The New York Times - 12.09.2019

T

HE person most capable of de- feating Donald Trump is Donald Trump. If Democrats are smart, they will let him do the job. President Trump thrives on outrage and resentment. He seethes with it, stirs it in others and mines it for his own political profit. His political project relies on driving Americans to their cultural and ideo- logical corners. He is Pavlov. We are the dogs. Mr. Trump’s serial assaults on the de- cency and the decorum upon which civil society depends are enraging — and meant to be. It is only natural to respond to his every provocation with righteous in- dignation. My advice to the Democratic nominee next year is: Don’t play. Wrestling is Mr. Trump’s preferred form of combat. But beating him will require jiu-jitsu, a different style of battle typically defined as the art of manipulating an op- ponent’s force against himself rather than confronting it with one’s own force. Mr. Trump was elected to shake things up and challenge the political establish- ment. And to many of his core supporters, his incendiary dog whistles, bullhorn at- tacks and nonstop flouting of “political correctness” remain energizing symbols of authenticity. But polling and focus groups reflect a growing unease among a small but poten- tially decisive group of voters who sided with Mr. Trump in 2016 but are increas- ingly turned off by the unremitting nasti- ness, the gratuitous squabbles and the endless chaos he sows. Plenty of attention has been paid to the historic shift in suburban areas Mr. Trump narrowly carried in 2016 but that broke de- cisively with his party last fall. That revolt was led by college-educated white women, who overwhelmingly turned against Republican candidates. But what should be of even greater concern to Mr. Trump is the potential erosion among the non-college-educated white women he is counting on as a core constit- uency. Those women gave Mr. Trump a 27- point margin over Hillary Clinton in 2016. Yet in a recent Fox News poll, Mr. Trump was beating former Vice President Joe Bi- den by just four points in that group. If I were sitting in the Trump war room, this number, more than any other, would alarm me. He won the presidency by the slimmest of margins in three battleground states. With little place to grow, even a

small erosion of support among these women could prove fatal to Mr. Trump’s chances. While they are inclined to many of his positions, the thing that is driving these voters away is Mr. Trump himself. And one thing we can be sure of as the election approaches: Donald Trump is not going to change. Given that Mr. Trump’s approval rating has been hovering around 40 percent throughout his presidency, his obvious and only strategy is to turn his dial further into the red. He will try to raise the stakes by painting the election as a choice between himself and a radical, left-wing

apocalypse. He will bay about socialism, open borders and “deep state” corruption and relentlessly work to inflame and ex- ploit racial and cultural divides. But as Mr. Trump seeks to rev up his base, he also runs a significant risk of driving away a small but decisive cohort of voters he needs. His frenetic efforts to create a panic over the immigrant caravan in the days leading up to the 2018 midterms may have stoked his base, but it also gen- erated a backlash that contributed to ma- jor losses for his party. With everything on the line and noth- ing, to his mind, out of bounds, the same dynamic will be in play in 2020, and this creates an opportunity for Democrats — if their party’s message allows Trump de- fectors to comfortably cross that bridge. There is a legion of arguments on moral, ethical and policy grounds for Mr. Trump’s defeat, and that’s leaving out the sheer in- competence. But the most effective ques-

tion for Democrats to get voters to ask is simply whether the country can survive another four years like this. Can we continue to wake each day to the tweets and tantrums, the nasty, often gratuitous fights and the ensuing turmoil that surrounds this president? Can we make progress on issues of concern to the way millions of people live their lives with a leader who looks for every opportunity to divide us for his own political purposes? And is a Trump freed of the burden of re- election really going to be less combative and more constructive in a second term? Um, no. Each time Mr. Trump lashes out, as he will with increasing ferocity and fre- quency as the election approaches, these questions will gain more resonance. Ev- ery erratic escalation — every needless quarrel, firing or convulsive policy lurch — will provide additional evidence in the case for change. Mr. Trump’s impulse is always to create a binary choice, forcing Americans to re- treat to tribe. He wants to define the battle around divisive cultural issues that will hem in his supporters, and it would be se- ductive for Democrats to chase every tweeted rabbit down the hole. The president would welcome a pitched battle over lines of race, ideology and culture. But while Mr. Trump’s thermonuclear politics may rally both his base and Demo- crats who slumbered in 2016, it is the para- lyzing disorder and anxiety his bilious be- havior creates that is a distressing turnoff to voters at the margins who will make the difference. To win, the Democrats will have turn Mr. Trump’s negative energy against him without embodying it themselves. 0

ILLUSTRATION BY ADAM MAIDA; PHOTOGRAPHS BY DOUG MILLS/THE NEW YORK TIMES, AND JUN TSUKUDA/AFLO, VIA GETTY IMAGES

Let Trump

Destroy Trump

DAVID AXELROD, the former senior strat- egist for Barack Obama, is the director of the Institute of Politics at the University of Chicago and the host of “The Axe Files” on CNN.

David Axelrod

The Democratic nominee

should use the president’s

carrying on against him.

THE NEW YORK TIMES OP-EDTHURSDAY, SEPTEMBER 12, 2019 N A35

O

N JAN. 1 a new Medicare policy is scheduled to go into effect that will eventually require doctors to use a computer algorithm to vet imaging tests to determine “appropriateness.” If the tests, such as CT scans and M.R.I.s, do not meet cer- tain “appropriate-use criteria,” Medicare may not reimburse the cost. Intended to reduce unnecessary imaging, the policy may penalize doctors who don’t comply by requiring them to get “prior authorization” before ordering imaging tests in the future — in other words, to follow another regulation. Predictably, many doctors want the policy reversed or at least delayed so that they can come up with an alternative. They say that there is little evidence that the regulation will achieve its intended aim. They have concerns about how the computer algorithm will interact with existing electronic medical records. More generally, they complain of bur- densome regulations, created largely without physician input, that they already must follow. The new policy, they say, is another affront to physicians’ de- cision-making authority — an authority gained over many years of training. These are all valid points, and yet after almost six years of delays — the law was passed in 2014 — doctors have not advanced an alternative solution. Mean- while, billions of dollars are still spent every year on unnecessary imaging, creat- ing not just financial waste but also real risks to patients, including excess radia- tion and false-positive diagnoses. If doctors can’t or won’t fix a problem that is almost universally acknowledged in our profession, how can we act outraged or surprised when an outside agency tries to do it for us? To be fair, medical specialty societies such as the American Board of Internal

Medicine have published lists of imaging tests that are generally not beneficial to patients, including M.R.I.s for most lower back pain and stress tests when there are no signs of heart disease. Using these criteria, doctors on their own have been able to reduce the volume of imaging. But publishing lists will take us only so far. I once worked with a cardiologist who was ordering stress tests on 20- somethings to generate revenue. Asking doctors to voluntarily reduce imaging along the lines of what medical societies have proposed will do little to counteract that kind of excess. The growth in the volume of imaging studies is partly a problem of society, driven by the aging of the population, new technology and the rise of chronic

diseases. But it is also a problem of doctors’ making, driven by forces such as “defensive” medicine to avert lawsuits, a reluctance by doctors (and patients) to accept diagnostic uncertainty (thus leading to more tests) and simply poor clinical decisions. No one is better equipped to address these issues than doctors. Instead of having a knee-jerk rejection of all regulations, doctors should design the regulations themselves, through or- ganizations like the American Medical Association. But we have been unwilling to assume this responsibility, only to re- act with outrage and self-pity when oner- ous or ineffective regulations are forced on us. This is hardly the first time doctors have behaved this way. Consider what happened after Medicare was created in

1965 as a social safety net for older Amer- icans. Health care spending (and doctors’ salaries) quickly skyrocketed. Re- ports of waste and fraud were rampant, partly because the government virtually guaranteed payment for medical services. To stem the rise in spending, lawmak- ers and insurers created managed care, a health care financing model that in- cluded price controls, fixed payments and insurer review of the necessity of services. Doctors fought back (and are still fighting). “Passengers who insist on flying the plane are called hijackers,” Russell Roth, president of the American Medical Association, acidly remarked in 1976 about the law that ushered in managed care, without acknowledging that doctors had done little to rectify the problems that made managed care necessary in the first place. Today, doctors continue to show little inclination to solve health care’s problems. Most of us are too busy with clinical work. As professionals, we are notori- ously independent and don’t often feel comfortable organizing and cooperating to achieve common goals. Most physicians don’t want to engage in the politics and economics of health care. We went to medical school because we were fasci- nated with human physiology, not the body politic. But if we are going to retain more of the independence we crave, we must be- come more active in addressing the problems of health care, some of which we have created ourselves. Doctors are already raising their voices on social me- dia and other platforms on issues like gun control and immigration policy. We need to turn that critical focus on ourselves. If we don’t want to cede control to “hijackers,” we must be willing to fly the plane. 0

Physician, Regulate Yourself

SANDEEP JAUHARis a cardiologist, a con- tributing opinion writer and the author, most recently, of “Heart: A History.”

Sandeep Jauhar

If doctors won’t fix flaws,

they can’t complain when

others do it for them.

WHEN A 2-YEAR-OLDGuatemalan boy had
trouble staying silent in an immigration
courtroom, the judge pointed his finger
at him.
“I have a very big dog in my office, and
if you don’t be quiet, he will come out and
bite you,” the judge, V. Stuart Couch, a
former Marine, yelled at the toddler in a
2016 hearing, according to a formal com-
plaint shared by the Charlotte Center for
Legal Advocacy and first , this week by
Mother Jones.
“Do you want him to bite you?” Couch
asked.
The boy, his mom and their advocate
were all soon sobbing. Couch later ac-
knowledged that he “did not handle the
situation properly,” according to the
judge who investigated the complaint,
Deepali Nadkarni.
Clearly Couch didn’t have a child’s
well-being in mind on that day. But ignor-
ing the welfare of our young is a day-to-
day problem in America, where our chil-
dren are falling behind those in other
wealthy countries.
On Thursday, 10 Democratic presiden-
tial candidates will debate. It would be a
natural opportunity to provoke a na-
tional conversation on the subject. But a
question about child poverty hasn’t been
asked at a presidential debate in 20
years, not since a Republican primary
debate in 1999, according to the Chil-
dren’s Defense Fund.
Presidential candidates have been
asked about the World Series, about
cursing in movies, even about flag lapel
pins more recently than they have been
questioned about child poverty. We’ve
had 147 presidential debates in a row
without a single question on the topic. I

hope Thursday’s debate won’t be the
148th.
UNICEF says America ranks No. 37
among countries in well-being of chil-
dren, and Save the Children puts the
United States at No. 36. European coun-
tries dominate the top places.
American infants at last count were 76
percent more likely to die in their first
year than children in other advanced
countries, according to an article last
year in the journal Health Affairs. We
would save the lives of 20,000 American
children each year if we could just
achieve the same child mortality rates as
the rest of the rich world.
Half a million American kids also suf-
fer lead poisoning each year, and the
youth suicide rate is at its highest level
on record.
These problems have been magnified
under President Trump, though Ameri-
can policy has shortchanged children as
a whole for decades. The Census Bureau
reported this week that the number of
uninsured children increased by 425,000
last year.
Trump also gave the green light to a
pesticide that I call Dow Chemical’s
Nerve Gas Pesticide. Formally called
chlorpyrifos, it is associated with brain
damage among young children. Over the
objections of the American Academy of
Pediatrics, the Trump administration
claims it’s safe. So when will we see it
sprayed in the White House to handle
cockroaches?
James Heckman, a Nobel laureate in
economics at the University of Chicago,
calculates that investments in early
childhood programs for at-risk kids have
an astronomical return, because of im-
proved productivity and reduced spend-
ing on police forces, courts, jails, special
education and health care.
Heckman has a new paper on a North
Carolina early childhood program that
began in the 1970s, the Abecedarian
project, finding an annual return on in-
vestment of almost 14 percent. In an-
other recent paper, he found that the
Perry preschool program in Michigan in
the 1960s benefited not only the children
involved but also, a generation later,
their children.
Likewise, one study found that each
dollar invested in reducing lead poison-
ing among children pays for itself at least
17 times over.
Here’s a suggestion for the candi-
dates: Embrace a landmark report this
year from the National Academies of Sci-
ences, Engineering and Medicine that
outlines how to reduce child poverty by
half over 10 years. This can be done: Brit-
ain under Tony Blair halved child pov-
erty in less than a decade.
The national academies calculate that
a combination of job programs and child
allowances could cut child poverty in half
in the United States at a cost of about
$100 billion a year. Yes, that’s a lot of
money. But child poverty has an eco-
nomic cost in crime, lost productivity
and other expenses that is at least $800
billion a year, the academies report.
The real question isn’t whether we can
afford to act, but whether we can afford
not to.
We don’t lack the tools to help, or the
resources. The challenge is just that in
our political system, children don’t count
— and never get mentioned in presiden-
tial debates.
“Kids don’t vote,” notes Nadine Burke
Harris, the surgeon general of California
and an expert on the lifelong costs of
childhood trauma. “They require us to
speak for them.” 0

NICHOLAS KRISTOF

Our Children

Deserve Better

American kids are falling

behind other countries’.

Do the candidates care?

O.K., CONCERNED CITIZENS,it’s debate time. Come back here and sit down! This is important. Let’s see if you’re prepared. First, name the 10 Democratic presidential candidates who will be sharing the stage Thursday night. Give yourself a big pat on the back if you got them all. Light tap on the shoulder if you got six or seven. If you failed to remember Joe Biden, Elizabeth Warren and Bernie Sanders, just leave the room. Admit it. You’re not going to watch this thing at all, are you? Those of you who have demonstrated your commitment should now recall the debate goes on for three hours. But there’s lots to look forward to! Will Beto O’Rourke obey the Democratic Na- tional Committee ban on “foul language”? He’s been using it a lot, particularly since the mass shooting in El Paso, when he laced into Donald Trump: “He’s been call- ing Mexican immigrants rapists and crim- inals. I don’t know, like, members of the press, what the [expletive]?” Now this was totally understandable, given the terrible tragedy and Trump’s ap- palling history of racism. However, it’s one thing to blurt out a four-letter word at a moment of great stress. It’s another to have your campaign sell T-shirts that say repeatedly “THIS IS F*CKED UP.” And what about Joe Biden? Every- body’s waiting to see if Biden will do some- thing... strange. Maybe refer to one of the questioners as “Mom.” Or start telling stories about his adventures in a M*A*S*H unit in the Korean War, forget- ting that was a TV series. So, we’ll be watching to see if Biden bloops or Beto bleeps. Two deeply different matters, since so far in this campaign, swearing is pretty much the only area where O’Rourke is leading the pack. And nobody really cares that Biden acciden- tally called the president “Donald Hump.” Admit it — you chortled. At the debate, our former vice president will be squished in between Bernie Sand- ers and Elizabeth Warren. That in itself should make it worth tuning in. If things go well, Biden could market T-shirts brag- ging “It’s Cool To Be In The Middle.” There’s a popular presumption that Bi- den needs to perform at least decently in these events if he wants to win the nomi- nation. But having trouble handling Sena- tor Warren in verbal combat is way different from being able to hold your own against Donald Trump. Particularly when the subject gets to whether a president should make up his own weather maps. How much of the audience will be think- ing about age? Biden, as the whole world knows, will soon turn 77. And Sanders is

Warren is 70, but she campaigns like a
maniac — her record for posing for selfies
with her fans has probably passed 45,000
by now.
Biden is taking things fairly easy, in a
world where hitting 13 events in three
weeks is sort of like goofing off. Still, if he
can stand up on the stage for three hours
trying to look both genial and hard-charg-
ing, that’s a pretty good sign that his age
doesn’t matter.
Or at least doesn’t matter above all else.
There are a few troubling precedents. One
of the presidents who was oldest at the
time of his inauguration, William Henry
Harrison, died after a month in office. And
the very oldest, Donald Trump, has been
known to forget which country his father
was born in.
Meanwhile, I’m betting Kamala Harris,
54, will try to vie with Pete Buttigieg, 37, in
an appeal to the youth vote. Only saying
that because she just sent out an anti-
Trump fund-raising email with the subject
line “This dude’s gotta go.”
It’s sometimes a little hard to keep track
of the actual issues when everybody’s vy-
ing to be youthful/likable/powerful/mem-
orable/not-disaster-prone. Warren and
Biden’s history of fighting over financial
law will surely surface. They tangled in
2005 when credit companies wanted to
make it harder for average Americans to
declare bankruptcy. She sided with aver-
age Americans and he sided with, um, the
banks. Which of them do you think will try
to bring that up?
Happy to report there will no longer be
any questions in which everybody has to
raise a hand. (“Do you think a mass mur-
derer who once assaulted a beloved guard
who was the sole support of 14 grandchil-
dren should be allowed to vote? Yes or
no?”)
This is, of course, only one step in the
long road toward... next year. Another
debate is coming in October, which will
probably have even more people. Remem-
ber the other candidates? How many can
you name? Five? Fantastic. Eight? You’re
beginning to get me a little worried.
One of them, Tom Steyer, has already
qualified for the next round. He’s the bil-
lionaire who keeps running ads saying
that he’s a better businessman than Don-
ald Trump.
What do you think about that?
A) My cousin Fred who runs a pickle
stand is a better businessman than Don-
ald Trump.
B) Is Steyer’s slogan going to be “What
this country needs is a hedge fund man-
ager in the White House”?
C) Just promise me I won’t ever have to
listen to Bill de Blasio.
Have a great debate night. Probably a
good idea to skip the drinking games.
There have been some suggestions you
should take a shot every time somebody
says “existential threat,” but remember,
we’re talking about three hours here. 0

GAIL COLLINS

10 Candidates,

No Weather

Maps

How many Democrats

does it take to fill a

campaign? It’s debatable.

The New York Times - 12.09.2019

David Axelrod

THE NEW YORK TIMES OP-EDTHURSDAY, SEPTEMBER 12, 2019 N A35

Sandeep Jauhar

NICHOLAS KRISTOF

GAIL COLLINS

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