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At the high end, the virus would add 20 percent or more to current costs of roughly $1.2 trillion a year.

Insurers and employers are already prodding Congress to consider helping them pay for the crisis by setting up a special reinsurance program that would cover the most expensive medical claims

While insurers have enjoyed strong profits in recent years, they say the cost of the pandemic could be overwhelming, especially to employers and workers already struggling to pay for coverage.

Employers and others have launched a new group, the Alliance to Fight for Health Care, that includes many of the same parties that worked together to defeat the enactment of the so-called Cadillac tax on high-cost employer plans

Mr. Lee warned that insurers are likely to seek rates that are double their additional costs from the virus. If their costs go up 20 percent, Mr. Lee says rates could jump as much as 40 percent in 2021.

He thinks his clients in New York, which is being particularly hard hit by the virus, could see additional costs of 4 to 5 percent. In other areas, if there are many fewer cases, costs could be less.

Rate increase requests still might be difficult for some states and consumers to swallow. The nation’s largest insurers, which include giant for-profit companies like Anthem, CVS Health and UnitedHealth, reported billions of dollars in profits last year, and analysts say these companies have abundant capital to absorb any losses because of the pandemic

Since the enactment of the Affordable Care Act, health care inflation has remained in the single digits.

Increases in medical costs of 3 to 4 percent “would be manageable by most insurers,” concluded a recent analysts at S&P Global Ratings

If costs were to go up by 10 to 12 percent, the analysts say the stress on the companies would be greater, with insurers reporting losses and forced to use their capital reserves to pay claims.

But some actuaries are predicting costs are likely to be much lower. One actuary said insurers have told him that they have no plans to raise rates sharply because the do not think the pandemic will change their predictions about ongoing medical expenses once it has run its course.

other actuaries are coming up with estimates that are lower because they have different assumptions about how many people might be hospitalized and whether that would be offset by the declines in medical care for other illnesses or surgeries as people stay home and elective procedures are postponed indefinitely

“These increased costs could mean that many of the 170 million Americans in the commercial market may lose their coverage and go without needed care as we battle a global health crisis,”

Another big unknown is whether people will be able to get treatment for Covid-19 or other illnesses, in spite of needing care.

If patients can’t get care, overall costs could be much lower than they would otherwise be,

Even then, how much the private sector will pay is unclear, especially if the government starts setting up hospital beds and temporary hospitals in various regions, and supplying staff to treat patients.

Another unknown factor is how much it will cost to treat those coronavirus patients who are hospitalized. “Everybody is still guessing what a coronavirus hospitalization stay looks like,”

While there are some estimates hovering around $20,000 for a hospital stay based on a typical pneumonia case, his group is estimating that the average could be closer to $72,000 for severe cases

Even in better times, this arrangement was a bad idea from a health perspective. Most Americans whose families depend on their employers for coverage are just a layoff away from being uninsured.

Many will sadly lose their jobs over the coming weeks – with one estimate projecting as many as 30%. And as they do, Americans are about to learn something horrifying: how irrational and irresponsible it is for so many to be dependent on employers for health insurance.

Take it from me. I’m a former health insurance executive who once profited from this system. It’s time for it to stop.

the cost of treatment for Covid-19 can run around $35,000. As the patient in the report exclaimed: “I was pretty sticker-shocked. I personally don’t know anybody who has that kind of money.”

During the last big recession, researchers at Cornell University found that 9.3 million Americans lost their health insurance between 2007 and 2009

During this time, roughly six in 10 Americans who lost their jobs became uninsured.

this problem compounds itself. If the reason you lost your health insurance is that you no longer have steady employment, how are you now going to be able to afford monthly premiums for some other private health care plan?

even in good times, the employer-based model fails to cover enough of us, with the number of Americans covered through an employer steadily dropping in general. Since 1999, the percentage of those with job-based coverage has declined by nine points.

at a time in our nation’s history where more will need quality care than ever before, the human cost will simply be too much to bear.

“Obviously it’s an improvement, but I think that it is inadequate given the health care crisis that we’re in,” said Representative Ro Khanna, a progressive Democrat from California who favors the single-payer, government-run system called Medicare for All that has been embraced by Senator Bernie Sanders, independent of Vermont, and the Democratic left.

“We’re in a national health care crisis,” Mr. Khanna said. “Fifteen million people just lost private health insurance. This would be the time for the government to say, at the very least, for those 15 million that we ought to put them on Medicare.”

The stimulus bill would make upper-middle-income Americans newly eligible for financial help to buy plans on the federal marketplaces, and the premiums for those plans would cost no more than 8.5 percent of an individual’s modified adjusted gross income. It would also increase subsidies for lower-income enrollees.

Just when Mr. Biden or Democrats would put forth such a plan remains unclear, and passage in an evenly divided Senate would be an uphill struggle. White House officials have said Mr. Biden wants to get past the coronavirus relief bill before laying out a more comprehensive domestic policy agenda.

The Affordable Care Act is near and dear to Mr. Biden, who memorably used an expletive to describe it as a big deal when he was vice president and President Barack Obama signed it into law in 2010. It has expanded coverage to more than 20 million Americans, cutting the uninsured rate to 10.9 percent in 2019 from 17.8 percent in 2010.

Even so, some 30 million Americans were uninsured between January and June 2020, according to the latest figures available from the National Health Interview Survey. The problem has only grown worse during the coronavirus pandemic, when thousands if not millions of Americans lost insurance because they lost their jobs.

Mr. Biden made clear when he was running for the White House that he did not favor Medicare for All, but instead wanted to strengthen and expand the Affordable Care Act. The bill that is expected to reach his desk in time for a prime-time Oval Office address on Thursday night would do that. The changes to the health law would cover 1.3 million more Americans and cost about $34 billion, according to the Congressional Budget Office.

Republicans have always said that their plan was to repeal and replace the health law, but after 10 years they have yet to come up with a replacement. Mr. Ayres said his firm is working on “coming up with some alternative health care message” that does not involve “simply throwing everybody into a government-run health care problem.”

Yet polls show that the idea of a government-run program is gaining traction with voters. In September, the Pew Research Center reported that over the previous year, there had been an increase, especially among Democrats, in the share of Americans who say health insurance should be provided by a single national program run by the government.

“I would argue there is more momentum for Medicare expansion given the pandemic and the experience people are having,” said Mr. Khanna, the California congressman. “They bought time, but I think at some point there will be a debate on a permanent fix.”

WASHINGTON — President Biden’s $1.9 trillion coronavirus relief bill will fulfill one of his central campaign promises, to fill the holes in the Affordable Care Act and make health insurance affordable for more than a million middle-class Americans who could not afford insurance under the original law.

Under the changes, the signature domestic achievement of the Obama administration will reach middle-income families who have been discouraged from buying health plans on the federal marketplace because they come with high premiums and little or no help from the government.

“For people that are eligible but not buying insurance it’s a financial issue, and so upping the subsidies is going to make the price point come down,” said Ezekiel Emanuel, a health policy expert and professor at the University of Pennsylvania who advised Mr. Biden during his transition.

But because those provisions last only two years, the relief bill almost guarantees that health care will be front and center in the 2022 midterm elections, when Republicans will attack the measure as a wasteful expansion of a health law they have long hated. Meantime, some liberal Democrats may complain that the changes only prove that a patchwork approach to health care coverage will never work.

The Affordable Care Act is near and dear to Mr. Biden, who memorably used an expletive to describe it as a big deal when he was vice president and President Barack Obama signed it into law in 2010. It has expanded coverage to more than 20 million Americans, cutting the uninsured rate to 10.9 percent in 2019 from 17.8 percent in 2010.

The poll found that 36 percent of Americans, and 54 percent of Democrats, favored a single national program. When asked if the government had a responsibility to provide health insurance, either through a single national program or a mix of public and private programs, 63 percent of Americans and 88 percent of Democrats said yes.

Just when Mr. Biden or Democrats would put forth such a plan remains unclear, and passage in an evenly divided Senate would be an uphill struggle. White House officials have said Mr. Biden wants to get past the coronavirus relief bill before laying out a more comprehensive domestic policy agenda.

Republicans have always said that their plan was to repeal and replace the health law, but after 10 years they have yet to come up with a replacement. Mr. Ayres said his firm is working on “coming up with some alternative health care message” that does not involve “simply throwing everybody into a government-run health care problem.”

In January, he ordered the Affordable Care Act’s health insurance marketplaces reopened to give people throttled by the pandemic economy a new chance to obtain coverage.

Yet polls show that the idea of a government-run program is gaining traction with voters. In September, the Pew Research Center reported that over the previous year, there had been an increase, especially among Democrats, in the share of Americans who say health insurance should be provided by a single national program run by the government.

With its expanded subsidies for health plans under the Affordable Care Act, the coronavirus relief bill makes insurance more affordable, and puts health care on the ballot in 2022.

cludes rich new incentives to entice the few holdout states — including Texas, Georgia and Florida — to finally expand Medicaid to those with too much money to qualify for the federal health program for the poor, but too little to afford private covera

“Biden promised voters a public option, and it is a promise he has to keep,” said Waleed Shahid, a spokesman for Justice Democrats, the liberal group that helped elect Representative Alexandria Ocasio-Cortez and other progressive Democrats. Of the stimulus bill, he said, “I don’t think anyone thinks this is Biden’s health care plan.”

“I think that argument has been fought and lost,” said Whit Ayres, a Republican pollster, conceding that the repeal efforts are over, at least for now, with Democrats in charge of the White House and both houses of Congress.

“This legislation is about giving the backbone of this nation — the essential workers, the working people who built this country, the people who keep this country going — a fighting chance,” Mr. Biden said in a statement. He said he looked forward to signing what he called a “historic piece of legislation” on Friday at the White House.

While Republicans argued the plan, whose final cost was estimated at $1.856 trillion, was bloated and unaffordable, surveys indicate that it has widespread support among Americans, with 70 percent of Americans favoring it in a Pew Research Center poll released this week.

Democrats fast-tracked their own measure through the House and Senate without pausing to court Republican support. They stayed remarkably united in doing so, with just one Democrat, Representative Jared Golden of Maine, voting against the final measure.

“This is the most consequential legislation that many of us will ever be a party to,” Speaker Nancy Pelosi of California said at a news conference after the bill’s passage. “On this day, we celebrate because we are honoring a promise made by our president, and we join with him in promising that help is on the way.”

“I’m not going to vote for $1.9 trillion just because it has a couple of good provisions,” he later told reporters.

Economists widely agree that the $787 billion stimulus law that resulted, which attracted scant Republican support anyway, was too small to address the crisis, and Democrats lost the House in the following midterm elections.

“The American people are going to see an American comeback this year,” said Senator Mitch McConnell of Kentucky, the minority leader, “but it won’t be because of this liberal bill.”

The stimulus payments would be $1,400 for most recipients.

Buying insurance through the government program known as COBRA would temporarily become a lot cheaper. COBRA, for the Consolidated Omnibus Budget Reconciliation Act, generally lets someone who loses a job buy coverage via the former employer. But it’s expensive: Under normal circumstances, a person may have to pay at least 102 percent of the cost of the premium. Under the relief bill, the government would pay the entire COBRA premium from April 1 through Sept. 30. A person who qualified for new, employer-based health insurance someplace else before Sept. 30 would lose eligibility for the no-cost coverage. And someone who left a job voluntarily would not be eligible, either.

There would be a big one for people who already have debt. You wouldn’t have to pay income taxes on forgiven debt if you qualify for loan forgiveness or cancellation — for example, if you’ve been in an income-driven repayment plan for the requisite number of years, if your school defrauded you or if Congress or the president wipes away $10,000 of debt for large numbers of people. This would be the case for debt forgiven between Jan. 1, 2021, and the end of 2025.

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.

Largely an office procedure when widespread screening was first recommended, colonoscopies have moved into surgery centers — which were created as a step down from costly hospital care but are now often a lucrative step up from doctors’ examining rooms — where they are billed like a quasi operation.

The high price paid for colonoscopies mostly results not from top-notch patient care, according to interviews with health care experts and economists, but from business plans seeking to maximize revenue; haggling between hospitals and insurers that have no relation to the actual costs of performing the procedure; and lobbying, marketing and turf battles among specialists that increase patient fees.

While several cheaper and less invasive tests to screen for colon cancer are recommended as equally effective by the federal government’s expert panel on preventive care — and are commonly used in other countries — colonoscopy has become the go-to procedure in the United States. “We’ve defaulted to by far the most expensive option, without much if any data to support it,”

Hospitals, drug companies, device makers, physicians and other providers can benefit by charging inflated prices, favoring the most costly treatment options and curbing competition that could give patients more, and cheaper, choices. And almost every interaction can be an opportunity to send multiple, often opaque bills with long lists of charges: $100 for the ice pack applied for 10 minutes after a physical therapy session, or $30,000 for the artificial joint implanted in surgery.

Even doctors often do not know the costs of the tests and procedures they prescribe. When Dr. Michael Collins, an internist in East Hartford, Conn., called the hospital that he is affiliated with to price lab tests and a colonoscopy, he could not get an answer. “It’s impossible for me to think about cost,” he said

The more than $35,000 annually that Ms. Yapalater and her employer collectively pay in premiums — her share is $15,000 — for her family’s Oxford Freedom Plan would be more than sufficient to cover their medical needs in most other countries. She and her husband, Jeff, 63, a sales and marketing consultant, have three children in their 20s with good jobs. Everyone in the family exercises, and none has had a serious illness.

A major factor behind the high costs is that the United States, unique among industrialized nations, does not generally regulate or intervene in medical pricing, aside from setting payment rates for Medicare and Medicaid, the government programs for older people and the poor. Many other countries deliver health care on a private fee-for-service basis, as does much of the American health care system, but they set rates as if health care were a public utility or negotiate fees with providers and insurers nationwide, for example.

“In the U.S., we like to consider health care a free market,” said Dr. David Blumenthal, president of the Commonwealth Fund and a former adviser to President Obama. ”But it is a very weird market, riddled with market failures.”

Consumers, the patients, do not see prices until after a service is provided, if they see them at all. And there is little quality data on hospitals and doctors to help determine good value, aside from surveys conducted by popular Web sites and magazines. Patients with insurance pay a tiny fraction of the bill, providing scant disincentive for spending.

The United States spends about 18 percent of its gross domestic product on health care, nearly twice as much as most other developed countries. The Congressional Budget Office has said that if medical costs continue to grow unabated, “total spending on health care would eventually account for all of the country’s economic output.”

Instead, payments are often determined in countless negotiations between a doctor, hospital or pharmacy, and an insurer, with the result often depending on their relative negotiating power. Insurers have limited incentive to bargain forcefully, since they can raise premiums to cover costs.

“People think it’s like other purchases: that if you pay more you get a better car. But in medicine, it’s not like that.”

"They don't have a massive eraser pen. They've got to go through the rule-making process," said Allison Orris, a former Obama administration official and counsel with Manatt Health, a professional services firm. "They are going to have to think about what comes first, second and third and be realistic about timing."

Plus, the Biden administration may opt to keep and continue several Trump administration efforts, including shifting to value-based care, rather than paying doctors for every visit and procedure, and increasing access to telehealth,

The two administrations also share common views on some measures to lower drug pricing, including basing Medicare payments on the cost of prescription medications in other countries and importing drugs from abroad. But Trump officials have not actually put these proposals in place.

While Trump focused on dismantling the Affordable Care Act, Biden will emphasize expanding the law and access to health coverage.

The Trump administration took the historic step in early 2018 of allowing states to require certain Medicaid recipients to work in order to receive benefits. Eight states have received approval, seven have pending requests and four had their waivers set aside in court, according to the Kaiser Family Foundation.

Biden's Health and Human Services secretary would be able to unwind the approvals, but it is a complicated task, said Joan Alker, executive director of the Center for Children and Families at Georgetown University. The secretary would have to determine whether to withdraw permission for the entire waiver or just certain features.

Several of these waivers included other provisions that could make it harder for low-income Americans to retain Medicaid coverage, such as lockouts for non-payment of premiums.

One executive order Trump repeatedly points to is expanding short-term health plans, which typically have lower premiums, but provide less comprehensive coverage and don't have to adhere to the Affordable Care Act's protections for people with pre-existing conditions.

"The short-term plans have important symbolic significance because they restrict coverage to people with pre-existing conditions, which was a prominent political issue in the campaign," said Larry Levitt, executive vice president for health policy at the Kaiser Family Foundation.

In its first year in office, the Trump administration slashed funds to promote Obamacare open enrollment and to assist consumers with selecting plans by 90% and 84%, respectively.

The Biden administration is expected to reverse all these measures to curtail Obamacare.

Biden has promised to revoke the Trump administration rule barring federally funded health care providers in the Title X family planning program from referring patients for abortions.

Biden has vowed to reverse the so-called Mexico City Policy, a ban on funding for foreign nonprofits that perform or promote abortions, which Trump reinstated and expanded during his tenure.

The Trump administration reinstated the measure -- which had previously impacted only family planning assistance -- in 2017 by presidential memorandum and extended it to all applicable US global health funding under the "Protecting Life in Global Health Assistance."

The Biden administration is also expected to reinstitute a directive that states cannot bar Medicaid funds from going to qualified providers that separately provide abortions, such as Planned Parenthood.

Trump also signed a bill in 2017 allowing states to withhold federal money from organizations that provide abortion services, including Planned Parenthood.

The Trump administration has been particularly hostile toward transgender Americans. Among its most criticized moves was an effort earlier this year to rollback an Obama-era regulation prohibiting discrimination in health care against patients who are transgender.

Biden's LGBTQ policy plan also says he will work to expand funding for mental health services for LGBTQ Americans and that his administration plans to automatically enroll low-income LGBTQ people in the public option, once it's created, if they live in rural areas in states that didn't expand Medicaid.

In any case, the fear of nuclear war has been around since the time of Hiroshima, but also, there are other fears. If we don’t get climate policy right, will we all be cooked? Or will climate-induced disruptions lead to great power war, nuclear conflict? Will changing technology — the AIs — take over? Whatever, we live in a time of existential fear, and foreign policy and all kinds of national policy questions get invested with these ultimate questions.

What makes democracy work under those circumstances tends to be senses of identification with elites, with different social-political groups. The glue that holds a democratic society — the cultural glue, intellectual glue, spiritual glue — becomes much more important

In terms of mass societies and democracies and large cultural groups, it’s profoundly destabilizing. You have that problem, that existential fear, which some people respond to by denial, some people fall into extremism — lots of responses, but you can see that.

Then the other thing is that, in a large democratic society like ours — 300-plus million people — if political power was divided equally among all 300 million Americans, it would mean that no one had any power.

Politics is less about, if we raise the sales tax half a percent, is that a good thing or a bad thing on balance? It’s more about, can we save the planet? Can we save human civilization? When people face those kinds of questions without some kind of grounding in some kind of religion, faith, it’s actually . . . There are individual people who can keep their psychological balance in the face of that. There are not many.

The American political-studies belief since World War II has essentially been, democracy is the only stable form of government. Everywhere democracy is inexorably rising, and every other form of government is incredibly unstable. This bears very, very little relationship to the facts outside of Western Europe, let’s say the world of NATO plus Japan and Australia.

to do foreign policy well

Which American president has best understood the Middle East, and then worst? MEAD: Interesting. Nobody’s gotten it totally. I’d say George H.W. Bush and Richard Nixon probably are the two, in my mind, who best understood what they were dealing with.

COWEN: What is it they had that maybe the others didn’t? MEAD: What they saw in the Middle East is that America has both hard-power goals and what you could call soft-power, idealistic goals in the Middle East, that our hard-power goals are vital, and they are achievable. Our soft-power goals are important but largely unachievable. What they did was, they set about dealing with what was essential, and they both did it pretty successfully.

The American academy is actually a terrible place for coming to understand how world politics works.

COWEN: Sorry. Is Germany still part of the Western Alliance? MEAD: Well, in the sense it’s been for some time. I remember that Kennan’s goal for Germany was to have a united, neutral, disarmed Germany at the heart of Europe. In some ways, [laughs] Kennan’s goal looks, maybe, closer than ever.

Look, I think Germany is a country whose basic economic model is now under question. The German model — and it’s very important in understanding that country — is based on the availability of cheap energy from Russia and large markets in China.

Again, let’s remember that the German establishment is more terrified of ordinary German public opinion than even the American liberal establishment is terrified of the Trumpists. You don’t have to look all that deeply into history to see why that would be the case. Providing stability, affluence, and employment for the mass of the German people is a key test of the legitimacy of the German state.

Really, ever since we failed to break up the large German corporations after World War II, that German establishment has been the motor of the astonishing success of postwar Germany. Now, suddenly, that engine is running out of fuel on the one hand, and its key customer, China, regardless of anything about human rights or geopolitics, the goal of the Chinese economic development strategy is to end its dependency on capital goods imported from countries like Germany by becoming an exporter of high-tech capital goods.

China’s development plans, much more than its Taiwan policy or its human rights, is a gun pointed at the head of German business. So, where do they go? It’s not clear where they go. I don’t think it’s clear to them where they go. That means that a fundamental element of the American alliance system is in a completely new place.

I think what we have to be doing in terms of analyzing where German foreign policy goes is to think a little bit less about ideology or things like the German anti-war sentiment or these kinds of things. Yes, these are all there, the Russian soul, all of that. It’s there, but really, how is Germany going to make a living? That’s the question that has to be answered, and that will drive Germany’s orientation in foreign policy.

I think, in our society, the ebbing of religion among some, certainly not all, Americans has tended to dissolve these bonds and leads, in all kinds of ways, both on the left and the right, to some of the sense of suspicion, of paranoia, a lack of trust, and declining support for democracy.

COWEN: How would you describe that advantage? MEAD: I don’t really believe in disciplines. I see connections between things. I start from reality. I’m not trying to be anti-intellectual here. You need ideas to help you organize your perceptions of reality. But I think there’s a tendency in a lot of social science disciplines — you start from a bunch of really smart, engaged people who have been thinking about a set of questions and say, “We’ll do a lot better if we stop randomly thinking about everything that pops up and try, in some systematic way, to organize our thinking of this.”

I think you do get some gains from that, but you see, over time, the focus of the discipline has this tendency to shift. The discipline tends to become more inward navel-gazing. “What’s the history of our efforts to systematize our thinking about this?” The discipline becomes more and more, in a sense, ideological and internally focused and less pragmatic.

I think that some of the problem, though, is not so much in the intellectual weaknesses of a lot of conventional postgrad education, but simply almost the crime against humanity of having whole generations of smart people spend the first 30, 35 years of their lives in a total bubble, where they’re in this academic setting, and the rule . . . They become socialized into the academy, just as much as prisoners get socialized into the routines of a prison.

COWEN: Do you think of it as an advantage that you don’t have a PhD? MEAD: Huge advantage.

COWEN: For our final segment, a few questions about the Walter Russell Mead production function. How much did growing up in South Carolina influence your views on foreign policy? MEAD: I think it’s affected my views of America, and that, in turn, affects my views. Growing up in the segregated South during the civil rights era, where, on the one hand, my father actually knew Martin Luther King and marched with him and was involved in a lot of things; but then I had relatives, older relatives who were very much on the other side. That gave me a certain sense of I could love my grandfather even though he voted for George Wallace.

MEAD: Yes. All right. The fact that I could love him while really disliking his politics helps me understand . . . I think it helps understand some of the divisions in America even today and gives you a more human rather than a strictly ideological look.

But there’s also this: that the South and the White South — which, of course, is where I come from — has had the experience of both being defeated and being wrong. That’s something that a lot of American political culture doesn’t have — your WASP Yankee patricians. I think neoconservatism reflected a sense of people who’ve never been wrong and never been beaten, at least in their own minds. There’s a hubris that comes with that.

Historically, one of the roles of Southern politics — think of William Fulbright during the Vietnam War — both for good and bad reasons, doubt that this American ideological project can be transferred, partly because they know America is bad at reconstruction. The failure of reconstruction, both in terms of the White South and the Black South after the Civil War, is a lesson that you get growing up in the South. And so you have an inherent sense of the limits of America’s ability to transform societies. That’s important.

COWEN: Your foreign policy understanding — what did it learn from going to Groton?

MEAD: Well, I learned a lot there. On the one hand, Groton is a place that prides itself on its tradition of producing foreign policy leaders: Dean Acheson, the Allsopp brothers, Averell Harriman, Franklin Roosevelt. That wonderful book, The Wise Men by David Halberstam — actually, my history teacher is in there. There’s a whole scene that could be from our fourth-form 10th-grade history class.

You got the sense of being part of a tradition, and you got the inside view. The way we were taught American history was in no way idealized. Just, say, reading something like the 1619 Project didn’t come to me as a shock. “Oh my gosh, there was slavery, there was injustice in America.”

In fact, one of the teachers at Groton used to take aside some of the boys — it was an all-boys school at the time — and explain to them how their family fortune was made. He might say, “Well, George, we’ve been reading a lot about war profiteers in World War I. You need to know that your grandfather . . .” Et cetera, et cetera. Unfortunately, none of my grandparents had participated in such things, so there was no need to explain to me the family fortune, as there wasn’t one.

More than that, though, I was at Groton ’65 to ’70. Those were the years of the Vietnam War. The national security adviser at the time, McGeorge Bundy, was the chair of the Groton Board of Trustees, so I had a close-up look at the aggressive self-confidence of the WASP establishment meeting the Vietnam War and beginning to come to grips with what was going wrong.

Those two visions of the inner workings of the American foreign policy elite, and then the ringside seat at the crisis of the old American foreign policy elite, have been profoundly important in my thinking about the world.

COWEN: You meet young people all the time. How do you spot the next Walter Russell Mead? What do you look for?

MEAD: Well, first of all, I’m hoping for somebody who’s a lot better than me. I’m looking for someone — what is it? Whose sandals I am unworthy to buckle. And I would say that I look for, first of all, curiosity, intense curiosity. I look for an understanding that the personal and the political are mixed, that character matters. You can learn about the world by coming to understand your own psychological flaws and distress, and vice versa.

That history matters a lot, and that you can’t know too much history. Now, you have to digest it, but you can’t know too much history. A hunger for travel. I think too many foreign policy types don’t actually get out into the field nearly as much as they should. Curiosity about other cultures. A strong grounding in a faith of your own, which can be a secular ideology, perhaps, in some cases, but more often is likely to be a great religious tradition of some kind.

I’m a Christian. I could wish that everyone was, but my friend Shadi Hamid is a Muslim, and I think his Muslim faith actually helps him navigate and understand the world, and I certainly have lots of Jewish friends in the same circumstance. Again, we’re ending up where we started, maybe, but a religious faith, connected to one of the great historical traditions, gives you a degree of insight and potential for self-criticism that are absolutely crucial to foreign affairs.

Over the next several hours, militants rampaged through around two dozen Israeli towns—killing, looting, burning, kidnapping, and reportedly raping civilians. They managed to penetrate as far as Ofakim, 20 miles into Israel. They effectively controlled several main roads, on which they gunned down passing traffic. It took the IDF 6 hours to begin seriously engaging the militants. 18 hours after the incursion began, fighting was taking place in 22 spots. It took over 48 hours before the last of the major clashes with this first wave of the militants’ incursion was over and the militants neutralized.

In total, as of the morning of October 11th, over 1,200 Israelis are confirmed killed, almost 3,000 wounded (hundreds critically), and somewhere between 100 and 150 kidnapped, including whole families with toddlers and senior citizens.

For months, Netanyahu has been cautioned that his divisive “governance reforms” represented a reckless gamble with the country’s national security. He received numerous private (and then public) warnings from every major security chief that his policies were eroding IDF preparedness and provoking Israel’s enemies to test its readiness. Netanyahu ignored, dismissed, or ridiculed every one of these warnings. He and his acolytes have systematically castigated those who voiced concern as disloyal “agents of the deep state” or, worse, “leftist traitors.”

The events of October 7th represented a colossal intelligence failure. With or without substantial Iranian assistance, it is now clear that Hamas had been preparing the attack for over a year. Astonishingly, it apparently did so without major leaks. The few tell-tale signs of an impending attack that did surface appear to have been ignored.

Taken by surprise, and made to fight for their lives in understaffed outposts, the IDF was operationally incapable of adequately responding to the militants’ land maneuver. Unarmed civilians were left to fend for themselves for long hours, with horrific consequences.

What will make October 7th uniquely egregious in the eyes of many Israelis (perhaps most) is the fact that events of this sort were not only reasonably foreseeable but were repeatedly foreseen and repeatedly ignored by Israel’s current leadership.

at least 950 Palestinians have been killed in retaliatory IAF air strikes.

As long as Israel faces immediate danger, all hands will be on deck and party politics largely put aside.

As long as the emergency continues, therefore, Netanyahu won’t have to face the pressure of public protests against his program to weaken the Israeli judiciary.          

But in the longer term, it is difficult to see how Netanyahu, the great political survivor, will survive the events of October 7th. His reputation as “Mr. Security” is in tatters and it is impossible to see how it could possibly recover.

Analysts keen to convey the magnitude of October 7th to American audiences have already tagged it Israel’s Pearl Harbor or 9/11. Neither label adequately captures the day’s true significance.

A more accurate name might be something like “Israel’s civic Yom Kippur.” Why? Because the very existence of the State of Israel was supposed to guarantee that a day like this would never happen. In the Yom Kippur War of October 1973—when Egypt and Syria launched a surprise assault—Israel lost some 2,700 soldiers, but it managed to effectively protect its civilian population. No Israeli towns or villages were ever breached. The social contract was honored, albeit at a terrible price.

On October 7, 2023, it was primarily civilians who were killed, maimed, and kidnapped. This was the day when the IDF wasn’t there to defend the people it was created to protect. This was the day when—livestreamed on social media—distraught family members saw their loved ones carried away, like livestock, into Hamas captivity in Gaza. This was the day when—in a horrifying echo of the Holocaust—defenseless Jewish mothers, citizens of a sovereign Jewish State, tried to keep their babies from crying as armed men lurked outside, listening to ascertain whether anyone was alive inside the home, before setting it on fire.

many Israelis, already mistrustful of their elected representatives and worn out by internal divisions, may have finally lost faith in their national leaders or, worse, in the core institutions of their nation state. Where was the army when murderous gunmen broke into our homes deep inside Israel itself?

Fifty years ago, in the aftermath of the 1973 Yom Kippur War, Israel appeared broken, internally torn, and internationally isolated. Yet, it proved itself remarkably resilient. Can Israel gather itself again from the terrible blow it sustained on October 7th? I have no doubt that it can.

The COVID vaccines are, without exaggeration, among the safest and most effective therapies in all of modern medicine. An unvaccinated adult is an astonishing 68 times more likely to die from COVID than a boosted one

Yet widespread vaccine hesitancy in the United States has caused more than 163,000 preventable deaths and counting

Even in absolute numbers, America’s unvaccinated and current-smoker populations seem to match up rather well: Right now, the CDC pegs them at 13 percent and 14 percent of all U.S. adults, respectively, and both groups are likely to be poorer and less educated.

Countries such as Denmark and Sweden have already declared themselves broken up with COVID. They are confidently doing so not because the virus is no longer circulating or because they’ve achieved mythical herd immunity from natural infection; they’ve simply inoculated enough people.

data suggest that most of the unvaccinated hold that status voluntarily at this point

The same arguments apply to tobacco: Smokers are 15 to 30 times more likely to develop lung cancer. Quitting the habit is akin to receiving a staggeringly powerful medicine, one that wipes out most of this excess risk.

If everyone who is eligible were triply vaccinated, our health-care system would be functioning normally again.

With a vaccination timeline that stretches over years, our patience for restrictions, especially on the already vaccinated, will be very limited. But there is middle ground. We haven’t banned tobacco outright—in fact, most states protect smokers from job discrimination—but we have embarked on a permanent, society-wide campaign of disincentivizing its use.

We should neither expect that every stubbornly unvaccinated person will get jabbed before next winter nor despair that none of them will ever change their mind. Let’s accept instead that we may make headway slowly, and with considerable effort

Long-term actions for COVID might include charging the unvaccinated a premium on their health insurance, just as we do for smokers, or distributing frightening health warnings about the perils of remaining uninoculated

And once the political furor dies down, COVID shots will probably be added to the lists of required vaccinations for many more schools and workplaces.

nother aspect of where we’re headed with COVID. Tobacco is lethal enough that we are willing to restrict smokers’ personal freedoms—but only to a degree. As deadly as COVID is, some people won’t get vaccinated, no matter what, and both the vaccinated and unvaccinated will spread disease to others.

anti-COVID actions, much like anti-smoking policies, will be limited not by their effectiveness but by the degree to which they are politically palatable.

Without greater vaccination, living with COVID could mean enduring a yearly death toll that is an order of magnitude higher than the one from flu.

this, too, might come to feel like its own sort of ending. Endemic tobacco use causes hundreds of thousands of casualties, year after year after year, while fierce public-health efforts to reduce its toll continue in the background. Yet tobacco doesn’t really feel like a catastrophe for the average person.

Losing a year or two from average life expectancy only bumps us back to where we were in … 2000.

We still care for smokers when they get sick, of course, and we reduce harm whenever possible. The health-care system makes $225 billion every year for doing so—paid out of all of our tax dollars and insurance premiums

Hospitals have a well-honed talent for transforming any terrible situation into a marketable “center of excellence.”

But we shouldn’t forget the most important reason that the coronavirus isn’t like the flu: We’ve never had vaccines this effective in the midst of prior influenza outbreaks, which means we didn’t have a simple, clear approach to saving quite so many lives. Compassionate conversations, community outreach, insurance surcharges, even mandates—I’ll take them all. Now is not the time to quit.

The low-income, middle-income and high-income health systems have extremely different problems. You know, in low-income countries, getting to a health post is hard. It’s very expensive. Whereas in rich countries, yes, you can get to your doctor. In low-income countries, the main problems you have is infectious diseases. We’re dealing with countries that in the worst case where kids have death rates of 20 percent and that’s all infectious disease. And nothing else. In the U.S., in terms of kids under 5, other than premature birth, you really don’t have big problems. Kids just don’t die of infectious disease.

in the U.S., what do people die of? From age 5 till age 50, you’ve got suicide, you’ve got traffic accidents. There’s very little cancer and heart disease before age 50.

what’s a year of life worth? They call it a disability-adjusted life year (DALY). When you’re running a poor country health-care system, you can’t treat a year of life as being worth more than, say, $200, $300 or else you’ll bankrupt your health system immediately. So, with very few exceptions, you do nothing for cancer. If you get cancer, you’re going to die. And so none of the stuff that’s going on in the U.S. about $300,000 a year chemotherapy drugs is relevant.

If you spend the less than 2 percent of what the rich countries spend, but you spend it on vaccinations and antibiotics, you get over half of all that healthcare does to extend life. So you spend 2 percent and you get 50 percent. If you spend another 80 percent you’re at over 90 percent.

in rich-world health, innovation is both your friend and your enemy. Innovation is inventing organ replacement, joint replacement. We’re inventing ways of doing new things that cost $300,000 and take people in their 70s and, on average, give them an extra, say, two or three years of life. And then you have to say, given finite resources, should we fire two or three teachers to do this operation? And with chemotherapies, we’ve got things where we’ll spend our dollars on treatments where you’re valuing a life here at over $10 to $20 million. Really big, big numbers, which if you were infinitely rich, of course that would be fine. So most innovations, unfortunately, actually increase the net costs of the healthcare system. There’s a few, particularly having to do with chronic diseases, that are an exception. If you could cure Alzheimer’s, if you could avoid diabetes — those are gigantic in terms of saving money. But the incentive regime doesn’t favor them.

We’re very uncomfortable putting a value on human life. The way I see our health system is we’ve chosen to pay a huge premium in order to avoid these questions. A prerequisite for the kind of cost-cutting innovations you’re talking about it is being willing to make judgments about what a human life is worth, or even what a few months of a human life are worth. Because if you can’t decide that, then of course you just pay for everything. But if you start trying to make those choices, or even get people to think about those choices, people cry “death panels!”

BG. Yes, someone in the society has to deal with the reality that there are finite resources and we’re making trade-offs, and be explicit about that. When the car companies were found to have a memo that actually said, “This safety feature costs X and saved Y lives,” the very existence of that memo was considered damning. It was “Oh, you think human life is only a bank account.” Or when you made it reimbursable for a doctor to ask, “Do you want heroic care at the end-of-life,” that was a death panel. No, it wasn’t a death panel! It was asking somebody to make a decision.

There’s also a pleasing simplicity to the causes of the growing gap between the 1 and the 99. There are only two, and both are familiar liberal targets: the rise of a deregulated financial sector and the erosion of accountability in compensating top executives outside finance

On those rare occasions when conservatives do bring it up, it’s the skills-based gap that usually draws their attention, because it offers an opportunity to criticize our government-run system of public education and especially teachers’ unions.

Liberals resist talking about the skills-based gap because they don’t want to tell the working classes that they’re losing ground because they didn’t study hard enough. Liberals prefer to focus on the 1 percent-based gap.

Conceiving of inequality as something caused by the very richest people has obvious political appeal, especially since (by definition) nearly all of us belong to the 99 percent.

One reason the left plays down the growing skills-based gap is that it accepts at face value the conservative claim that educational failure is its root cause.

both represent a dramatic reversal of economic trends that prevailed in the United States for most of the 20th century. From the 1930s through the 1970s the 1 percent saw its share of national income decline, while the “college premium” either fell or followed no clear up-or-down pattern over time.

Since 1979 the income gap between people with college or graduate degrees and people whose education ended in high school has grown. Broadly speaking, this is a gap between working-class families in the middle 20 percent (with incomes roughly between $39,000 and $62,000) and affluent-to-rich families (say, the top 10 percent, with incomes exceeding $111,000)

Another reform both conservatives and liberals have supported — though at different times — is withholding federal aid from colleges and universities that can’t control tuition increases

THERE is also more bipartisan support than you might suppose for restricting some of the Wall Street excesses that enrich the 1 percent.

a growing chorus of conservative voices, including the columnist George F. Will, the former Utah governor Jon M. Huntsman Jr. and Richard W. Fisher, president of the Federal Reserve Bank of Dallas, favor breaking up the big banks.

At least some of the tools to restore these more egalitarian trends shouldn’t be divisive ideologically. Liberals and conservatives both recognize the benefits of preschool education,

But the decline of labor unions is just as important. At one time union membership was highly effective at reducing or eliminating the wage gap between college and high school graduates. That’s much less true today

Only about 7 percent of the private-sector labor force is covered by union contracts, about the same proportion as before the New Deal. Six decades ago it was nearly 40 percent.

Although conservatives often insist that the 1 percent’s richesse doesn’t come out of the pockets of the 99 percent, that assertion ignores the fact that labor’s share of gross domestic product is shrinking while capital’s share is growing

the G.D.P. shift from labor to capital explains fully one-third of the 1 percent’s run-up in its share of national income.

Trump donated just $31,000 to his campaign in early October despite promises to give up to $100 million to his campaign, according to a fundraising report filed Thursday. He has only donated $56 million to his race as of October 20.

The drumbeat of WikiLeaks disclosures yielded material to lambast Hillary Clinton and her family's foundation. And news of rising Obamacare premiums gave him an opening to criticize President Barack Obama's legacy that Clinton is running to inherit.

But 11 days before the election, Trump is down six points in CNN's Poll of Polls. His path to the 270 electoral votes needed to capture the presidency remains daunting and it will be tough to overcome the deficit in the remaining time. Trump seemed to acknowledge the challenges Thursday.

"This is the wealthiest country in the history of the world. It is time we got our national priorities right," Sanders told the Michigan rally.

Britt Waligorski, 31, a health care administrator for a dental practice, said she didn't get health insurance through work but has been covered through the health law for three years. While the premiums have gone up, she said she is concerned that services for women will be taken away if it is repealed.

About 2,000 people cheered and held rainbow and American flags and signs that read "Don't Make America Sick Again" and "Health Care For All" at the rally.

Republicans want to end the fines that enforce the requirement that many individuals buy coverage and that larger companies provide it to workers.

With eager anticipation, the Kremlin is counting the days to Donald Trump's inauguration and venting its anger at Barack Obama's outgoing administration, no holds barred.

At the same time, Russian officials are blasting the outgoing U.S. administration in distinctly undiplomatic language, dropping all decorum after Obama hit Moscow with more sanctions in his final weeks in office.

On Sunday, Vice President-elect Mike Pence insisted the Trump presidential campaign had no contacts with Russia and denied that the incoming national security adviser spoke with Russian officials in December about sanctions. He added that such questions were part of an effort to cast doubt on Trump's victory.

In an interview Friday with The Wall Street Journal, Trump said he might do away with Obama's sanctions if Russia works with the U.S. on battling terrorists and achieving other goals.

"We and many analysts believe that the (agreement) is consolidated. The new U.S. administration will not be able to abandon it," Araqchi told a news conference in Tehran, held a year after the deal took effect.

Trump, who will take office on Friday, has threatened to either scrap the agreement, which curbs Iran's nuclear programme and lifts sanctions against it, or seek a better deal.

"It's quite likely that the U.S. Congress or the next administration will act against Iran and imposes new sanctions."

But Iran is still subject to an U.N. arms embargo and other restrictions, which are not technically part of the nuclear agreement.

The event was marked by tense exchanges as Trump repeated his refusal to release his tax returns and denounced media outlets that published stories based on unverified allegations about his ties to the Kremlin

Trump began his remarks on Tuesday by blaming “inaccurate news” for his decision not to take questions from the press more often.

Trump went on to address a pair of reports published Tuesday night that touched on unverified accusations about his relationship with Russia. The first report, which came from CNN, said intelligence officials had presented information to Trump alleging that the Russian government had an ongoing relationship with members of his campaign — and, more sensationally, possessed compromising information about him that could be used for blackmail.

“I want to thank a lot of the news organizations … some of whom have not treated me very well over the years. …

“It’s all fake news. It’s phony stuff. It didn’t happen, and it was gotten by opponents of ours, as you know, because you reported it and so did many of the other people.

“No, no, no,” Jones said with a sly grin that barely disguised his evident hostility. Sitting back in his barber chair, he shook his head and narrowed his eyes. “That’s not why you are here. You’re here because of the billboards, because of the KKK. That’s why you are here.”

When the controversial billboards were ripped down and defaced, they were replaced almost immediately.

“While Trump wants to make America great again, we have to ask ourselves, ‘What made America great in the first place?

The Trump campaign quickly disavowed the endorsement