THE NEW YORK TIMES OP-EDWEDNESDAY, DECEMBER 2, 2020 N A23I
T APPEARS that our democracy
dodged a bullet — or, more precisely,
multiple concerted efforts by the
president of the United States to tor-
pedo its very foundations.
While President Trump rages relent-
lessly about election “fraud,” many Re-
publican leaders continue to parrot false
denials of the validity of President-elect
Joe Biden’s clear victory. Yet, so far, our
democracy has withstood the greatest
stress test of our lifetimes.
Mr. Trump and his political allies have
been employing nearly every weapon at
their disposal to try to retain the White
House, notwithstanding the will of the
people.
First, the Trump campaign labored to
concoct bogus conspiracy theories to dis-
credit Mr. Biden by falsely smearing his
son Hunter. To do so, Mr. Trump and his
associates solicited assistance from
Ukraine and China and relied on Russian
agents to disseminate disinformation.
Second, Trump supporters worked as-
siduously to suppress the vote by deni-
grating the legitimacy of mail-in ballots
during a pandemic, limiting access to bal-
lot drop-boxes and polling stations, ma-
nipulating the postal service and using so-
cial media to dampen minority voter turn-
out, among other tactics.
Third, some of Mr. Trump’s most ardent
supporters intimidated voters at the polls.
Heeding calls to “stand by” and “go into
the polls and watch very carefully,” they
deployed, sometimes armed, in Black and
brown communities under the guise of en-
suring no fraudulent votes were cast.
Fourth, in the run-up to Election Day,
Mr. Trump dispatched an army of litigants
to enlist the courts in curtailing access to
the polls.
Since the election, his legal team has
tried to toss out legitimately cast votes
that most likely favored Mr. Biden. And
Mr. Trump summoned Michigan’s Repub-
lican leaders to the White House, appar-
ently in an attempt to coax the state’s Leg-
islature into unilaterally appointing
Trump electors.
Despite these machinations, the worst
fears about this election failed to material-
ize. Defying the combined challenges of
the pandemic, foreign interference and
presidential sabotage, the election proved
to be, according to senior U.S. officials, the
“most secure” in our history.
The American people voted in unprece-
dented numbers, risking their health and
foiling efforts in many states to make vot-
ing as difficult as possible. African-Ameri-
cans, especially, braved countless barri-
ers to casting their ballots.
There is no proof, nor even credible evi-
dence, of significant voting irregularities,
much less fraud. Republican and Demo-
cratic state and local officials largely ad-
hered to their legal responsibilities. Offi-
cials effectively minimized the impact of
Russian electoral interference.
The mainstream media prepared the
public for a protracted counting process,
refrained from rushing to call the out-
comes in key states and resisted ampli-
fying false allegations of fraud. There has
been no significant election-related vio-
lence. Countries around the world have
accepted the result, almost uniformly con-
gratulating Mr. Biden on his decisive vic-
tory.
For now, our democracy has held.
Still, the lesson we must learn is not a
reassuring one: A determined autocrat in
the White House poses a threat to our
democratic institutions and can under-
mine faith in our elections, particularly
when backed by partisans in Congress.
Perhaps only when the stars are opti-
mally aligned — when voters turn out in
huge numbers, when the outcome is not
close, when state and local officials and
the courts adhere to the rule of law, when
foreign interference is thwarted, when the
media behaves responsibly and when peo-
ple remain peaceful — can our democracy
survive its greatest tests.
Mr. Trump will leave office on Jan. 20,
whether he acknowledges defeat or not.
Yet, if his Republican enablers in Congress
retain a Senate majority, they will not hesi-
tate to reprise the politics of power at any
cost, even by again subverting the demo-
cratic process.
So, bolstering our democracy depends
in large part on the people of Georgia vot-
ing out their incumbent senators on Jan. 5.
If the Senate flips to Democratic control,
Congress will be able to apply the lessons
of our democracy’s near-death experi-
ence.
It would enact the For the People Act to
combat corruption, strengthen ethics
rules and improve voter access as well as
the John Lewis Voting Rights Advance-
ment Act to restore the protections of the
1965 legislation. It would also pass the
Protecting Our Democracy Act, which
would constrain the power of future presi-
dents who deem themselves above the
law, and finally adopt long-stalled legisla-
tion to shore up our election infrastructure
against adversaries, foreign or domestic.
Now is no time for self-congratulation
or complacency. We must act with the
unique urgency and courage of those who
know they are living on borrowed time. 0
The next Congress
must shore up
our institutions.
Democracy’s
Near-Death
Experience
Susan E. Rice
SUSAN E. RICE, a former national security
adviser and a former U.S. ambassador to
the United Nations, is a contributing
opinion writer.
WITH THE ASSASSINATIONpresumably by
Israel of Iran’s top nuclear warhead de-
signer, the Middle East is promising to
complicate Joe Biden’s job from Day 1.
President-elect Biden knows the region
well, but if I had one piece of advice for
him, it would be this: This is not the Mid-
dle East you left four years ago.
The best way for Biden to appreciate
the new Middle East is to study what
happened in the early hours of Sept. 14,
2019 — when the Iranian Air Force
launched 20 drones and precision-
guided cruise missiles at Abqaiq, one of
Saudi Arabia’s most important oil fields
and processing centers, causing huge
damage. It was a seminal event.
The Iranian drones and cruise missiles
flew so low and with such stealth that
neither their takeoff nor their impending
attack was detected in time by Saudi or
U.S. radar. Israeli military analysts, who
were stunned by the capabilities the Ira-
nians displayed, argued that this sur-
prise attack was the Middle East’s “Pearl
Harbor.”
They were right. The Middle East was
reshaped by this Iranian precision mis-
sile strike, by President Trump’s re-
sponse and by the response of Israel,
Saudi Arabia and the United Arab Emir-
ates to Trump’s response.
A lot of people missed it, so let’s go to
the videotape.
First, how did Trump react? He did
nothing. He did not launch a retaliatorystrike on behalf of Saudi Arabia — even
though Iran, unprovoked, had attacked
the heart of Saudi Arabia’s oil infrastruc-
ture.
A few weeks later Trump did send
3,000 U.S. troops and some antimissile
batteries to Saudi Arabia to bolster its
defense — but with this message on Oct.
11, 2019: “We are sending troops and
other things to the Middle East to help
Saudi Arabia. But — are you ready?
Saudi Arabia, at my request, has agreed
to pay us for everything we’re doing.
That’s a first.”
It sure was a first. I’m not here to criti-
cize Trump, though. He was reflecting a
deep change in the American public. His
message: Dear Saudis, America is now
the world’s biggest oil producer; we’re
getting out of the Middle East; happy to
sell you as many weapons as you can pay
cash for; but don’t count on us to fight
your battles. You want U.S. troops? Show
me the money.
That clear shift in American posture
gave birth to the first new element that
Biden will confront in this new Middle
East — the peace agreements between
Israel and the United Arab Emirates, and
between Israel and Bahrain — and a
whole new level of secret security co-
operation between Israel and Saudi Ara-
bia, which will likely flower into more for-
mal relations soon. (Prime Minister Ben-
jamin Netanyahu of Israel reportedly
visited Saudi Arabia last week.)In effect, Trump forced Israel and the
key Sunni Arab states to become less re-
liant on the United States and to think
about how they must cooperate among
themselves over new threats — like Iran
— rather than fighting over old causes —
like Palestine. This may enable America
to secure its interests in the region with
much less blood and treasure of its own.
It could be Trump’s most significant for-
eign policy achievement.
But an important result is that as Bi-
den considers reopening negotiations torevive the Iran nuclear deal — which
Trump abandoned in 2018 — he can ex-
pect to find Israel, Saudi Arabia, Bahrain
and the United Arab Emirates operating
as a loose anti-Iran coalition. This will al-
most certainly complicate things for Bi-
den, owing to the second huge fallout
from the Iranian attack on Abqaiq: the
impact it had on Israel.
After Trump scrapped the nuclear
deal, Iran abandoned its commitments to
restrict its enrichment of uranium that
could be used for a nuclear bomb. But
since Biden’s election, Iran has said it
will “automatically” return to its nuclearcommitments if Biden lifts the crippling
sanctions imposed by Trump. Only after
those sanctions are lifted, said Iran,
might it discuss regional issues, like
curbs on its precision missile exports
and capabilities.
This is where the problems will start
for Biden. Yes, Israel and the Sunni Arab
states want to make sure that Iran can
never develop a nuclear weapon. But
some Israeli military experts will tell you
today that the prospect of Iran having a
nuke is not what keeps them up at night
— because they don’t see Tehran using it.
That would be suicide, and Iran’s clerical
leaders are not suicidal.
They are, though, homicidal.
And Iran’s new preferred weapons for
homicide are the precision-guided mis-
siles that it used on Saudi Arabia and that
it keeps trying to export to its proxies in
Lebanon, Yemen, Syria and Iraq, which
pose an immediate homicidal threat to
Israel, Saudi Arabia, the United Arab
Emirates, Iraq and U.S. forces in the re-
gion. (Iran has a network of factories
manufacturing its own precision-guided
missiles.)
If Biden tries to just resume the Iran
nuclear deal as it was — and gives up the
leverage of extreme economic sanctions
on Iran, before reaching some under-
standing on its exporting of precision-
guided missiles — I suspect that he’ll
meet a lot of resistance from Israel, the
U.A.E. and Saudi Arabia.
Why? It’s all in the word “precision.” In
the 2006 war in Lebanon, Iran’s proxy
militia, Hezbollah, had to fire some 20
dumb, unguided, surface-to-surface
rockets of limited range in the hope of
damaging a single Israeli target. With
precision-guided missiles manufactured
in Iran, Hezbollah — in theory — needs to
fire just one rocket each at 20 different
targets in Israel with a high probability of
damaging them all. We’re talking about
Israel’s nuclear plant, airport, ports,
power plants, high-tech factories and
military bases.
That is why Israel has been fighting a
shadow war with Iran for the past five
years to prevent Tehran from reaching
its goal of virtually encircling Israel with
proxies in Lebanon, Syria, Iraq and
Gaza, all armed with precision-guided
missiles. The Saudis have been trying to
do the same versus Iran’s proxies in
Yemen, who have fired on its airports.
These missiles are so much more lethal.
“Think of the difference in versatility
between dumb phones and smart-
phones,” observed Karim Sadjadpour, a
senior fellow at the Carnegie Endow-
ment. “For the past two decades we have
been consumed by preventing Iran’s big
weapon, but it is the thousands of small
smart weapons Iran has been proliferat-
ing that have become the real and imme-
diate threat to its neighbors.”
That is why Israel and its Gulf Arab al-
lies are not going to want to see the
United States give up its leverage on Iran
to curb its nuclear program before it also
uses that leverage — all those oil sanc-
tions — to secure some commitment by
Iran to end its exporting of these mis-
siles.
And that is going to be very, very diffi-
cult to negotiate.
So, if you were planning a party to cele-
brate the restoration of the Iran-U.S. nu-
clear deal soon after Biden’s inaugura-
tion, keep the champagne in the fridge.
It’s complicated. 0THOMAS L. FRIEDMANIt’s Not About Iran’s Nukes Anymore
Reinstating the old accord
won’t address the biggest
threat Tehran now poses.
Iranians burned pictures of President Trump and Joe Biden after Iran’s top nuclear scientist was assassinated last week.ARASH KHAMOOSHI FOR THE NEW YORK TIMESP
RESIDENT-ELECT JOE BIDEN
has pledged to “marshal the
forces of science” in his adminis-
tration. Undoubtedly he needs to
start by bolstering the credibility of the
Food and Drug Administration and the
Centers for Disease Control and Preven-
tion.
But a third health agency, central to
the lives of older Americans, low-income
families and the disabled, is sorely in
need of his attention.
Science has also been under assault at
the Centers for Medicare & Medicaid
Services, which provides federal health
insurance to more than 130 million
Americans at a cost of more than $1 tril-
lion, nearly twice the Pentagon’s budget.
C.M.S. does more than just write
checks for medical care. Its scientists
and analysts determine which treat-
ments should be offered — I am the
chairman of the committee that advises
Medicare on those decisions — and how
best to care for the patients it serves.
Unfortunately, the Trump White
House has steadily eviscerated the agen-
cy’s dispassionate approaches to making
those determinations.
Recently, for instance, the Trump ad-
ministration set in motion a plan to strip
C.M.S. of its ability to assess for itself
whether new medical devices approved
by the F.D.A. are appropriate for the old-
er patients it covers.
This is important because the benefits
and risks of such devices and pro-
cedures, which range from implantable
hips and cardiac stents to digital apps
and laboratory tests, can vary widely
based on patient age and disability.
The proposed rule requires Medicare
to pay for any new device so long as the
F.D.A. labels it a “breakthrough.” And
that word does not mean what you think
it does.
The F.D.A. calls a device a “break-
through” when it is expected — though
not yet proved — to be helpful to patients
with serious conditions. The designation
has nothing to do with how the device
works in older patients, or even if it was
studied in that population at all.
The proposed rule would also require
Medicare to cover any new drug or de-vice if at least one commercial insurer
covers it for its members, even if its
members are young and healthy.
Already, companies seldom generate
enough data on their products for C.M.S.
to assess their value for its patients. In
2019, for instance, data was insufficient
in just under half of new F.D.A. drug ap-
provals to assess benefits or side effects
in older patients.
The proposed rule would drain the last
remaining motivation that companies
have to study their treatments in the pa-
tients who are likely to ultimately re-
ceive them.
C.M.S. scientists and analysts do more
than evaluate new treatments. They also
test alternative ways to organize and pay
for patient care.
The agency has found, for example,
that enrolling people at risk of diabetes in
gym sessions reduced how often theywere hospitalized.
But some seemingly obvious ways to
improve health care don’t work: C.M.S.
also found it could not reduce hospital-
izations for cancer patients by paying
their doctors to actively manage their
patients’ care.
The fact that so many promising ideas
don’t work as expected is the reason
C.M.S. needs to double down on evalua-
tions of how medical care is delivered to
its patients.
This administration has gone in the
other direction. Just before the election,
the White House conjured up a plan to
send older people a $200 prescription
drug discount card in the mail.
Research has already demonstrated
that if you give people money to buy pre-
scription drugs, they will buy more of
them. The pharmaceutical industry
knows this, too. That’s why it hands out
coupons worth billions of dollars.
These same studies also show that
when people are indiscriminately given
cash for medicines — instead of only
those who need that money the most — it
costs much more overall than it saves.
No wonder the discount card giveawaywould have cost around $8 billion. Fortu-
nately, the president has yet to follow
through with it.
In another troubling development, the
administration announced on Nov. 20
that it would run an experiment in which
reimbursements to physicians will be cut
for dozens of high-cost drugs they ad-
minister in the office, such as chemother-
apies and treatments for inflammatory
diseases.
C.M.S. financial analysts warned that
the cuts will lead many Medicare pa-
tients to lose access to these important
treatments. Scientists should evaluate
this prediction by including a compari-
son group of patients whose doctors
would not receive a cut in payment.
But the agency administrator, Seema
Verma, made it clear that she didn’t be-
lieve the warning. No comparison group
is planned. That is no way to evaluate
whether our nation’s vulnerable would
be helped or hurt by this significant pol-
icy change.
Another example of a poorly designed
experiment involved taking Medicaid
coverage away from able-bodied people
who are not working or going to school,
under an ill-founded theory that doing so
would inspire them to seek employment.
Such a study is best done narrowly, so
that any harms are minimized. Instead,
the administration invited multiple
states in 2018 to test the outcome.
A Harvard study found that a work re-
quirement in Arkansas led to a rise in the
number of uninsured people and no sig-
nificant changes in employment.
Thousands of Medicaid beneficiaries
in Michigan and New Hampshire were
set to lose their coverage before work re-
quirements in those states were ended.
Given those results, the overall program
should have been canceled. The adminis-
tration broadened it.
Through its reliance on scientific eval-
uation of what it should pay for, and how,
C.M.S. has remained financially viable
for more than half a century. As the new
president plans to fix the damage done
by the current president, this vital
agency demands his attention. 0Science Under Assault at Medicare and Medicaid
Peter B. BachPETER B. BACH,a physician at Memorial
Sloan Kettering Cancer Center, was a
senior adviser to the administrator of the
Centers for Medicare & Medicaid Serv-
ices in 2005 and 2006.An agency’s leaders
ignore objective analysis
in evaluating treatments.
Seema Verma, head of the Centers for Medicare & Medicaid Services.ERIN SCHAFF/THE NEW YORK TIMES