Worthy Reads: High Anxiety
Worthy Reads for March 2025
Welcome to Worthy Reads, where I share some things that I think are worth your time. It has the rare De Civitate paywall. Everyone gets the first half of Worthy Reads, but only paying subscribers get the second half and the footnotes. (They keep me writing, so don’t begrudge them. They deserve it.) Retweets are not endorsements.
“As Fellow Pro-Lifers, We Are Begging Marco Rubio to Save PEPFAR,” by Leah Libresco Sergeant, Kathryn Jane Lopez, Matthew Loftus, and Kristin M. Collier (UPDATE: this is now a gift link):
Every minute counts: In South Africa alone, a shutdown of PEPFAR aid is expected to result in the birth of 230 H.I.V.-positive babies per day.
Waivers signed in recent weeks by the Trump administration were supposed to keep some lifesaving aid going, but they haven’t been enough to fully restart operations. That’s because bank and email accounts have been locked, invoices are not being paid and there’s no way to fund ongoing work. Organizations on the ground need formal clearance to operate, but, in many cases, the U.S.A.I.D. workers who provide that clearance were placed on leave. On Friday, a federal judge ordered the temporary reinstatement of hundreds of these workers, but these programs require more stability than appeals, injunctions and stays can provide.
As a result, clinics are closing their doors and rationing what little medication they have left. One of us, Dr. Loftus, works at a mission hospital in Kenya that since the Jan. 24 stop-work order has seen no funds for its more than 3,160 H.I.V. patients and the 42 workers serving them.
Look, this isn’t a surprise. I’m a pro-life conservative. PEPFAR was George W. Bush’s greatest accomplishment, at least besides Samuel Alito. PEPFAR saves a lot of babies at a very low cost. This letter lays it all out.
I was one of the signatories to an early version of this letter. Thanks to Leah Libresco Sergeant for pulling this all together. She’s a good egg.
I’ve never felt a great deal of passion about foreign aid in general. Yes, it does some good. It also does a great deal of bad. Yes, much of it is waste. However, it’s such a small fraction of the federal budget that it hardly matters. I would love to get rid of all the waste and evil so that the U.S.’s foreign aid taxpayer dollars do nothing but efficiently save the lives of foreign babies. Making U.S. foreign aid perfectly efficient would have virtually zero net effect on our looming national debt crisis, so it’s not the first (or tenth) place I would focus my energy, but I do see significant benefits to scrutinizing USAID.
I’m also a unitary executive-minded guy. Again, this isn’t a surprise: I was a Bushie from the tender age of eleven. I’ve been actively annoyed about Humphrey’s Executor since I first heard of it, some time around the end of W.’s second term. I think it’s a good thing when the nation’s chief executive exercises executive authority over the executive branch, and I support challenging statutes that impede that authority. It is true that the presidency faces far too few checks and balances from the other branches right now, but he should never face checks and balances from within his own branch. DOGE is not a constitutional crisis. DOGE restructuring USAID and rolling most of its functions into the State Department is not a constitutional crisis.
Most of the people calling DOGE a constitutional crisis cheered loudly for DACA/DAPA, the employer mandate suspension, several obviously illegal covid measures (which were eventually slapped down by the courts), a range of state-and-municipal measures to nullify the Supreme Court’s decision in Dobbs v. Jackson, and of course Joe Biden’s attempt to perform a little coup on behalf of the self-styled “Equal Rights Amendment” just last month. Such people are not to be taken seriously. (The outlook for our constitution remains about the same as it was six months ago: mostly cloudy.)
I also share the desperation of conservatives in the face of the entrenched federal bureaucracy, which (as a wholly-owned subsidiary of the Democratic Party) has foiled conservative policy by maliciously undermining it for generations. When someone objects that the process of decimating the federal government is turning out to be messy and expensive, with some good employees losing their jobs along with the bad, my first instinct is to shout, “What did y’all think ‘taking back our government’ meant? Vibes? Papers? Essays?” My better judgment usually prevails, but that’s my instinct.
In other words, I am pretty much Elon Musk’s target audience: an unattached conservative who feels pretty alienated by Donald Trump, but who desires a cleanup of foreign aid and a robust attack on the administrative state, both as good policy and good law.
However, if the housecleaning of foreign aid, the boost for the unitary executive, and the firing of Sir Humphrey Appleby comes at the expense of PEPFAR, count me out. As Libresco’s letter lays out, PEPFAR is a very good thing that we should keep doing. The costs are very low. The benefits are very high (even though they accrue to foreign babies rather than to Americans). All the other benefits of blowing up the foreign aid establishment do not outweigh that good, or even come particularly close.
PEPFAR has received some waivers, multiple times, but, as of this writing, DOGE continues to block even the limited payments allowed under the waivers, even though Secretary of State Marco Rubio has authorized them. As a result, some number of children will die of AIDS who would not have died of AIDS if PEPFAR had continued uninterrupted. I doubt that number is as high as the PEPFAR Impact Tracker reports (nearly 2,000 dead babies as of tonight), but, at the same time, I am sure the number is well above zero. How could it not be?
Given that I am scoring this White House largely on “how many babies did Trump save relative to a President Harris?,” this is a very bad start, and I pray the Administration soon relents.
“A Comprehensive Federal Budget Plan to Avert a Debt Crisis,” by Jessica Riedl:1
A debt crisis will not likely come in a single cataclysmic crash that brings chaos and depression. Instead, persistent deficits of 8%–10% of GDP might bring a series of financial “mini-panics” of rising interest rates and economic stagnation that force Washington to rein in budget deficits. The most likely scenario involves Congress initially targeting lower-hanging fruit such as taxing the rich, trimming defense, and cutting programs such as foreign aid. When these savings prove insufficient to close such large and swelling deficits, lawmakers might reform other tax breaks, as well as spending on antipoverty and social programs. Eventually, they will discover that Social Security and Medicare shortfalls approaching 10% of GDP cannot remain completely protected by eviscerating the rest of the budget and taxing the rich at revenue-maximizing rates. With all savings alternatives tapped out, the only remaining option will be to go where the money is: Social Security, Medicare, and middle-class taxes. If most baby boomers are too old to absorb benefit changes, financing the projected budget deficits might require payroll tax increases as high as 10% combined with a value-added tax exceeding 10%. The result will be a massive debt, sluggish economy, high interest rates, and European-sized taxes—without the accompanying social benefits enjoyed by working European families.
No one can predict whether the financial markets will force reforms in 5, 15, or 25 years. However, the math always wins, and no economy can finance structural budget deficits of 8%–10% of GDP (and eventually higher) forever.
The whole thing is worth reading, or at least skimming. It is a refreshing antidote to the theatrical, sometimes fake (but never meaningful2) debt-slashing happening over at DOGE right now.
Riedl knocks down the silly pseudo-economic budgetary fantasies on both Right and Left. No, we cannot “grow our way out of debt.” Cutting foreign aid and welfare doesn’t come close to beginning to touch the real problem. Neither does “taxing the rich.” Nor does cutting defense. Medicare-for-All makes everything worse, not better.
Then Riedl gets to the plan. The key highlights:
Reduce cost-of-living adjustments to Social Security payments, especially for higher-income retirees.
Raise the full retirement age to 69.
Move Medicare to an insurance voucher system (like the current Medicare Advantage).
Raise Medicare premiums substantially for Part B (medical insurance) and Part D (prescription drugs).
Cut and cap Medicaid payments to states, especially the large subsidies offered by the Affordable Care Act.
Allow defense spending to fall to 2.7% of GDP (the lowest since the 1930s).
Harsh sequestration limits on other spending.
Tax increases on the top tax bracket.
Eliminate the 20% pass-through business deduction.
Tax increase on good employer-provided health insurance
Raise Medicare payroll tax rate from 3% to 4%.
Raise the gas tax by 15 cents per gallon.
I was pleasantly surprised by how painless this is! It’s very, very painful, and will politically fail for that reason. It’s just much less painful than I expected.
Either way, a debt crisis is coming (as I’ve written). The longer we delay, the more painful the eventual solution is going to be. Everyone’s ox is going to be gored. Taxes will be raised and spending will be cut, and there is no longer any plausible way to avoid this. The best time to fix this was twenty years ago, when we still had good options for doing so. (If we’d let George W. Bush change Social Security to include some private investments, we’d all be rich by now.) The second-best time to fix it is now. We won’t, but, if we were remotely serious, we would consider something very close to Riedl’s plan.
I do have one serious objection to Riedl’s plan: I think it is wrong to raise the retirement age on young people in order to balance the Social Security budget for old people. I didn’t vote for this fiscal crisis. Neither did my generation. My parents’ generation did that. The reason we didn’t solve this twenty years ago is because my parents’ generation, the Boomers and the X’ers, specifically voted to prevent the spending reforms that might have stopped it. Millennials, Zenniels, and today’s little kids are already going to have to suffer mightily to pay for the Boomers’ and Xers’ fiscal sins. They should not bear the additional burden of having to work even longer to pay for those sins while the Boomers and X’ers get to live high off the hog at 65. (I speak as a Millennial. I already have to work to 67 to pay for the fiscal sins of a generation that retires at 65. That’s plenty.)
[CORRECTION 13 March: X’ers also have to work until 67, and even tail Boomers have to work a little bit past 65 for full benefits. Everyone can work until 70 to gain extra Social Security benefits. Apologies to Gen X for my thoughtless swipe at them! h/t @CrownMaybe]
Thus, Social Security benefits for current and imminent retirees should be cut as much as necessary to balance the budget without raising the retirement age. My back-of-the-envelope math suggests this would require about a 6% benefit cut across the board. We could shape this cut so that higher-income Social Security recipients receive bigger cuts and impoverished recipients receive no cut at all, but, broadly speaking, the generations that collectively voted for this situation needs to collectively bear the biggest costs of fixing this situation.
(My apologies to my parents, lovely people who did not vote for this situation but who, under this plan, would face a >6% benefit cut. Of course, their alternative, if the government does nothing to balance the books, is an across-the-board 25% benefit cut for all seniors when the Social Security Trust Fund runs out in 2033. My parents’ current retirement plan assumes this will happen.)
All this being said, no politician or political party should run on Riedl’s plan, because the American People have made it absolutely clear that they are determined to bury their heads in the sand about the national debt until the economy collapses. The People will reject any candidate who tries to do the painful things necessary to fix the debt. A key reason Donald Trump is in office instead of Paul Ryan is because Trump promised never to touch Medicare or Social Security, whereas Paul Ryan promised to fix them. Lesson learned! The wise must simply wait for the debt crisis and prepare for it, while focusing most of their energy on policies that stand an actual chance of becoming law.
Thus, Donald Trump’s current strategy of pretending he’s making big cuts while actually increasing the deficit is close to politically optimal. However, I think the ideal would be to have a political leader who runs up deficits on child tax credits, bridge-building, and naval construction while openly admitting that it’s extremely irresponsible, that America will have to pay for it very painfully in the end, but that there’s no political will to do so, so he’s going to make the best of it while it lasts. I don’t know how that level of honesty would play in the papers, but, since I think everyone knows, deep down, that we’re living on our children’s credit, I suspect a president who said it aloud would be more popular than you’d expect. This would also help Americans mentally prepare for the day when we will, inevitably, have to pay the piper.
“It’s Time to Break Up Big Medicine,” by Matt Stoller:
Yes, there are significant profits throughout the health care system, but the true way that the monopolization shows itself is through administrative overhead. Medicare Advantage, with its fancy capitation through monopolists like UnitedHealth Group, requires more than $100 billion a year more than just regular Medicare in overpayments. That’s a lot of money. But this kind of waste is everywhere; the top three pharmacy benefit managers in America, who are basically just firms who manage spreadsheets, have more revenue than France spends on health care.
The point is that it’s not “smiling doctors” who want to charge high prices for a hospital visit causing our problem; as I mentioned, these doctors are largely just employees now, working for an insurance company or a hospital or a private equity firm. And this illustrates the error when Smith refers to “providers” as the doctors and nurses. With corporate consolidation on both the provider and insurance side, what results is massive administrative overhead and price gouging, a red queen’s race where every big company is investing in administrative bloat to fight with every other big company, often with perverse spending outcomes that lead to crazy amounts of waste in some areas and a total lack of care in others. And the idea that doctors know what a price of an operation or procedure might be implies that there is a single price. But there isn’t. A drug or procedure for one patient could be five times as expensive for someone else, depending on their plan or other factors.
One of the several things I love about Matt Stoller’s theories about the many facets of our broken economy is that he builds on the best insights of both contemporary left-wing and right-wing economic arguments, while pointing out the false assumptions shared by both sides.
In America’s endless health-care debates, the Left’s position is that American health care is expensive because the very concept of private health care motivates “profits over people.” Our health care would be both cheap and effective if we put the people in charge of the DMV in charge of administering the system directly. Yet we can see with our own eyes how Canada’s single-payer system has gotten so expensive that the system is now all-but-openly encouraging “assisted suicide” as a cost-savings measure and so tightly rationed that Canadians regularly die on waiting lists for treatment that Americans can access quickly. The U.K.’s National Health Service is racing to the same destination. (Also, the U.K. has developed a weird, bipartisan cult-like worship of its own bad health care system, which is like building your national identity around 7-Eleven.)
The Right’s position, on the other hand, is that our health care costs too much because it’s too amazingly great and we use too much of it, wasting vast sums of money and time on unnecessary care. All we need is to discourage consumers from getting all these silly extra luxury tests, plus make doctor’s offices run more efficiently through good management practices learned from the business world, and our health care would be both cheap and effective. This is even more obviously wrong.
I have good insurance, which cost $22,500 last year. (Most of that is paid by my employer.) Last year, my household consumed the following health care:
Annual physical and vaccines for the kids, required by their school.
Strep and flu testing when the eldest was ill. (It was the flu.)
Some blood tests for my wife in July.
The four of us spent a combined total of maybe 60 minutes in a room with a nurse or doctor last year.
Our insurance covered none of this—not one penny—because our family deductible is $8,000, and we used far less than $8,000 last year, because we only go to the doctor’s office when it seems absolutely necessary. I get the strong sense that nearly everybody in America lives like this. (Many have insurance that is far worse than ours.) Old people go to the doctor a lot more, of course, but they’re on Medicare, which shouldn’t affect the cost of private insurance for everyone else.
We have had high-utilization years, of course. I had a weird thing a couple years ago where I suddenly had frequent intestinal pain and lost five pounds a month for five months for no evident reason. I took a lot of tests to find out what that was. However, since I got sick in October and it mysteriously went away in April, I paid for all those tests out-of-pocket, because I never hit my deductible.3
The years we actually hit our deductible have been the years when my children were born, because, for some reason, sitting in a hospital bed on a pitocin IV all day, followed by a night in the NICU for observation, costs the same as an entire semester’s tuition at Yale (about $40,000).
As far as I can tell, we’re one of the lucky families. There’s much worse insurance out there. It simply doesn’t seem to be the case that most people are running around asking for endless unnecessary medical tests and treatments. When we do ask for medical tests and treatments, we mostly pay for them out of our own pockets! Only the wealthy seem to have insurance that allows them to waste money willy-nilly, and they pay through the nose for the privilege. Perhaps the editorial board of the Wall Street Journal, the home of traditional right-wing thinking about medical care reform, is rich enough to do this, and mistakenly thinks normies are doing it, too.
Yet, even as our high-deductible plans have pressured us to stop going to the doctor’s office, ever, costs have risen, even though right-wing orthodoxy says they should have fallen.
Into this bipartisan failure to diagnose the root causes steps Matt Stoller, who sees the economy through the lens of private-equity middle-men, monopoly, and the financialization of everything. Through this lens, a lot of things make sense that don’t if you subscribe to the old partisan narratives. (At least, not without a lot of epicycles!)4
Here’s the paywall. The good people who keep the lights on around here deserve a treat. To read about wasted foreign aid money in Swaziland, the ridiculousness of chromosomal sex, and a defense of the comedies of remarriage—plus the videos of the month—join them for $4.17/month:
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