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“This is a population of people who have been historically ignored, abused and mistreated,” said Dr. Mike Wasserman, a geriatrician and former president of the California Association of Long Term Care Medicine. “It is laziness on the part of anyone to force these folks to take a vaccine. I believe that we need to be putting all of our energy into respecting, honoring and valuing the work they do and educating them on the benefits to them and the folks they take care of in getting vaccinated.”

At Jackson Health System in Miami, a survey of about 5,900 employees found that only half wanted to get a vaccine immediately, a hospital spokeswoman said.

Henry Ford Health System, which runs six hospitals in Michigan, said that as of Wednesday morning, about 22 percent of its 33,000 employees had declined to be vaccinated.

At Houston Methodist, a hospital system in Texas with 26,000 employees, workers who take the vaccine will be eligible for a $500 bonus. “Vaccination is not mandatory for our employees yet (but will be eventually),” Dr. Marc Boom, the hospital’s chief executive, wrote in an email to employees last month.

Both have been found to be safe and highly effective. So why are so many hospital and long-term care workers reluctant to get inoculated?

Underlying the hesitancy is a lack of trust in authorities — the federal government, politicians, even their employers — that have failed for the past year to get the virus under control.

“We are left behind in the dust — no one sticks up for us,”

Another concern about forcing workers to get vaccinated is that it could prompt hesitant employees to resign. That’s a particular worry in long-term care, where the pandemic has exacerbated a shortage of certified nursing assistants.

Gov. Mike DeWine of Ohio said last month that roughly 60 percent of nursing home staff members offered the vaccine in his state had declined it.

At Norton Healthcare, a health system in Louisville, Ky., workers who refuse the vaccine and then catch Covid-19 will generally no longer be able to take advantage of the paid medical leave that Norton has been offering to infected employees since early in the pandemic.

At Juniper — which has 20 senior living communities in New Jersey, Pennsylvania and Colorado — officials have tried to educate workers about the safety and benefits of Covid-19 vaccines, including hosting a webinar with a registered nurse who was enrolled in a clinical trial of the Moderna vaccine. Officials told staff last month that vaccines would be mandatory.

After Mr. Trump’s impeachment for inciting his supporters before the deadly riot at the Capitol, and with Republican leaders turning on him, the pardon power remains one of the last and most likely outlets for quick unilateral action by an increasingly isolated, erratic president.

He has also discussed issuing pre-emptive pardons to his children, his son-in-law and senior adviser, Jared Kushner, and Mr. Giuliani.

He has paid Mr. Tolman at least $10,000 since late last year to lobby the White House and Congress for a pardon for his son Jeremy Hutchinson, a former Arkansas state lawmaker who pleaded guilty in 2019 to accepting bribes and tax fraud, according to a lobbying disclosure filed this month.

That system favors pardon seekers who have connections to Mr. Trump or his team, or who pay someone who does, said pardon lawyers who have worked for years through the Justice Department system.

“This kind of off-books influence peddling, special-privilege system denies consideration to the hundreds of ordinary people who have obediently lined up as required by Justice Department rules, and is a basic violation of the longstanding effort to make this process at least look fair,” said Margaret Love, who ran the Justice Department’s clemency process from 1990 until 1997 as the United States pardon attorney.

“The criminal justice system is badly broken, badly flawed,” said the former senator, Tim Hutchinson, a Republican who served in Congress from 1993 to 2003.

. Any explicit offers of payment to the president in return could be investigated as possible violations of bribery laws; no evidence has emerged that Mr. Trump was offered money in exchange for a pardon.

A filing this month revealed that Mr. Tolman was paid $22,500 by an Arizona man named Brian Anderson who had retained him in September to seek clemency for Ross Ulbricht, the Silk Road founder. Mr. Ulbricht was sentenced to life in prison in 2015 for engaging in a continuing criminal enterprise and distributing narcotics on the internet.

The former Trump campaign adviser, Karen Giorno, also had access to people around the president, having run Mr. Trump’s campaign in Florida during the 2016 primary and remaining on board as a senior political adviser during the general election.

Though the name was never publicly disclosed, Mr. Kiriakou was sentenced to 30 months in prison. In the meeting, at the Washington office of his lawyer, Mr. Kiriakou said he had been wronged by the government and was seeking a pardon so he could carry a handgun and receive his pension.

In July 2018, Ms. Giorno signed an agreement with Mr. Kiriakou, a copy of which was obtained by The New York Times, “to seek a full pardon from President Donald Trump of his conviction” for $50,000 and promised another $50,000 as a bonus if she secured a pardon.

When broken out by how masculine or feminine they identified themselves, completely masculine men were the only group where the majority (60 percent) said they had voted for Trump.

research conducted before the election found that these men, or men who fall into a similar category, were less likely to wear masks in the first place or take other precautions to stop the spread of COVID-19, including social distancing.

this conclusion lines up with a broader tendency among men to take fewer health precautions period — like wearing seat belts or going to the doctor regularly. Cassino said that traditional stereotypes around masculinity encourage men to shake off vulnerability, such as hiding a fear of illness and instead projecting strength

“COVID-19 makes men focus more on their masculine identity than they otherwise would have, because they feel this pressure to say and demonstrate, ‘Yeah, this big scary medical crisis is happening, but it’s not going to affect me,’” Cassino said.

this reflects the extent to which Americans’ views about gender roles have become intertwined with their partisan identity,

. “Reaffirming that you are traditionally masculine is itself a political statement today — a way to push back on changes to the way society is organized,” he said.

Republican men who identified as completely masculine were somewhat more likely than less-masculine Republican men to approve of the way Trump has handled the pandemic, although the difference wasn’t necessarily all that huge (79 percent compared with 69 percent).

One possible explanation is that the threat of business closures or other restrictions on the economy may have been alarming especially to men who identify as completely masculine. “Because employment and working is so central to American masculinity, job loss is seen as a threat to masculinity,”

by actively seizing on the spread of COVID-19 as an opportunity to emphasize his own brand of hypermasculinity and portray his opponent as weak and ineffective, Trump may have crafted a tailor-made pitch for men whose own sense of masculinity was threatened by the pandemic.

Now living on $350 a week plus food stamps, Ms. Jeffcoat and her husband have gone without electricity because they cannot afford generator fuel (their house is off the power grid) and have spent weeks without propane for cooking and hot showers. “We stick with cold meals — cereals,” she said.

“There’s just lots of opportunity that’s not being accessed — we’ve got to get people back to work,” said Jason Turner, who runs the Secretaries’ Innovation Group, which advises conservative state officials on aid policies. “I’m not as alarmed about poverty as I am about unemployment. Poverty is an arbitrary income threshold, and people who dip below it, they make adjustments. If you’re not working at all, that’s a huge deal. Physical and mental health declines, substance abuse goes up.”

“I’ve definitely found myself feeling a little more anxious — snappier with the children,” Ms. Jeffcoat said.

But some opponents of further assistance argue it has discouraged people from working.

Among individuals eligible for stimulus checks, about 30 percent failed to receive them, the Columbia researchers estimate. While most families received them automatically, those too poor to have filed tax returns had to apply.

Both studies showed poverty started to rise before the unemployment bonus expired in July, suggesting the stimulus checks, which arrived earlier, played an important role.

Still, the stories they tell are consistent. “The Cares Act was very successful,” Mr. Wimer said. “But one of its shortcomings was its temporary nature.”

But when such crises occur during a sitting president's reelection campaign, voters have historically turned him out in favor of a challenger offering a new direction for the nation. In short, incumbents fail when they cannot convince the American people to stay the course.

Times were flush in America when the nation elected Hoover -- touted as the "Great Engineer" -- as president in 1928. Four years later, the country faced the worst economic crisis in its history, the Great Depression. The popular outcry against the president summoned new words into existence: "Hooverville" for a shantytown of the homeless and "https://nam04.safelinks.protection.outlook.com/?url=https%3A%2F%2Furldefense.proofpoint.com%2Fv2%2Furl%3Fu%3Dhttps-3A__nam04.safelinks.protection.outlook.com_-3Furl-3Dhttps-253A-252F-252Furldefense.proofpoint.com-252Fv2-252Furl-253Fu-253Dhttps-2D3A-5F-5Fnam04.safelinks.protection.outlook.com-5F-2D3Furl-2D3Dhttps-2D253A-2D252F-2D252Fwww.ushistory.org-2D252Fus-2D252F48d.asp-2D26data-2D3D04-2D257C01-2D257Cbalcerskit-2D2540easternct.edu-2D257Cf504669cb9cd421b19d308d87ba94456-2D257C00bc4ae8576c45e3949d4f129d8b670a-2D257C1-2D257C0-2D257C637395314221385811-2D257CUnknown-2D257CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0-2D253D-2D257C1000-2D26sdata-2D3DZ-2D252BQzKDaHxQ2jYBKYrQvJuRk1RPwMeJOLvEB-2D252B7DyJGH4-2D253D-2D26reserved-2D3D0-2526d-253DDwMGaQ-2526c-253Dtq9bLrSQ8zIr87VusnUS9yAL0Jw-5FxnDiPuZjNR4EDIQ-2526r-253DfqdvyATuskufZZ6lHWLDX7rjOgtfuIwFFgyFWTSfNss-2526m-253DxIZtC-5FUtx-2DbHITyb6-2D8CwaYXg5eK-5Fmk9FWumiGu6d6M-2526s-253Dq96yS8DFGwSISOOmLLR5WbA0V2YS1apeWBDmpXUf00E-2526e-253D-26data-3D04-257C01-257Cbalcerskit-2540easternct.edu-257C8d842cd7f6654944dc0d08d87babf248-257C00bc4ae8576c45e3949d4f129d8b670a-257C1-257C0-257C637395325741251331-257CUnknown-257CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0-253D-257C1000-26sdata-3DkRZ-252FoKQ05pJxDSHqKx2XgnLUHtWa-252BHnkZddOrHzzXfc-253D-26reserved-3D0%26d%3DDwMGaQ%26c%3Dtq9bLrSQ8zIr87VusnUS9yAL0Jw_xnDiPuZjNR4EDIQ%26r%3DfqdvyATuskufZZ6lHWLDX7rjOgtfuIwFFgyFWTSfNss%26m%3DPsd0YU3mz1QSXOmUwvnRXVoJyl9RuP_TWfEHJ0yDWxw%26s%3DqL37mqHWsBhBnO2QOtSnmsOuXDDjmapvvunVTxkoapo%26e%3D&data=04%7C01%7Cbalcerskit%40easternct.edu%7C0d8701f780904a7323f608d87bad4758%7C00bc4ae8576c45e3949d4f129d8b670a%7C1%7C

But Hoover's own actions made matters far worse. To combat the depression, he promoted voluntarism with limited government intervention.

In July 1932, Hoover ordered the US Army, under the command of Gen. Douglas MacArthur, to clear out the "Bonus Army" encampment of World War I veterans. Then, as now, the optics were terrible.

Democratic challenger Franklin D. Roosevelt touted a "New Deal" for the American people.

The nation elected Bush with a wave of popular support in 1988. Like Hoover before him, Bush followed two terms of Republican control of the White House. But by 1992, a sharp recession had set in, leaving many Americans out of work and facing difficult times.

Political life in America reached a new low in 1974 when President Richard Nixon resigned amid scandal. His successor, Gerald Ford, pardoned the ex-president, leaving him vulnerable to a Democratic challenger in 1976. Former Georgia Gov. Carter ran as an outsider and won a narrow victory.

By 1980, however, a global economic downturn had weakened the country. Oil shocks, rising inflation and industrial competition from abroad all took a toll. Abroad, the United States suffered a humiliating setback when Iranian militants took Americans hostage at the US embassy in Tehran.

In 1979, Carter described a "crisis in confidence" affecting the country.

To make matters worse, Carter asked for the resignation of his entire Cabinet, and five members acceded to the demand.

Republican challenger Ronald Reagan, by contrast, projected a sunny optimism, famously declaring recovery happens "when Jimmy Carter loses his" job.

As the 1970s yielded to the 1980s, the nation chose a new direction, handing Reagan a resounding victory over the incumbent Carter

An unprecedented 40 million Americans voted that November, yielding FDR an even larger popular victory than Hoover had won four years earlier.

With the government facing revenue shortfalls, Bush went against his own campaign rhetoric -- his "read my lips" promise to not raise taxes -- and increased taxes in 1991.

Political controversies also hurt. The nomination of Clarence Thomas to the Supreme Court, during which Anita Hill accused him of sexual harassment, rankled. When combined with domestic challenges, such as the Los Angeles riots in the spring of 1992, Bush was the definition of an embattled incumbent president.

Democratic challenger Bill Clinton proved popular, leading many to choose the younger candidate and informal motto: "It's the economy, stupid." Bush also likely lost votes to the third-party candidate Ross Perot. Although no candidate won a majority of the popular vote in November, Clinton secured enough electoral votes to become president.

Yet Bush could not win reelection in 1992 for similar reasons to his long-ago predecessor -- an economic downturn had soured the American people against him.

the police and fire departments, lag behind.

About 69% of NYPD employees and 60% of FDNY workers are vaccinated and both the fire and police commissioners have endorsed the mandate.

The mandate is expected to include all employees from sanitation workers to office workers and will require some 161,000 workers to have their first dose by Oct. 29.

Those who receive their first dose at a city-run vaccination site will receive a $500 bonus

Municipal employees who do not get vaccinated will be placed on unpaid leave

Over the past four decades, governments have slashed budgets and privatized basic services. This has two important consequences for public health

First, people are unlikely to trust institutions that do little for them.

second, public health is no longer viewed as a collective endeavor, based on the principle of social solidarity and mutual obligation. People are conditioned to believe they’re on their own and responsible only for themselves.

an important source of vaccine hesitancy is the erosion of the idea of a common good.

compared with white Americans, communities of color do experience the American health care system differently. But a closer look at the data reveals a more complicated picture.

Since the spring, when most American adults became eligible for Covid vaccines, the racial gap in vaccination rates between Black and white people has been halved. In September, a national survey found that vaccination rates among Black and white Americans were almost identical.

Other surveys have determined that a much more significant factor was college attendance: Those without a college degree were the most likely to go unvaccinated.

Education is a reliable predictor of socioeconomic status, and other studies have similarly found a link between income and vaccination.

It turns out that the real vaccination divide is class.

“People are thinking, ‘If the government isn’t going to do anything for us,’” said Elden, “‘then why should we participate in vaccines?’”

during the 1950s polio campaigns, for example, most people saw vaccination as a civic duty.

But as the public purse shrunk in the 1980s, politicians insisted that it’s no longer the government’s job to ensure people’s well-being; instead, Americans were to be responsible only for themselves and their own bodies

Entire industries, such as self-help and health foods, have sprung up on the principle that the key to good health lies in individuals making the right choices.

Without an idea of the common good, health is often discussed using the language of “choice.”

there are problems with reducing public health to a matter of choice. It gives the impression that individuals are wholly responsible for their own health.

This is despite growing evidence that health is deeply influenced by factors outside our control; public health experts now talk about the “social determinants of health,” the idea that personal health is never simply just a reflection of individual lifestyle choices, but also the class people are born into, the neighborhood they grew up in and the race they belong to.

food deserts and squalor are not easy problems to solve — certainly not by individuals or charities — and they require substantial government action.

Many medical schools teach “motivational interviewing,”

the deeper problem:

Being healthy is not cheap. Studies indicate that energy-dense foods with less nutritious value are more affordable, and low-cost diets are linked to obesity and insulin resistance.

Another problem with reducing well-being to personal choice is that this treats health as a commodity.

This isn’t surprising, since we shop for doctors and insurance plans the way we do all other goods and services

mothers devoted many hours to “researching” vaccines, soaking up parental advice books and quizzing doctors. In other words, they act like savvy consumers

When thinking as a consumer, people tend to downplay social obligations in favor of a narrow pursuit of self-interest. As one parent told Reich, “I’m not going to put my child at risk to save another child.”

Such risk-benefit assessments for vaccines are an essential part of parents’ consumer research.

Vaccine uptake is so high among wealthy people because Covid is one of the gravest threats they face. In some wealthy Manhattan neighborhoods, for example, vaccination rates run north of 90 percent.

For poorer and working-class people, though, the calculus is different: Covid-19 is only one of multiple grave threats.

When viewed in the context of the other threats they face, Covid no longer seems uniquely scary.

Most of the people we interviewed in the Bronx say they are skeptical of the institutions that claim to serve the poor but in fact have abandoned them.

he and his friends find reason to view the government’s sudden interest in their well-being with suspicion. “They are over here shoving money at us,” a woman told us, referring to a New York City offer to pay a $500 bonus to municipal workers to get vaccinated. “And I’m asking, why are you so eager, when you don’t give us money for anything else?”

These views reinforce the work of social scientists who find a link between a lack of trust and inequality. And without trust, there is no mutual obligation, no sense of a common good.

The experience of the 1960s suggests that when people feel supported through social programs, they’re more likely to trust institutions and believe they have a stake in society’s health.

While the reasons vary by country, the underlying causes are the same: a deep mistrust in local and international institutions, in a context in which governments worldwide have cut social services.

In one Syrian city, for example, the health care system now consists of one public hospital so underfunded that it is notorious for poor care, a few private hospitals offering high-quality care that are unaffordable to most of the population, and many unlicensed and unregulated private clinics — some even without medical doctors — known to offer misguided health advice. Under such conditions, conspiracy theories can flourish; many of the city’s residents believe Covid vaccines are a foreign plot.

In many developing nations, international aid organizations are stepping in to offer vaccines. These institutions are sometimes more equitable than governments, but they are often oriented to donor priorities, not community needs.

“We have starvation and women die in childbirth.” one tribal elder told us, “Why do they care so much about polio? What do they really want?”

In America, anti-vaccine movements are as old as vaccines themselves; efforts to immunize people against smallpox prompted bitter opposition in the turn of the last century. But after World War II, these attitudes disappeared. In the 1950s, demand for the polio vaccine often outstripped supply, and by the late 1970s, nearly every state had laws mandating vaccinations for school with hardly any public opposition.

What changed? This was the era of large, ambitious government programs like Medicare and Medicaid.

The anti-measles policy, for example, was an outgrowth of President Lyndon Johnson’s Great Society and War on Poverty initiatives.

Research shows that private systems not only tend to produce worse health outcomes than public ones, but privatization creates what public health experts call “segregated care,” which can undermine the feelings of social solidarity that are critical for successful vaccination drives

Only then do the ideas of social solidarity and mutual obligation begin to make sense.

The types of social programs that best promote this way of thinking are universal ones, like Social Security and universal health care.

If the world is going to beat the pandemic, countries need policies that promote a basic, but increasingly forgotten, idea: that our individual flourishing is bound up in collective well-being.

Every law embodies a particular hypothesis about how the world works, a hope that if you pull on levers A and B, then outcomes C and D will result

Democrats hope to create an economy where the government doesn’t just help Americans buy green technologies; it also helps nurture the industries that produce that technology.

The idea is this: The era of passive, hands-off government is over. The laws embrace an approach to governing the economy that scholars call “industrial policy,” a catch-all name for a wide array of tools and tactics that all assume the government can help new domestic industries get started, grow, and reach massive scale.

If “this country used to make things,” as the saying goes, and if it wants to make things again, then the government needs to help it. And if the country believes that certain industries bestow a strategic advantage, then it needs to protect them against foreign interference.

From its founding to the 1970s, the country had an economic doctrine that was defined by its pragmatism and the willingness of its government to find new areas of growth.

It’s more like a toolbox of different approaches that act in concert to help push technologies to grow and reach commercial scale. The IRA and the two other new laws prefer four tools in particular.

“Yes, there was an ‘invisible hand,’” Stephen Cohen and Brad DeLong write in their history of the topic, Concrete Economics. “But the invisible hand was repeatedly lifted at the elbow by the government, and placed in a new position from where it could go on to perform its magic.”

That pragmatism faded in the 1980s, when industrial policy became scorned as one more instance of Big Government coming in to pick so-called winners and losers.

The two other large bills passed by this Congress—the $1 trillion bipartisan infrastructure law and the CHIPS and Science Act—make down payments on the future as well; both laws, notably, were passed by bipartisan majorities.

it is in the IRA that these general commitments become specific, and therefore transformative.

Since the 1980s, when Congress has wanted to spur technological progress, it has usually thrown money exclusively at R&D. We have had a science policy, not an industrial policy

inextricable from that turn is Washington’s consuming anxiety over China’s rise—and China has embraced industrial policy.

although not a single Republican voted for the IRA, its wager is not especially partisan or even ideological.

the demonstration project. A demonstration project helps a technology that has previously existed only in the lab get out in the real world for the first time

supply-push policies. As the name suggests, these tools “push” on the supply side of an industry by underwriting new factories or assuring that those factories have access to cheap inputs to make things.

demand-pull policies, which create a market for whatever is coming out of those new factories. The government can “pull” on demand by buying those products itself or by subsidizing them for consumers.

protective policies, meant to insulate industries—especially new ones that are still growing—from foreign interference

Although both parties have moved to embrace industrial policy, Democrats are clearly ahead of their Republican colleagues. You can see it in their policy: While the bipartisan infrastructure law sets up lots of demonstration projects, and the CHIPS Act adopts some supply-push and protectionist theory, only the IRA uses all four tools.

In order to stop climate change, experts believe, the United States must do three things: clean up its power grid, replacing coal and gas power plants with zero-carbon sources; electrify everything it can, swapping fossil-fueled vehicles and boilers with electric vehicles and heat pumps; and mop up the rest, mitigating carbon pollution from impossible-to-electrify industrial activities. The IRA aims to nurture every industry needed to realize that vision.

Hydrogen and carbon removal are going to benefit from nearly every tool the government has. The bipartisan infrastructure law will spend more than $11 billion on hydrogen and carbon-removal “hubs,” huge demonstration projects

These hubs will also foster geographic concentration, the economic idea that when you put lots of people working on the same problem near one another, they solve it faster. You can see such clustering at work in San Francisco’s tech industry, and also in China, which now creates hubs for virtually every activity that it wants to dominate globally—even soccer.

Then the IRA will take over and deploy some good ol’ supply push and demand pull. It includes new programs to underwrite new hydrogen factories; on the demand side, a powerful new tax credit will pay companies for every kilogram of low-carbon hydrogen that they produce

Another tax credit will boost the demand of carbon removal by paying firms a $180 bounty for trapping a ton of carbon dioxide and pumping it undergroun

Today, not only does China make most batteries worldwide; it alone makes the tools that make the batteries, Nathan Iyer, an analyst at RMI, a nonpartisan energy think tank, told me. This extreme geographic concentration—which afflicts not only the battery industry but also the solar-panel industry—could slow down the energy transition and make it more expensive

the new tax credit is also supply-minded, arguably even protectionist. Under the new scheme, very few electric cars and trucks will immediately qualify for that full $7,500 subsidy; it will go only toward vehicles whose batteries are primarily made in North America and where a certain percentage of minerals are mined and processed in the U.S. or one of its allies. Will these policies accelerate the shift to EVs? Well, no, not immediately. But the idea is that by boosting domestic production of EVs, batteries will become cheaper and more abundant—and the U.S. will avoid subsidizing one of China’s growth industries.

Right now, next to no solar panels are made in the U.S., even though the technology was invented here. The IRA endeavors to change that by—you guessed it—a mix of supply-push, demand-pull, and protectionist policies. Under the law, the government will underwrite new factories to make every subcomponent of the solar supply chain; then it will pay those factories for every item that they produce

“It’s realistic that within four to five years, [U.S. solar manufacturers] could completely meet domestic demand for solar,” Scott Moskowitz, the head of public affairs for the solar manufacturer Q CELLS, told me.

In each of these industries, you’ll notice that the government isn’t only subsidizing factories; it is actually paying them to operate. That choice, which is central to the IRA’s approach, is “really defending against the mistakes of the 2009 bill,” Iyer told me. In its stimulus bill passed during the Great Recession, the Obama administration tried to do green industrial policy, underwriting new solar-panel factories across the country. But then Chinese firms began exporting cheap solar panels by the millions, saturating domestic demand and leaving those sparkly new factories idle

So many other industries will also be touched by these laws. There’s a new program to nurture a low-carbon aviation-fuel industry in the U.S. (Long-distance jet travel is one of those climate problems that nobody knows how to solve yet.)

the revelation of the IRA is that decarbonizing the United States may require re-industrializing it. A net-zero America may have more refineries, more factories, and more goods production than a fossil-fueled America—while also having cheaper cars, healthier air, and fewer natural disasters. And once the U.S. gets there, then it can keep going: It can set an example for the world that a populous, affluent country can reduce its emissions while enjoying all the trappings of modernity,

There are a slew of policies meant to grow and decarbonize the U.S. industrial sector; every tax credit pays out a bonus if you use U.S.-made steel, cement, or concrete. “You would need thousands and thousands of words to capture the industries that will be transformed by this,” Josh Freed, the climate and energy leader at Third Way, a center-left think tank, told me.

Five EVs were sold in China last year for every one EV sold in the United States; that larger domestic market will provide a significant economy of scale when Chinese EV makers begin exporting their cars abroad. For that reason and others, many people in China are “deeply skeptical” that the U.S. can catch up with its lead,

We are about to have a huge new set of vested interests who want the economy to be clean and benefit from that. We’ve literally never had that before,” Freed told me.

“This is going to change everything,” he said

that is the IRA’s biggest idea, its biggest hypothesis: that America can improve its standard of living and preserve its global preeminence while ruthlessly eliminating carbon pollution; that climate change, actually, doesn’t change everything, and that in fact it can be addressed by changing as little as possible.

This hypothesis has already proved itself out in one important way, which is that the IRA passed, and the previous 30 years of climate proposals did not. Now comes the real test.

But the diagnoses had a lucrative side effect: They let the insurers collect more money from the federal government’s Medicare Advantage program.

Medicare Advantage, a private-sector alternative to traditional Medicare, was designed by Congress two decades ago to encourage health insurers to find innovative ways to provide better care at lower cost.

by next year, more than half of Medicare recipients will be in a private plan.

a New York Times review of dozens of fraud lawsuits, inspector general audits and investigations by watchdogs shows how major health insurers exploited the program to inflate their profits by billions of dollars.

The government pays Medicare Advantage insurers a set amount for each person who enrolls, with higher rates for sicker patients. And the insurers, among the largest and most prosperous American companies, have developed elaborate systems to make their patients appear as sick as possible, often without providing additional treatment, according to the lawsuits.

As a result, a program devised to help lower health care spending has instead become substantially more costly than the traditional government program it was meant to improve.

Eight of the 10 biggest Medicare Advantage insurers — representing more than two-thirds of the market — have submitted inflated bills, according to the federal audits. And four of the five largest players — UnitedHealth, Humana, Elevance and Kaiser — have faced federal lawsuits alleging that efforts to overdiagnose their customers crossed the line into fraud.

The government now spends nearly as much on Medicare Advantage’s 29 million beneficiaries as on the Army and Navy combined. It’s enough money that even a small increase in the average patient’s bill adds up: The additional diagnoses led to $12 billion in overpayments in 2020, according to an estimate from the group that advises Medicare on payment policies — enough to cover hearing and vision care for every American over 65.

Another estimate, from a former top government health official, suggested the overpayments in 2020 were double that, more than $25 billion.

The increased privatization has come as Medicare’s finances have been strained by the aging of baby boomers

Medicare Advantage plans can limit patients’ choice of doctors, and sometimes require jumping through more hoops before getting certain types of expensive care.

At conferences, companies pitched digital services to analyze insurers’ medical records and suggest additional codes. Such consultants were often paid on commission; the more money the analysis turned up, the more the companies kept.

they often have lower premiums or perks like dental benefits — extras that draw beneficiaries to the programs. The more the plans are overpaid by Medicare, the more generous to customers they can afford to be.

Many of the fraud lawsuits were initially brought by former employees under a federal whistle-blower law that allows them to get a percentage of any money repaid to the government if their suits prevail. But most have been joined by the Justice Department, a step the government takes only if it believes the fraud allegations have merit. Last year, the department’s civil division listed Medicare Advantage as one of its top areas of fraud recovery.

In contrast, regulators overseeing the plans at the Centers for Medicare and Medicaid Services, or C.M.S., have been less aggressive, even as the overpayments have been described in inspector general investigations, academic research, Government Accountability Office studies, MedPAC reports and numerous news articles,

Congress gave the agency the power to reduce the insurers’ rates in response to evidence of systematic overbilling, but C.M.S. has never chosen to do so. A regulation proposed in the Trump administration to force the plans to refund the government for more of the incorrect payments has not been finalized four years later. Several top officials have swapped jobs between the industry and the agency.

The popularity of Medicare Advantage plans has helped them avoid legislative reforms. The plans have become popular in urban areas, and have been increasingly embraced by Democrats as well as Republicans.

“You have a powerful insurance lobby, and their lobbyists have built strong support for this in Congress,”

Some critics say the lack of oversight has encouraged the industry to compete over who can most effectively game the system rather than who can provide the best care.

But for insurers that already dominate health care for workers, the program is strikingly lucrative: A study from the Kaiser Family Foundation, a research group unaffiliated with the insurer Kaiser, found the companies typically earn twice as much gross profit from their Medicare Advantage plans as from other types of insurance.

In theory, if the insurers could do better than traditional Medicare — by better managing patients’ care, or otherwise improving their health — their patients would cost less and the insurers would make more money.

But some insurers engaged in strategies — like locating their enrollment offices upstairs, or offering gym memberships — to entice only the healthiest seniors, who would require less care, to join. To deter such tactics, Congress decided to pay more for sicker patients.

Almost immediately, companies saw ways to exploit that system. The traditional Medicare program provided no financial incentive to doctors to document every diagnosis, so many records were incomplete

Under the new program, insurers began rigorously documenting all of a patient’s health conditions — say depression, or a long-ago stroke — even when they had nothing to do with the patient’s current medical care.

“Even when they’re playing the game legally, we are lining the pockets of very wealthy corporations that are not improving patient care,”

The insurers also began hiring agencies that sent doctors or nurses to patients’ homes, where they could diagnose them with more diseases.

Cigna hired firms to perform similar at-home assessments that generated billions in extra payments, according to a 2017 whistle-blower lawsuit, which was recently joined by the Justice Department. The firms told nurses to document new diagnoses without adjusting medications, treating patients or sending them to a specialist

Nurses were told to especially look for patients with a history of diabetes because it was not “curable,” even if the patient now had normal lab findings or had undergone surgery to treat the condition.

Adding the code for a single diagnosis could yield a substantial payoff. In a 2020 lawsuit, the government said Anthem instructed programmers to scour patient charts for “revenue-generating” codes. One patient was diagnosed with bipolar disorder, although no other doctor reported the condition, and Anthem received an additional $2,693.27, the lawsuit said. Another patient was said to have been coded for “active lung cancer,” despite no evidence of the disease in other records; Anthem was paid an additional $7,080.74. The case is continuing.

The most common allegation against the companies was that they did not correct potentially invalid diagnoses after becoming aware of them. At Anthem, for example, the Justice Department said “thousands” of inaccurate diagnoses were not deleted. According to the lawsuit, a finance executive calculated that eliminating the inaccurate diagnoses would reduce the company’s 2017 earnings from reviewing medical charts by $86 million, or 72 percent.

Some of the companies took steps to ensure the extra diagnoses didn’t lead to expensive care. In an October 2021 lawsuit, the Justice Department estimated that Kaiser earned $1 billion between 2009 and 2018 from additional diagnoses, including roughly 100,000 findings of aortic atherosclerosis, or hardening of the arteries. But the plan stopped automatically enrolling those patients in a heart attack prevention program because doctors would be forced to follow up on too many people, the lawsuit said.

Kaiser, which both runs a health plan and provides medical care, is often seen as a model system. But its control over providers gave it additional leverage to demand additional diagnoses from the doctors themselves, according to the lawsuit.

At meetings with supervisors, he was instructed to find additional conditions worth tens of millions of dollars. “It was an actual agenda item and how could we get this,” Dr. Taylor said.

few analysts expect major legislative or regulatory changes to the program.

Even before the first lawsuits were filed, regulators and government watchdogs could see the number of profitable diagnoses escalating. But Medicare has done little to tamp down overcharging.

Several experts, including Medicare’s advisory commission, have recommended reducing all the plans’ payments.

Congress has ordered several rounds of cuts and gave C.M.S. the power to make additional reductions if the plans continued to overbill. The agency has not exercised that power.

The agency does periodically audit insurers by looking at a few hundred of their customers’ cases. But insurers are fined for billing mistakes found only in those specific patients. A rule proposed during the Trump administration to extrapolate the fines to the rest of the plan’s customers has not been finalized.

Ted Doolittle, who served as a senior official for the agency’s Center for Program Integrity from 2011 to 2014, said officials at Medicare seemed uninterested in confronting the industry over these practices. “It was clear that there was some resistance coming from inside” the agency, he said. “There was foot dragging.”

Last year, the inspector general’s office noted that one company “stood out” for collecting 40 percent of all Medicare Advantage’s payments from chart reviews and home assessments despite serving only 22 percent of the program’s beneficiaries. It recommended Medicare pay extra attention to the company, which it did not name, but the enrollment figure matched UnitedHealth’s.

“Medicare Advantage overpayments are a political third rail,” said Dr. Richard Gilfillan, a former hospital and insurance executive and a former top regulator at Medicare, in an email. “The big health care plans know it’s wrong, and they know how to fix it, but they’re making too much money to stop. Their C.E.O.s should come to the table with Medicare as they did for the Affordable Care Act, end the coding frenzy, and let providers focus on better care, not more dollars for plans.”

It's thought that all or part of Zealandia may have existed as an island for a while. But then around 25 million years ago, it was disappeared beneath the ocean

The first real clues that New Zealand might represent just a tiny, visible portion of a vast incognito landmass came in 2002, when scientists used bathymetry – the study of the depth of bodies of water – to analyse the region. The ocean above what we now call Zealandia is considerably shallower than that surrounding it, suggesting that the area was not underlain by an oceanic tectonic plate – like most of the world's oceans – but a continental one.

The clincher came in 2017, when scientists put several lines of evidence together, including data about the kinds of rocks it contains and its relative thickness – oceanic plates tend to be thinner – to propose that this is indeed a new continent. This is not a mere continental fragment or microcontinent, as had previously been proposed, but the real deal, 95% of which is submerged underwater.

despite the excitement around the discovery of a new continent, and more than a decade of intensive research, many details of Zealandia's early formation have remained elusive. This is partly because of a strange event that occurred when it split from Gondwana.

In 2019, an international team of scientists mapped the geology of South Zealandia. Their research revealed that at some point, Zealandia had been stretched – pulled apart by tectonic forces, thinning the continent compared to regular continental plates and creating ruptures that later became oceanic crust. In the process, it became twisted and this made reconstructing its history to work out its original form much more challenging. 

The researchers' analysis of rocks from the lost continent revealed that the stretching happened in two stages. The first began around 89-101 million years ago, and led to a rip which became the Tasman Sea inbetween Australia and New Zealand. The second phase started 80-90 million years ago and led to Zealandia splitting off from West Antarctica and creating the Pacific Ocea

For the latest study, another research group – involving many of the same geologists as before – charted North Zealandia. This time, they analysed rocks that had been dredged up from the Fairway Ridge, a region of the South Pacific off the coast of Australia, which forms the northernmost tip of Zealandia. These ancient remnants, which have not had a dry day for 25 million years, included a mixture of igneous rocks – those formed by volcanic processes – and sedimentary ones made in shallow basins just off the coast of Zealandia.

The resulting maps of Zealandia transform it from a featureless mass into a place with many bands of distinctive geology running along its length from northwest to southeast. These fit together with the geology of West Antarctica like a jigsaw puzzle, confirming that this region and Zealandia once slotted together.

It’s dropping in developing countries, too. India surpassed China as the most populous country last year, yet its fertility is now below replacement.

“The demographic winter is coming,”

Smaller populations come with diminished global clout, raising questions in the U.S., China and Russia about their long-term standings as superpowers.

Some demographers think the world’s population could start shrinking within four decades—one of the few times it’s happened in history.

A year ago Japanese Prime Minister Fumio Kishida declared that the collapse of the country’s birthrate left it “standing on the verge of whether we can continue to function as a society.”

Had fertility stayed near 2.1, where it stood in 2007, the U.S. would have welcomed an estimated 10.6 million more babies since

In 2017, when the global fertility rate—a snapshot of how many babies a woman is expected to have over her lifetime—was 2.5, the United Nations thought it would slip to 2.4 in the late 2020s. Yet by 2021, the U.N. concluded, it was already down to 2.3—close to what demographers consider the global replacement rate of about 2.2

He has found that national birth registries are typically reporting births 10% to 20% below what the U.N. projected.

China reported 9 million births last year, 16% less than projected in the U.N.’s central scenario. In the U.S., 3.59 million babies were born last year, 4% less than the U.N. projected. In other countries, the undershoot is even larger: Egypt reported 17% fewer births last year. In 2022, Kenya reported 18% fewer.

In 2017 the U.N. projected world population, then 7.6 billion, would keep climbing to 11.2 billion in 2100. By 2022 it had lowered and brought forward the peak to 10.4 billion in the 2080s. That, too, is likely out of date

the University of Washington now thinks it will peak around 9.5 billion in 2061 then start declining. 

The falling birthrates come with huge implications for the way people live, how economies grow and the standings of the world’s superpowers.

In the U.S., a short-lived pandemic baby boomlet has reversed. The total fertility rate fell to 1.62 last year, according to provisional government figures, the lowest on record.

In 2017, when the fertility rate was 1.8, the Census Bureau projected it would converge over the long run to 2.0. It has since revised that down to 1.5. “It has snuck up on us,”

Historians refer to the decline in fertility that began in the 18th century in industrializing countries as the demographic transition. As lifespans lengthened and more children survived to adulthood, the impetus for bearing more children declined. As women became better educated and joined the workforce, they delayed marriage and childbirth, resulting in fewer children. 

Some demographers see this as part of a “second demographic transition,” a societywide reorientation toward individualism that puts less emphasis on marriage and parenthood, and makes fewer or no children more acceptable. 

In research published in 2021, the University of Maryland’s Kearney and two co-authors looked for possible explanations for the continued drop. They found that state-level differences in parental abortion notification laws, unemployment, Medicaid availability, housing costs, contraceptive usage, religiosity, child-care costs and student debt could explain almost none of the decline

“We suspect that this shift reflects broad societal changes that are hard to measure or quantify,” they conclude.

while raising children is no more expensive than before, parents’ preferences and perceived constraints have changed

“If people have a preference for spending time building a career, on leisure, relationships outside the home, that’s more likely to come in conflict with childbearing.” 

Once a low fertility cycle kicks in, it effectively resets a society’s norms and is thus hard to break, said Jackson. “The fewer children you see your colleagues and peers and neighbors having, it changes the whole social climate,”

Fertility is below replacement in India even though the country is still poor and many women don’t work—factors that usually sustain fertility.

Urbanization and the internet have given even women in traditional male-dominated villages a glimpse of societies where fewer children and a higher quality of life are the norm. “People are plugged into the global culture,

mothers and fathers, especially those that are highly educated, spend more time with their children than in the past. “The intensity of parenting is a constraint,”

Sub-Saharan Africa once appeared resistant to the global slide in fertility, but that too is changing. The share of all women of reproductive age using modern contraception grew from 17% in 2012 to 23% in 2022

Jose Rimon, a professor of public health at Johns Hopkins University, credits that to a push by national leaders in Africa which, he predicted, would drive fertility down faster than the U.N. projects. 

Mae Mariyam Thomas, 38, who lives in Mumbai and runs an audio production company, said she’s opted against having children because she never felt the tug of motherhood. She sees peers struggling to meet the right person, getting married later and, in some instances, divorcing before they have kids. At least three of her friends have frozen their eggs,

Danielle Vermeer grew up third in a family of four children on Chicago’s North Side, where her neighborhood was filled with Catholics of Italian, Irish and Polish descent and half her close friends had as many siblings as her or more.

Her Italian-American father was one of four children who produced 14 grandchildren. Now her parents have five grandchildren, including Vermeer’s two children, ages 4 and 7.

The 35-year-old, who is the co-founder of a fashion thrifting app, said that before setting out to have children, she consulted dozens of other couples and her Catholic church and read at least eight books on the subject, including one by Pope Paul VI. She and her husband settled on two as the right number.“The act of bringing a child into this world is an incredible responsibility,” she said.

Perhaps no country has been trying longer than Japan. After fertility fell to 1.5 in the early 1990s, the government rolled out a succession of plans that included parental leave and subsidized child care. Fertility kept falling.

In 2005, Kuniko Inoguchi was appointed the country’s first minister responsible for gender equality and birthrate. The main obstacle, she declared, was money: People couldn’t afford to get married or have children. Japan made hospital maternity care free and introduced a stipend paid upon birth of the child. 

Japan’s fertility rate climbed from 1.26 in 2005 to 1.45 in 2015. But then it started declining again, and in 2022 was back to 1.26.

This year, Prime Minister Fumio Kishida rolled out yet another program to increase births that extends monthly allowances to all children under 18 regardless of income, free college for families with three children, and fully paid parental leave.

noguchi, now a member of parliament’s upper house, said the constraint on would-be parents is no longer money, but time. She has pressed the government and businesses to adopt a four-day workweek

If you’re a government official or manager of a big corporation, you should not worry over questions of salary now, but that in 20 years time you will have no customers, no clients, no applicants to the Self-Defense Forces.”

Hungarian Prime Minister Viktor Orban has pushed one of Europe’s most ambitious natality agendas. Last year he expanded tax benefits for mothers so that women under the age of 30 who have a child are exempt from paying personal income tax for life. That’s on top of housing and child-care subsidies as well as generous maternity leaves. 

Hungary’s fertility rate, though still well below replacement, has risen since 2010. But the Vienna Institute of Demography attributed this primarily to women delaying childbirth because of a debt crisis that hit around 2010. Adjusted for that, fertility has risen only slightly, it concluded.

The usual prescription in advanced countries is more immigration, but that has two problems.

With no reversal in birthrates in sight, the attendant economic pressures are intensifying. Since the pandemic, labor shortages have become endemic throughout developed countries. That will only worsen in coming years as the postcrisis fall in birthrates yields an ever-shrinking inflow of young workers, placing more strain on healthcare and retirement systems.

worsening demographics could make this a second consecutive “lost decade” for global economic growth.

The Institute for Health Metrics and Evaluation found little evidence that pronatalist policies lead to sustained rebounds in fertility. A woman may get pregnant sooner to capture a baby bonus, researchers say, but likely won’t have more kids over the course of her lifetime.

As more countries confront stagnant population, immigration between them is a zero-sum gam

Historically, host countries have sought skilled migrants who enter through formal, legal channels, but recent inflows have been predominantly unskilled migrants often entering illegally and claiming asylum.

High levels of immigration have also historically aroused political resistance,

Many of the leaders keenest to raise birthrates are most resistant to immigratio

As birthrates fall, more regions and communities experience depopulation, with consequences ranging from closed schools to stagnant property values. Less selective colleges will soon struggle to fill classrooms because of the plunge in birthrates that began in 2007, said Fernández-Villaverde. Vance said rural hospitals can’t stay open because of the falling local population.

An economy with fewer children will struggle to finance pensions and healthcare for growing ranks of elderly. South Korea’s national pension fund, one of the world’s largest, is on track to be depleted by 2055

There’s been little public pressure to act, said Sok Chul Hong, an economist at Seoul National University. “The elderly are not very interested in pension reform, and the youth are apathetic towards politics,” he said. “It is truly an ironic situation.”