer Brendan Murphy told a parliamentary committee that Dr Vine would bring a clinical perspective to the work of the commission.

What else is needed to build a twenty-first-century mental health system out of a fragmented set of services that already needed a lot of work, especially in the wake of the bushfires?

Leaving aside for a moment major structural changes of the kind discussed by Jennifer Doggett in Inside Story last year, five early actions are essential. First, telehealth can only deliver its promised benefits if everyone has access, and that means tackling the digital divide and the exigencies of the National Broadband Network.

Second, all frontline healthcare workers should be offered counselling now to forestall long-term symptoms of overwork and trauma, and to ensure they can keep doing their jobs with the intensity demanded of them — something that will be even more essential if there is a resurgence of Covid-19.

Third, given the strong links between unemployment, income inequality and suicide, priority needs to be given to providing a combination of education, employment, social and health services, especially for young people. This will require greater coordination between sectors and jurisdictions, and more attention to the already-evident gaps in safety nets. Yes, this will be yet another cost to the budget, but without it the cost will be measured in lives lost.

Fourth, more must be done to tackle what the BMI’s Sebastian Rosenberg calls the missing middle — the big service gaps for the people most in need of care. That means more specialised outpatient care and multidisciplinary care for those in need.

Finally, none of this can be done without efforts to address the missing mental health workforce. Australia needs more GPs trained to better integrate mental and physical healthcare, more psychiatrists and psychologists working in the public sector and outside the major cities, more mental health nurses and more peer-support workers.

The existing gaps in the system will come under intense scrutiny in the final report of the Productivity Commission’s mental health inquiry, which goes to government next month and must then be released within twenty-five sitting days. Last October’s draft report highlighted a lack of sustained investment in mental health treatment, poor coordination and a fundamental lack of responsiveness to the needs of those most affected. It also called for more prevention and early intervention measures, particularly for children and young adults.

The findings and recommendations from this final report, along with those from the royal commission into Victoria’s mental health system, due shortly, must drive the reforms needed to ensure that Australia’s mental health system cares properly for all who need treatment. •

The post Covid-19’s second wave appeared first on Inside Story.

What has been learned and how is that knowledge being used?

The story of the origin of the coronavirus pandemic is now fixed in the public mind. In late 2019, it goes, a new virus was generated as wild animals (pangolins are often invoked) and humans came together in the Wuhan wet market.

In reality, we don’t know exactly what happened — and it is important to trace the genesis of this virus because it’s the key to stopping the next pandemic. It now seems most likely that the coronavirus originated in bats, which are natural reservoirs for viruses. But we still don’t know which species served as an intermediate host before the virus moved to humans. Bats were where the 2002 SARS outbreak started, moving to civets before infecting humans. As the detection of the new virus in pets and a tiger in the Bronx zoo shows, coronaviruses like SARS-CoV-2 are circulating all the time in the animal kingdom.

There is definitely some sort of connection to the Wuhan wet market, which was the first epicentre of the pandemic, but the first recognised case in Wuhan had no clear link and pangolins are unlikely to be involved.

How and when the virus arrived in the United States is also unknown. Recently released evidence overturns the idea that the first infections were in a Washington state nursing home and the first coronavirus-related death in Seattle on 29 February, shifting the timeline of the virus’s spread to weeks earlier. Two Californians who died in their homes in early to mid February were infected, which means the virus was circulating in California for at least a month before it was detected in Washington state.

New York City announced its first confirmed Covid-19 case on 1 March, but modelling suggests nearly 11,000 people in the city could already have been infected. Moreover, genetic analyses show that most infections in New York came from multiple locations in Europe rather than directly from China. No one then was paying attention to the planes flying into New York from these locations.

This undercover start — and subsequent difficulties in containing it in countries like the United States, Italy and Spain — reflects Covid-19’s long and variable incubation period (the time between exposure and first symptoms is typically five to six days but may range from two to fourteen days) and the fact that some infected people have only very mild symptoms or none at all. Recent studies suggest about 40 per cent of those infected are “silent carriers,” although one study from China put this as high as 80 per cent.

Children and young, healthy people seem more likely to be asymptomatic, but it is unclear if this also means they are not infectious. French researchers found one child who was simultaneously infected with coronavirus, influenza virus and the common cold. Both of his siblings caught the latter two viruses, but the research subject didn’t pass coronavirus on to either of them, nor to any of the other 172 people he had contact with.

A small study by the National Centre for Immunisation Research and Surveillance came to the same conclusion — that children are unlikely to transmit coronavirus between each other or to adults. This report is being cited by the federal government as it advocates the reopening of schools.

Infectious disease experts are still trying to understand this variability in who gets infected and who shows symptoms, but the lesson learned is that widespread testing is essential to understand the full extent of infection in the community.

The SARS-CoV-2 virus is most commonly found in the upper respiratory tract and in fluids from the lungs. It spreads primarily through infected droplets generated by coughing and sneezing, or when hands touch surfaces or objects contaminated by these droplets and particles. Some studies have suggested that aerosol transmission is plausible, though others dispute this.

It is not clear whether pregnant women can pass the infection on to their babies. While several cases of newborns with coronavirus have been reported, no traces of the coronavirus have yet been found in the placenta or the umbilical cord, making it unlikely that a mother can infect her child while it is still in the womb. This could change as more information becomes available.

Viable, infectious SARS-CoV-2 has also been isolated from blood, urine, and faeces. It is not yet known whether other non-respiratory body fluids from an infected person — vomit, breast milk or semen, for instance — can be sources of infectious SARS-CoV-2.

Infectivity is measured by the reproduction number (the number of people an infected person will pass the illness to). For SARS-CoV-2 this is 2.0 to 2.6 – higher than the flu (1) but considerably less than measles (15). Scientists don’t know how many virus particles of SARS-CoV-2 are needed to trigger infection, and the extent to which viral load is an indicator of the severity of disease is unclear. Two studies in the Lancet reported that people who develop more severe pneumonia had, on average, higher viral loads when they were first admitted to hospital; but another study found that some asymptomatic patients had similar viral loads to patients with Covid-19 symptoms.

The virus enters the body through the mucous membranes of the face (eyes, nose and mouth), which provide a direct pathway to the throat and lungs. The path from the point of infection varies enormously and is determined by each individual’s immune system.

About 80 per cent of people with Covid-19 recover without needing any specialist treatment. But sometimes, even in otherwise healthy patients, the immune response is excessive or prolonged and causes what’s known as a “cytokine storm.” In these cases, the inflammation and organ damage can be fatal.

The most common cause of death in people with Covid-19 is acute respiratory distress syndrome, or ARDS, the result of a build-up of fluid in the lungs. Elderly people and those with chronic lung disorders are more likely to develop ARDS. A predominant theory is that these patients have increased levels of angiotensin converting enzyme 2, or ACE2, which acts as a receptor for the virus. There is confusion about whether the infection is amplified by a class of drugs used to treat hypertension that affect ACE2 levels and are often taken by patients most susceptible to coronavirus.

Some evidence also suggests that in severe cases, the virus may enter the brain through the olfactory nerve in the nose and damage that part of the brain that controls breathing.

One of the most shocking aspects of this pandemic is how people become so ill so quickly. Clinicians are just beginning to recognise that Covid-19 pneumonia initially causes a form of oxygen deprivation called “silent hypoxia” because it is insidious and hard to detect, and patients don’t feel short of breath. By the time their situation is recognised, patients’ oxygen levels are seriously compromised. Then the only treatment is mechanically to take over the patient’s breathing. Simple monitoring of blood oxygen levels can prevent this.

A striking feature of Covid-19 is that it disproportionately affects males. A meta-analysis of 206,128 cases around the world found that, although the number of infections was roughly equal between sexes, men were more than twice as likely to get so sick they needed intensive care and about 60 per cent more likely to die.

Two previous emerging coronavirus diseases, SARS and MERS, also disproportionately affected men, as, to a lesser extent, does influenza. This may be related to the very different immune systems of men and women and/or hormonal differences. Some have proposed a role for smoking, as smoking rates are universally higher in men. Another possibility is that men — especially older men — are in generally worse health than women. When the authors of a New York study factored prior health status into their analysis, they found that sex was no longer one of the main risk factors for severe Covid-19.

A prime risk factor for severe complications from Covid-19 is obesity. Although people with obesity frequently have other medical problems (such as heart disease and diabetes), studies indicate that obesity in and of itself is exceeded only by age as the most significant risk factor — and, surprisingly, is more important than asthma and other chronic respiratory conditions — for hospitalisation. Young adults with obesity appear to be at particular risk.

It is postulated that in coronavirus-infected patients with obesity, there is greater inflammation of adipose tissue, the fatty layer under the skin and around internal organs, and this contributes to immune activation, an enhanced cytokine storm, and increased virus shedding. There is a view that obese people shed virus for longer and that their quarantine should therefore be longer.

A shocking aspect is the racial disparities seen in coronavirus hospitalisations and deaths, especially obvious in the United States and Britain. Data from the US Centers for Disease Control and Prevention show that the rate of recorded Covid-19 deaths among African Americans (92.3 deaths per 100,000 population) and Hispanics/Latinos (74.3) were substantially higher than for white (45.2) or Asian (34.5) Americans.

Reports from cities including Chicago, New York and New Orleans indicate even greater racial disparities in death rates. A Washington Post headline described the virus “ravaging one of the country’s wealthiest black counties.” The situation appears to be worse for Native Americans living on tribal lands. Of the first 2249 patients with confirmed Covid-19 in Britain, 35 per cent were non-white, much higher than the proportion of non-white people in the population. Sadly, the fate of many patients, especially people of colour, is sealed by pre-existing social determinants of health and established racial inequalities.

While there is growing understanding of the risk factors and causative mechanisms of Covid-19 disease, this has yet to deliver a vaccine to prevent it or pharmaceutical treatments for the pneumonia it causes.

In desperate bids to find these treatments, researchers, clinicians and pharmaceutical companies around the globe have launched a raft of studies and clinical trials investigating experimental drugs, a decades-old malaria medicine, a veterinary drug that also kills head lice and the parasites that cause river blindness, and cutting-edge therapies that have worked for other conditions such as HIV and rheumatoid arthritis.

The value of this work is undermined by a lack of national, let alone international, strategies, leading to overlapping efforts and an array of small-scale trials that will not lead to definitive answers. No agreements have been reached about how to prioritise efforts, which data to collect and how to share findings to get answers faster. It’s been described by one observer as “chaotic.” A key hedge to the many trials is that there is no recognised “standard of care” against which to compare the drugs being studied.

Such results as have been delivered to date are, not surprisingly, either negative or inconclusive. Regulators have warned about the risks of the malaria drug hydroxychloroquine (much promoted by Donald Trump), and early reports from clinical trials of this drug and Remdesivir (a failed candidate for treating Ebola) have been damning, although other studies are still under way. Published results from a trial of the combined antiretroviral drug lopinavir/ritonavir also showed no improvement in clinical outcomes. A study of the head lice drug ivermectin is proceeding despite warnings that the dosage needed to kill coronavirus is up to one hundred times higher than approved doses.

The real quest is for a vaccine to prevent infection. Many vaccine prospects are being explored using a wide range of research approaches. Fortunately, the international cooperation has been much greater than for pharmaceuticals, as evidenced by the work of the Coalition for Epidemic Preparedness Innovations. One survey of the Covid-19 vaccine development landscape found 115 vaccine candidates. Of the seventy-eight confirmed active projects, seventy-three are currently at exploratory or preclinical stages and only a handful have moved into clinical development and testing. Hanging hopes on the development and large-scale production of a safe and effective vaccine within the next few years is an exercise in unbounded optimism.

As a way of buying time, researchers in four countries will start a clinical trial of an unorthodox approach testing the century-old BCG vaccine, used against tuberculosis, to see if it can generate a non-specific immune response that will fight off the coronavirus. Options for repurposing other vaccines are also being explored.

Most research funding is being spent on finding a vaccine and effective drugs. That effort is vital, but it must be accompanied by research on how to target and improve the non-drug interventions that are the only effective interventions so far.

The only established treatment for Covid-19 is supportive — basically the provision of oxygen via masks, respirators, ventilators and, in extreme cases, extracorporeal membrane oxygenation to help maintain high oxygen levels until patients’ lungs have recovered sufficiently for them to function normally.

These latter two treatments are resource-intensive and expensive forms of life support, with the potential for causing severe complications including infection and haemorrhage. Ventilating patients with Covid-19 seems to drive the infection deeper into the lungs and saves few lives. Avoiding the use of a ventilator is better for both patients and the healthcare system, so there is an urgent need for controlled clinical trials of ventilation versus non-invasive oxygen therapy in these patients.

In terms of prevention, the only approaches currently available require physical isolation, hand hygiene and protective equipment like masks. These interventions have been assessed by only a handful of studies, most of which have been assessed as of low quality or small sample size.

Work is under way to understand if the levels of immunity in individuals and the population after infection are protective, and how long that immunity could last. With no widespread inherent immunity to a new virus like SARS-CoV-2, scientists are starting from ground zero.

Doctors examining the blood of patients recovering from a Covid-19 infection are finding that fairly high levels of neutralising antibodies are made by the immune system. These antibodies coat an invading virus at specific points on its surface, blocking its ability to break into cells and thus conferring immunity. Most virologists believe that immunity against SARS-CoV-2 will last only a year or two, in line with other coronaviruses that infect humans. That means that even if most people do eventually become exposed to the virus, it is still likely to become endemic, with seasonal peaks of infection.

Current antibody tests, which show who has been infected, are often inaccurate, and it is not clear whether a positive result signals immunity to the coronavirus. The World Health Organization has warned against relying on these tests for policy decisions such as the introduction of “immunity passports.

It is possible that antibodies can be turned into therapies. Plasma containing the antibodies from recovered patients is transfused to gravely ill patients in an experimental treatment known as convalescent plasma therapy. Early results from a small number of Chinese patients, published in late March, were promising. Doctors have been using convalescent plasma transfusions to help patients fight diseases as far back as the Spanish flu of 1918. More recently, the procedure has been used in patients with SARS, Ebola, and H1N1.

Both vaccine development and plasma therapy depend on the virus not mutating in a way that modifies the shape of its antigens. Several studies have also established the relative stability to date of the SARS-CoV-2 genome, perhaps because the virus is encountering few immune hosts who could halt its spread.

Researchers have shown that two major strains of SARS-CoV-2 now exist. The newer and more aggressive L type accounts for about 70 per cent of the analysed cases, while the rest are linked to the older S type version. The mutations don’t seem to have affected the S1 spike protein, which is the antigen most people are targeting for vaccine production. But another study from China suggests that the virus’s ability to mutate has been vastly underestimated, providing laboratory evidence that certain mutations could create strains deadlier than others. Much more research is needed in this area, including monitoring virus samples from different locations over time to track mutations.

Finally, what do Covid-19 recoveries look like, and what are we to make of the host of side effects that are now appearing? On these questions, evidence is thin.

The recovery path for Covid-19 patients is very slow. Most cases recover within three weeks, but they can take much longer and be much more complicated and less linear for the sickest patients. Weaning patients off ventilators can take several weeks, and patients who have been in intensive care can experience delirium and symptoms of post-traumatic stress syndrome.

Once thought to be a pathogen that primarily attacks the lungs, the virus now seems to inflict long-lasting damage on many of the body’s organs. Reports are coming in of kidney damage requiring dialysis; strokes, even in young people who had only mild symptoms; Guillain–Barré syndrome, blood-clotting complications; neurological problems; and liver and intestinal damage. Doctors in Britain, Italy and Spain have been warned to look out for an inflammatory condition (perhaps the rare Kawasaki disease) in children, which is possibly linked to coronavirus. For many patients, surviving Covid-19 means a long road back to health.

How the pandemic ends will depend on medical advances still to come and perhaps yet to be predicted. In the interim, for communities and nations, surviving depends on individual behaviours and compliance with evidence-based guidelines. •

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So much has changed since then, although Trump continues to give daily cause for despair. Much of the United States is in shutdown, hospitals in cities like New York, Los Angeles, Chicago and Detroit are rationing care, hundreds of thousands of Americans are infected and thousands are dead and dying, and people are fearful. Trump now warns there will be “a lot of death.”

Along the way, the electoral process has almost ground to a halt. Only one certainty remains — Americans will go to the polls to elect their president and their political representatives on 3 November. Everything else is open to question, and made doubly fraught by the longstanding shortcomings of America’s electoral arrangements.

The electoral process has always put obstacles in the way of voters trying to exercise their democratic rights, especially if they belong to particular groups. Partly as a consequence, voter turnout is also a serious problem. The obstacles seem set to be even greater this year, with those most likely to be denied easy access to voting also being hardest hit by the pandemic. (This is especially the case for African Americans and Native Americans.)

The Democratic primaries are essentially on hold, with most states either pushing back their voting dates or extending the deadlines for mail-in votes. (Trump effectively short-circuited the Republican process, frightening off any challengers.) With about 60 per cent of delegates allocated, Biden holds an almost unassailable lead over Sanders: of the 1991 delegates needed, he has 1217 to Sanders’s 914. If the push for Sanders to stand aside succeeds, it would not only obviate the need for further primaries but would also enable the Democrats to campaign with one voice against Trump. But Sanders is pressing on, and his campaign says he will take part in any debate in April.

Even if the Democrats’ presidential nominee is determined by default, elections for local, state and federal lawmakers must proceed. Around the country, with state and local stay-home orders increasing and calls growing for all states to implement them, officials are looking for ways to ensure access and safety during the upcoming contests.

In doing so, they face an increasingly coordinated backlash from the right. This is exemplified in Wisconsin, where the Republican legislature, backed by the state Supreme Court and (shockingly) the US Supreme Court, refused to allow absentee voting for the 7 April primary. This meant that voters faced a difficult choice — to risk infection standing in long lines at polling places or forgo their democratic right to vote.

Republicans in New Mexico are staking out similar territory, with the state party filing a lawsuit this week to block an effort by county clerks to hold the June primary by mail.

Trump and a growing number of Republican leaders are aggressively challenging efforts to make voting easier and blocking emergency measures such as proactive mailing of ballots to voters. The Republican National Committee has launched voting-related lawsuits in Minnesota, Michigan, Arizona, Florida, Wisconsin and New Mexico.

Republicans say their efforts are driven by concerns that looser rules could lead to election fraud. But they also say that expanding voter access would hurt the party (for unexplained reasons voter fraud would apparently only favour Democrats, if indeed it occurred at all). “I think a lot of people cheat with mail-in voting,” claimed Trump, who voted absentee in New York in 2018 and has requested a Florida absentee ballot for 2020. What is certainly true is that making voting easier would remove obstacles faced by voters who tend to support the Democrats.

Congress included US$400 million to deal with the coronavirus’s impact on elections in the US$2.2 trillion rescue package enacted earlier this month. Democrats, recognising that it is not enough simply to allow citizens to vote by mail, wanted far more funds to help states expand absentee voting and online registration and to equip the postal service for a rush of ballots.

But Senate Republicans pushed back, arguing this was an attempt to “permanently override state control of elections.” Trump said the Democrats’ proposal “had things — levels of voting that, if you ever agreed to it, you’d never have a Republican elected in this country again.” The Republican speaker of the Georgia state House of Representatives offered a similar view, saying that an expansion of absentee voting would be “extremely devastating to Republicans and conservatives in Georgia.”

In fact, most states already allow voters to cast mail-in ballots, although eligibility is generally restricted. Only a few — including California, Hawaii, Oregon, Washington, Colorado and Utah — allow anyone to cast a ballot by mail. In the 2018 congressional elections, one in four votes was cast by mail-in ballot and the only detected fraud was perpetrated on behalf of a Republican in a North Carolina race. Several million military personnel, state department employees and expatriate Americans vote by mail without any recognised problems.

It should be noted that the unwillingness of Republican state officials to facilitate voting during the pandemic is not universal; many of the eighteen states that have taken steps to ease absentee voting have Republican governors or secretaries of state. And of the six states that have promised to automatically mail absentee-ballot request forms to eligible voters, five are categorised as “red.”

Holding large nominating conventions during the pandemic will be unwise if not impossible. The Republican National Committee has signalled it will still stage its convention in Charlotte in late August, and it is certain that Trump will insist on some sort of public coronation as candidate. The Democratic National Committee has pushed back its convention in Milwaukee from July to 17 August.

Campaigning will continue between now and election day, with virtual rallies, podcasts and social media. To this end Trump uses the daily White House coronavirus taskforce briefings essentially as campaign events. They can stretch to two or more hours, with cabinet secretaries, co-opted business leaders and medical experts required to sing Trump’s praises, and Trump himself using every opportunity to digress, cast blame, rebuke the media, and praise his own (often imaginary) efforts. Veracity, scientific fact and reliable medical advice are often casualties of his long-winded rants and ruminations.

Worse, it seems he is playing political favourites when deciding which states get scarce essential resources. New York, a Democratic stronghold, must endlessly plead for more supplies in the face of Trump’s assertions they are either not needed or the state should have organised them, while Florida, a swing state where Trump might be in trouble, apparently gets all it needs. Recent media reports suggest that Trump’s son-in-law, Jared Kushner, is running a shadow coronavirus taskforce and inserting himself in decisions about where assistance and equipment is directed.

Despite Sanders’s lingering presence, Biden is increasingly operating from a position of strength. While he must fight for attention against Trump’s megaphone (on cable news the White House briefings reach an average daily audience of 8.5 million), his interviews, virtual events and digital content were seen by more than twenty million people during the last two weeks of March.

His strategy is to get out in front on the health and economic effects of the pandemic without appearing to be openly politicking. He is trying to walk a fine line between criticising Trump and his administration and showing how he would unite and lead in a crisis.

The contrast between Trump and Biden was highlighted after Trump delivered a wooden address to the nation from the Oval Office in early March. Biden laid out his own plans for combating coronavirus: a mix of short- and long-term economic and public health reforms that, he argued, shouldn’t wait until after the election to be implemented. Trump’s speech was seen as a lost opportunity that left “a sense of unease.” Biden’s was described as “everything Trump’s was not,” with the former vice-president presenting himself as a steady hand in turbulent times.

The impact of Trump’s poor handling of the crisis on his re-election chances is hard to judge because so much potential misery and disruption still lies ahead. The state of the economy will be a key factor in how people vote.

Recent polling indicates trouble ahead for Trump. The FiveThirtyEight poll average for 5 April shows that support for his handling of the coronavirus crisis, after a small initial bump, appears to have diminished over the past two weeks. RealClearPolitics’s average of the polls has Biden ahead of Trump by 5.9 percentage points. If the Wisconsin primary goes ahead, Biden looks set to replicate his winning Michigan performance, with polling from late last week putting him nearly thirty percentage points ahead of Sanders. Trump won both Michigan and Wisconsin in 2016; now the University of Virginia’s Center for Politics classifies Michigan as “leans Democratic” and Wisconsin as a “toss up” in the presidential race.

But back to that one certainty in these uncertain times, the national vote on 3 November. Postponing the date is all but impossible, although we can expect Trump to try, or to wish aloud that he could try.

The 20th amendment to the constitution requires that the new Congress must be sworn in at noon on 3 January and the new president at noon on 20 January. Because these dates are immutable, all votes cast must be counted by the beginning of January. The precise date of the election is set by a law enacted in 1845 that requires general elections for federal offices to take place on “the Tuesday next after the first Monday in the month of November” (thus placing this year’s election on 3 November). To alter this law would require congressional approval — something speaker Nancy Pelosi and the House Democratic majority are extremely unlikely to support.

It’s true that these are unusual times. But it’s worth remembering that presidential elections were held in 1864, in accordance with the usual requirements, when the country was being torn apart by civil war, and that midterm elections were held in 1918 despite the widespread quarantining occasioned by the Spanish flu. Even as a self-described “wartime president,” Donald Trump is no Abraham Lincoln or Woodrow Wilson. It is imperative that the “invisible enemy” he and the rest of the nation is battling isn’t allowed to erode democratic rights during the upcoming election. •

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An ethical framework for dealing with the pandemic has international, national, community and personal dimensions. They play out in the familiar conflict between the needs and desires of individuals and of the group, and in the ability of the well-off, and well-off countries, to get more benefits than the disadvantaged. Decisions made by policymakers in times of crisis, and how the community responds hold up a mirror to our national ethos. Do we like what we see?

The World Health Organization sees three broad ethical issues. Who gets priority access to healthcare resources? What are the obligations of healthcare workers in light of the risks to their own health? And how do we balance necessary isolation and travel restrictions with protecting the rights of individuals? When a pandemic has dramatic economic impacts, that list should also include the question of who gets financial assistance. Affordable childcare options, internet access and room to work at home create a gulf between rich and poor.

Some of the ethical issues should be relatively straightforward. We need to ensure that some groups of people aren’t more likely to get tested than others simply because of their status or connections. We need to keep cracking down on people who flout instructions about social isolation and quarantine, especially when the capacity of certain groups to protect themselves and their families is already compromised by the essential work they do — not just as doctors, nurses and carers, but also in transport and delivery, cleaning and food services, and garbage collection. Hoarding, too, is anything but victimless during a pandemic.

The thornier ethical dilemmas arise when the number of seriously ill people requiring acute care rises to a level at which hospitals and healthcare facilities cannot cope. That has been the case for several weeks in Italy and is increasingly the case in New York City.

In Australia, the government and its advisers have provided reassuring advice about the ability of hospitals to increase their surge capacity, and the rationales for how we can flatten the curve to avoid the pressures on intensive care. But if the most worrying scenarios were to play out, Australian hospitals would not have the capacity to accommodate possible demand, and some types of care — specifically intensive care, ventilators and respirators — would need to be rationed. This would not be a discretionary decision but a necessity, and the level of rationing would increase if significant numbers of healthcare workers were infected.

Efforts to increase testing and social isolation will come to nothing if a similar level of investment is not put into protecting healthcare workers in hospitals and carers elsewhere in the community. Yet daily there are stories about the severe lack of appropriate personal protective equipment. This adds to the stress and anxiety of people who face the constant risk of infection and worry about their own families. At their extreme, the shortages could have the dreadful consequences highlighted by stories from Europe.

In deciding who gets access to rationed care, the overriding principle will be one of utilitarianism — maximising the benefits produced by the scarce resources — in the knowledge that available intensive care treatments are by no means guaranteed to produce the desired outcome.

In the United States, a conversation is already taking place in public about how to ensure, when lifesaving resources are scarce, that hospitals have consistent, transparent guidance for patient care. These “crisis standards of care” prioritise the survival of the group over the survival of the individual patient during disasters. But although the US Centers for Disease Control and Prevention has outlined general principles, it’s up to individual hospitals, health systems and states to decide policy. The result is a patchwork system, with states including New York and Minnesota having drawn up detailed guidelines for allocating resources but others having yet to confront these tough issues. If the pandemic and ventilator shortages get as bad as the worst predictions, some envisage palliative care being offered to people who might have survived with intensive care.

In Italy, the peak body for intensive care medicine has published a grim guide stating that “resources may have to be used first for those with a higher probability of survival and, secondly, [for those who have] the most years of life left, and offer the maximum number of benefits to the majority of people.” Others reach the same conclusions. “If we give scarce treatments to those who don’t stand to benefit (and have a high chance of dying anyway), then not only will they die, but those with higher likelihood of survival (but require ventilator support) will also die,” says Lydia Dugdale, director of the Center for Clinical Medical Ethics at Columbia University. “It’s not fair to distribute scarce resources in a way that minimises lives saved.”

In Australia, rationing has been mentioned in passing, but whatever expert discussions are taking place are out of public view and don’t involve public consultation. In drawing up guidelines and making these decisions, hospitals and doctors will consider the number of co-morbidities, the severity of respiratory failure and the probability of surviving prolonged intubation — factors that are generally linked to the patient’s age. But as medical experts both in Australia and overseas have noted, the primary criterion for rationing should be the chance of survival, whatever a patient’s age.

Being on life support in intensive care is challenging even for young, previously healthy people; patients often require fifteen to twenty days of ventilation and then a slow weaning. Intensive care is hugely resource-intensive, involving sophisticated equipment and large numbers of trained staff. Even the process of intubating a patient to go on a breathing machine presents a major infection risk to the doctor involved.

If a patient in these circumstances is not doing well, is it ethical to give the ventilator to another patient with a better chance of survival? Who would make that decision and what would guide them? This question might be hypothetical now but could become real in a very short time.

Little discussed is the extent to which the use of resources for treating patients with Covid-19 limits the treatment of patients with other medical conditions. Patients will continue to present with trauma, heart attacks, strokes and even complications arising from seasonal flu, and they too will need intensive care and ventilators.

The challenge of balancing the needs of Covid-19 patients and patients with other serious conditions applies also to medicines. Media hype about the possibility of treating coronavirus infections with chloroquine, pushed along by Donald Trump in the United States and Clive Palmer in Australia, has led to international shortages of a drug normally used by patients with serious conditions like lupus and rheumatoid arthritis. Here in Australia, people have purchased asthma medications in case they need them, reducing availability for people with chronic respiratory diseases.

The life-and-death decisions that rationing will force will be made more difficult if doctors are hamstrung by unnecessary procurement failures and shortages, if the system is rife with access disparities for some segments of the population, and if there is insufficient support and guidance for how such decisions should be made.

International organisations like the WHO and the OECD have called for a global effort and international cooperation to tackle the coronavirus pandemic. However, a pandemic inevitably means that countries look inwards to their own needs. President Trump’s policies have worsened the problem in the United States. Developed nations are all reeling from their own disease burden, which has been exacerbated in some countries, including Australia, by a lack of forward planning that leaves them facing shortages of testing reagents and kits as well as medical equipment. The situation will be much worse for developing countries.

In the weeks ahead, will the world be willing to share resources, as China has done for Italy? Or will there be isolationism, as seen in reports that the Trump administration was seeking to buy a German vaccine “only for the United States”? Will Australia look to see what help it can offer to Papua New Guinea and Pacific island nations? And who will ensure that the millions of people in refugee camps get the help they need as coronavirus spreads relentlessly?

The American College of Chest Physicians’ statement on care during pandemics and disasters makes the case that focusing on ethical principles is not a luxury but an obligation, necessary to engender trust and alleviate moral distress and burnout in providers. Trust is in short supply these days, as scarce as personal protective equipment for healthcare workers; clear principles can go some way towards restoring it.

That is why Australia needs explicit guidelines for how it behaves internationally, nationally and at the community level when needed resources are scarce. These must be ethically grounded, transparent, publicly developed, effectively communicated to all, and regularly reviewed. Because one day history will hold us accountable for what was done and why in this time of pandemic disease. •

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In the event, Trump’s prime-time address to the nation last week failed spectacularly to reassure Americans and unify the nation. Over the subsequent twenty-four hours, corrections had to be issued to errors in his statement, the European Union protested that it hadn’t been consulted about the new travel ban, and another early-morning collapse gutted the stock market. Then, not long after Trump claimed that testing had “been going very smooth [sic],” expert witness Anthony Fauci told a congressional hearing that it was “failing.”

This speech was followed by a hastily organised media event in the Rose Garden at which Trump announced a national emergency and touted his business links. The outcome was little better — the stock market rose but the public health messages were garbled. (“Trump is breaking every rule in the Centers for Disease Control and Prevention’s 450-page playbook for health crises,” said one public health expert.) The president also denied responsibility for coronavirus testing delays.

Trump and his advisers seemed to panic as they realised that the declining economy and lack of trust in his leadership on this issue could pose a threat to his re-election chances.

“Who would have thought?” the president had mused during a recent visit to the Centers for Disease Control and Prevention, apparently blind to the fact that he and his administration have ignored repeated high-level advice about the threat of a pandemic. In 2017, for instance, the global health security unit of the National Security Council, set up by President Obama after the Ebola crisis, advised that the threat of a pandemic was “the number one health security concern.” Soon enough, the unit was abolished, for reasons Trump can’t now explain.

A January 2019 report from the office of the Director of National Intelligence warned that the United States would “remain vulnerable to the next flu pandemic or large-scale outbreak of a contagious disease that could lead to massive rates of death and disability, severely affect the world economy, strain international resources, and increase calls on the United States for support.” Two months later the prestigious Washington-based Center for Strategic and International Studies predicted a coronavirus pandemic and worked through what the impact would be.

When it became obvious in January that the coronavirus had spread from China to the United States, the very defensible first response, and the one preferred by Trump, was to impose travel restrictions and institute incoming passenger screenings and quarantine. So far, so good — but the administration failed to follow through by enhancing readiness and creating a reliable surveillance strategy.

The first outbreak of coronavirus, in Seattle, was identified in sentinel surveillance work by independent scientists. But this type of monitoring, which has the potential to detect viral hotspots quickly, isn’t common, and restrictions on who could access the testing left public health officials blind to the spread that had already occurred.

Preparedness for the inevitable spread was hindered by Trump’s insistence on viewing coronavirus as an outside threat that was under control within the United States. Evidence also suggests that Trump didn’t take early advice about testing — which would inevitably have meant more cases were discovered — because he thought low infection numbers would boost his re-election chances. In any case, approved testing kits were not then (and are still not) available in anywhere near the numbers needed.

Several factors helped create the kit shortage. The Centers for Disease Control and Prevention chose to develop its own test for the virus and then, when this was found to be flawed, insisted on taking time to revamp the test rather than adopting the WHO test or allowing other US-based labs to develop their own. Only now is the availability starting to ramp up. But the daily number of tests remains limited and varies by testing facility, partly because of a shortage of key chemicals needed to run the tests. As Dr Fauci, the only straight talker on the White House coronavirus task force admitted, “The idea of anybody getting [testing] easily the way people in other countries are doing it — we’re not set up for that.”

This leaves the United States with two possible paths: to emulate South Korea, which appears to have reversed the outbreak, or to be like Italy, where the situation has deteriorated rapidly and healthcare rationing is proposed.

Realistically, the possibility of stopping the spread of the disease is now all but lost. As of 11 March, 7695 tests had been conducted in a population of 329 million people, whereas South Korea had conducted 189,236 tests in a population of 51.3 million. South Korea is now seeing a steady decline in the number of new cases reported each day.

The main goal now must be to slow the spread of infection, or “flatten the curve” using social distancing, quarantining, proper hygiene and other initiatives. These measures reduce the number of cases at any given time, easing the pressures on hospital services that have been assessed as inadequate for the task.

But it’s not only a question of the adequacy and appropriateness of the measures being introduced by the president and his coronavirus task force; it’s also about whether reliable advice will be adopted across a country in which so many people don’t have affordable access to healthcare and other social services.

“Stay home from work if you get sick,” says the Centers for Disease Control and Prevention. “See a doctor. Use a separate bathroom from the people you live with. Prepare for schools to close, and to work from home.” But many Americans don’t have health insurance, many more are underinsured or have substantial deductibles that have not yet been met. And many don’t get paid sick leave or care leave and don’t have the ability to work remotely.

A 2019 survey of private industry and state and local government workers found that while paid sick leave is nearly universal for high earners, the figure is just 31 per cent among people earning US$10.80 an hour or less. Some 33.6 million people have no cover, and a significant percentage of them work in the food industry and hospitality and have close interactions with many people.

After a meeting with the heads of some of the largest health insurance companies this week, Trump and vice-president Mike Pence announced that the companies promised to waive all co-payments for coronavirus testing and to extend coverage for treatment. But they didn’t mention that this agreement covers, at best, only around 240 million Americans; left out are the estimated thirty million people who lack health insurance, the forty-four million who have inadequate insurance, and the eleven million undocumented immigrants.

The picture quickly became more complicated. The day after the meeting, the health insurance industry group and individual companies appeared to indicate that some private health plans would still have cost-sharing requirements for the test.

Several Democrat-led states — including California, Missouri, New York and Washington — have ordered health insurers to cover the tests without cost-sharing requirements for their members. They have also made sure people covered by Medicaid are tested for free. Such initiatives are yet to be seen in Republican-controlled states.

Federal funds could be used to protect individuals from the costs of testing, quarantine and treatment in other ways, too, if only the administration chose to do so. Trump’s health and human services secretary could authorise states to expand Medicaid coverage to people with a Covid-19 diagnosis, as has been done in other emergencies. For people who are unable to pay their virus-related healthcare costs, the health and human services secretary, via the Centers for Disease Control and Prevention — which can authorise payments for testing, treatment, care and quarantine — can be a “payer of final resort.”

Meanwhile, the plunging US stock market has highlighted the economic ramifications of the pandemic and concerns about the administration’s inadequate response. By one measure, the entire rise in stock market value since Trump was elected has been erased in recent days. Trump has always claimed responsibility for jobs growth and a booming economy; now he must own the downturn.

A few days ago he promised a fiscal stimulus package of “dramatic” economic measures. But his key proposal — a temporary payroll tax cut through to the end of the year, estimated to cost nearly US$700 billion — was floated apparently without prior consultation and was very coolly received by Republican lawmakers and the president’s own economic aides. Since that pushback, he has evinced little willingness to pursue his other proposals, which include an infrastructure plan, paid sick leave for hourly employees, and help for the nation’s ocean-cruise industry and airlines.

Instead, the running has been left to congressional Democrats under House leader Nancy Pelosi and Senate minority leader Chuck Schumer, who have worked with Treasury secretary Steven Mnuchin on a multibillion-dollar economic relief package.

The package provides short-term benefits for people affected by coronavirus, including unemployment insurance, additional funding for food security for low-income children, and funds for family and sick leave. It would provide US$500 million for low-income women, mothers with young children and pregnant women who lose their jobs due to the virus, US$400 million for food banks, and a waiver of work requirements for the SNAP (food stamps) program. The bill also includes free coronavirus testing and a boost in Medicaid reimbursement to help states with testing and treatment.

Despite Mnuchin’s involvement, the White House equivocated for several days on the bill, with Trump apparently holding stubbornly to the idea of payroll tax relief. Pelosi’s leadership finally prevailed and the House passed the Families First Coronavirus Response Act, 363–40, late on Friday. The bill will go to the Senate this week, where support from Senate leader Mitch McConnell seems cool at best. He will be pushed into action because Republican senators campaigning for re-election don’t want to return home without having been seen to act — and because Trump now says, astonishingly, “Look forward to signing the final Bill, ASAP!”

Washington media report that Trump has grown increasingly irate as his attempts to contain the political fallout from coronavirus continue to fall short. He now recognises that the 2020 election campaign will be very different from what was expected just a few weeks ago.

In a response to Trump’s address to the nation, former vice-president Joe Biden highlighted how coronavirus has laid bare the shortcomings of the Trump administration. He spelt out a detailed roadmap for tackling the virus, emphasising the need for solidarity and championing science.

Eager as Trump might be to blame others for the current situation, he has directly and indirectly contributed in many ways. He has consistently sought to erode scientific expertise and cut funding for federal efforts to tackle epidemics internationally and within the United States. He and his enablers have sought to limit transparency, subvert data and minimise the importance of the issues. He continues to claim that the nation is prepared — that “we’re doing a great job with it. It will go away. Just stay calm. It will go away.”

It’s hard to believe a president who repeatedly contradicts his public health experts and blames everything on his critics. A current fact check lists twenty-eight ways Trump and his team have been dishonest about the coronavirus.

Innumerable examples show the importance to voters of how political leaders respond to national catastrophes. But, as a 2009 study showed, voters reward presidents for delivering relief spending after disaster strikes, rather than for ensuring preparedness — which means, theoretically at least, Trump still has time to respond to voters’ concerns and be rewarded. But given his inherent inability to fully grasp the issues, his unwillingness to take expert advice, and his narcissism, this is unlikely to happen.

Several commentators have described the coronavirus threat as “Trump’s Chernobyl,” arguing that prioritising ideology and myth-making during a crisis is, literally, deadly. Certainly, by putting his own beliefs above objective facts, Trump has tried to construct a reality that does not exist. Worse, scientific and public health experts have been intimidated and even muzzled and have too often failed to contradict him.

It is too soon to say if Trump’s posturing will result in unnecessary deaths and an economic recession. But the evidence to make that case could be on hand by November. If this happens, the incumbent could face a landslide defeat. •

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Presenting the report to parliament yesterday, prime minister Scott Morrison described it as a “stark and sobering” tale of “hope, frustration and disappointment.” He said something very similar last year, calling out the failure of the current approach and the hubris of those who had created it.

Yet the past year has not only seen problems go unresolved, it has also seen considerable progress in some areas — and enough of each to generate both scepticism and optimism.

The basis of the optimism is the December 2018 commitment by the Council of Australian Governments, or COAG, to partner with Indigenous people in refreshing the Closing the Gap framework and creating a forum for ongoing engagement. The formal partnership agreement between COAG and the National Coalition of Aboriginal and Torres Strait Islander Peak Organisations (Coalition of Peaks) came into effect in March last year.

Since then, a series of community consultations has considered how this new partnership might work. In January, the Coalition of Peaks released its Community Engagement Snapshots report, which found strong support for the three reform priorities it had proposed: developing formal partnerships between government and Aboriginal and Torres Strait Islander people to close the gap, boosting community-controlled services, and improving mainstream service delivery. A fourth reform priority — local data projects led by local communities and organisations — will be sent to COAG.

The Indigenous leaders engaged in this process are feeling optimistic that a full partnership approach can show the way forward. But their view is offset by the prime minister’s refusal to commit to an Indigenous recognition referendum until “there is consensus,” a position at odds with his commitment to the beginning of a “new era.” It will be hard for Indigenous people to trust the government to deliver a new approach when it consistently sidelines the work of the Referendum Council and the central importance of the Uluru Statement from the Heart.

How can Closing the Gap be improved? Fully recognising that their validity is limited by my non-Indigenous status and a lack of formal consultation, these are a few thoughts.

In policy terms, the focus must be on the key underlying causes of disadvantage.

First, racism. The lack of progress on this key determinant of the physical and mental health of Indigenous Australians may explain part of the unremitting gap in health and socioeconomic outcomes. Tackling and reducing racism, including ensuring that healthcare is culturally safe and respectful, should be an integral part of policies and interventions aimed at improving Indigenous health, especially that of children.

Second, very high rates of Indigenous incarceration are, in the words of a recent PwC report, “unfair, unsafe and unaffordable.” Inappropriate imprisonment and the failure to ensure needed post-release services lead to loss of culture, identity and connection to the land, aggravating the cycle of disadvantage and poverty. A new justice target is part of the refresh of the Closing the Gap framework, but if it is to be effective then the courts, police, corrections services and social services will all need to adopt its principles.

Third, safe and secure housing is key to the health, wellbeing, safety and dignity of Indigenous Australians. A new report from the Australian Institute of Health and Welfare found that in 2016, 29 per cent of Indigenous Australians were living in a dwelling with major structural problems, with 15 per cent of households lacking at least one basic facility (a functioning kitchen, bathroom, laundry or toilet). The proportions are higher in remote areas.

In focusing on these three areas, the government must commit to a real and enduring partnership with Aboriginal and Torres Strait Islander communities and organisations. Despite the rhetoric, the Morrison government’s commitment to consultation has generally been deficient.

Not long after the last election, the prime minister announced a new National Indigenous Australians Agency within his own department. Indigenous affairs minister Ken Wyatt described it as a “new era of co-design and partnership,” but the decision was made without consulting Indigenous groups. Meanwhile, the National Congress of Australia’s First Peoples lost its funding and the government persisted with its expansion of the cashless welfare card in Indigenous communities.

The decision to double down on the cashless card came despite growing evidence that it is adversely affecting many lives, has failed to get users into jobs, and is opposed in many communities. Many people subject to the card feel they have been punished by a loss of control over their own finances. This blanket imposition of a political ideology backed by very little evidence is completely counter to a partnership approach.

Another consultation-free act was the axing of funding for the secretariat that oversees the thirteen-member National Family Violence Prevention and Legal Services Forum. This annual $244,000, a tiny outlay for government, was justified by reference to an independent evaluation that, on the contrary, recommended increased resourcing.

And on the day Scott Morrison was promising a new approach to Closing the Gap, it was rumoured that the government had taken a unilateral decision to end funding of Indigenous housing — a dismayingly plausible possibility that highlights how little attention is paid to the social determinants of health.

These various government decisions also highlight the lack of coordination across departments and agencies. When prime minister Tony Abbott moved responsibility for the majority of Indigenous programs to the prime minister’s department in 2014, under the rubric of the Indigenous Advancement Strategy, the shocking news that he also cut more than $500 million from the programs hid the fact that the move might facilitate a whole-of-government approach to tackling Indigenous problems.

That has never come to pass — and it still doesn’t happen even within portfolios. Hearing loss, trachoma and rheumatic heart disease, for instance, all involve a similar healthcare approach (cleanliness) for prevention, yet these conditions continue to be tackled under a series of separate programs. Their high incidence in Indigenous communities won’t be reduced without a coordinated effort to improve housing.

“Every minister in my government is a minister for Indigenous Australians,” the prime minister declared yesterday. Given the known occasions on which the real Indigenous affairs minister, Ken Wyatt, has been sidelined (the referendum, for instance), Indigenous communities will need some convincing on this point.

They will also be looking for evidence that programs are introduced — and evaluated — where they are needed. Here, the signs haven’t been good. A June 2019 report from the Australian National Audit Office identified delays in evaluating the five-year-old Indigenous Advancement Strategy. The prime minister’s department had not met guidelines, the report said, and nor had the department kept records of key decisions or set targets for all programs and projects.

In October 2019, the new National Indigenous Australians Agency released an equally, if not more, damning report on the past ten years of Closing the Gap. (Oddly, the date on the report is March 2018, more than a year before the agency was established.) Among its findings were three fundamental criticisms. Cultural determinants are not captured in the policy framework, which makes collaborating with Indigenous Australians difficult. The evidence base to support many programs is lacking or weak, and programs are rarely evaluated. And the effort to close the gap has been hampered by inconsistent political leadership, constantly changing policies, insufficient resources, and workforce and funding cuts.

Finally, the funding maze needs to be streamlined and made more transparent. Organisations and communities deal with a level of complexity and “red tape” that would never be tolerated by the general business community, with the evidence suggesting that some Aboriginal health services are juggling forty or more funding sources with separate application and reporting requirements. Too often communities are unaware of services for which they are eligible.

A 2016 study identified 1082 separate Indigenous-specific programs. Less than one in ten had been evaluated, and most have produced little evidence of effectiveness. Multiple service providers often compete in the same communities (assuming there are providers), and duplication and waste are rife.

The impact of funding conditions on the governance and performance of Indigenous organisations is under-researched. Evidence suggests that the public financing of Indigenous organisations is successful when the focus is on the organisation rather than the program. Funded organisations should always be required to be accountable to their constituents; performance indicators should be negotiated rather than imposed; achievements should be rewarded.

Encouragingly, the health department will introduce a new funding model for the Indigenous Australians’ Health Program’s primary healthcare program in July this year. Three-year funding agreements, annually indexed, will become the norm, and the administrative burden will be reduced.

Recent efforts by the Productivity Commission have gone some way to tackling the lack of transparency. Preparing an analysis for Oxfam in 2017, I found it very difficult to track spending on Indigenous programs on the basis of publicly available data. But I did find every indication that the government is increasingly looking to mainstream services and programs to meet Indigenous people’s needs, especially in non-remote areas. While 55 per cent of the programs funded under the Indigenous Advancement Strategy were run by Aboriginal and Torres Strait Islander organisations, 81 per cent of direct Indigenous expenditure went towards mainstream services.

Pat Turner, lead convenor of the Coalition of Peaks, has described the gap between Indigenous and non-Indigenous Australians as “a gaping wound on the soul of our nation.” This wound won’t be healed without the best efforts of all Australians. The prime minister is right to say that the Closing the Gap strategy has reinforced “the language of failing and falling short” and neglected to “celebrate the strengths, achievements and aspirations of Indigenous people.”

Refreshing the program must involve building on the expertise and wisdom of Indigenous individuals and communities and the abundant success stories that have largely been unrecognised and uncelebrated. The Oxfam report In Good Hands: The People and Communities Behind Aboriginal-led Solutions is just one of the many excellent places to start. •

The post Gap year appeared first on Inside Story.

In his State of the Union address — relatively speaking, the high-road version of his case for re-election — he touted the economy, job creation, increased defence spending and warnings on immigration and Democrats’ socialist health policies, all with little regard for accuracy. Laced with reality TV–inspired moments of drama, the speech was designed to appeal to a range of voter segments (African Americans, those against abortion, military families, and fans of ultra-right-wing talkback radio) and highlight his complete control of the issues his supporters care about. Despite the impeachment process having split the country, sharpened the partisan fights in Congress and tested civic and constitutional norms, Trump made no gestures towards unity.

The Republican politicians listening in the chamber stood and chanted “four more years” and the majority-Republican TV audience watching loved it. Democrats’ reactions fell largely into two camps — the one exemplified by Nancy Pelosi (“He shredded the truth, so I shredded his speech”) and the one that fears the consequences of Trump’s ability to tailor his well-funded re-election bid around a strong economy and visceral appeals to his ardent supporters. The fears of this latter group were only reinforced by the Democratic caucuses debacle in Iowa and the fact that a strong presidential candidate is yet to emerge from the Democrat field.

Just two days later, after the Senate had voted to dismiss the impeachment charges, Trump launched his fightback in the East Room of the White House, surrounded by his enablers and supporters. Billed as a “celebration,” it was a vicious and vengeful performance. Driven by his ever-present sense of victimhood, his desire for revenge, and his obsession with re-election, Trump has been emboldened by his Senate acquittal.

He cursed, mocked and played the victim in what was described as a “festival of grievance.” House leader Nancy Pelosi was a “horrible person,” Adam Schiff (one of the House leaders on impeachment) a “vicious, horrible person,” the FBI leadership the “crookedest, most dishonest, dirtiest” people he has ever seen.

His White House audience laughed at his jokes and applauded his malice, highlighting and abetting the “new normal” in American political and ethical life. With all the adults having left the White House, as commentators have noted, no one who remains appears to be willing or able to curb Trump’s worst instincts.

The situation in Congress is little better. While a number of sitting Republicans (senators Lamar Alexander, Marco Rubio, Susan Collins, Rob Portman and Lisa Murkowski) made clear they believed the president was not innocent of the impeachment charges, only Mitt Romney was brave enough to vote on his convictions.

Their reward is for Trump to tell the world that their mild concerns about his behaviour constituted disloyalty. Those who ventured that Trump would never misuse his power again because he had learned his lesson have already been disabused of that idea. Romney’s act of courage changed nothing.

Senate majority leader Mitch McConnell, senator Lindsey Graham, attorney-general William Barr and secretary of state Mike Pompeo stand out as Trump’s key enablers and defenders. Vice-president Mike Pence stands silently by, unwilling or unable to be an independent voice.

When Romney outlined why he voted in accordance with the oath he took to deliver impartial justice, he was excoriated by Trump, his colleagues and even his niece, who chairs the Republican National Committee. When Trump had National Security Committee staffer Lieutenant Colonel Alexander Vindman (who had testified to the House about Trump’s Ukraine call) marched out of the White House by security guards, Senator Graham justified this on the basis of an allegation that Vindman was part of a plot against Trump among FBI and CIA agents and justice department lawyers.

Trump’s “Friday night massacre” continued with his firing of Gordon Sondland, his ambassador to the European Union, who had testified that there was a quid pro quo linking American military aid to Ukraine’s investigation of Hunter Biden’s activities. Pompeo acquiesced to Sondland’s firing just as he had in the campaign waged by Trump’s lawyer Rudy Giuliani to have ambassador Marie Yovanovitch recalled.

Attorney-general Barr has gone to incredible lengths to ensure that the core truths about Trump’s 2016 election victory disappear. And now, just days after a request from Republican senators, the treasury department, which for years has fought all congressional subpoenas in an effort to keep Trump’s tax returns secret, has turned over financial records from Hunter Biden and associates. Meanwhile, the justice department has what is described as “evidence of questionable origin” about Hunter Biden obtained by Giuliani from Ukraine. Giuliani calls these documents a “smoking gun.”

We can expect much more of this. Trump is at his most consistent when it comes to getting even. Reports suggest that Trump was compiling a Nixonian “enemies list” — surely including John Bolton, Nancy Pelosi and Adam Schiff — even before last week’s final impeachment votes.

Donald Trump will be the first president carrying the stain of impeachment to run for re-election. Although that won’t bother his committed supporters, this is not a group that shows any signs of growing. Polling suggests that his recent efforts to reach out to African Americans, for example, have failed. (African Americans are deeply pessimistic about the state of the nation under Trump, but if he could win just a few extra percentage points of their support the election would be harder for the Democrats.)

Many worry that the Democrats damaged their chances in the House and Senate by proceeding with impeachment, and not a few party members now believe that denying Trump a second term could be far more difficult than they had calculated. But the broad national polling numbers suggest they might be unduly concerned. Trump’s disapproval rating is the highest of any postwar president at this point in the electoral cycle. Senators who voted to convict Trump represent eighteen million more Americans and received twelve million more votes than those who voted to acquit.

Can Democrats capitalise on this sentiment and turn out the votes to win? Already Democratic super PACs are targeting vulnerable Republican senators in Arizona (Martha McSally), Maine (Susan Collins), North Carolina (Thom Tillis) and Colorado (Cory Gardner). “We know you’re angry…” the mailout to voters says. Conservative New York Times columnist David Brooks proposes that the Democrats should argue that the time is right to take advantage of prosperity and begin the moral and social revival that so many Americans long for.

Much rides on who comes through as the Democrats’ presidential and vice-presidential candidates, not least because turnout and therefore House and Senate races will ride on their coat tails. In last week’s New Hampshire debate (ahead of that state’s primary this Tuesday), the candidates all talked a fine line about needing to work together to get Trump voted out of office, but these primary fights are as much about beating the others as about beating Trump. Standing above the fray, meanwhile, is former New York governor Mike Bloomberg and his spray of effective and expensive advertisements, frustrating his competition but untested by voters.

The real support the various candidates can gather won’t be exposed until Super Tuesday on 3 March, when fourteen states with more diverse populations than Iowa and New Hampshire (Alabama, Arkansas, California, Colorado, Maine, Massachusetts, Minnesota, North Carolina, Oklahoma, Tennessee, Texas, Utah, Vermont and Virginia) hold their presidential primaries. It remains to be seen whether some candidates who might do well in these states can survive the public scrutiny and financial pressures of the next few weeks.

National polls obscure the local issues. Despite Trump’s huge campaign chest, House Republicans are in the midst of a full-blown fundraising crisis. Pollster Larry Sabato (one of the targets of Trump’s weekend tweeting) sees the strength of Trump’s coat tails as very important for these congressional districts, especially as there has been an increase in straight-ticket voting and a waning of the power of incumbency. It’ll be a big job: to have a majority in the House, Republicans will need to win twenty or so seats that are currently held by Democrats.

For the moment, though, national and international attention is on New Hampshire. The Democrat presidential candidates are barnstorming the state, criticising their rivals’ policies and qualifications for the job. It looks like battles royal between Sanders and Buttigieg for first and second place and Warren and Biden for third and fourth, with Amy Klobuchar still potentially in the race. That’s interesting because Sanders and Buttigieg and Warren and Biden are not really competing for the same voters — those competitions are between Sanders and Warren (on the left) and Buttigieg, Biden and Klobuchar (more centrist).

New Hampshire is regarded as a testing ground. Only a few delegates are up for grabs, but the media coverage is massive. Voter turnout is usually high after weeks of candidate scrutiny, many voters are independent, and the group as a whole is recognised as having a contrarian streak. Two other factors are important in weighing the results: the population of New Hampshire is 94 per cent white, and no Democrat who has won the New Hampshire primary has won the presidency since Jimmy Carter in 1976.

That’s why the Nevada caucuses on 22 February and the South Carolina primaries on 29 February — both of them states in which Hispanic and African-American votes will be important — will provide much more information about who will emerge as the potential winner/s on Super Tuesday.

Of course, Donald Trump is busy making sure it’s all about Trump. Ahead of today’s Democratic primary, which he has written off as a “really boring deal,” he held a rally last night in Manchester, New Hampshire. •

The post Whatever it takes appeared first on Inside Story.

As the process has progressed over the past week, the media has captured the divide in American politics in 2020 as a series of stark contrasts.

While House speaker Nancy Pelosi was formally signing the articles of impeachment to send to the Senate, and Supreme Court chief justice John Roberts and senators were being sworn in for his trial, Trump was madly tweeting his capitalised rage: “I JUST GOT IMPEACHED FOR MAKING A PERFECT PHONE CALL!” and “PROMISES MADE, PROMISES KEPT.”

While Democrat presidential candidates were debating serious issues of war and foreign policy in Iowa, Trump (who will countenance no competition in the Republican primaries) was at a rally in Milwaukee ranting about the failures of modern dishwashers and toilets.

While the Republican-controlled Senate was sitting on a pile of bills passed by the Democrats in the House, Trump was touting a face-saving trade deal with China and diverting another US$7.2 billion from the military budget to build his wall on the Mexican border.

Also consuming the media was the release of a huge number of incriminating documents from Ukrainian-American businessman Lev Parnas, and the nasty, gossipy revelations of yet another book about machinations inside the Trump White House. As the other member of my household, political commentator Bruce Wolpe, recently put it, this is the “split-screen presidency.” Expect to see much more of it in the weeks ahead.

Despite his bravado, Trump is described by insiders as unnerved and obsessed by the coming trial. To offset the almost continuous newsfeeds from the Senate, we can expect a series of carefully staged Oval Office events highlighting how an undistracted president is working for Americans even as the Democrats are working against him. At rallies with the party faithful, meanwhile, he will abandon scripted remarks to rail against his persecution, denigrate those he deems responsible, and highlight his efforts to make America great again.

Impeachment appears to be helping Trump’s fundraising: his re-election campaign recently announced that it raised US$46 million in the final quarter of 2019, far more than any of the quarterly totals announced so far by Democratic candidates. Individual donors can now contribute up to US$580,600 to his campaign.

Increasingly, the evidence suggests the president is looking to create a made-for-TV drama out of the trial. His newly announced legal defence team is a prime exhibit: in addition to White House attorney Pat Cipollone and Trump’s personal attorney Jay Sekulow, the team now includes Alan Dershowitz and Ken Starr, the duo who helped Jeffrey Epstein evade prison time with their infamous plea deal with Palm Beach prosecutors back in 2007.

Dershowitz, a regular on cable news shows, has represented O.J. Simpson, Patty Hearst and other controversial celebrities. Starr, who led the impeachment prosecution against President Bill Clinton, is a more surprising inclusion; Trump has called him a “lunatic,” “wacko” and “off his rocker.” Interestingly, the team doesn’t include Trump stalwart Rudy Giuliani. It’s possible he’s too brazen even for the president, or perhaps he is afraid Giuliani will be called as a witness.

Dershowitz and Starr may have been brought on board because Trump, always attuned to these issues, is worried that Cipollone is not TV savvy. But this attempt at scripting could easily be derailed by Senate leader Mitch McConnell or, less likely, by the chief justice, both of whom might also see themselves as stage managers. McConnell has already placed restrictions on media coverage; as a counter, expect a long line-up of Trump allies giving their version of the trial and its meaning on Fox News and other cable television programs.

The politics of this impeachment trial will extend to the Democrats’ presidential campaigns. Three of the top contenders — senators Elizabeth Warren, Bernie Sanders and Amy Klobuchar — must return to Washington for as long as the trial lasts and need to be seen to act with decorum and perspicacity in their role as jurors. With senators able to probe prosecutors, Trump’s legal team and any witnesses only by submitting written questions to the chief justice, the format of the trial won’t give any of them the chance to shine. Joe Biden and Pete Buttigieg will no doubt relish the three senators’ absence from the hustings as the first important primaries, in Iowa and New Hampshire, loom.

The RealClearPolitics average of Iowa polls puts Biden (21 per cent), Sanders (20 per cent), Buttigieg (17 per cent) and Warren (16 per cent) within five points of each other — essentially a dead heat. In New Hampshire, Sanders (23 per cent) and Biden (21 per cent) are ahead of Warren (16 per cent) and Buttigieg (15 per cent). The most recent average of the national polls has Biden (27 per cent) leading Sanders (19 per cent) and Warren (16 per cent), with Buttigieg (7 per cent) and Klobuchar (3 per cent) trailing. Early wins are important, especially in a crowded field like this, because they ensure media prominence and increase fundraising capacity.

It isn’t yet clear how the trial in the Senate will proceed, or for how long. Whether witnesses will be called, and whether the White House would allow someone like former national security advisor John Bolton to appear, is yet to be resolved. The votes may be there, but if negotiations turn on a quid pro quo — with Republicans allowing witnesses only if they can call Joe Biden or his son Hunter — the Democrats may forgo the option. Complicating the situation is the fact that Trump’s views on this and overall strategy change by the day.

White House and Republican actions to dismiss, diminish or delegitimise the trial will mean that Trump can never validly claim exoneration. Indeed, he could face these charges again after the election. But it does seem unlikely that the votes will be there to find Trump guilty of the charges outlined in the House impeachment document.

Along with the new material from the Ukraine investigation made public last week, the Government Accountability Office’s finding that Trump broke the law in withholding military aid to Ukraine adds weight to the Democrats’ charges. But this new information is dismissed by Republicans and slides off Trump like water off a duck’s back. Regardless of the findings, he will strive to make the outcome both a victory and proof of persecution with which to galvanise his followers.

Although Trump is expected to run in November, the electoral implications of the trial and its outcome are unclear. Never before has an impeached president — a recipient of “the scarlet letter of impeachment marked with indelible ink on his page in the history books,” as the New York Times describes it — stood for re-election.

In November, FiveThirtyEight looked in detail at how impeachment could shape the election. No substantial new data has emerged since then to support or dismiss any of its scenarios.

Undoubtedly impeachment and Trump’s presidential behaviour will bring out voters on both sides. Anger against Trump and concern at the precedents being created by him and his enablers (people like McConnell, attorney-general William Barr and secretary of state Mike Pompeo) are likely to unite Democrats in their support of whoever wins in the primary, regardless of his or her popularity.

Trump will be damaged in the eyes of many of these voters, but his standing will be enhanced for others. Overall, current polling shows that 49.9 per cent of voters support impeaching Trump, with 45.9 per cent against. Not surprisingly, this breaks down primarily along party lines: 86.3 per cent of Democrats support impeachment and 84 per cent support Trump’s removal from office, but just 12.6 per cent of Republicans support impeachment and 8 per cent support his removal. Of key independent voters, 47.7 per cent support impeachment and 43 per cent support Trump’s removal.

While only the brave would risk predictions based on the current polling, indications suggest that Trump began 2020 as the underdog. The RealClearPolitics average of recent polls puts him several points behind Biden and Sanders in a match-up, equal with Warren and Buttigieg and just pipped by mayor Michael Bloomberg. (Bloomberg’s unusual approach to the primaries and multimillion-dollar advertising spend appears to be working.) The betting markets currently have odds on Biden winning the Democrat nomination and Trump losing the popular vote (again) but winning the presidency.

Impeachment will do nothing to boost the standing of politicians and could further erode record-low public trust in the political process. Trump and the Republicans will work hard to blame the Democrats for inaction on the issues that voters care about — the cost of prescription drugs, for instance — and the Democrats may take a hit in the polls if the strategy is successful. Voters care most about candidates’ positions on healthcare, national security and gun control.

And, of course, it is impossible to predict what unanticipated international and domestic events will influence voters’ decisions in November. Less than a fortnight ago, the United States seemed to be teetering on the brink of war with Iran, and the conflict between the two countries is still far from resolved. Then there’s Afghanistan, North Korea and Syria — and what is Putin planning as he sets himself up to be president for life? The ongoing trade wars could affect voters’ purchasing capacity, and Americans daily fear another major gun massacre. Frighteningly, it is well within Trump’s capacity to engineer a crisis to distract from his own problems.

There is wide agreement that the decisions about whether the president deserves to be removed from office should be made not by impeachment but at the ballot box. But the current process serves a critical function that anchors the United States as a democracy: it asserts the supremacy of law and convention in a political system imperilled by a leader who believes himself to be exempt from both. •

The post Known unknowns appeared first on Inside Story.

Congressional Republicans seem set to adopt a similar response to the impeachment proceedings. Reports suggest they will acknowledge that Trump used US military aid to force Ukraine to investigate Joe Biden and his family, but will insist that it wasn’t illegal and certainly didn’t rise to the level of an impeachable offence.

Trump’s day-to-day response to impeachment follows a familiar script. He accuses his opponents of whatever he is accused of — treason or illegal behaviour, for example — and then throws dirt and obscenities at them. In recent weeks he has repeatedly attacked the whistleblower who made the original complaint (and demanded to know his identity, in contravention of a number of legal protections), slammed anyone who has testified to congressional committees, and lambasted the few Republicans (or “human scum”) who have objected to his conduct.

His most savage remarks have been reserved for House leader Nancy Pelosi and House Intelligence Committee chair Adam Schiff. He has accused Schiff of lies, “massive fraud” and treason, and suggested that Pelosi is guilty of “High Crimes and Misdemeanors, and even Treason.” Both of them, he insists, should be impeached. He doesn’t care and may not even know that such a course of action would have no legal basis.

Previous presidents, by contrast — even those facing imminent impeachment, like Bill Clinton and Richard Nixon — understood that, in the end, respect for the rule of law means complying with the law. But ignorance of the law is embedded in Trump’s approach to the presidency. His willingness to both use and abuse the law, a practice learned from his father, has been an essential part of his business practice.

Fred Trump, who made much of his real estate fortune by exploiting federal housing programs and tax loopholes, is described by one of his son’s biographers as a businessman who “never missed a chance to bend the rules.” In 1973, when the federal Department of Justice accused Trump Management of clear-cut Fair Housing Act violations at thirty-nine Trump-owned apartment buildings, young Donald retained lawyer Roy Cohn, a fixer notorious for being chief counsel during senator Joseph McCarthy’s hearings. Together they launched a protracted battle against the charges of racial discrimination, including a $100 million countersuit accusing the Department of Justice of defamation. The Trumps also filed a contempt-of-court charge against one of the prosecutors, accusing her of turning the investigations into a “Gestapo-like interrogation.”

After two years of legal wrangling, the countersuit was dismissed and the Trumps signed a consent decree that required costly restitution but no admission of guilt. Donald Trump claimed victory and Trump Management continued the violations. A few years later they were back in court accused of breaching the consent decree.

The 1973 lawsuit had long-lasting consequences: it not only brought Trump and Cohn together in a relationship during which Trump learned from an expert how to abuse both the legal system and those who opposed him, it also gave the twenty-seven-year-old his first, addictive taste of public attention. Cohn died in 1986 but his legacy lingers in the White House today. Once, in a fit of rage at then attorney-general Jeff Sessions over his recusal from overseeing the Mueller probe, Trump reportedly demanded, “Where’s my Roy Cohn?”

When Trump was running as the Republican presidential nominee in 2016, USA Today undertook a massive investigation that found he and his businesses had been involved in at least 3500 lawsuits. These included disputes over multimillion-dollar real estate deals, defamation suits and even petty cases against individuals over casino debts.

Although the Trump Organisation described this as “the cost of doing business,” the USA Today analysis showed that Trump was involved in more legal cases than the five top US real estate business executives combined. That unprecedented number grew by seventy in the year after he announced his candidacy for the presidency in June 2015.

The pattern continued once Trump decided to contest the presidency. His campaign and his associates undoubtedly violated the law in their drive for electoral success, both by cooperating with Russian interference — as the Mueller inquiry found — and by paying hush money to two women in a clear violation of campaign finance laws. (The latter might explain why the president has failed to nominate new members to the Federal Election Commission, which now lacks a quorum and so cannot meet, investigate complaints, issue opinions or fine violators.)

Trump was accompanied into the White House by an ever-changing phalanx of personal lawyers, including Michael Cohen (now in jail), Jay Sekulow and Rudy Giuliani. But he has also sought to co-opt administration lawyers, from whom he also expects loyalty rather than fidelity to the law. Increasingly, those who work for him either reflect his own ethos and conduct or — as in the case of FBI director James Comey, attorney-general Jeff Sessions, secretary of state Rex Tillerson, White House counsel Don McGahn and deputy attorney-general Rod Rosenstein — are sacked or resign.

In recent weeks it has become clear that the president’s personal lawyer, Rudy Giuliani, has been running a campaign of shadow diplomacy in support of Trump’s own interests. His attorney-general William Barr, meanwhile, together with Justice Department attorneys and White House counsels, has been representing the president rather than the government. Challenged, Trump says that he has an “absolute right to do what I want to do with the Justice Department.” His model of an attorney-general is someone who “protects the president,” as he claims Eric Holder did for president Barack Obama.

During frequent overseas trips Barr has been pushing Trump’s Ukraine agenda. He broke the law by keeping the original Ukraine whistleblower’s complaint from Congress. Under his auspices the Justice Department has even begun a criminal investigation into the Mueller inquiry. Small wonder that New York University law professor Stephen Gillers recently referred to Barr as “Trump’s new Roy Cohn.”

Former acting attorney-general Matt Whitaker disclosed his Trumpian views when he said that “abuse of power is not a crime.” Trump’s personal attorney William Consovoy recently told a federal judge that, as president, Trump could not be prosecuted even if he shot a person on Fifth Avenue. One thing the president can legally do is order his subordinates to violate the law and promise them pardons for doing so, and Trump has done exactly that.

The impeachment proceedings against Donald Trump are not about violations of tax law, campaign financing regulations or the emoluments clause of the constitution. They are about whether the president pressured Ukrainian president Volodymyr Zelenskyy to investigate the business ties of former vice-president Joe Biden’s son, and whether he withheld federal military aid to make that happen.

At the heart of this and previous impeachment proceedings is one common theme: that a president has abused the power of his office and so is unfit to serve. Presidents can abuse power in many ways, legal and illegal, and in these cases impeachment is the sole mechanism of accountability. Trump calls the House of Representatives’ impeachment enquiry a “witch hunt” but the constitution and whistleblower laws explicitly provide for Congress, as a co-equal branch of government, to scrutinise wrongdoing within the executive branch.

The Wall Street Journal recently looked at the efforts of Trump’s lawyers to give him sweeping immunity — not just from prosecution but also from investigation — even if he were indeed to commit murder on Fifth Avenue. They have pushed for him to be considered beyond the reach of any other federal, state or local institution and to be immune to civil lawsuits, judicial orders, criminal investigations and congressional probes.

In a memorandum dated 8 October 2019, White House counsel Pat Cipollone lays out Trump’s rationale for keeping the entire executive branch from cooperating with the impeachment inquiry. The inquiry “lacks any legitimate foundation” under the constitution, he says, and is constitutionally improper because it seeks to overturn the results of the election.

In the Atlantic, legal expert Kim Wehle says that if the Justice Department’s legal opinion on the whistleblower complaint or Cipollone’s memo on impeachment were part of a filing in a federal court, they would be thrown out on the grounds they violate the Federal Rules of Civil Procedure. These are the rules designed to prevent lawyers from making arguments that are frivolous or have no legal support.

While this isn’t the first administration to invoke executive privilege to deflect scrutiny, it has pushed that law to an extreme. A letter about the Mueller inquiry sent by Cipollone to the chair of the House Judiciary Committee in May effectively rejected congressional oversight as illegitimate. “Congressional investigations are intended to obtain information to aid in evaluating potential legislation,” it said, “not to harass political opponents or to pursue an unauthorised ‘do-over’ of exhaustive law enforcement investigations conducted by the Department of Justice.”

No surprises here: Trump declared his intent to resist all congressional inquiries long before the impeachment process started and has an established pattern of resistance. By one count, he is currently defying as many as twenty different efforts to examine his conduct.

Members of the executive branch requested or subpoenaed to testify to Congress are left with an excruciating dilemma. Some, like lieutenant colonel Alexander Vindman and acting Ukraine ambassador William Taylor, have chosen to defy Trump and testify; others, like Russell Vought, who heads the Office of Management and Budget, intend to defy the subpoenas. Former national security aide Charles Kupperman has asked the courts to decide whether he must obey Congress or a White House order. Kupperman was John Bolton’s deputy, so the results of this lawsuit could determine whether Bolton himself testifies.

Trump is reportedly angry that so many of “his employees,” as he refers to them, are going to Capitol Hill and testifying. He has apparently asked for copies of witness statements so he can decide how to criticise those he perceives as disloyal, and has complained that his lawyers are not doing enough to stop people from talking. He has even encouraged Republican members of Congress to question the credibility of people working in his own administration.

As a recent article in the Guardian points out, each new controversial memo, opinion or tweet maligning individuals who speak out feeds a running debate about “where assertive lawyering ends and malpractice begins.” The pattern of resistance and use of executive privilege is leading inexorably to the conclusion that it is undertaken in bad faith. As such, it is another abuse of presidential power. •

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Now Morrison faces the challenge of explaining to Australian voters his government’s willingness to delve into the role played by Alexander Downer, former Australian high commissioner in London, in creating what Trump and his allies see as a “deep state” conspiracy to bring down Trump’s presidency. The fact that Downer is a most unlikely double agent of the left has eluded the hunkered-down occupants of a White House roiling under the threat of impeachment hearings.

Talk of impeachment dates back to before Trump took office, and was initially based on his failure to deal with financial conflicts. But even as the list of potentially impeachable offences grew, so did his apparent ability to evade censure. Indeed, after the Mueller report failed to deliver grounds for an indictment, Trump and his officials showed a new level of contempt for the constitution and Congress, or at least for the Democrat-controlled House of Representatives.

Yet, like a dog with a bone, Trump remains obsessed with the validity of his presidency. He has embraced conspiracy theories that see people in every corner of government out to undermine him and his administration. Their latest iteration holds that Ukraine, not Russia, was the source of Hillary Clinton’s leaked emails, that former vice-president Joe Biden meddled in the Ukrainian justice system, and that Biden’s son benefited financially from illegal business dealings in Ukraine. Trump conflated all this with the opportunity to smear Biden and his family in order to deal with what he obviously sees as an election threat, and then compounded his overreach by tying American aid to Ukraine’s cooperation.

The emergence of a whistleblower’s report on Trump’s phone conversation with Ukrainian president Volodymyr Zelenskyy (and the fact that account was backed up by the modified transcript released by the White House) broke open the secret efforts of Trump and his lawyer Rudy Giuliani, along with Barr and secretary of state Mike Pompeo, to push Ukraine (and Australia, Britain and Italy) to discredit the findings of US intelligence agencies that led to the Mueller report.

The Ukraine phone call so clearly involved soliciting a foreign government’s help to undermine a political rival — in other words, misusing the office of the president for personal gain — that House speaker Nancy Pelosi was left with little choice but to announce a formal impeachment investigation. The imperative was highlighted when it emerged that the justice department’s Office of Legal Counsel had downgraded the inspector-general’s determination that the whistleblower’s complaint was of “urgent concern” in order to sidestep the requirement that it be shared with Congress.

Then, just days later, came the story of Trump’s phone call to Morrison. The floodgates of concern are suddenly open and new information is emerging almost hourly. Underlining the seriousness of the situation, more than 300 US national security and foreign policy officials have signed a statement supporting the impeachment inquiry on the basis that the president “appears to have leveraged the authority and the resources of the highest office in the land to invite additional foreign interference into our democratic processes.”

For Pelosi and the Democrats, impeachment is fraught with peril — but so too is not acting. It is not just a matter of whether the process will succeed, it is also about the attitude of voters already annoyed that Congress is failing to deal with the issues that matter to them, and about how much the inquiry will rent the fabric of an already deeply divided nation. An impeachment inquiry could jeopardise the Democrats’ majority in 2020 and possibly give Trump’s re-election bid a boost.

Pelosi had said that she would act when the justification was clear, and she initially indicated that she thought it should be a bipartisan initiative. Her keen sense of the mood of the caucus meant she recognised that House Democrats, already frustrated by the administration’s lack of comity, felt a barrier had been breached with Trump’s Ukraine phone call. There was no longer room for caution. Almost all Democrats now support a process to impeachment and voter polls show a steady rise in public support too.

Time is a key factor here. The Democrats must act while the recent dramatic developments are fresh in the public’s mind. It has been reported that the House could vote on articles of impeachment as soon as late October. House leaders must make decisions on the scope of the case for impeachment, and they are likely to confine it to the Ukraine issue.

House committees will hear from the former US envoy to Ukraine, Kurt Volker, and, in private, from the whistleblower. They have subpoenaed Pompeo (who is resisting) and asked for state department documents relating to Trump’s efforts to pressure Ukraine. (The state department’s inspector-general has asked for an urgent meeting with the House about these documents.) Three House committees have subpoenaed Giuliani as an agent of the president, demanding that he turn over documents relating to his Ukraine contacts. Not surprisingly, he has raised the issue of attorney–client privilege.

The removal of a president under the impeachment process is a complicated process that involves a finding of “treason, bribery, or other high crimes and misdemeanours.” While several House committees are involved in collecting and examining the evidence, the articles of impeachment will be drawn up by the judiciary committee. The House will then hold a floor vote, which it is safe to assume will pass.

The articles then move to the Senate (which is controlled by the Republicans) for a trial overseen by the chief justice of the Supreme Court, John Roberts. A team of lawmakers from the House act as prosecutors; the president has defence lawyers; and the Senate serves as the jury. If at least two-thirds of the senators find the president guilty, he is removed and the vice-president becomes president. There is no appeal.

While there has been some disquiet among Republican senators, and it is possible that formal pressure from the House might exert some particular pressure on senators up for re-election in 2020, it is generally assumed that the impeachment move will fail in that chamber.

Senate leader Mitch McConnell, known for his partisan obstructionism, has said that the Senate would have “no choice” but to move forward with impeachment proceedings if the House ultimately votes to bring charges. There is speculation that McConnell would move quickly to throw out the case (which would require just a majority vote), but that might depend on how involved Justice Roberts chooses to be.

Meanwhile, President Trump and the White House are in chaos, struggling to pull together an organised response, and Republicans are left trying to justify the president’s efforts with the usual rhetoric. White House aide Stephen Miller claims the whistleblower is “a deep-state operative, pure and simple.” Senator Lindsey Graham says the president is being persecuted.

Media stories say that a taskforce or war room is being created to develop strategy and coordinate the response to impeachment proceedings, perhaps headed by political operative Corey Lewandowski. Some insiders are reported to be concerned that this level of organisation would simply highlight the seriousness of the situation; more likely Trump thinks he can manage his own affairs and communications.

Trump knows that the impeachment efforts will enrage his supporters, and he is making every effort to egg them on. In recent days he has dialled up the hate-mongering, or what some have called “apocalypse punditry.” He has made personal threats against the chair of the House intelligence committee, the former US ambassador to the Ukraine and the whistleblower. He has demanded the right to meet the whistleblower amid concerns that this would put the individual’s safety at risk. He veers from talk of treason, civil war, lawlessness and a coup designed to “take away the power of the people” to wallowing in a sense of victimisation.

This “devil’s bargain” motivates his base but alienates even further the moderates and independents who voted for him in 2020. The polls show he is in big trouble, with this week’s CNBC All-America Economic Survey finding that only 37 per cent of Americans approve of Trump’s handling of his job, the lowest level of his presidency.

Impeachment is a political not a legal matter, and in this case is already turning into a battle between the executive and legislative branches of government. Trump is interpreting the attacks on him as attacks on the government itself. But there are many ways he can survive the impeachment proceedings, and the process may or may not boost his chances in the election campaign next year.

For the moment there are only two things we can say for sure: whether through impeachment or the election ballot box, Trump won’t leave the presidency without a vicious fight; and Scott Morrison has become tainted by his association with this president’s White House. •

The post Crossing the line appeared first on Inside Story.

On the face of it, that weekend’s carnage might seem unlikely to dramatically change the gun-control debate in America. That didn’t happen when twenty-six people, including twenty children, were gunned down at Sandy Hook elementary school, or when seventeen students and staff were shot to death at a high school in Parkland in Florida. It didn’t happen when gunmen invaded religious sanctuaries and murdered Christians in Texas, Jews in Pennsylvania and Sikhs in Wisconsin. And it didn’t happen when shootings occurred on military bases and in a gay night club.

The president and Congress are away from Washington on August vacations, and it seems that anything that does happen won’t happen for at least several more weeks. The contrast to New Zealand’s response to the Christchurch massacre couldn’t be starker. Americans seem increasingly resigned to living in communities in which no trip to a shopping centre, a school, a place of worship or a festival is safe. Indeed, a poll last week found that 78 per cent of Americans expected another mass shooting within three months.

While pleas to “do something” are being heard in El Paso and Dayton, the once-active student voices of Parkland have become more muted and the parents of children who died at Sandy Hook struggle to keep the issue of gun control on the political agenda. The battle also comes at a cost: this year two survivors of the Parkland shooting and the father of a child killed at Sandy Hook elementary school died by suicide.

As was the case after the Parkland shooting, Trump has shown no leadership and provided no comfort and consolation, seemingly veering between wanting to do more and worrying that doing so could prompt a revolt from his political base. He has put forward a mishmash of ideas to reduce gun violence, many of them ill-defined and lacking either evidence or Republican support. Regardless of whatever he really thought or wanted to do, he was clearly constrained by White House aides and hamstrung by the NRA and Senate leader Mitch McConnell.

McConnell — whose obstruction on this issue, even of bills with bipartisan support, has been epic — said that he would not call the Senate back early to consider new gun legislation. In doing so, he rejected a plea from more than 200 mayors, including those from El Paso and Dayton. Nor would he bring any gun-control legislation to the floor without widespread Republican support, which is code for saying nothing will be done.

Yet there are a number of reasons why it is just possible that August 2019 will be a tipping point in this saga.

First, this is an issue that the Democrat presidential candidates have seized and will continue to push, keeping it front and centre in the debates. The biggest Democrat presidential field in history is also the most united ever in favour of gun control, and candidates are offering competing and aggressive gun safety plans.

Second, while the NRA is still a major force, its power is waning. It has failed to get its top priorities signed into law under Trump; is experiencing internecine power battles, allegations of financial misconduct and embarrassing headlines; and is being outspent by a growing and emboldened gun-control lobby.

Third, there is growing recognition of the role that extreme white nationalism has played in radicalising the perpetrators of gun massacres. The overt racism that drove the shooting in El Paso, and the influence of Trump’s demagoguery about Latino “invasion” in the shooter’s manifesto have frightened and galvanised many Americans, especially those in Hispanic communities who feel increasingly unsafe and unprotected. Many feel that radicalised white nationalism has placed them in its crosshairs, and that this means, for them, “the death of the American dream.” America’s sixty million or so Latinos, who are more likely to vote for Democrats, account for 18 per cent of the national population. That’s a powerful voting bloc.

Fourth, that and other demographic features are changing the electoral map. In Texas, a growing Hispanic population and an influx of younger people attracted by new industries could see the state turn from Republican red to politically purple. In the 2018 midterm elections a surge in Hispanic turnout in that state helped Democrats make significant gains. The likelihood of this happening again in 2020 is highlighted by the recent announcements by four members of the Texas congressional delegation that they will not contest their seats next year.

The 2018 midterms also highlighted the continuing collapse of support for the Republican party in the suburbs, especially among white women. An analysis shows that the majority of the forty-one seats flipped by Democrats in 2018 were predominantly suburban. Now, suburban areas of Atlanta, Philadelphia, Dallas and Houston in states Trump won in 2016 are seen as increasingly leaning Democrat. A growing economy is not overcoming residents’ dislike for Trump’s rhetoric and behaviour, their fears for everyday safety and their dismay that schoolchildren need to learn lockdown procedures.

Fifth, even in the absence of presidential and congressional action, many states are enacting their own gun-control laws. This year, states hit by gun violence have acted to require background checks on all gun sales (Nevada and New Mexico), to mandate the responsible storage of firearms and prohibit the sale and possession of bump stocks (Nevada), and to keep firearms out of the hands of individuals who pose an imminent threat to themselves or others (New York, Colorado, District of Columbia). Increasing numbers of state legislatures are rejecting bills that would allow teachers to be armed, guns on college campuses, and “stand your ground” responses that encourage the escalation of violence.

Finally, and sadly, while Trump and the Republicans may think that diversion, delay and denial will mean that the anger and attention and push for action will evaporate, the chances are that these sentiments will be fired up by yet another massacre. On average, four or more people have been killed in a mass shooting every forty-seven days since June 2015, when a young white supremacist killed nine people at a Bible study class in a historic African-American church in Charleston, South Carolina.

The pressure these factors have brought to bear on Trump and McConnell have seen some changes in their public pronouncements in the last few days, and it seems that they are now more inclined to take steps towards some substantive action. Whether this results in new laws and regulations remains to be seen.

Trump has faced major criticism for his language, his lack of empathy and his demeanour during visits to El Paso and Dayton, and in his Twitter attacks on politicians from these cities. Speeches from presidential candidates including former vice-president Joe Biden and senator Cory Booker served as reminders of what a president should offer his country at such times.

This past weekend, at a forum in Iowa, sixteen of the Democrats running in the presidential primary spoke out against the obstruction by Trump, McConnell and the NRA. They also voiced support for a common set of gun-control proposals, including a requirement for universal background checks and a ban on military-style semiautomatic rifles.

Trump is reportedly furious that his reputation has been damaged by charges of racism and that his language has been linked to the massacre at El Paso. McConnell is facing public outrage over his failure to act on gun control and accusations that his pandering to the NRA has cost people’s lives. It’s likely that polling is also influencing them. A majority of those surveyed in a recent poll, including 59 per cent of Republicans, said the Senate should pass the two gun-control measures to tighten background checks on gun purchasers approved in February by the House of Representatives.

Now Trump is claiming “tremendous support for really common sense, sensible, important background checks” and arguing that McConnell and senators who are “hard line on the second amendment” are “totally onboard.” And McConnell now says that Trump is “anxious to get an outcome and so am I.”

If Trump backed such legislation and McConnell was willing to bring it up in the Senate, it would signal a fundamental change in the gun-control debate. It would also signal that Republicans were, finally, listening to the voters.

Even before the shootings in El Paso and Dayton, Gallup reported the highest level of support for stricter gun laws in twenty-five years. Universal background checks are now supported by more than 90 per cent of Americans. Only 23 per cent of all voters oppose an assault weapons ban. Surveys from a variety of sources all show a rise in the number of Americans who say they believe controlling gun violence is more important than protecting gun rights.

In a recent GQR survey of likely 2020 voters, more than one in four people said their views on guns have changed within the past five years, and of these, 78 per cent — and 70 per cent of Republicans — have moved towards supporting stronger gun laws.

In February 2018, just after the massacre at Marjory Stoneman Douglas High School in Parkland, Florida, Trump met with members of Congress and chastised them for being “petrified” of the NRA and for doing nothing on gun control. “It’s time that a president stepped up, and we haven’t had them,” he said. “And I’m talking Democrat and Republican presidents — they have not stepped up.” Now, eighteen months and too many deaths later, it’s time the president took his own advice. •

The post Could this be a tipping point for gun control? appeared first on Inside Story.

Despite the District Court of New York’s decision to stop the question appearing in the 2020 census — a decision since upheld by the Supreme Court — and despite assertions by commerce secretary Wilbur Ross and the justice department that the courts would be heeded, Trump says he is considering an executive order to force the question onto the census.

Some legal experts think this end run around the Supreme Court and Congress will bring chief justice John Roberts and House Leader Nancy Pelosi into the fray. It would certainly put the White House squarely at loggerheads with those two bodies, and could provoke a constitutional crisis.

How did America reach this contretemps? Under the Constitution, an “actual enumeration” of everyone living in the United States must take place every decade. Seats in the House of Representatives are then apportioned according to “the whole number of persons in each state.” The census also determines each state’s quota of electoral college votes, as well as helping shape electoral maps and ensuring the equitable allocation of some US$900 billion in federal funds for Medicaid, development grants, public schools, law enforcement and disaster relief.

Despite the Census Act’s requirement that Congress be notified of planned questions three years in advance, citizenship was not on the list Ross sent to Congress in March 2017. But we now know that the topic was being discussed within the White House, though perhaps mainly among since-departed right-wing functionaries like Steve Bannon and Stephen Miller.

The public debate was kicked off by a leaked January 2017 draft executive order calling for the Census Bureau to add the question as part of a range of new immigration enforcement measures. Secretary Ross approved the question in March last year, overriding career officials at the bureau who were concerned that the question would reduce the response rate among non-citizens.

In congressional testimony later that month, Ross denied having discussed the matter with the White House and said he was responding solely to a request from the justice department; but it later emerged that he had discussed the matter with Bannon and attorney-general Jeff Sessions in the spring of 2017. Leaked emails show that the idea had been pushed by a justice department political appointee who, in private practice, had defended partisan electoral boundaries introduced by Republican legislators.

Adding new questions to the census isn’t unusual, and nor is asking about citizenship — though only in census-related surveys targeted at a sample of households rather than in the questionnaire received by every household. Those latter forms haven’t included questions about citizenship or country of birth since 1950.

As early as 2015, four former census directors were warning that a citizenship question to all households would undermine the accuracy of the count. They argued that significant numbers of people — especially those from immigrant and minority families — would be fearful of responding. That fear was heightened when Trump threatened that immigration enforcement agents would begin rounding up and removing millions of people without approved documentation.

Because of their potential impact on response rates, all questions proposed for the census must be adequately tested. The citizenship question hasn’t been through that process, but testing of the existing 2020 census questionnaire had already revealed a heightened reluctance to answer the survey and increased concern about confidentiality and privacy. Although the federal government is barred from using individual census data for law enforcement, most people don’t know or perhaps don’t believe that.

With the Census Bureau required to make follow-up efforts to collect data from non-responding households, a low response rate will be costly. For every percentage point of non-responsiveness, the bureau is expected to spend around US$55 million following up.

For some states in particular, inaccurate census data will result in less representation in Congress and less federal funding. By one estimate, 6.5 million people will be missing nationally, with Arizona, California, Florida, Illinois, New York and Texas potentially losing seats in Congress. According to a Pew Research Center study, a majority of the nation’s undocumented immigrants live in just twenty metropolitan areas, with most of them resident in New York, Los Angeles, Houston, Dallas, Chicago, Miami and Washington, DC.

Along with lawmakers in states like California and New York, urban leaders, who are mostly Democrats, are alarmed by the proposed question. Their fears appear well founded. The justice department’s official view is that it needs to know how many people are eligible to vote so it can better enforce the Voting Rights Act. But recent evidence — in the form of files found on the computer of a Republican strategist after his death — suggests that the citizenship question was drafted specifically to benefit Republicans. In 2015, the strategist, Thomas Hofeller, conducted a study that found a citizenship question would help Republicans in their efforts to shape electoral boundaries to their advantage during the periodic “redistricting” process. Hofeller contributed to a memorandum for the justice department arguing that the question was critical to enforcing “voting rights.”

Not surprisingly, more than twenty states and cities, along with civil liberty groups, filed lawsuits about this issue, culminating in the Supreme Court decision that shocked Trump and his administration. In what has been described as a “split the baby” decision, the Supreme Court upheld, 5–4, the decision of the New York District Court requiring the commerce department to give a true explanation for its decision to include the citizenship question in the census.

Chief justice John Roberts was the surprise swinging vote. He sided first with the conservatives on the court to uphold the right of the administration to add the question, finding that this was constitutionally and statutorily permissible. Then he switched sides and, along with the four liberals on the court, held that the commerce secretary had not given the true reasons for needing the question on the census. The opinion written by Roberts suggested that Ross was motivated by partisan politics and could face charges for his “pretexts” (a lawyerly term for lies) and for blatantly misleading the courts.

The justice and commerce departments appeared to accept the Supreme Court decision, announcing that the census materials would now be able to meet the 1 July deadline for printing. Trump, fuming, had other ideas. At 1.04am on American Independence Day he undercut his officials to tweet that “News Reports about the Department of Commerce dropping its quest to put the Citizenship Question on the Census is incorrect or, to state it differently, FAKE! We are absolutely moving forward, as we must, because of the importance of the answer to this question.”

What followed was a round of chaotic manoeuvring, as administration officials quickly reversed themselves and pledged to restore the question to census forms. Attorney-general William Barr now says the Supreme Court decision was wrong, and that there is “an opportunity potentially to cure the lack of clarity that was the problem” — presumably this means Ross’s lies — “and that we might as well take a look at doing that.”

By one count the Trump administration has changed its position on the citizenship story at least ten times in the past four months. But the real thinking behind the citizenship question became clearer in the argy-bargy following the Supreme Court’s decision. The acting director of the citizenship and immigration services said the questions would help “financially and legally with the burden of those who are not here legally,” and Trump said, “I think it’s important to find out if somebody is a citizen as opposed to an illegal.”

The justice department’s search for a “legally available path under the Supreme Court’s decision” appears to have hit a roadblock. Earlier this week the lawyers charged with this task were removed from the case with no explanation. Just as I write this, though, it is reported that a federal judge, acting at the request of the American Civil Liberties Union and other plaintiffs, has barred government lawyers from leaving until they meet a legal requirement to satisfactorily explain their departure and show that it would not impede the case they were working on going forward.

It seems likely the legal team’s departure is linked to the legality of Trump and Barr’s pushing ahead and aggravated by Trump’s threat of an executive order to bypass the courts’ decisions and get the citizenship question on the ballot. However much Trump might want to do this, a presidential order cannot override existing court rulings. And federal courts also have the power to set aside unconstitutional executive orders. Moreover, Congress cannot cede its constitutional responsibility for the census to the executive branch and the president.

It’s hard to imagine chief justice Roberts and House leader Nancy Pelosi allowing Trump to get away with this testing of the boundaries of executive power, and this is why some legal experts see a constitutional crisis looming.

The administration has other, less dramatic options, as Trump himself has acknowledged. “We could also add an addition on,” he has said, allowing time for a renewed effort to introduce the citizenship question by normal means. “So we could start the printing now and maybe do an addendum after we get a positive decision. So we’re working on a lot of things including an executive order.” Trump also says he has asked the administration’s lawyers if they can delay the census.

From a logistical point of view, though, any delay or add-on could be problematic. The census is mandated to take place on 1 April 2020 and changing the date would require an act of Congress. Printing and distributing a separate question would be prohibitively expensive.

Even if the troublesome question doesn’t make it into the census, the damage has probably already been done, with people’s confidence and willingness to accurately supply information compromised. Certainly, the job of the thousands of census workers in certain neighbourhoods has been made doubly difficult. Beyond the census itself, this has now become a civil rights issue.

Unless there is a reasonable resolution soon, this contentious issue will be a major factor in the 2020 election. Trump’s recent tweets give an indication of how he will use the census to play to his base. On Tuesday he tweeted about the “strained” Supreme Court ruling, saying it “shows how incredibly important our 2020 Election is.” •

The post In for the count appeared first on Inside Story.

The debates did offer some insight into the men and women who are putting themselves forward to run against Donald Trump in November 2020, and the fallout is already showing up in their polling and fundraising. But the short story of the debates is that some candidates don’t have a snowball’s chance in hell, and a long battle will take place among the smaller number of well-qualified candidates before the Democrat nominee emerges.

This battle will be fought not just on policies but also on the contenders’ likely ability to get out the vote and sway the left and right of the party. It will also rest on how voters in the primaries balance factors like race, gender, sexual identity, age and experience, and how much they are attracted by a candidate’s record outside the Beltway.

The old men — former vice-president Joe Biden (aged seventy-six) and senator Bernie Sanders (seventy-seven) — are starting to look and act their age. Questions about Biden have shifted from whether his policy record and positions are out of step with today’s Democrats to whether he is up to the job. Is he old-fashioned or just too old?

Sanders still seems perpetually angry but — to quote one pundit — “his bark does not seem to have the same bite as in 2016.” With a number of other candidates pushing policies like Medicare for All and reductions in fees for tertiary education, he is also beginning to sound repetitious rather than revolutionary.

Two female candidates — senator Elizabeth Warren and senator Kamala Harris — saw their chances improve as a result of their debate performances. Warren sent a clear message that she will challenge Sanders for support from the party’s left. She got good reviews for her suite of policies (“I’ve got a plan for that”), but they could be too liberal to woo moderates during the election campaign.

Harris got noticed in the debate because she tackled Biden on busing and his early record of working with segregationists, but she also presented credible centrist positions that undermined his status as the centre’s frontrunner. In the short term her gamble to take on the perceived leader of the pack seems to have paid off in the polls. But she is likely to end up competing with a number of other newer, younger faces.

Mayor Pete Buttigieg, who responded to questions in a low-key style, showed that the recent hype around his candidature is not without foundation. While he faces scrutiny over the recent police shooting of a black man in his hometown of South Bend, he earned kudos for his willingness to deal directly with that issue and take responsibility for having not done more to push the diversification of the local police force.

He will face competition from Julian Castro (housing and urban development secretary in the Obama administration and former mayor of San Antonio) and senator Cory Booker (former mayor of Newark), both men of colour with impressive personal stories and résumés who will appeal to minorities and young voters.

A handful of candidates — people like senators Amy Klobuchar, Kirsten Gillibrand and Michael Bennet and governors Jay Inslee and John Hickenlooper — might have looked more impressive in a smaller field. Some might be considered as vice-presidential material, and some might do better as time goes by, but mostly they have generated questions about why they are running and why they don’t stay in their current positions where their abilities are clearly needed.

And then there are the long shots, or more accurately the B-graders. Sadly, they include former congressman Beto O’Rourke, who seems to have lost the infectious energy he exhibited in his Senate battle in Texas in 2018. Others include New York mayor Bill de Blasio, former congressman John Delaney, businessman Andrew Young and the four candidates who didn’t qualify to be part of the first debates.

Two women who fall into this category got some attention by virtue of their unusual positions: self-help author Marianne Williamson, who says she will “harness love” to defeat Trump, and congresswoman Tulsi Gabbard whose anti-interventionist foreign policy stance has endeared her to some on the right.

A feature of both debates was how far left the majority of candidates (and arguably all of the major contenders) are veering in their embrace of liberal positions on healthcare, immigration, taxes, transgender rights and abortion. This is perhaps most obvious in the pressure Biden is under to change his stances on abortion and criminal justice for drug offenders.

Of course, Democrat candidates are known to run to the left during primaries only to become more centrist during the general campaign. But this tendency is particularly dangerous in this election.

First, it runs counter to last year’s successful midterm strategy, which saw the Democrats take back the House with a program of moderate policies. It leaves in a vulnerable position newly elected moderates facing re-election and denies the power this group has been able to wield in the House.

Second, it gives Trump, untroubled by a serious primary challenge, and the Republicans plenty of opportunities to highlight divisions among the Democrats and demonise their “socialist” policies.

Third, with such a large field of candidates creating pressure to stand out, some could adopt quite extreme policy positions and attempt to take down their Democrat opponents rather than Trump. The debate format obviously aggravates this pressure. Attack politics can backfire, especially when the targets are of a different race or gender.

And finally, there is a very real risk that the current focus on Medicare for All, healthcare access for undocumented immigrants, and free college tuition means that other issues that are top-of-mind for voters are not taken up.

Americans consistently put healthcare at the top of the list of things they want to see addressed. In a poll by the Pew Research Center, 69 per cent of those polled saw it as the key priority, along with the economy (70 per cent) and terrorism (67 per cent) — well ahead of jobs (50 per cent) and deficit reduction (48 per cent). But the public’s concerns are with healthcare costs, especially the increasing cost of health insurance premiums and medicines, rather than with coverage. Costs top the list of worrying household expenses, and for many the spectre of medical bankruptcy looms.

At a time when Obamacare has never been more popular and yet never more threatened by executive orders from the Trump administration and court challenges launched by Republican states, abandoning the commitment to restore and expand Obamacare in favour of Medicare for All is a dangerous gamble. It is also a lost opportunity to fight the Republicans on the solid ground of their failure to support the law, and its consequences. Medicare for All, which comes in many forms, provides Trump with plenty of material for fearmongering.

Single-payer healthcare is a confounding idea for the many Americans who have been convinced that it is socialised medicine and socialised medicine is bad. Perhaps because Medicare is so popular with older Americans, the general idea of Medicare for All has a surprisingly high level of support, but this drops precipitously when details are provided.

Polls from the Kaiser Family Foundation show that 56 per cent of Americans favour Medicare for All, and 74 per cent favour allowing people under sixty-five the option of buying into Medicare for health insurance coverage. But when told that Medicare for All would raise taxes and eliminate private health insurance, support falls to 37 per cent.

On the question of who is best placed to prevail against a president with a capacity to control the political conversation and a ruthless drive to keep his presidency, the most recent polls show Biden and Sanders losing ground to Warren and Harris. Otherwise, as this CNN poll shows, there has been little change. Harris seems to have made the most gains, especially among African-American voters.

The next debates are scheduled for 30 and 31 July in Michigan. By the time the September–October debates are scheduled, tougher qualifying rules will have whittled down the candidates considerably. Currently only Biden, Sanders, Warren, Harris, Buttigieg and possibly O’Rourke will qualify. That will allow greater scrutiny of policies, more probing of how they will improve the lives of all Americans, and an increased focus on foreign affairs.

One certainty is that the scrutiny of personal foibles and past records will continue, aggravated by Trump’s commentating from the sidelines. Unless they lose their cool, candidates who are already well known — Biden, Sanders and Warren — are likely to survive this scrutiny better. Harris, Buttigieg and Booker, on the other hand, will be more vulnerable to the inevitable exposés.

No agreement seems to exist among Democrats and their advisers about how to deal with the dirt, lies and obfuscation that will be part of the Trump campaign. Should they go high, or go low? Relatively few Democrat voters say that their presidential nominee should “fight fire with fire,” but some candidates, like Warren, Sanders and Gillibrand, have chosen to attack Trump as the problem. It was encouraging to see how many of the Democrat candidates responded strongly and promptly to insinuations about Kamala Harris’s racial background this past week.

As the primary campaign proceeds, the Democrats will need to work hard to generate voter enthusiasm, and particularly to appeal to swing voters. Trump’s election strategy appears to be to stick with his rusted-on base — a strategy that respected analyst Rachel Bitecofer sees as costly — and maybe even to play games with vice-president Mike Pence, which would lose him votes with evangelical Christians.

Voter turnout will be galvanised if there is a woman, a person of colour, or a Latino on the ticket, says Bitecofer. That’s looking increasingly likely. But some Americans are allowing themselves to dream of a Harris-Buttigieg ticket, and that might be one too many precedents for America in 2020. •

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