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Donald Trump is a “con artist,” says Marco Rubio — who has promised to enact giant tax cuts, undertake a huge military buildup and balance the budget without any cuts in benefits to Americans over 55.

“There can be no evasion and no games,” thunders Paul Ryan, the speaker of the House — whose much-hyped budgets are completely reliant on “mystery meat,” that is, it claims trillions of dollars in revenue can be collected by closing unspecified tax loopholes and trillions more saved through unspecified spending cuts.

Oh, and it’s Ted Cruz, not Mr. Trump, who seems eager to “carpet bomb” people, without appearing to know what that means

Yes, he’s a con man, but they all are. So why is this con job different from any other? The answer, I’d suggest, is that the establishment’s problem with Mr. Trump isn’t the con he brings; it’s the cons he disrupts.

First, there’s the con Republicans usually manage to pull off in national elections — the one where they pose as a serious, grown-up party honestly trying to grapple with America’s problems. The truth is that that party died a long time ago, that these days it’s voodoo economics and neocon fantasies all the way down.

Equally important, the Trump phenomenon threatens the con the G.O.P. establishment has been playing on its own base. I’m talking about the bait and switch in which white voters are induced to hate big government by dog whistles about Those People, but actual policies are all about rewarding the donor class.

I find the prospect of a Trump administration terrifying, and so should you. But you should also be terrified by the prospect of a President Rubio, sitting in the White House with his circle of warmongers, or a President Cruz, whom one suspects would love to bring back the Spanish Inquisition.

we should actually welcome Mr. Trump’s ascent. Yes, he’s a con man, but he is also effectively acting as a whistle-blower on other people’s cons. That is, believe it or not, a step forward in these weird, troubled times.

most people primarily seek the approval of people in their own reference groups.

Acceptance within some circles is contingent on refusal to cooperate with the Biden administration’s public-health campaign. Getting vaccinated is a betrayal of that group norm, and those who get the shot can legitimately fear losing their job or incurring the wrath of their families and other reference groups.

Sociology solves mysteries like these by zeroing in on problematic relationships, not the decisions that individuals make in isolation

Having expressed doubts about COVID-19 vaccination or other pandemic mitigation likely makes Ivey and DeSantis more effective in persuading other conservatives: Their previous positions signify authenticity and in-group loyalty, making them more trustworthy, not less. High-status leaders such as Scalise, Ivey, Blunt, and DeSantis can expand the range of acceptable behavior for other group members through the example of their own actions.

The seminal text in the field—Erving Goffman’s 1952 essay “On Cooling the Mark Out”

all targets of con artists eventually come to understand that they have been defrauded, yet they almost never complain or report the crime to authorities. Why? Because, Goffman argues, admitting that one has been conned is so deeply shameful that marks experience it as a kind of social death.

people targeted by con jobs can save their pride by denying the con as long as possible—or claiming they were in on it the whole time. This saves face and cheats social death, but allows the con to continue unchecked, entrapping others.

con artists employ specialists to “cool” marks down when the deception is finally revealed. A cooler, he writes, “has the job of handling persons caught out on a limb—persons whose expectations and self-conceptions have been built up and then shattered.” Coolers prevent blowback from angry marks

a very distinctive type of relationship that sociologists have been studying for more than 70 years: the con job. Con artists gain social or financial advantage by convincing their marks to believe highly dubious claims—and to block out all information to the contrary.

The conservative coolers are finally on the case, and only they have a chance of transforming partisan vaccine refusers into vaccine adopters.

The point is that Trumpism was more or less fated to happen. Trump’s crude racism and blatant dishonesty are only exaggerated versions of what his party has been selling for decades, while his substantive policy agenda — slashing taxes on corporations and the wealthy, taking health care away from lower-income families — is utterly orthodox.

Here’s the third implication, which should scare you: The nature of the modern G.O.P.’s game gives it a bias against democracy. After all, one way to protect yourself against voters who figure out what you’re up to is to stop them from voting. Vote suppression and extreme gerrymandering are already key parts of Republican strategy, but what we’ve seen so far may be just the beginning.

What Donald Trump has been doing is telling the base that it can order à la carte. He has, in effect, been telling aggrieved white men that they can feed their anger without being forced to swallow supply-side economics, too

If there’s a puzzle here, it’s why this didn’t happen sooner. One possible explanation is the decadence of the G.O.P. establishment, which has become ingrown and lost touch. A

Probably more important, however, is the collision between demography and Obama derangement. The elite knows that the party must broaden its appeal as the electorate grows more diverse — in fact, that was the conclusion of the G.O.P.’s 2013 post-mortem. But the base, its hostility amped up to 11 after seven years of an African-American president (who the establishment has done its best to demonize) is having none of it.

The Republican establishment has been routed because it has been playing a con game on its supporters all along, and they’ve finally had enough.

One other small thing to note: More than a fifth of Americans, according to this survey, now speak a language other than English at home. In Nevada and Florida, nearly a third of residents don’t speak English at home.

very few previous waves of immigrants have been so homogeneous for as long as the Spanish-speaking immigrants from Mexico and Central America currently are; their numbers are higher than any other previous wave; and few have been so thoroughly dispersed.

the sheer scale of the cultural transformation of the last couple of decades — the CDC predicts that close to a quarter of Americans will be Hispanic by 2035 — is undeniable.

If you ignore that, or insist that worrying about too fast a pace of cultural change is inherently racist, it’s relatively easy to insist that there is no immigration crisis

if you believe that nations require some continuity and cultural unity to cohere and endure, then the picture is somewhat different. There is a reason this issue has become so prominent in this country. And it isn’t entirely bigotry.

What began as a revolutionary set of technologies ended up concentrating enormous private power over key services and locking in business models that come at extraordinary cost to our privacy and security.

The trajectory of the Web 2.0 era was not inevitable — it was instead shaped by a broad range of policy choices. And we now face another moment of choice. As the use of A.I. becomes more widespread, public officials have a responsibility to ensure this hard-learned history doesn’t repeat itself.

the Federal Trade Commission is taking a close look at how we can best achieve our dual mandate to promote fair competition and to protect Americans from unfair or deceptive practices.

we already can see several risks. The expanding adoption of A.I. risks further locking in the market dominance of large incumbent technology firms. A handful of powerful businesses control the necessary raw materials that start-ups and other companies rely on to develop and deploy A.I. tools. This includes cloud services and computing power, as well as vast stores of data.

Enforcers have the dual responsibility of watching out for the dangers posed by new A.I. technologies while promoting the fair competition needed to ensure the market for these technologies develops lawfully.

generative A.I. risks turbocharging fraud. It may not be ready to replace professional writers, but it can already do a vastly better job of crafting a seemingly authentic message than your average con artist — equipping scammers to generate content quickly and cheaply.

bots are even being instructed to use words or phrases targeted at specific groups and communities. Scammers, for example, can draft highly targeted spear-phishing emails based on individual users’ social media posts. Alongside tools that create deep fake videos and voice clones, these technologies can be used to facilitate fraud and extortion on a massive scale.

we will look not just at the fly-by-night scammers deploying these tools but also at the upstream firms that are enabling them.

these A.I. tools are being trained on huge troves of data in ways that are largely unchecked. Because they may be fed information riddled with errors and bias, these technologies risk automating discrimination

We once again find ourselves at a key decision point. Can we continue to be the home of world-leading technology without accepting race-to-the-bottom business models and monopolistic control that locks out higher quality products or the next big idea? Yes — if we make the right policy choices.

When confronted by the Donald Trump phenomenon, the American corporate news media was flummoxed by his disregard for facts, inconsistency and willingness to rapidly change his positions on a given issue, overt racism and bigotry of his followers and movement, fascism-fueled hostility and contempt for journalists, and utter disregard for the rules of normal politics.

On Monday’s edition of “CNN Tonight with Don Lemon,” New York Times columnist and author Charles Blow refused to comply with Donald Trump’s political con job and an American corporate news media that has acted irresponsibly in aiding and abetting his presidential campaign.

In social psychology, the bystander effect is a phenomenon whereby a group or crowd of people will often ignore an individual person who is in distress. This dynamic changes when a member of the crowd or group decides to render aid to the person in distress. Other people will then follow the new rule — what is now one of care and concern — instead of ignoring and looking away

On Monday’s edition of “CNN Tonight with Don Lemon,” Charles Blow established a new rule for how journalists and other commentators should interact with Donald Trump’s agents and rabble

The question now becomes, Will other members of the Fourth Estate follow Charles Blow’s lead and the new rule that he has tried to establish or will they continue to be supplicants for Donald Trump?

Trump also rebuffed criticism of his reliance on immigrant labor here and foreign labor abroad by arguing that “because nobody knows the system better than me…I’m the one that knows how to change it.

Trump recently acknowledged that he’s been milking the system for a very long time, but turned that, too, into an argument for his candidacy. “I’ve always been greedy. I love money, right?” he said. “But you know what? I want to be greedy for our country.”

attacks on Trump’s less-than-pristine ways of acquiring his wealth, which are designed to portray him as a sleazy, greedy profiteer, lead a lot of GOP voters, particularly his supporters, to say: “So Trump is a sleazy, greedy, profiteer? Good — please be sleazy, greedy and profiteering on my behalf.”

“Talents for low intrigue, and the little arts of popularity,” might suffice for someone to be elected to the governorship of a state, but not the presidency. Election would “require other talents, and a different kind of merit,” to gain “the esteem and confidence of the whole Union,” or enough of it to win the presidency. As a result, there would be “a constant probability of seeing the station filled by characters pre-eminent for ability and virtue.” This was the Framers’ goal in designing the system that would make “the choice of the person to whom so important a trust was to be confided.”

In a nutshell, while carrying out his official duties, a president has to put the country, not himself, first; he must faithfully follow and enforce the law; and he must act with the utmost care in doing all that.

can Trump do all that? Does his personality allow him to? Answering those questions doesn’t require mental-health expertise, nor does it really require a diagnosis. You can make the argument for Trump’s unfitness without assessing his mental health: Like James Fallows, for example, you could just ask whether Trump would have been allowed to retain any other job in light of his bizarre conduct

More than a diagnosis, what truly matters, as Lincoln’s case shows, is the president’s behavioral characteristics and personality traits. And understanding how people behave and think is not the sole province of professionals; we all do it every day, with family members, co-workers, and others.

its criteria for personality disorders—they don’t require a person to lie on a couch and confess his or her innermost thoughts. They turn on how a person behaves in the wild, so to speak.

Donald Trump, as president of the United States, is probably the most observable and observed person in the world. I’ve personally met and spoken with him only a few times, but anyone who knows him will tell you that Trump, in a way, has no facade: What you see of him publicly is what you get all the time, although you may get more of it in private

accounts of a person’s behavior from laypeople who observe him might be more accurate than information from a clinical interview, and that this is especially true when considering two personality disorders in particular—what the DSM calls narcissistic personality disorder and antisocial personality disorde

These two disorders just happen to be the ones that have most commonly been ascribed to Trump by mental-health professionals over the past four years. Of these two disorders, the more commonly discussed when it comes to Trump is narcissistic personality disorder, or NPD—pathological narcissism

it touches directly upon whether Trump has the capacity to put anyone’s interests—including the country’s and the Constitution’s—above his own.

A certain amount of narcissism is healthy, and helpful—it brings with it confidence, optimism, and boldness. Someone with more than an average amount of narcissism may be called a narcissist. Many politicians, and many celebrities, could be considered narcissists

“Pathological narcissism begins when people become so addicted to feeling special that, just like with any drug, they’ll do anything to get their ‘high,’ including lie, steal, cheat, betray, and even hurt those closest to them,”

The “fundamental life goal” of an extreme narcissist “is to promote the greatness of the self, for all to see,

To many mental-health professionals, Donald Trump provides a perfect example of such extreme, pathological narcissism: One clinical psychologist told Vanity Fair that he considers Trump such a “classic” pathological narcissist that he is actually “archiving video clips of him to use in workshops because there’s no better example”

The goal of a diagnosis is to help a clinician guide treatment. The question facing the public is very different: Does the president of the United States exhibit a consistent pattern of behavior that suggests he is incapable of properly discharging the duties of his office?

Even Trump’s own allies recognize the degree of his narcissism. When he launched racist attacks on four congresswomen of color, Senator Lindsey Graham explained, “That’s just the way he is. It’s more narcissism than anything else.” So, too, do skeptics of assigning a clinical diagnosis. “No one is denying,” Frances told Rolling Stone, “that he is as narcissistic an individual as one is ever likely to encounter.” The president’s exceptional narcissism is his defining characteristic—and understanding that is crucial to evaluating his fitness for office

The DSM-5 describes its conception of pathological narcissism this way: “The essential feature of narcissistic personality disorder is a pervasive pattern of grandiosity, need for admiration, and lack of empathy that begins by early adulthood and is present in a variety of contexts.”

The diagnostic criteria offer a useful framework for understanding the most remarkable features of Donald Trump’s personality, and of his presidency. (1) Exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements?

(2) Preoccupied with fantasies of unlimited success, power, brilliance

(3) Believes that he or she is “special” and unique and should only associate with other special or high-status people?

Trump claims to be an expert—the world’s greatest—in anything and everything. As one video mash-up shows, Trump has at various times claimed—in all seriousness—that no one knows more than he does about: taxes, income, construction, campaign finance, drones, technology, infrastructure, work visas, the Islamic State, “things” generally, environmental-impact statements, Facebook, renewable energy, polls, courts, steelworkers, golf, banks, trade, nuclear weapons, tax law, lawsuits, currency devaluation, money, “the system,” debt, and politicians.

(4) Requires excessive admiration? Last Thanksgiving, Trump was asked what he was most thankful for. His answer: himself, of course. A number of years ago, he made a video for Forbes in which he interviewed two of his children. The interview topic: how great they thought Donald Trump wa

(5) A sense of entitlement? (9) Arrogant, haughty behaviors? Trump is the man who, on the infamous Access Hollywood tape, said, “When you’re a star, they let you do it. You can do anything you want”—including grabbing women by their genitals. He’s the man who also once said, “I could stand in the middle of Fifth Avenue and shoot somebody and I wouldn’t lose any voters.”

(8) Envious of others? Here’s a man so unable to stand the praise received by a respected war hero and statesman, Senator John McCain, that he has continued to attack McCain months after McCain’s death;

(6) Interpersonally exploitative? Just watch the Access Hollywood tape, or ask any of the hundreds of contractors and employees Trump the businessman allegedly stiffed, or speak with any of the two dozen women who have accused Trump of sexual misconduct, sexual assault, or rape.

Finally, (7) Lacks empathy: is unwilling to recognize or identify with the feelings or needs of others? One of the most striking aspects of Trump’s personality is his utter and complete lack of empathy

The notorious lawyer and fixer Roy Cohn, who once counseled Trump, said that “Donald pisses ice water,” and indeed, examples of Trump’s utter lack of normal human empathy abound.

“It made no sense, Priebus realized, unless you understood … ‘The president has zero psychological ability to recognize empathy or pity in any way.’

What kind of human being, let alone politician, would engage in such unempathetic, self-centered behavior while memorializing such horrible tragedies? Only the most narcissistic person imaginable—or a person whose narcissism would be difficult to imagine if we hadn’t seen it ourselves. The evidence of Trump’s narcissism is overwhelming—indeed, it would be a gargantuan task to try to marshal all of it, especially as it mounts each and every day.

A second disorder also frequently ascribed to Trump by professionals is sociopathy—what the DSM-5 calls antisocial personality disorder

Central to sociopathy is a complete lack of empathy—along with “an absence of guilt.” Sociopaths engage in “intentional manipulation, and controlling or even sadistically harming others for personal power or gratification. People with sociopathic traits have a flaw in the basic nature of human beings … They are lacking an essential part of being human.” For its part, the DSM-5 states that the “essential feature of antisocial personality disorder is a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood.”

Trump’s sociopathic characteristics sufficiently intertwine with his narcissistic ones that they deserve mention here. These include, to quote the DSM-5, “deceitfulness, as indicated by repeated lying, use of aliases, or conning others.” Trump’s deceitfulness—his lying—has become the stuff of legend; journalists track his “false and misleading claims” as president by the thousands upon thousands.

Other criteria for antisocial personality disorder include “failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest”; “impulsivity or failure to plan ahead”; and “lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

As for impulsivity, that essentially describes what gets him into trouble most: It was his “impulsiveness—actually, total recklessness”—that came close to destroying him in the 1980s

And lack of remorse? That’s a hallmark of sociopathy, and goes hand in hand with a lack of human conscience. In a narcissistic sociopath, it’s intertwined with a lack of empathy. Trump hardly ever shows remorse, or apologizes, for anything. The one exception: With his presidential candidacy on the line in early October

In a way, Trump’s sociopathic tendencies are simply an extension of his extreme narcissism

articular, “They change reality to suit themselves in their own mind.” Although Trump “lies because of his sociopathic tendencies,” telling falsehoods to fool others, Dodes argues, he also lies to himself, to protect himself from narcissistic injury. And so Donald Trump has lied about his net worth, the size of the crowd at his inauguration, and supposed voter fraud in the 2016 election.

The latter kind of lying, Dodes says, “is in a way more serious,” because it can indicate “a loose grip on reality”—and it may well tell us where Trump is headed in the face of impeachment hearings. Lying to prevent narcissistic injury can metastasize to a more significant loss of touch with reality

Experts haven’t suggested that Trump is psychotic, but many have contended that his narcissism and sociopathy are so inordinate that he fits the bill for “malignant narcissism.” Malignant narcissism isn’t recognized as an official diagnosis; it’s a descriptive term coined by the psychoanalyst Erich Fromm, and expanded upon by another psychoanalyst, Otto Kernberg, to refer to an extreme mix of narcissism and sociopathy, with a degree of paranoia and sadism mixed in

In the view of some in the mental-health community, such as John Gartner, Trump “exhibits all four” components of malignant narcissism: “narcissism, paranoia, antisocial personality and sadism.”

Mental-health professionals have raised a variety of other concerns about Trump’s mental state; the last worth specifically mentioning here is the possibility that, apart from any personality disorder, he may be suffering cognitive decline.

His “mental state,” according to Justin A. Frank, a former clinical professor of psychiatry and physician who wrote a book about Trump’s psychology, “include[s] so many psychic afflictions” that a “working knowledge of psychiatric disorders is essential to understanding Trump.” Indeed, as Gartner puts it: “There are a lot of things wrong with him—and, together, they are a scary witch’s brew.”

when you line up what the Framers expected of a president with all that we know about Donald Trump, his unfitness becomes obvious. The question is whether he can possibly act as a public fiduciary for the nation’s highest public trust. To borrow from the Harvard Law Review article, can he follow the “proscriptions against profit, bad faith, and self-dealing,” manifest “a strong concern about avoiding ultra vires action” (that is, action exceeding the president’s legal authority), and maintain “a duty of diligence and carefulness”? Given that Trump displays the extreme behavioral characteristics of a pathological narcissist, a sociopath, or a malignant narcissist—take your pick—it’s clear that he can’t.

To act as a fiduciary requires you to put someone else’s interests above your own, and Trump’s personality makes it impossible for him to do that. No president before him, at least in recent memory, has ever displayed such obsessive self-regard

Indeed, Trump’s view of his presidential powers can only be described as profoundly narcissistic, and his narcissism has compelled him to disregard the Framers’ vision of his constitutional duties in every respect

Trump’s incapacity affects all manner of subjects addressed by the presidency, but can be seen most acutely in foreign affairs and national security.

All in all, Trump sought to impede and end a significant counterintelligence and criminal investigation—one of crucial importance to the nation—and did so for his own personal reasons. He did precisely the opposite of what his duties require. Indeed, he has shown utter contempt for his duties to the nation

hat constitutional mechanisms exist for dealing with a president who cannot or does not comply with his duties, and how should they take the president’s mental and behavioral characteristics into account?

it turns out that impeachment is a more practical mechanism

In short, now that the House of Representatives has embarked on an impeachment inquiry, one of the most important judgments it must make is whether any identified breaches of duty are likely to be repeated. And if a Senate trial comes to pass, that issue would become central as well to the decision to remove the president from office. That’s when Trump’s behavioral and psychological characteristics should—must—come into pla

One of the most compelling arguments about the meaning of those words is that the Framers, in Article II’s command that a president faithfully execute his office, imposed upon him fiduciary obligations. As the constitutional historian Robert Natelson explained in the Federalist Society Review, the “founding generation [understood] ‘high … Misdemeanors’ to mean ‘breach of fiduciary duty.’

Eighteenth-century lawyers instead used terms such as breach of trust—which describes the same thing. “Parliamentary articles of impeachment explicitly and repetitively described the accused conduct as a breach of trust,” Natelson argues, and 18th-century British legal commentators explained how impeachment for “high Crimes and Misdemeanors” was warranted for all sorts of noncriminal violations that were, in essence, fiduciary breaches.

why the discussion of Morris’s suggestion was so brief—the drafters knew what the words historically meant, because, as a House Judiciary Committee report noted in 1974, “at the time of the Constitutional Convention the phrase ‘high Crimes and Misdemeanors’ had been in use for over 400 years in impeachment proceedings in Parliament

Certainly Alexander Hamilton knew by the time he penned “Federalist No. 65,” in which he explained that impeachment was for “those offenses which proceed from the misconduct of public men, or, in other words, from the abuse or violation of some public trust.

What constitutes such an abuse or violation of trust is up to Congress to decide: First the House decides to bring impeachment charges, and then the Senate decides whether to convict on those charges. The process of impeachment by the House and removal by trial in the Senate is thus, in some ways, akin to indictment by a grand jury and trial by a petit jury

As Laurence Tribe and Joshua Matz explain in their recent book on impeachment, “the Constitution explicitly states that Congress may not end a presidency unless the president has committed an impeachable offense. But nowhere does the Constitution state or otherwise imply that Congress must remove a president whenever that standard is met … In other words, it allows Congress to exercise judgment.”

As Tribe and Matz argue, that judgment presents a “heavy burden,” and demands that Congress be “context-sensitive,” and achieve “an understanding of all relevant facts.” A president might breach his trust to the nation once in some small, inconsequential way and never repeat the misbehavior, and Congress could reasonably decide that the game is not worth the candle.

It’s also an appropriate mechanism, because the constitutional magic words (other than Treason and Bribery) that form the basis of an impeachment charge—high Crimes and Misdemeanors, found in Article II, Section 4 of the Constitution—mean something other than, and more than, offenses in the criminal-statute books. High Crimes and Misdemeanors is a legal term of art, one that historically referred to breaches of duties—fiduciary duties—by public officeholders. In other words, the question of what constitutes an impeachable offense for a president coincides precisely with whether the president can execute his office in the faithful manner that the Constitution requires.

there’s another reason as well. The people have a right to know, and a need to see. Many people have watched all of Trump’s behavior, and they’ve drawn the obvious conclusion. They know something’s wrong, just as football fans knew that the downed quarterback had shattered his leg. Others have changed the channel, or looked away, or chosen to deny what they’ve seen. But if Congress does its job and presents the evidence, those who are in denial won’t be able to ignore the problem any longer.

In just about every other consumer market you can think of, the Internet, by making prices instantly available and comparable, has resulted in prices that are lower, more uniform and more closely tied to costs. But in health care, where pricing remains opaque, prices are rising faster than inflation, faster than costs and faster than the incomes of the people paying for it

The new rules would require hospitals (and the doctors whose practices are owned by hospitals) to publish, in an easy-to-use format, their minimum and maximum rates for 300 common services, along with the amount the hospital is willing to accept from someone without insurance. The aim is to make it easier for uninsured patients, or insured patients with co-payments and deductibles, to shop around for the best value.

More controversial, however, is a second rule that would require health insurers to create an interactive website that would tell customers what their out-of-pocket cost would be for a service at any provider, whether in network or out, as well as the price it has negotiated for that service with in-network providers. The effect would be to let every hospital and insurer know the rates negotiated between every other hospital and insurer — rates that under current contracts must be kept secret.

Within minutes of these regulations being announced, the hospitals and the health insurers announced their opposition, warning the rules would result in higher prices for consumers

Their argument is that if negotiated rates were made transparent, then the hospitals offering the deepest discounts would feel compelled to stop doing so out of fear that they would be forced to offer similar discounts to all insurers. In highly consolidated hospital markets — which at this point describes two-thirds of the country — there is also concern that allowing hospitals to share price information would make it easier for them to tacitly collude and keep price competition to a minimum.

major hospital chains and insurance already have a pretty good sense where they stand relative to their competitors in terms of pricing. A number of firms — including one owned by United Healthcare, the nation’s largest insurer — already gather and analyze pricing data and sell it to both hospitals and insurers. The only parties who are really in the dark are the consumers and employers who ultimately pay the bills.

if it is true that transparency will lead the lowest-price hospitals to raise their bids, then logically it should be also true that it will lead the insurers now paying the highest prices to demand better deals. Given that the market for health insurance is now as consolidated as the market for hospital services, the possibility of collusion is high on both sides.

Indeed, if transparency has any effect on prices, the most likely outcome is to eliminate the outliers at both the top and bottom of the price range, reducing the enormous variations in prices. And to the degree that transparency causes average prices to move in any direction, the more likely direction is down, not up

Such a positive outcome is suggested from experience in New Hampshire, the first state to establish a website listing how much customers of different insurance plans would be charged at different hospitals and labs for medical imaging such as X-rays, CT scans and MRIs. Zach Brown, an economist at the University of Michigan, found that the cost of imaging declined by an average of 4 percent for insurers and 5 percent for consumers, rising to 11 percent after five years.

Statewide, the range between the highest and lowest negotiated prices shrunk by 15 percent.

In today’s highly consolidated health-care markets, the goal for hospitals and insurers isn’t so much to lower costs as to shift costs onto someone else. When dominant insurers use their market power to extract lower prices from hospitals, the hospitals’ natural response is to try to extract higher payments from smaller insurers to cover their costs and meet their profit targets.

As this cost-shifting plays itself out, small insurers and small hospitals find themselves squeezed as they are forced to pay more and charge less.

The dirty little secret is that neither side in these hospital-insurer negotiations really wants to drive down prices. What matters to either side is not what price they pay or receive in an absolute sense — in general, both hospitals and insurers profit more when prices and premiums are high. The thing they really care about is whether they are getting a better price than their competitors

The reason insurers and hospitals are prepared to use whatever legal muscle they have to fight price transparency is the same reason pharmaceutical companies and pharmacy benefit managers fought a similar proposal by the Trump administration on drug pricing — because it would expose this con game.

Given the anti-regulatory tilt of the federal courts, the inevitable legal challenge is likely to succeed. Which means the only way Americans are likely to get genuine price competition in health care is if transparency rules are written into law by a Congress not captured by business interests and free-market ideology.

That didn’t give me instant access to wealthier friends, but it was still a small-enough town that public school did.

Nearly all my acquaintances were better off. This meant that by sheer virtue of seeing how other kids acted in school and going to their homes, I saw what middle class looked like — what “better” was.

it was my friendship with one family that gave me a window into how I might attain it. Alison’s parents weren’t ostentatiously wealthy, but their lives held all the hallmarks of middle-class aspiration. Books, games and art projects were scattered around the family room; they read newspapers and magazines, and they discussed current events. They not only set a high bar for their children but also reinforced their children’s ability to meet it, daily. Good grades were a baseline. Extracurriculars were not optional. Success was treated as inevitable — not some lucky break, as it had been among my class of origin.

acting “right” was the secret sauce, and that was heavily dependent on knowing what was considered acceptable and unacceptable even in normal conversations with other people. They didn’t burp the alphabet, like my sister could, or tell crass jokes, like I did. Money wasn’t discussed.

So, I memorized these behaviors and ditched my poverty tells until I figured out my own values

Middle class meant napkins neatly folded in laps, pleases and thank yous unrolling sincerely and automatically.

my mother certainly did. But working two jobs and the exhaustion of raising four girls alone made those conditions impossible to create to the degree this two-parent family could.

Bringing up my con-man father whose name I didn’t even know, or the struggles of my less-educated kin? Not great table talk. Learning when not to talk was a big hurdle.

You can still catch me eating bologna, and no study would ever convince me that growing up poor was a loss when I consider the resilience and gratitude it imparted.

it didn’t take a good SAT score to notice what I was supposed to act like, dress like, talk like, and seem like to make those friends, to improve my lot. The sooner I accomplished that, the sooner I realized no one knew what class I grew up in — unless I told them.

I have no doubt it was critical to succeeding, but it’s still not easy to admit to myself the extent to which I was willing to happily join in on that erasure all on my own. For all the study’s merits, that’s a cost it did not seem able to account for.