WEDNESDAY, JULY 31 , 2019. THE WASHINGTON POST EZ RE A
WEDNESDAY Opinion
J
ust in time for her second Democratic
presidential debate appearance, on
Wednesday night, Sen. Kamala
D. Harris (Calif.) has unveiled a
Medicare-for-all plan.
The timing of Harris’s release is excellent
news for health-care wonks; now CNN’s
Dana Bash, Don Lemon and Jake Tapper
will have an opportunity to ask her to fill in
the plan’s somewhat scanty details. Here
are some questions about Harris’s
Medicare-for-all plan the debate modera-
tors might want to consider:
Sen. Harris, like Bernie Sanders, you
envision your Medicare-for-all plan cover-
ing many services that Medicare currently
doesn’t, such as dental, vision and hearing
aids. Will it eliminate co-pays and out-
of-pocket expenses, as the Sanders plan
does? Exactly how much do you estimate
this plan will cost?
Your plan will make private insurance
illegal for covered services. Will clinics and
physicians be able to provide covered ser-
vices for cash, or will there be no way to
obtain those treatments outside the public
system?
Unlike Sen. Sanders, who foresees a
four-year transition, your plan would take
10 years to fully implement. That’s more
than two full presidential terms. Republi-
cans are likely to hold one or more branch-
es of government during at least part of its
implementation. Do you expect Republi-
cans to behave differently toward your plan
than they did toward Obamacare?
Your plan will cover “comprehensive
reproductive health care services.” Presum-
ably that means childbirth, contraception
and abortion, but will it also cover fertility
treatment? Gender reassignment surgery?
After your plan is established, a Republi-
can Congress might well abolish coverage
for controversial items such as abortion,
embryo-destroying in-vitro fertilization or
gender reassignment surgery. Or a Repub-
lican administration could drop the reim-
bursement rates for those things so low
that no doctors or hospitals could afford to
provide them. If that happens, how would
Americans get access to those services
under your system?
You say pharmaceutical companies
won’t be able to charge Americans more
than they charge “comparable countries.”
It’s likely that high drug prices in the
United States encourage pharmaceutical
firms to pour more funds into very expen-
sive drug development projects, in the
hopes of reaping those outsize rewards.
Many experts worry that U.S. price controls
would reduce the number of lifesaving new
drugs produced. Will your plan monitor
drug markets to verify that lower drug
prices haven’t meant firms and investors
pulling back from drug development?
If R&D does decline, what alternative
mechanism would you use to ensure that
we don’t inadvertently shut down a devel-
opment pipeline that’s still delivering revo-
lutionary treatments for serious conditions
such as cancer, hepatitis C and multiple
sclerosis? Will your government offer priz-
es for developing drugs that meet govern-
ment-established benchmarks? Create a
public agency to develop drugs directly?
Use some other model to assure lifesaving
treatments for future generations?
Your plan offers an immediate buy-in to
existing Medicare for non-seniors. Pre-
sumably, when people do buy in, you plan
to pay their providers at current Medicare
rates, which are well below those offered
by private insurance. If a lot of people buy
in to Medicare, hospital revenue will be
sharply hit, and with hospital operating
margins averaging only 2.56 percent,
they’ll need to streamline operations to
stay solvent. What services, facilities or
staff positions should hospitals be cutting
over the next few years to balance their
budgets? How will you deal with hospitals
that end up insolvent anyway?
As you probably know, the trust fund for
Medicare’s hospital insurance program will
run out in 2026, and under current law,
benefits will have to be cut to match
revenue. If we’re going to add a lot more
people to Medicare, it will be even more
critical to stabilize the program. How will
you do that? Can it be managed without
even deeper cuts to hospital payments?
If you expand access without increasing
the number of doctors and other providers,
then people who currently have insurance
are likely to experience longer wait times or
difficulty finding a doctor who will take
new patients. Will your plan do anything to
increase the number of doctors and other
providers?
Your Medicare-for-all plan uses the basic
framework offered by Sen. Sanders, both in
the comprehensiveness of its benefits and
in many of the taxes that are proposed to
offset its costs. Yet many experts think that
his “revenue raisers” would barely cover
even half of the new spending. How would
you close that gap?
A recent Kaiser Family Foundation poll
found that while majorities support the
generic idea of Medicare-for-all, sup-
port drops dramatically if Medicare-for-all
means threatening the current Medicare
program, paying higher taxes, losing pri-
vate insurance, or enduring delays for tests
or treatments. How will you reassure those
Americans who fear that your plan would
involve all those things?
Twitter: @asymmetricinfo
MEGAN MCARDLE
Burning
questions
on Harris’s
health plan
P
resident Trump was wrong to per-
sonally attack Rep. Elijah E. Cum-
mings (D-Md.), a man widely re-
spected by Democrats and Repub-
licans alike. But Trump was absolutely
right when he called Baltimore “danger-
ous,” “filthy” and “rodent infested” — that
is, if you can believe what you read in the
“failing New York Times.”
In March, the Times Sunday magazine
published a heart-rending story titled
“The Tragedy of Baltimore,” which chroni-
cled the precipitous decline of the city. It
described how then-Mayor Catherine
Pugh (D) toured the Highlandtown sec-
tion of southeast Baltimore, as communi-
ty leaders showed her a block where pros-
titutes gathered, uncollected garbage
piled up and a liquor store allowed drunks
to congregate while pretending to wait for
the bus. “ ‘Watch your step,’ someone
called out as the group neared a dead rat,”
the Times reported.
The city’s “regression has been swift
and demoralizing,” the Times wrote, add-
ing that officials have “struggled to re-
spond to the rise in disorder, leaving
residents with the unsettling feeling that
there was no one in charge.” One resident
contrasted the tourist-friendly Inner Har-
bor with her West Baltimore neighbor-
hood, where, she said, “we’re all bolted in
our homes, we’re locked down.”
Residents are locked down with good
reason. In 2017, Baltimore had 343 homi-
cides, a new record for killings per capita
— more than New York City, which has
14 times Baltimore’s population. In 2018,
there were 309 homicides, and in 2019,
there were 171 homicides as of July 11 — up
from 147 homicides at the same time last
year. Baltimore is quite literally experi-
encing “American carnage.”While the national poverty rate has
dropped from 14.8 percent to 12.3 percent
since 2014, Baltimore’s remains virtually
unchanged at 22.4 percent. Children are
trapped in failing schools that can’t teach
them to read or do math at grade level. No
wonder Sen. Bernie Sanders (I-Vt.) once
compared Baltimore to “a Third World
country” and said it is “a community in
which half of the people don’t have jobs
[and] in which there are hundreds of
buildings that are uninhabitable.” This is
happening in Maryland, the richest state
in the country. Talk about income
inequality!
Pointing out these facts is not racist. It
is also not racist to say that no one would
want to live in these conditions — we
should all agree that no one should have
to. Nor is it racist to point out that this
human tragedy is the responsibility of
Baltimore’s leaders, and the direct result
of five decades of Democratic rule. Dem-
ocrats have held a lock on the Baltimore
mayor’s office since 1967. They run the
city council, the school system, the sani-
tation system, the housing authority and
police department, and they represent
the city in Washington. Gov. Larry Hogan
(R), only the second Republican gover-
nor of Maryland since 1969, does bear
some responsibility. But Baltimore is a
deep-blue city in a deep-blue state; its
plight is almost entirely a Democrat-
created disaster.
Trump is wrong to attack Cummings
for conducting vigorous oversight of con-
ditions on the southern border; as chair-
man of the House Oversight Committee,
that is his job. But Democrats want to
have it both ways. They want to criticize
what they see as inhumane conditions in
U.S. detention facilities (and give a pass to
those, including Democratic Rep. Alexan-
dria Ocasio-Cortez of New York, who out-
rageously compare those facilities to
“concentration camps”) but then call
Trump a racist for criticizing inhumane
conditions in Baltimore.
The irony is that Democrats are in large
part responsible for both situations. For
months they refused to provide the emer-
gency funds Trump requested to address
the surge in border crossings, which left
U.S. facilities on the border under-
resourced and overwhelmed. And for
years they have ruled Baltimore as a one-
party fiefdom as the city turned into an
island of despair amid a sea of prosperity.
The tragedy of Trump’s presidency is
that he should be championing the people
of Baltimore rather than using their
plight to attack one of his critics. In 2016,
Trump visited a black church in Detroit
and gave a major speech in Charlotte in
which he promised black Americans,
“Whether you vote for me or not, I will be
your greatest champion.” Last year, he
was supposed to visit Baltimore to deliver
a similar message but canceled. That
would have been a lot more effective than
a tweetstorm that only prompts Balti-
more’s beleaguered residents to rally
around their incompetent Democratic
leaders.
Twitter: @marcthiessenMARC A. THIESSENTrump’s
criticism
of Baltimore
was fair
BY DORSA AMIRN
early 100 years ago, a team of
archaeologists working in
Greenland stumbled onto
something strange: careful ar-
rangements of brightly colored stones
nestled into the frozen landscape.
There was no mistaking they were in-
tentional, the ovals of red and white
pebbles, but what were they?
The team traced the formations to
the walrus-hunting Thule people of the
medieval era, the predecessors of the
Inuit. And they assumed what archaeol-
ogists often assume, that the structures
were religious in nature.
But they were wrong.
The stones weren’t talismans for
hunting or warding off evil spirits. They
were something arguably more won-
drous: children’s playhouses.
The stones were the remnants of
miniature dwellings that children had
built to mimic adults’ structures. They
even had small caches for storing imagi-
nary meat and blubber, represented by
the red and white pebbles.
The Thule children were doing what
children have done for millennia: learn-
ing about the adult world through play.
And the archaeologists were doing
something that is all too common: un-
derestimating the importance of chil-
dren’s culture.
When we think about our hunter-
gatherer ancestors, it’s easy to overlook
the children. Even the exhaustive eth-
nographies that dot the anthropologi-
cal literature tend to focus on adults —
on their warfare, subsistence and mar-
riage patterns, the busy lives they led.
But our understanding of who we are
as a species is incomplete without con-
sidering childhood.
Childhood is unique to humans. Our
primate cousins debut into the world
after weaning as more-or-less inde-
pendent juveniles. But Homo sapiens’
children stick around. Years after wean-
ing, they are still in our care. This long
period of dependence gives humanstime to master the enormous number of
skills we need to become successful
adults.
For 99 percent of humanity’s exis-
tence, that meant being a successful
forager. Children needed not just eco-
logical knowledge, such as which plants
were safe to eat, but also a wealth of
social and technical knowledge — how
to build a sturdy dwelling, with whom
to cooperate.
To meet this challenge, we evolved
something rather remarkable: a
society-within-a-society composed of
children, generating their own culture
as they mastered the adult one.
While we can’t perfectly re-create the
details of these child cultures — bones
fossilize, behavior doesn’t — we can
infer their existence from a variety of
sources. We find their echoes in archae-
ological ruins, such as the Thule play-
houses. Or we catch glimpses in old
ethnographies, such as Bronislaw
Malinowski’s amused observation of
Trobriand Island children “standing of-
ten in... collective opposition” to
adults. “If the children make up their
minds to do a certain thing,” he wrote a
century ago, “... the grown-ups and
even the chief himself... will not be
able to stop them.”
Some of us anthropologists are lucky
enough to see children’s cultures in
person among the few remaining small-
scale societies in the world. In my own
fieldwork among the Shuar of Ecuador,
I watch play groups reshuffle through-
out the day, just out of the adults’ sight. I
see boys with small machetes mimick-
ing work, girls showing younger sib-
lings how to keep the fire alive.
We find commonalities among such
societies everywhere we look, from the
Arctic to the Amazon. Children spend
their time immersed in child commu-
nities, age-mixed and sometimes
gender-mixed, operating in parallel to
and largely independent of the adult
ones. The children learn as a collective,
with younger kids following the mod-
els of older kids. Given the consistencyof these characteristics, we can infer
that these cultures of childhood are
probably ancient, even pre-dating
Homo sapiens.
Such consistent features of our evo-
lutionary past leave enduring marks on
our psychology. Our innate perceptual
system expects a sun that lights the
world from above. Our linguistic system
expects language, even in the womb.
Perhaps our learning systems function
the same way, expecting a culture of
childhood marked by independence
and play.
Unfortunately, that culture is quickly
slipping away.
In the past 10,000 years — a barely
perceptible sliver of evolutionary time
— virtually every feature of childhood
has changed, particularly in industrial-
ized societies. Instead of growing up in a
mixed-age collective, our children
spend most of their time indoors with
same-age peers. Gone are the days of
evading grown-ups: Constant supervi-
sion is expected. Recess, the last vestige
of free play, is on the brink of extinction.
I contributed to this myself as a camp
counselor, shepherding kids to struc-
tured activities, convinced that by
teaching them rules or settling their
disputes, I was helping them grow.
I don’t think this anymore.
Children’s cultures didn’t evolve by
accident. They served a function. In free
play, children practice creative think-
ing and problem-solving. In mixed-age
play groups, they learn from older peers
and teach younger ones, meanwhile
consolidating their skills.
Without understanding its evolu-
tionary function, it’s easy to underesti-
mate children’s culture. And through
this pathological undervaluation, what
we have effectively managed to do is
slash and burn core features of child-
hood — the very roots of what makes us
human.The writer is an evolutionary anthropologist
and postdoctoral research fellow at Boston
College.What have we done
to childhood?
MICHELLE KONDRICH FOR THE WASHINGTON POSTBY SCOTT GOTTLIEBC
annabidiol — better known as
CBD — is everywhere, from small
specialty shops to large national
retail chains. It can be found in
foods, supplements, drugs, oils, creams,
pet foods and more, and sellers purport
that the compound treats everything
from cancer to depression. Analysts say
the market could surpass $20 billion by
2024.
But many of the compound’s expansive
benefits are fanciful, and in fact, the sale
of much of the product is illegal under
current law. The Food and Drug Adminis-
tration must act to make sure commer-
cial interests don’t strip away any legiti-
mate value that the compound might
have.
Much CBD is derived from hemp, the
commodity that was legalized in the 2018
farm bill. But the law still prohibits put-
ting the chemical in food or pet food, and
the FDA has issued repeated warnings
and actions on the blooming CBD indus-
try. In fact, there’s only one legally avail-
able purified form of CBD: the drug
Epidiolex, approved by the FDA in 2018 to
treat seizure disorders.
This doesn’t mean there can’t be a
route for CBD to be legally sold in other
forms, including as a food ingredient. Nor
does it mean that CBD can’t offer poten-
tial benefits. But a legal path should be
based on a clear and efficient regulatory
process and sound science to guide its
proper use.
CBD has risks: It can cause damage to
the liver at high doses, and it may have a
cumulative effect. If you eat CBD in your
breakfast, lunch and dinner, you could get
a toxic dose. Currently marketed products
might also have undeclared ingredients
and impurities, including the psychoac-
tive compound found in marijuana,
delta-9-tetrahydrocannabinol (THC).
Any path to allow CBD to be added to
food products needs to preserve the
incentive to study the compound in rigor-
ous clinical trials to prove its therapeutic
potential as a medicine. It’s not appropri-
ate or legal to make such claims
otherwise.
The conflict in grappling with these
illegal products stems from the misper-ception that the 2018 farm bill fully “le-
galized” CBD. When Congress passed the
bill, it established a category of cannabis
from hemp defined by extremely low
concentrations of THC. But in doing so,
Congress explicitly preserved the FDA’s
authority to regulate CBD-containing
products to make sure they’re safe and
that their claims are valid.
Under current law, CBD is permitted in
food or dietary supplements only if the
FDA issues a regulation allowing its use.
This is a multiyear process subject to
notice and comment, requiring a sub-
stantial amount of scientific data that the
FDA must evaluate.
Given the pressure on the FDA to
create a more immediate path for CBD
products, this route might simply take
too long. But there is a way that the FDA
can fulfill its public-health obligations
and meet the political demand for these
goods: It can approve the sale of some
CBD products immediately, while effect-
ing a framework for their safe and proper
regulation and a pathway for an enforce-
able market for these goods.
The FDA could put the onus on manu-
facturers to bring forward petitions to
demonstrate that CBD can be safely add-ed to products such as food. These sub-
missions can take the form of new dietary
ingredient notifications or food additive
petitions, which would include toxicity
studies to evaluate the safety of CBD.
These are the same standards any new
food ingredients are held to. Congress
can help by passing language saying that
the FDA doesn’t need to issue a broad
regulation on CBD and can instead rely
on petitions filed by individual, prospec-
tive producers.
In the meantime, the FDA could exer-
cise enforcement discretion to allow CBD
to be marketed in food so long as the
products meet certain conditions. These
criteria can include meeting good manu-
facturing requirements, demonstrating
traceability, adhering to safe levels for the
purity and potency of the CBD being
added, and demonstrating that CBD is
being added to food products only in very
low concentrations that are unlikely to
pose health risks.
In setting such a policy, the FDA could
make clear that any CBD products that
remain on the market — subject to a
limited period of enforcement discretion
— may not make any claims to treat
disease. Other claims — for example, that
it might help with relaxation — would
have to be substantiated with evidence.
This framework should also be expressly
unique to CBD. Otherwise, there’s a risk it
becomes a precedent for food and supple-
ment makers seeking a back door to add
other drugs to foods.
The FDA is being pushed by all sides to
act quickly. Meanwhile, responsible food-
makers waiting for regulators to address
the legal and safety considerations before
launching CBD products are being
eclipsed by unscrupulous purveyors. Ob-
ligating the industry to do the front end of
this scientific work — and sweeping the
market of those who won’t — could ad-
vance a safe path and help establish the
stable market for hemp-derived CBD
envisioned by lawmakers.The writer, a resident fellow at the
American Enterprise Institute, was the
23rd commissioner of the Food and Drug
Administration, from May 2017 to April 2019.
He consults with and invests in
biopharmaceutical companies.The CBD craze is getting out of hand
The city’s plight
is almost entirely a
Democrat-created disaster.
SIMON DAWSON/BLOOMBERG NEWS
A worker makes smoothies containing
cannabidiol, or CBD, at the Europe
CBD Expo in London on July 12.