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The doctor is here On-demand services could stir rejuvenation for house calls PAGE 12

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KLMNO WEEKLY

THE FIX

Why La. won’t turn over voter data BY

A MBER P HILLIPS

P

resident Trump’s voting commission has fallen flat on its face, with nearly every state refusing to hand over the voter registration data the commission is asking for. Louisiana, a solid Republican state, is one of those. I talked to Secretary of State Tom Schedler (R) about why. Our conversation has been edited for length and clarity.

THE FIX: What was your reaction in January, when the new president said millions of illegal votes almost cost him the election?

SCHEDLER: As secretary of state of Louisiana, I take exception to that. I don’t think we have a bunch of illegal votes being cast in Louisiana. Our list maintenance, I would put it up against any state.

Louisiana has been a photo-ID state since 1987. We don’t have same-day registration. We don’t have automatic registration. We’re not an all-paper ballot state. So I think the safeguards we do have give me somewhat of a comfort zone that maybe didn’t exist 30 to 40 years ago. A lot of the prejudice against Deep South Louisiana go back to the mid-’60s, when we were a pre-clearance state. I often tell people, much to my conservative principles, that Louisiana deserved to be on that.

We have a drastically different state than what we were then, and I stand on the process we have here.

Given Louisiana’s history with voting rights, did you take Trump’s accusations about voter fraud personally?

Yeah, you don’t like somebody saying that, but it’s not so much personal to me. We’ve seen an erosion of voter participation and voter confidence across the state, so anytime someone brings into question the integrity of elections, that doesn’t help the situation.

And usually, people who are saying that really

KLMNO WEEKLY

don’t understand the voting system. My job here is to make the process easy, efficient, practical, accessible, but make it damn hard to cheat.

And you realize your criticisms sound like they extend to the voting commission Trump put together?

Yes and no. I welcome the investigation. I think it’s time to put the concerns to rest once and for all. We’ve got Democrats calling voter suppression. We’ve got Republicans claiming voter fraud. We’ve got it coming from all angles, and at the end of the day, it diminishes voter participation. It’s a difficult thing in the states for us to fight.

[Editor’s note: No study has shown the existence of widespread voter fraud.]

PAUL J. RICHARDS/AGENCE FRANCE-PRESSE VIA GETTY IMAGES

So what could this commission do differently to get your cooperation?

It was the way the ask was approached. If you look at [commission vice chair] Kris Kobach’s letter, on the first page he asks only for publicly available voter rolls that are legal under your state law. But then he goes on to get into some things that get a little out there: Social Security numbers, mother’s maiden name, date of birth and the like. Only recently did he finally say what he should have said from the get go: “I’m only asking for public information that anybody can get. I’d like to get A, B, C, D and E, but if you’re law doesn’t allow it, that’s okay.”

This publication was prepared by editors at The Washington Post for printing and distribution by our partner publications across the country. All articles and columns have previously appeared in The Post or on washingtonpost.com and have been edited to fit this format. For questions or comments regarding content, please e-mail weekly@washpost.com. If you have a question about printing quality, wish to subscribe, or would like to place a hold on delivery, please contact your local newspaper’s circulation department. © 2017 The Washington Post / Year 3, No. 39

And would you have handed that data over?

I would have been a little less verbal, I would have just said: “Hey, Kris, this is where you get the public information that’s available.

It’s address, name, party affiliation and frequency of voting. It’s readily available to anyone.”

And let me get the hypocrisy of politics today for just a moment. Five years ago I was sued by Eric Holder’s Department of Justice regarding we didn’t with “sufficient vigor” register people to vote at social services offices. They wanted me to produce in discovery the voter registration lists that included the birthday, the Social Security number, the mother’s maiden name and the code of how to manipulate the data. I refused, I was defending the confidentiality of people’s voting information. I didn’t give this to Obama. I’m not giving it to Trump.

I think the difference between the two administrations is the president accused states like yours, among others, as trying to hide something.

I wouldn’t necessarily disagree with you. I think they have created this environment. I think, done in a different way, this could have been accomplished. And it still can be accomplished.

Are states under attack in terms of their election integrity?

I don’t know if we are under attack, but it goes back to: There are so many people engaged in this that don’t have a clue how elections are run. It’s beyond me.

Things have become so caustic, and the sad thing is that it’s spilled over now into the most precious right we have as Americans, the vote.

And that’s what’s so frustrating to me, no matter who is claiming fraud or whatever. I’m so tired of this back-and-forth and nobody brings the proof. n

© The Washington Post

CONTENTS POLITICS THE NATION THE WORLD COVER STORY VISUAL HISTORY BOOKS OPINION FIVE MYTHS

4 8 10 12 16 18 20 23

ON THE COVER In the age of apps and on-demand services, house calls from physicians might be making a comeback. Illustration by Istockphoto.

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POLITICS

The dental lobby has real teeth M ARY J ORDAN Augusta, Maine BY

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ittle in politics has surprised Richard Malaby as much as the power of dentists.

For years, local dentists held four Christmas parties at Malaby’s 19th-century country inn in the picturesque town of Hancock.

But in 2014, Malaby, a Republican lawmaker in the Maine state legislature, voted to create a new type of dental provider to perform basic services in poor and rural areas.

The Maine Dental Association, which opposed the bill, was furious. And the dentists took their Christmas parties elsewhere, costing Malaby $6,000 that December and every Yuletide since.

Among the general public, dentists tend to have a Norman Rockwell appeal — solo practitioners who clean your teeth, tell your kids to cut down on the candy, and put their seal of approval on a range of minty toothpastes and mouthwashes. But lawmakers from Maine to Alaska see a different side of dentists and their lobby, the American Dental Association, describing a political force so unified, so relentless and so thoroughly woven into American communities that its clout rivals that of the gun lobby.

“I put their power right up there with the NRA,” Malaby said.

“Dentists do everything they can to protect their interests — and they have money.”

As the cost of dental care rises beyond the reach of millions of Americans, the dental lobby is coming under increasing scrutiny. Critics say the ADA has worked to scuttle competition that could improve access to dental care in underserved areas and make routine checkups and fillings more affordable.

The Federal Trade Commission has battled dentists in state after state over anti-competitive conduct. In 2007, the FTC successfully settled a complaint over a South Carolina dental board requirement that dentists examine children in school clinics before

LINDA DAVIDSON/THE WASHINGTON POST

As pushback to Maine bill shows, dentists are powerful political force hygienists can clean their teeth, adding greatly to the cost. In 2015, the FTC won a Supreme Court ruling against the North Carolina dental board, which tried to block teeth-whitening businesses from operating in malls.

This year, the FTC publicly commented on a growing campaign to improve access to dental care by creating a category of mid-level practitioners, or “dental therapists,” to provide some routine services. In a letter to the Ohio lawmakers considering such a measure, FTC officials said therapists “could benefit consumers by increasing choice, competition, and access to care, especially for the underserved.”

More than a dozen states are considering similar proposals,

despite fierce resistance from the ADA and its state affiliates. During the Maine debate, so many dentists flooded the statehouse in Augusta that besieged lawmakers taped up signs declaring their offices a “Dental Free Zone.”

The dentists had a unique way to get around the blockade: the regular checkup. While the bill was pending, some lawmakers found themselves getting an earful when they stretched out and opened wide for an oral exam.

“I’m certainly a captive audience when I am in the dental chair,” said Brian Langley (R), a Maine state senator who also got calls from four other dentists in his district and ended up siding with them.

The bill establishing a new

Michael Hanson had all his teeth pulled after being priced out of oral care. A new model promises lower costs, but most dentists oppose it.

provider type ultimately passed, but “it was brutal, very brutal,” recalled David Burns, a Republican state senator who retired after supporting the measure. Afterward, Burns said, he got a call from his dentist, who vowed never to treat him again, saying, “This relationship is over.”

Most of the 200,000 dentists in America work solo, in offices that are essentially small businesses.

They are known for projecting a remarkably unified voice on issues relating to their livelihood.

The ADA says 64 percent of dentists belong to the association. By comparison, only 25 percent of physicians belong to the American Medical Association.

The ADA agrees that too many Americans are getting inad-

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POLITICS equate dental care. They argue that the answer is not the creation of “lesser trained” therapists, but more government funding and “community dental health care coordinators” to educate people and get them to a dentist.

“Dentistry has a fundamental belief that dentists should be the only ones to do surgical, irreversible procedures,” said Michael Graham, senior vice president of the ADA’s Division of Government and Public Affairs. “A lot of things can happen when you cut into a tooth.”

Others argue that the American model of dentistry is badly in need of innovation and competition. The Pew Charitable Trusts and other foundations advocate therapists as a way to improve access and affordability.

Therapists cost less to train than dentists do, and states set the rules governing their training and scope of practice. Supporters say the idea is for the therapists to work in concert with a licensed dentist but be more mobile, visiting people in nursing homes and underserved rural areas to perform basic oral exams and fill and pull some teeth.

They would also treat people on Medicaid, the government health-care program for the poor.

Two-thirds of licensed dentists do not accept Medicaid, and hospital emergency rooms are swamped with people with neglected teeth.

Louis Sullivan, a physician who served as secretary of health and human services under President George H.W. Bush, said dentists’ opposition to therapists is largely about money.

“They think dental therapists will be competing against them and therefore will compromise their income,” he said.

Sullivan noted that doctors strongly opposed the creation of nurse practitioners in the 1970s.

Now doctors — and the healthcare system — can’t live without them, he said.

As in the nurse-doctor battle, there is a gender factor: More than 95 percent of dental hygienists are female. As a group, they support the idea of therapists and, with additional training, could join their ranks. Currently, hygienists work in small offices with licensed dentists, 70 percent of whom are male.

Dentistry has “been an old boys’ club,” said Ruth Ballweg, a

SARAH RICE FOR THE WASHINGTON POST

Dentist Jonathan Shenkin vocally joined the Maine Dental Association in opposition of the bill. He says the fight for lower costs is misplaced.

Dental therapy programs Allowed

Under consideration statewide

In tribal areas

Not allowed ME

WI

In tribal areas and under consideration statewide

HI

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OR

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SD

IA

IN

OH

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UT

CO

NE

MO

KY

AZ

NM

KS

AR

OK

LA

AK

TX

Source: The Pew Charitable Trusts

professor and physician assistant at the University of Washington School of Medicine who has been involved in the fight for dental therapists. “But the model is changing.”

More than 50 countries, from Canada to New Zealand, have dental therapists. Alaska Native tribal areas first introduced dental therapists to the United States in 2004. Since then, Minnesota, Maine and Vermont have approved them. Ohio, Kansas, Massachusetts, North Dakota and several other states are now contemplating their authorization.

The ADA has spent millions of dollars trying to block the bills. It also filed multiple lawsuits trying without success to stop the Alaska program.

“They went after these Alaskan therapists like they were ISIS. It was embarrassing,” said Jack Dillenberg, a dentist who has taught

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FL THE WASHINGTON POST

at the Harvard School of Dental Medicine.

Dillenberg visited the Alaska program, where therapists working in consultation with a licensed dentist — sometimes by telemedicine — visit islands, remote villages and other underserved areas.

“I thought they were awesome,” said Dillenberg, one of few dentists to publicly support the therapist idea.

Of two dozen dentists interviewed, a handful said they liked the idea, with some arguing that the existence of therapists would let them concentrate on more complicated procedures. Another proponent, Maine dentist Aatif Ansari, posted pro-therapist comments on Facebook during the 2014 debate. He got hammered by his colleagues.

“It was very aggressive. Folks were upset,” Ansari said. “They

said things like, ‘How could you? I spend this many years in school and how could you let someone with inferior training do this work?’ ” The ADA and its state associations often argue that therapists provide second-class care. Jonathan Shenkin, a Maine dentist who is active in the lobby, said the push for therapists is misplaced.

He argues for more emphasis on prevention, including better nutrition and regular brushing.

In Maine, the therapist bill turned out to be the most contentious issue of the 2014 legislative session. It passed only after opponents added multiple restrictions, including a requirement that therapists work only in the presence of a dentist. Supporters failed even to persuade lawmakers to let therapists travel to nursing homes alone. Three years later, resistance remains high. Dentists control the dental schools and the state licensing board, and not one therapist has yet been trained. Supporters of the legislation say restrictions and bureaucracy have made becoming a therapist less desirable.

Meanwhile, people who can’t pay continue to put off care. On a recent Friday, Michael Hanson, 54, a lobsterman who went 15 years without seeing a dentist, was sitting in the community health clinic near Maine’s Acadia National Park. Over time, lack of care and poor health ruined Hanson’s teeth. In February, they were all pulled. He sat toothless, talking about eating soft food for months while he awaits his dentures.

Hanson said his daughter, too, skips annual exams because it is hard to come up with the money.

The dental system is broken, he said. “You go to the hospital and they give you time to pay your bill.

But you go to the dentist and they want you to pay right there, and people just don’t have the money.”

Heather Sirocki, a Maine lawmaker who backed the therapist bill, is a hygienist by training. She has seen the swollen jaws and blackened teeth of people who can’t afford dental care. She’s even heard of people driving to Canada to seek treatment.

People like Hanson “are not asking for a free handout,” Sirocki said. “They are asking for a dental appointment.” n ©The Washington Post

KLMNO WEEKLY

Richard Malaby, a Republican lawmaker in the Maine state legislature, says, “Dentists do everything they can to protect their interests — and they have money.”

Heather Sirocki, a lawmaker who trained as a dental hygienist, cosponsored the bill that ultimately passed.

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POLITICS

Blue cities battle red-state leaders S ANDHYA S OMASHEKHAR Austin BY

T

he grand old oak called Patsy Cline rises gracefully on three trunks. Waylon Jennings leans lazily before angling back toward the sun.

And Willie Nelson, tall and broad, ascends on a torso three feet thick before bursting into a dense green canopy.

Citizens here named the trees in an effort to save more than a dozen of them — all protected under a city ordinance — that stand in the way of a planned new mixed-use development. It is the kind of quintessentially local battle that plays out in cities across the country, albeit one with a distinctly local flavor in this quirky, musically inclined town.

But here in Texas, the bigger battle over tree ordinances is whether they represent a form of local government overreach. Gov. Greg Abbott (R), citing grave worries about “socialistic” behavior in the state’s liberal cities, has called on Texas lawmakers to gather this month for a special session that will consider a host of bills aimed at curtailing local power on issues ranging from taxation to collecting union dues.

Texas presents perhaps the most dramatic example of the increasingly acrimonious relationship between red-state leaders and their blue city centers, which have moved aggressively to expand environmental regulations and social programs often against the grain of their states.

Republican state leaders across the country have responded to the widening cultural gulf by passing legislation preempting local laws.

The best-known example is North Carolina’s “bathroom bill,” which was partially reversed this year. It was originally aimed at undercutting Charlotte’s efforts to expand civil rights laws to include LGBT people and to prevent cities from setting their own minimum wage.

“These preemption laws are designed to intimidate and bully local officials into doing the bidding of a smaller group of folks,” said Michael Alfano of the Campaign to

ILANA PANICH-LINSMAN FOR THE WASHINGTON POST

In Texas, a tree ordinance in the famously liberal capital is the latest scuffle with GOP lawmakers Defend Local Solutions, a new nonprofit organization aimed at fending off state efforts to undermine local power.

The Texas special session has not been greeted kindly in the state capital of Austin, a liberal outpost where officials say they are being used as a political punching bag by Republican state lawmakers appealing to voters elsewhere in this conservative state.

A war of words has erupted between Abbott and city officials, with a city councilman calling Abbott “cowardly” for his approach to a crackdown on “sanctuary cities” — where officials refuse to help detain and deport those in the country illegally — and Abbott mocking the smell of Austin’s air.

“Once you cross the Travis County line, it starts smelling different,” Abbott joked at a recent gathering of Republicans, referring to the county that includes Austin. “And you know what that fragrance is? Freedom. It’s the

smell of freedom that does not exist in Austin, Texas.”

The comments did not land well in this fast-developing city that boasts a high quality of life.

“The air in Austin is pretty sweet with an unemployment rate that is a point lower than the state, a lower violent crime rate than the state, with the highest rates of patents and venture capital in the state,” Austin Mayor Steve Adler (D) shot back. “And the air is sweet with tacos.”

Adler has accused the governor of waging a “war on cities,” calling the state’s attempts to interfere with what local communities think work best for them “the height of micromanaging.”

Republican state lawmakers counter that cities like Austin have gone too far in regulating citizens, and tree-hugging ordinances that limit what landowners can do with their own properties are a prime example.

Texas’s tree ordinance issue is among 20 agenda items Abbott

Karen Sironi, 63, touches Waylon, one of the doomed “heritage” oak trees she named in Austin.

Despite local opposition, a developer gained permission to remove all but one of the 750 targeted trees on the site of a planned mixed-use project. The project is called Austin Oaks.

wants lawmakers to consider at the special session that begins July 18. Other, far more hefty proposals, include a teacher pay raise, new abortion restrictions and a measure styled after North Carolina’s bathroom bill — by far the most controversial issue.

Still, the tree issue has been an animating one in Texas, with multiple bills introduced during the regular session taking aim at local tree ordinances.

The ordinance came up recently during heated debate about the Austin Oaks, an ambitious development that will bring housing, shops and glossy office space to a shady area in the northern part of town. It is marked by boxy office buildings built in the 1970s and 1980s, and expanses of parking lot shaded by sprawling old trees.

The proposal to shear the property of hundreds of trees, including about a dozen “heritage” oaks whose girth exceeds 24 inches, infuriated local residents, and they decided to make their displeasure known in distinctly Austin ways.

One resident, Karen Sironi, a retired airline worker, decided to give names to each of the heritage trees in hopes of humanizing them for city officials. Most of the monikers were of country-western singers, though a few drew from other inspirations. When that didn’t work, she painted each tree’s portrait lined with black — to represent its death, she said.

In the end, the developer gained permission to remove all of the trees except Willie Nelson. On a recent morning, as the temperatures in Austin began their ascent to 100 degrees, Kwak and Sironi rested in the cool shade cast by the tree they called Lady Yoga, lamenting that anyone would consider taking her down.

Sironi said she has no patience with those who think Austin’s ordinance essentially bars landowners from cutting down their own trees. After all, she said, the developer here won.

“And what about my rights as a property owner to live in the kind of community I want?” she said.

“That’s my right, too.” n ©The Washington Post

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POLITICS

KLMNO WEEKLY

Economy falls short of promises

BY D AMIAN P ALETTA AND A NA S WANSON

D

espite bravado and big promises, the economy that President Trump has been touting in recent days looks a lot like the one he lambasted as a candidate: a slow, largely steady grind that has chipped away at the damage done by the 2008-2009 recession but failed to produce the prosperity of decades past.

Now, as he approaches the six-month marker of his presidency, Trump faces several new warning signs that key areas of the economy could be losing steam, including in industries he specifically promised to revitalize.

Meanwhile, the legislative packages that Trump promised would deliver his economic boom, including a rewrite of the nation’s tax code and a massive investment in infrastructure, are nowhere to be seen, languishing in a deadlocked Congress.

“Stock Market at all time high, unemployment at lowest level in years (wages will start going up) and our base has never been stronger!” Trump posted on Twitter last week. He reiterated the message in another post Monday afternoon: “Really great numbers on jobs & the economy! Things are starting to kick in now, and we have just begun! Don’t like steel & aluminum dumping!”

Indeed, the unemployment rate has dropped from 4.8 percent to 4.3 percent under Trump’s watch, and the stock market is hitting record levels. Business and consumer confidence is high, though both have cooled recently.

Companies are announcing plans to expand and add jobs, such as Samsung’s announcement last week that it would add almost 1,000 jobs over the next three years with the construction of a facility in South Carolina.

But there are troubling undercurrents. Automobile sales, the heart of the manufacturing economy, are in a months-long swoon.

Both General Motors and Ford on Monday reported that their sales

MELINA MARA/THE WASHINGTON POST

The president touts progress, but everything looks a lot like what he hated as a candidate had slid 5 percent in June as the industry’s workers continue to be hit with layoffs. U.S. factory output fell in May, while new orders for durable goods such as furniture, electronics and appliances declined, as well. Construction of new homes fell to an eight-month low.

Overall, the 362,000 jobs added from March to May are the fewest during a three-month period since mid-2012.

“It’s difficult to say the economy is doing well overall,” said Lindsey Piegza, chief economist at Stifel Fixed Income. “At this point, we’re still struggling to see a more robust recovery after years and years of lower growth . . . We’re still treading water and struggling to get to that 2 percent [economic growth] on a consistent basis.”

Caught between Trump’s promises and an unyielding reality, White House officials are highlighting positive economic trends while also urging Congress to enact key parts of their agenda.

Top advisers are pushing for an overhaul of the tax code that would slash rates, something the White House says would spur

more hiring and investment.

They are also trying to design a large-scale infrastructure plan that would rebuild roads, bridges and airports, among other things.

Visible progress on those plans, however, has been nearnonexistent, with Republicans’ summer agenda dominated by disagreements over how to repeal and replace the Affordable Care Act and looming budget and borrowing crises ready to command Congress’s attention in the fall. Trump has had more success slashing regulations, but that has not had a material impact on hiring and growth, several economists said.

White House officials believe that for the economy to grow as fast as Trump has promised, Congress will have to move quickly to enact his agenda, including the tax cuts and the infrastructure spending. He is also pushing for new bilateral trade agreements and a widespread reduction in regulations.

National Economic Council Director Gary Cohn, in a statement to The Washington Post, outlined several positive trends

“That’s not this year.

That’s not next year. It will take some time to set in.”

Treasury Secretary Steven Mnuchin, above, saying President Trump’s promises will take time to materialize

in the economy, including the lower unemployment rate, and said things are improving.

“These are all good trends, but we know there is more work to do, including improving wage growth for hardworking Americans,” he said. “We believe this Administration can help drive a better job environment in this country, and that’s why we’re working every day to address burdensome regulations, reform the tax code and restore our nation’s infrastructure.”

Treasury Secretary Steven Mnuchin, asked in late June about the restrained economic performance so far, said Trump’s promises will take time to materialize. “That’s not this year,” he said. “That’s not next year. It will take some time to set in.”

The Congressional Budget Office on Thursday projected that the economy would grow just 2.1 percent this year, an increase from last year but far lower than Trump’s goals. It also projected the economy would begin to slow in 2019 and 2020, growing only 1.6 percent in those years.

Trump inherited an economy with low unemployment and low inflation, but it also had weak wage growth, rising debt levels, an aging population and a large number of people who were not participating in the labor force.

Economists say achieving the rate of growth Trump is targeting will be difficult, given underlying changes such as the aging of the U.S. workforce and slower productivity growth. It also remains unclear whether companies that touted plans to hire thousands of workers at the beginning of the year plan to do so.

Harley Lippman, head of an IT consulting company called Genesis10, said chief executives are still cautiously optimistic but that their patience could soon run short.

“People are willing to cut him slack for a little while, but it’s not going to last that long, and people are going to become impatient and disappointed with that administration,” Lippman said. n ©The Washington Post

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KLMNO WEEKLY

NATION

Good dog, good therapist?

BY

K ARIN B RULLIARD

A

therapy-animal trend grips the United States.

The San Francisco airport now deploys a pig to calm frazzled travelers. Universities nationwide bring dogs (and a donkey) onto campus to soothe students during finals. Llamas comfort hospital patients, pooches provide succor at disaster sites and horses are used to treat sex addiction.

And that duck on a plane? It might be an emotional-support animal prescribed by a mental health professional.

The trend, which has accelerated hugely since its initial stirrings a few decades ago, is underpinned by a widespread belief that interaction with animals can reduce distress — whether it happens over brief caresses at the airport or in long-term relationships at home. Certainly, the groups offering up pets think this, as do some mental health professionals. But the popular embrace of pets as furry therapists is kindling growing discomfort among some researchers in the field, who say it has raced far ahead of scientific evidence.

Earlier this year in the Journal of Applied Developmental Science, an introduction to a series of articles on “animal-assisted intervention” said research into its efficacy “remains in its infancy.” A recent literature review by Molly Crossman, a Yale University doctoral candidate who recently wrapped up one study involving an 8-year-old dog named Pardner, cited a “murky body of evidence” that sometimes has shown positive short-term effects, often found no effect and occasionally identified higher rates of distress.

Overall, Crossman wrote, animals seem to be helpful in a “small-tomedium” way, but it’s unclear whether the critters deserve the credit or something else is at play.

“It’s a field that has been sort of carried forward by the convictions of practitioners” who have seen patients’ mental health improve after working with or adopting animals, said James Ser-

CHRIS CARLSON/ASSOCIATED PRESS

Embrace of animals as providers of emotional support has raced ahead of scientific evidence pell, director of the Center for the Interaction of Animals and Society at the University of Pennsylvania School of Veterinary Medicine. “That kind of thing has almost driven the field, and the research is playing catch-up. In other words, people are recognizing that anecdote isn’t enough.”

Using animals in mental health settings is nothing new. In the 17th century, a Quaker-run retreat in England encouraged mentally ill patients to interact with animals on its grounds. Sigmund Freud often included one of his dogs in psychoanalysis sessions. Yet the subject did not become a research target until the American child psychologist Boris Levinson began writing in the 1960s about the positive effect his dog Jingles had on patients.

But the evidence to date is problematic, according to Crossman’s review and others before it. Most studies had small sample sizes, she wrote, and an “alarming num-

ber” did not control for other possible reasons for a changed stress level, such as interaction with the animal’s human handler. Studies also tend to generalize across animals, she noted: If participants are measurably soothed by one golden retriever, that doesn’t mean another dog — or another species — will evoke the same response.

Even so, media headlines are often about the happiness bounce.

Hal Herzog, a Western Carolina University psychologist who has long studied human-animal interactions, recalls a 2015 study on the health benefits for children of having a pet dog. “Here’s a reason to get a puppy,” NBC announced.

“Kids with pets have less anxiety.”

That’s actually not what the study concluded. The authors did find that children with dogs had lower anxiety based on screening scores than children without dogs. Still, they cautioned that “this study does not answer

Logan, a therapy dog, waits to visit with inmates at the Twin Towers Correctional Facility in Los Angeles in April. Research on the effectiveness of such animals in reducing stress “remains in its infancy,” one report said.

whether pet dogs have direct effects on children’s mental health or whether other factors associated with acquisition of a pet dog benefit their mental health.”

It was a classic case of conflating correlation and causation, which Herzog says is common.

Cherry-picked positive results also are a problem, as he says happens in promotional materials from the Human-Animal Bond Research Initiative (HABRI). The pet-industry backed organization funds research on the topic.

“The number of papers I see that start out, ‘It is now well-established that there are health benefits from owning pets’ — that drives me crazy,” Herzog said.

“Yes, there’s literature that supports that. But there’s also literature that doesn’t find that.”

To many animal lovers and pet owners, the back-and-forth might sound horribly wonky. There’s something intuitive about the good feelings animals give us.

Why over-analyze it?

But there are good reasons for rigorous research on animals and mental health. In 2012, the Department of Veterans Affairs said it would not cover costs of service dogs for veterans with post-traumatic stress disorder, citing “a lack of evidence to support a finding of mental health service dog efficacy.” The department is now in the midst of a multiyear study on the topic, which could lead to government funding for these pooches.

Another reason, the scientists say, is for the animals’ sake. Crossman pointed to a 2014 incident at Washington University in St. Louis as an example of animal therapy gone wrong. A bear cub brought to campus during finals week nipped some students, causing a rabies scare that almost ended with the animal being euthanized.

The research is getting stronger, in part because funding is growing.

“Kids are already participating in this on a huge scale,” Crossman said. “Ideally, the order goes the other way around: We test the idea, and then we implement.” n ©The Washington Post

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To earn a diploma, they need a plan E MMA B ROWN Chicago BY

T

o graduate from a public high school in Chicago, students will soon have to meet a new and unusual requirement: They must show that they’ve secured a job or received a letter of acceptance to college, a trade apprenticeship, a gap year program or the military.

Mayor Rahm Emanuel (D) said he wants to make clear that the nation’s third-largest school system is not just responsible for shepherding teenagers to the end of their senior year, but also for setting them on a path to a productive future.

“We are going to help kids have a plan, because they’re going to need it to succeed,” he said. “You cannot have kids think that 12th grade is done.”

Few would dispute that kids often need more than a high school diploma to thrive in today’s economy, but there is a simmering debate about the extent to which schools should be — and realistically can be — expected to ensure their graduates receive further training.

Emanuel’s plan, approved by the Board of Education in late May, has planted Chicago at the center of that debate.

Experts say Chicago Public Schools is the first big-city system to make post-graduation plans a graduation requirement. But the question is whether the cashstrapped district can provide enough mentoring and counseling to help its neediest students succeed when the rule takes effect in 2020.

Jermiya Mitchell, 17, a rising senior at Morgan Park High School on the South Side, said she has had few interactions with her guidance counselor. “We never had that conversation about life after high school,” she said. “I would like to have a counselor that really wanted to know what I wanted to do after high school and would help me get there.”

Some students, parents and teachers have embraced the move as a way to level the playing field

JOSHUA LOTT FOR THE WASHINGTON POST

Chicago high school requirement won’t allow students to graduate without mapping out future for teens whose parents aren’t equipped to help them envision where they want to go after high school — or figure out how to get there.

Critics say Emanuel’s idea is an empty gesture that does nothing to address the fact that many teenagers are graduating in impoverished, violence-racked neighborhoods with few jobs, or that the most readily accessible community colleges are ill-prepared to meet the needs of firstgeneration students from low-income families. They also point out that the 381,000-student district laid off more than 1,000 teachers and staff members in 2016, and it is in such difficult financial straits that it struggled to keep its doors open for the final weeks of the school year.

“It sounds good on paper, but the problem is that when you’ve cut the number of counselors in schools, when you’ve cut the kind of services that kids need, who is going to do this work?” said Karen Lewis, president of the Chica-

go Teachers Union and Emanuel’s longtime political opponent. “If you’ve done the work to earn a diploma, then you should get a diploma. Because if you don’t, you are forcing kids into more poverty.”

School and city officials are impatient with the notion that the new requirement — originally suggested to Emanuel by Arne Duncan, the former Chicago schools chief who was education secretary under President Barack Obama — asks too much of students or schools.

Emanuel announced the initiative in April. Officials describe it as the logical next step in Chicago’s efforts to improve public education. Despite the school system’s financial woes, nearly 74 percent of students now graduate within four years — 16 points higher than the rate five years ago, although that’s lower than the national average of 83 percent.

Nationally, there is a move afoot to hold schools accountable

Jermiya Mitchell, 17, a rising senior at Morgan Park High School, said she hasn’t interacted much with her guidance counselor.

“I would like to have a counselor that really wanted to know what I wanted to do after high school and would help me get there,” she said.

for what high school students do after graduation. Out of 17 states that have laid out plans for rating school performance under a new federal law, at least four plan to incorporate the percentage of graduates who enroll in college or another postsecondary option.

Chicago rates its high schools’ performances based partly on the number of graduates who go to college and stay at least a year.

High school graduates are guaranteed admission to one of the city’s community colleges, if they apply, and about 40 percent of the Class of 2015 enrolled in a fouryear college, approaching the national average (44 percent) that year.

The first students affected by the new requirement are rising sophomores in the Class of 2020.

Emanuel argues that gives schools enough time to make sure students are ready, even without additional resources.

Given the new graduation requirement, seniors beginning this fall will take a year-long seminar on planning for life after high school.

Janice Jackson, the school system’s chief education officer, said that is how the new requirement is supposed to work — pushing principals to improve efforts to help students prepare for the future. About 60 percent of district students have postsecondary plans when they graduate, she said, and she doesn’t think the schools should wait for more money to set an expectation that the remaining 40 percent follow suit.

Would Chicago really withhold diplomas from students who meet every requirement except the new one? Jackson says it won’t come to that, because principals, counselors and teachers won’t let it. They’ll go to students in that situation and press them to make sure they have a plan.

“There’s a big group in there who aren’t doing a whole lot after they leave high school,” she said.

“It’s our responsibility to . . . guide them in the right direction.” n ©The Washington Post

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N. Korean missile test surprises U.S. Experts say the ICBM was ‘the real thing’ and puts American cities within reach

BY

J OBY W ARRICK

T

he North Korean missile that soared high above the Sea of Japan on Tuesday was hailed by staterun television as a “shining success.” But to U.S. officials, it was a most unwelcome surprise: a weapon with intercontinental range, delivered years before most Western experts believed such a feat possible.

Hours after the apparently successful test, intelligence agencies continued to run calculations to determine precisely how the missile, dubbed the Hwasong-14, performed in its maiden flight. But the consensus among missiles experts was that North Korea had achieved a long-sought milestone, demonstrating a capability of striking targets thousands of miles from its coast.

Initial Pentagon assessments said North Korea had tested a “land-based, intermediate-range” missile that landed in the Sea of Japan just under 600 linear miles from its launch point, Panghyon Airfield, near the Chinese border.

But government and independent analyses showed the missile traveling in a steep arc that topped out at more than 1,740 vertical miles above the Earth’s surface.

If flown in a more typical trajectory, the missile would have easily traveled 4,000 miles, potentially putting all of Alaska within its range, according to former government officials and independent analysts. A missile that exceeds a range of 3,400 miles is classified as an intercontinental ballistic missile, or ICBM. “This is a big deal: It’s an ICBM, not a ‘kind of’ ICBM,’ ” said Jeffrey Lewis, director of the East Asia program at the Center for Nonproliferation Studies. “And there’s no reason to think that this is going to be the maximum range.”

David Wright, senior scientist for the Union of Concerned Scientists, calculated in a published analysis that the Hwasong-14’s demonstrated capability exceeded 4,100 linear miles, based on preliminary estimates released Monday.

Altitude: 2,000 miles 1,500

Test had a lofted trajectory of 1,700 miles.

The missile flew for 37 minutes and traveled roughly 580 miles from its launch point.

1,000

On a normal trajectory with the same flight time, the distance would be 4,100 miles.

Projected trajectory

500

International Space Station orbit 0

1,000

2,000 Range in miles

4,000

3,000

North Pole RUSSIA D.C.

Alaska CHINA

CANADA

Chicago

Anchorage

U.S. Seattle

JAPAN Okinawa

Approximate location of test launch landing site.

Pacific Ocean

San Francisco

MEX.

4,100-mile radius from North Korea

Guam Hawaii Source: David Wright via All Things Nuclear Blog

“That range would not be enough to reach the Lower 48 states or the large islands of Hawaii, but would allow it to reach all of Alaska,” Wright said.

North Korea’s apparent accomplishment puts it well ahead of schedule in its years-long quest to develop a true ICBM. The Hwasong-14 tested last week could not have reached the U.S. mainland, analysts say, and there’s no evidence to date that North Korea is capable of building a miniaturized nuclear warhead to fit on one of its longer-range missiles. But there is now little reason to doubt that both are within North Korea’s grasp, weapons experts say.

“In the past five years, we have seen significant, and much more rapid-than-expected development of their ballistic-missiles ca-

THE WASHINGTON POST

pability,” said Victor Cha, a former director of Asian affairs for the George W. Bush administration’s National Security Council. “Their capabilities have exceeded our expectations on a consistent basis.”

While U.S. intelligence officials have sought, with some success, to disrupt North Korea’s progress, Pyongyang has achieved breakthroughs in multiple areas, such as the development of solid-fuel rocket engines and mobile-launch capabilities, including rockets that can be fired from submarines. Early analysis suggests that the Hwasong-14 uses a new kind of indigenously built ballisticmissile engine, one that North Korea unveiled with fanfare on March 18. Nearly all the country’s previous ballistic missiles used engines based on modifications of

older, Soviet-era technology.

“It’s not a copy of a crappy Soviet engine, and it’s not a pair of Soviet engines kludged together — it’s the real thing,” Lewis said.

“When they first unveiled the engine on March 18, they said that the ‘world would soon see what this means.’ I think we’re now seeing them take that basic engine design and execute it for an ICBM.” In announcing the test in a special TV broadcast Monday, North Korean officials proclaimed that the country had achieved an ICBM capability that would safeguard the communist government from attacks by the United States and other adversaries. According to U.S. analysts, leader Kim Jong Un has long calculated that nuclear-armed ICBMs are the best deterrence against threats to his survival, as any perceived aggression against him could trigger a retaliatory strike targeting U.S. cities.

“As the dignified nuclear power who possesses the strongest intercontinental ballistic rocket which is capable of hitting any part of the world along with the nuclear weapons, the Democratic People’s Republic of Korea will fundamentally terminate the U.S. nuclear war threats and blackmail and credibly protect the peace and stability of the Korean Peninsula and the region,” a government spokeswoman said in a bulletin read on state-run television.

The spokeswoman added that the missile’s trajectory was deliberately set “at the highest angle” to avoid harming neighboring countries.

That claim rang true to U.S. analysts, who agreed that the high arc was likely intended to avoid possibly hitting Japanese territory. Moreover, the rocket’s flight path also would help North Korea secure another objective: secrecy.

By sending the spent engine splashing into the deep waters of the Sea of Japan, Pyongyang ensured that it would be hard, if not impossible, for U.S. and Japanese divers to find and retrieve the parts. n ©The Washington Post

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Under the sea, a quest for diamonds High-tech ships vacuum up the gems from the seafloor off the coast of southern Africa

BY

K EVIN S IEFF Off the Coast of Namibia

Mining diamonds from the ocean

D

1. The seafloor is scanned and sampled. A plan for mining is mapped out.

eep beneath this frigid stretch of the Atlantic Ocean, some of the world’s most valuable diamonds are scattered like lost change.

The discovery of such gems has sparked a revolution in one of the world’s most storied industries, sending mining companies on a race for precious stones buried just under the seafloor.

For over a century, open-pit diamond mines have been some of the most valuable real estate on Earth, with small swaths of southern Africa producing billions of dollars of wealth. But those mines are gradually being exhausted. Experts predict that the output of existing onshore mines will decline by around 2 percent annually in coming years. By 2050, production might cease.

Now, some of the first “floating mines” could offer hope for the world’s most mythologized gemstone, and extend a lifeline to countries like Namibia whose economies depend on diamonds.

Last year, mining companies extracted $600 million worth of diamonds off the Namibian coast, sucking them up in giant vacuumlike hoses.

“As [Namibia’s] land-based mines enter their twilight years, it’s very important for us and for Namibia that we have long-term mining prospects,” said Bruce Cleaver, the chief executive of De Beers, in an interview.

But as companies weigh the prospect of more offshore operations, environmentalists have raised concerns about the damage that could be inflicted on the seafloor.

Diamonds are formed when carbon is subjected to high temperatures and pressure deep underground. Some were hurled toward the surface millions of years ago in volcanic eruptions. In recent decades, geologists realized that because diamonds could be found in Namibia’s Orange River, there was a good chance they could also be detected at sea, swept there by the current. As it

4. Recovered diamonds are catalogued, packaged and flown off the boat by helicopter several times a week.

Diamond mining boat

2. Sediment is dredged from the seafloor by a crawler and sucked to the ship by a large pipe.

ple unaided by the diamond rush.

Released sediment Sorting

3. Once on board, the material is then crushed and sifted until diamonds can be extracted. Leftover sediment is returned to the ocean.

Crawler Source: De Beers Group

turned out, the underwater gems were among the world’s most valuable stones — with far greater clarity than diamonds mined on land.

De Beers, which historically dominated global diamond production, purchased mining rights to more than 3,000 square miles of the Namibian seafloor in 1991. So far, it has explored only 3 percent of that area.

The technology to extract the underwater diamonds took years to develop. Only recently has the firm been able to efficiently scavenge the sea for diamonds. Underwater gems only represent about 13 percent of the value of diamonds De Beers mines onshore each year, but more countries are pushing for exploration to begin along their coastlines.

Mining sites turned ghost towns In 1908, a railroad worker named Zacharias Lewala found a shiny stone in the desert of southwestern Namibia. South Africa’s diamond rush had been underway for a few decades, and now another boom began in the territory to its northwest, with miners finding some valleys strewn with the precious stones. A century later, many of those mining sites are

THE WASHINGTON POST

now ghost towns. All that’s left of Kolmanskop, where Lewala found his diamond, is a cluster of abandoned wooden houses.

In the 1990s, De Beers sent its first commercial vessels into the Atlantic in search of diamonds.

Now, more than 90 percent of Namibia’s diamond-related revenue comes from offshore finds.

These days, the company uses drones to fly over vast stretches of the ocean, looking for areas that might be worth exploring. Then it sends vessels like the Mafuta to dredge the most promising areas.

Most of the diamonds are close to the surface, De Beers said, so it does not go deeper than six feet beneath the seafloor.

Ninety-eight people live aboard the Mafuta, which has the urgent, frenzied feeling of a naval ship. A few weeks ago, it was hammered with 30-foot swells as it tried to operate.

Diamond mining contributes roughly a tenth of Namibia’s gross domestic product, and its offshore contract with De Beers is a 50-50 partnership with the government.

But while the soaring revenue has made some Namibians rich, this remains the world’s third most unequal country, according to the World Bank, with millions of peo-

Debate over ecological damage Although Namibia is considered the easiest place to extract offshore diamonds, mining executives are not ruling out exploring other stretches of ocean. Marine mining has also taken place off the coast of South Africa, though it has proven less lucrative.

But environmental groups have raised concerns about the offshore mining operations, which spew the sediment back into the ocean after it is processed for diamonds.

“My concern with this and all deep-sea mining is that we just don’t know much about the deep sea at all,” said Emily Jeffers, an attorney with the Center for Biological Diversity, a U.S. nonprofit organization. “The worry is that we are going to irreparably harm this environment and these species before we discover them.”

De Beers says its offshore operations do not cause significant ecological damage, as sediment is returned to the sea and eventually resettles. The company says it employs ecologists who monitor the environment where they have mined to make sure it is recovering.

The culling process is entirely mechanized, and the diamonds are only visible to workers when they are dropped into the can.

When enough of the gems accumulate there, the can is sealed and flown to Windhoek, Namibia’s capital.

That is where, in an office on the 11th floor of a nondescript building, Peter Kayser inspects highvalue diamonds that could be worth anywhere from tens of thousands to millions of dollars.

One day last month, his attention was on a diamond about the size of the tip of his thumb that had recently been vacuumed up from the ocean floor. He passed the gem through a machine that calculated its weight. It took a few moments before the number flashed on a screen: at least seven carats.

Kayser smiled.

“This could be a very expensive stone.” n ©The Washington Post

Barbara Bennett goes over her daughter’s medical history with pediatrician Adam Lowry while Claire watches medical assistant Kierra Wynn unpack equipment during a Heal house call in Great Falls, Va.

Doctor

on demand How app culture could revive a long-dead relic in health care: The house call

BY HAYLEY TSUKAYAMA

KATHERINE FREY/THE WASHINGTON POST

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A

lison Mintzer and her family were on a flight from New York to Los Angeles when her daughter complained that she felt sick. By the time they landed, Mintzer’s normally uncomplaining 6-year-old said that her neck and ears hurt. When a fever soon followed, it was enough to convince her parents that she needed to see a doctor.

Thousands of miles from their pediatrician, and unable to find one quickly in L.A., Mintzer didn’t know what to do. Then a family friend suggested an app called Heal that could use new technology to drum up a relic from the past: doctors who make house calls.

Once upon a time, a visit with the doctor meant welcoming one into your home, rather than heading out to a clinic or hospital waiting room. But around the 1960s, the house call fell out of favor as doctors’ offices sought to become more efficient, and the doctor-patient relationship changed from “Marcus Welby” to something less personal with the rise of hospitals and modern insurance plans.

Now, however, the trend for on-demand service in the age of Uber could revive the house call. Services such as Heal — which launched in the District in June after operating in California since 2014 — and competitors such as Pager and Curbside Care are expanding their footprints across the country. And research suggests that house calls can provide a better standard of care for some patients than a hospital visit. A University of Southern California study of a house call program in the state found that hospitalization rates dropped for patients who were enrolled in the program for six months: Of 1,000 patients, 96 were hospitalized after being enrolled, down from 159 before the program.

Costs can also drop, since patients can avoid hospital visits. A 2013 Brookings Institution report said a Department of Veterans Affairs analysis of its home-based care program found a “25 percent reduction in hospital admissions, a 36 percent reduction in hospital days, and a 13 percent reduction in combined costs.”

The chief executive of Heal, Nick Desai, co-founded the start-up with his wife, Renee Dua, a physician. Their own parental trip to the emergency room inspired the service, after the couple, unable to contact their regular pediatrician, sat in an emergency room for seven hours with their feverish 3-month-old son.

“My wife turned to me and said, ‘There’s got to be a better way,’ ” Desai recalled. So Heal was born — a service that can work with patients’ insurance. For those without insurance, a visit costs up to $99.

“Our number one, main goal is that, five years from now, you won’t have to go to the doctor’s office,” Desai said.

That’s certainly been the case for Tony Rog-

KATHERINE FREY/THE WASHINGTON POST

Barbara Bennett, director of the D.C. market for Heal, a health start-up, looks over information she received when she booked Adam Lowry through the service to schedule her daugher a last-minute appointment for a physical.

ers, a 57-year-old Heal patient in Orange County, Calif., whose health problems have made it progressively more difficult for him to leave his home. Just after Christmas in 2015, he decided he’d paid his last visit to the doctor he’d seen for 35 years, because it was too hard to get to the office. His sister found out about Heal online and recommended it to him.

Rogers said it has been a revelation. He can now see a doctor on his front porch; he even had an ultrasound taken in his own bed. When he received a diabetes diagnosis, his physician took an immediate audit of his kitchen, pointing out which foods were fine to eat and which weren’t. She was also able to look at the laundry detergent he was using and recommend brands that would not irritate his skin.

“She told me, ‘This is good, this is not.’ It was a really nice teaching experience,” Rogers said.

For others, the fact that Heal appointments can easily fit into their lives is key. Barbara Bennett, director of the D.C. market for Heal, recently used the service to schedule a last-

“Our number one, main goal is that, five years from now, you won’t have to go to the doctor’s office.”

Nick Desai, chief executive and co-founder of Heal

minute physical at her Great Falls, Va., home for her daughter, Claire. An appointment with her normal pediatrician would have required waiting at least a week — past the deadline to submit forms for summer camp. With Heal, Bennett scheduled a same-day appointment.

The convenience was a big plus, she said. “I didn’t feel drained. I hadn’t sat in traffic. I just picked up and kept going on with the day,” she said. And the forms? They arrived that night, allowing her to turn everything in on time.

Limits and potential There are many things Heal and other on-demand doctor apps can’t deliver. For one, apps are not a substitute for emergency care.

(They can cut down on unnecessary trips to the emergency room — which advocates say is a benefit of the service.) If patients input symptoms into Heal that indicate an emergency, they will be directed to call 911. At a patient’s home, doctors can provide a range of standard care but can’t cart around heavier or more complex equipment, such as an MRI machine.

Nor can they do something major, such as surgery or procedures that require highly specialized equipment or expertise.

Heal also isn’t a solution to providing care in places where doctors are scarce, as its current markets are heavily urban. Desai said Washington is an attractive market in part because of its density and its transient population, which means there are probably a lot of people in the area who don’t have a regular primary-care doctor.

And finally, while some people, such as Rogers, have used Heal for consistent care, Heal isn’t specifically designed for intense, long-term care in the home. But other housecall programs, such as Hospital at Home at Johns Hopkins University’s medical school, have demonstrated many of the same benefits that Heal claims for its patients.

Mattan Schuchman, a Johns Hopkins physician specializing in geriatrics, makes regular monthly or bimonthly house calls to homebound patients. Programs such as his, he said, are more specialized to treat those with chronic conditions.

“I do think we are set up to be more of a primary-care service,” he said, particularly for homebound patients who need consistent attention. He agrees that house calls give doctors more context and can help them build better relationships with patients, if a service allows for them to see the same physician regularly. In his experience, house calls always give doctors more time with patients than appointments in a clinic.

Desai said Heal doctors see an average of 14 patients a day, which works out to slightly less than the weekly average estimated by the American Academy of Family Physicians. For Schuchman and other doctors who make house calls, that’s a positive. But it can be an economic challenge for doctors who give up practices where they can charge by service and see patients in rapid succession.

Plus, house calls involve travel, which can feel like wasted time, said Eric Topol, a physi-

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KATHERINE FREY/THE WASHINGTON POST

cian and director at the Scripps Translational Science Institute. While Topol is a strong proponent of house calls, he notes that this was one reason they fell out of fashion in the first place.

“Efficiency was a big part of the equation,” Topol said. “And it’s not efficient for doctors to be roving around like an Uber or Lyft driver.”

Technology helps house calls Advances in medical technology have made house calls easier again, Topol said, particularly the increased portability of electronic healthcare records and the medical equipment that doctors use. Doctors can now also do paperwork on the go.

Still, the problem of efficiency will be difficult for any program to get around, said Glenn Melnick, a health-care economics professor at the University of Southern California. Melnick co-authored the USC study.

House call programs can reduce overall costs for the health-care system, if patients use house calls rather than heading for expensive emergency room care. But recruitment and retention can be tricky for house-call programs, he said. Melnick’s study of a house-call program in Los Angeles found that, over time, costs associated with the program went down — but only because the services began relying more on other types of medical professionals, such as nurse practitioners and physical therapists.

That’s not necessarily a negative, but it could be less appealing to patients who specifically want to see a doctor.

Desai said that Heal hasn’t had problems recruiting doctors. Many, he said, are craving a deeper connection with patients.

“Doctors are coming to us to practice a better brand of medicine,” he said.

For Mintzer, the close relationships empha-

Adam Lowry examines Barbara Bennett’s 8-year-old daughter, Claire, at her home in Great Falls, Va.

sized by Heal turned out to be a potential lifesaver — though in conjunction with a more traditional hospital experience. The on-demand physician not only treated her daughter but also was concerned enough to come back the next day and urge the family to seek further treatment for their 6-year-old from a specialist.

The doctor told Mintzer about a lump and said he believed an ear and throat infection had caused an abscess in her daughter’s throat that needed further inspection. Without the Heal doctor’s advice — something more personal than she might have gotten in urgent care, Mintzer said — she would not have known to take her daughter in as quickly.

“We got her into the hospital and onto her IV antibiotics earlier than we would have,” Mintzer said. “Without that, it would have gotten worse much faster.” © The Washington Post

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BOOKS

Tracing Lincoln’s ‘wilderness years’ N ONFICTION

I WRESTLING WITH HIS ANGEL The Political Life of Abraham Lincoln Vol. II, 1849-1856

By Sidney Blumenthal Simon & Schuster.

581 pp. $35

l

REVIEWED BY

M ICHAEL G REEN

t was no small feat thatAbraham Lincoln was able to maneuver his reelection in 1864.

The last president to win a second term, Andrew Jackson, did so in 1832 with his party united and without the weight of a bloody, three-year-old war. Lincoln was, in the words of Doris Kearns Goodwin and others, a “political genius.”

Sidney Blumenthal would agree. Blumenthal, a longtime journalist who worked for a president who won two terms, believes that Lincoln accomplished what he did because he was a politician from his toenails to the top of his stovepipe hat. How Lincoln balanced politics and principle is central to “Wrestling With His Angel,” the second of Blumenthal’s projected four volumes on Lincoln’s political career. It follows last year’s “A Self-Made Man,” which examined Lincoln’s first 40 years.

In that volume, Lincoln was mostly a local politician who tried to stick to his party’s principles while broadening its appeal, as Blumenthal’s former boss Bill Clinton sought to do in the Democratic Party of the 1990s. Lincoln’s efforts proved less successful. In 1849, he returned to Illinois as a one-term congressman, a capable lawyer and a minor cog in a creaky Whig political machine that soon disintegrated.

In 1860, five years after the Whig Party collapsed, Lincoln was elected president. How he emerged from that wilderness — how “he entered his wilderness years a man in pieces and emerged on the other end a coherent steady figure” — is the story Blumenthal tells with panache and understanding.

Lincoln grasped that “when the events changed he had to change to align himself with them.” As Blumenthal puts it, “The selfmade man educated himself in the politics of democracy,” “apprenticed in logrolling,” studied “peculiar nuances of power that could not be commanded by fiat” and belonged to “the first American

JONATHAN NEWTON/THE WASHINGTON POST

How Abraham Lincoln balanced politics and principle is central to Sidney Blumenthal’s “Wrestling With His Angel.”

generation innovating in party organization, mass media, and public opinion.”

Two political figures — Sen. Albert Beveridge, an early 20th-century Progressive and biographer, and George McGovern, who carried the baggage of a PhD in history when he ran for president — have written biographies of Lincoln, but they did not focus, as Blumenthal does, on Lincoln as the political operative who also wrote editorials and financed newspapers. Blumenthal has spent his life in the interconnected worlds of politics and journalism, and it shows: He grasps that political genius in ways others could not, making Lincoln more politically plausible.

In explaining Lincoln’s transition from just another Whig to a rising Republican, Blumenthal keeps the man himself off the stage. Indeed, Lincoln was in the wings, watching and analyzing events as they unfolded. Blumenthal explains those developments and the personalities at the center

of them, from the rigid and manipulative Jefferson Davis (Blumenthal clearly delights in discussing Davis’s herpes, which caused serious vision problems, and his extramarital affair with an Alabama politician’s wife) to the ceaselessly pandering Stephen Douglas, the longtime political rival whom Lincoln (and Blumenthal) disdained.

Blumenthal begins his story by explaining cholera, which ends up being crucial to Lincoln’s — and America’s — political evolution. In 1849, a cholera epidemic killed Mary Lincoln’s father, Robert Todd, requiring Lincoln to go to Kentucky for a lawsuit over his estate.

At the time, Kentucky was debating a new constitution. Pro-slavery forces defeated efforts for gradual, compensated emancipation led by allies of Henry Clay, Lincoln’s “beau ideal of a statesman” and a friend of Mary’s father. Lincoln lost the estate case to some of those pro-slavery politicians. Blumenthal’s understanding of politics leads him to the logical conclusion that losing the legal battle to those waging the

political battle hardened Lincoln’s views.

President Zachary Taylor died during that same cholera epidemic in 1850. His death empowered Whigs who supported slavery or were willing to compromise on its expansion. When Clay died in 1852, Lincoln, increasingly conscious of the key issue, gave a eulogy that made the Kentuckian sound more anti-slavery than he really was. But, writing to a Kentucky lawyer shortly afterward, Lincoln privately called Clay’s view of slavery “bankrupt.” Lincoln’s letter, Blumenthal observes, “transformed the Revolution into a slave revolt and the Declaration of Independence into a kind of Emancipation Proclamation.”

Ironically, Douglas enabled Lincoln to break his old shackles by brooking no compromise. In 1854, hoping to gain support from the increasingly rigid South, Douglas drove Congress to pass the Kansas-Nebraska Act, which obliterated existing limits on slavery and permitted it to extend north and west. When Lincoln responded to Douglas in a speech at Peoria, Ill., in October 1854, he claimed the Founding Fathers and the Declaration of Independence on behalf of abolition. Blumenthal shows how Lincoln maneuvered himself and others toward the new Republican Party without entirely leaving the Whigs, at least at first.

Lincoln once said, “I am slow to learn and slow to forget that which I have learned.” During the first half of the 1850s, he continued to learn about politics and about himself. Blumenthal guides us through what Lincoln learned and how he learned it as he wrestled with slavery and politics, and matured into someone who could find the better angels of our nature. n Green is an associate professor of history at the University of Nevada at Las Vegas and the author of several books on the Civil War era and on Nevada history. This was written for The Washington Post.

SUNDAY, JULY 9, 2017

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BOOKS

KLMNO WEEKLY

Jojo Moyes writes with an artful twist

From comedy to conspiracy theories

F ICTION

N ONFICTION

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REVIEWED BY

A NTON D I S CLAFANI

eading Jojo Moyes’s newest novel, “The Horse Dancer,” I had to keep reminding myself that I was not, in fact, reading Dickens.

There’s the seedy section of East London. There are adults involved in nefarious activities.

There are stark differences between the gilded lives of the wealthy and the turbulent lives of the poor. And, perhaps most of all, there is the resilient, quickthinking orphan who outmaneuvers adults so deftly that it’s occasionally hard to believe she is only 14 years old. But then again, as Moyes is quick to remind us, children are surprisingly resourceful when their backs are up against a wall.

In this case, the wall is attached to a stable, the stable home to Sarah’s enduring passion: a horse named Boo. This reader had to suspend her disbelief just a little bit to believe that Sarah’s grandfather, a man with no money, could get a piece of the finest horseflesh in the world from France to a stable a stone’s throw from a housing project. And then a little bit more to believe that this elderly man could train the girl-horse duo to perform complex movements that adults spend their entire lives perfecting.

But that’s the magic of “The Horse Dancer”: Characters are thrown into situations as surprising as they are compelling. Moyes writes so masterfully of the communion between horse and rider that she manages to make Le Cadre Noir, the exclusive French riding school, a realistic goal for young Sarah.

Early in the novel when Sarah’s grandfather has a stroke, in step Mac and Natasha, a couple in the throes of a very long divorce. Although they are not entirely capable of saving the girl from her desperate situation, they are willing to try. And so we jump between the upwardly mobile world of Natasha and Mac, who own a

house in a quickly gentrifying neighborhood, and the seedy world of Maltese Sal, who conducts illegal harness racing when he’s not terrorizing children.

The details of the barn — the sweet smell of good hay, the nearly conversational quality of a horse’s constantly moving ears — are beautifully wrought. And the characters of the stables, though they might on occasion come close to it, do not veer into caricature. Cowboy John, who has a heart of gold, along with a casual marijuana habit, is as believable and compelling as Ralph, the 12year-old, cigarette-smoking sidekick of Maltese Sal. Much of the book is concerned with how children complicate and enlarge the lives of the adults who care for them, either by choice or circumstance. Moyes writes movingly of how easy it is for a child to be damaged by well-meaning adults, and we see how the same family can swing from grinding desperation to domestic bliss. The trick, Moyes suggests, is to trust each other.

As a storyteller, Moyes again takes a note from Dickens, moving easily between several storylines, toggling between the past and the present, the urban and the rural, the domestic and the professional, with ease and confidence. We meet the lowest of the low and the noblest of the noble.

As in “Me Before You,” her bestselling 2012 novel, which was adapted for the screen last year, Moyes writes convincingly of how money determines destiny and also of what happens when tragedy befalls good, or at least average, people. In this case, the very worst brings out the very best, but not in a cloying or sentimental way. Moyes’s vision of people lifted from despair by nothing more than love (and a little money) is nothing if not poignant. n DiSclafani is the author, most recently, of “The After Party.” This was written for The Washington Post.

I THE HORSE DANCER

By Jojo Moyes Penguin.

444 pp. Paperback, $16

LAST MAN STANDING Mort Sahl and the Birth of Modern Comedy

By James Curtis Univ. Press of Mississippi. 400 pp. $39.95

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REVIEWED BY

K EVIN C ANFIELD

n the 1960s, when he was an A-list comedian and hosted a pioneering satirical news show, Mort Sahl often took the stage with a bit of reading material. Newspaper in hand, he zipped across the political landscape, offering wry takes on the day’s knotty issues. When a U.S. spy plane was downed in the Soviet Union, he looked for the upside: “If we’re lucky they may steal some of our secrets and then they’ll be two years behind.” Other times, when his props included, say, the Warren Commission report, Sahl might spend an hour fuming about cabals and coverups. He called himself “everyone’s conscience,” but his zealousness shortened his career.

James Curtis captures the dueling sides of Sahl’s persona in “Last Man Standing,” his fair-minded new biography. He meticulously charts his subject’s path from striving club comic to mercurial star. Coupled with deep dives into the morgues of Hollywood trade magazines, Curtis’s interviews with the likes of Woody Allen, Dick Cavett and Sahl himself (he turned 90 this year) give the reader a clear sense of his nimble mind and his influence on younger talents.

Emerging from the San Francisco club scene, Sahl capably straddled two worlds in the 1950s. His stream-of-consciousness monologues played well at jazz joints, where he shared bills with hip musicians.

Meanwhile, he notched mainstream milestones, co-hosting the 1959 Oscars and cutting an album that the Library of Congress would declare “the earliest example of modern standup comedy on record.”

Unlike the proudly coarse Lenny Bruce, to whom he was sometimes compared, Sahl “was a genuine Puritan when it came to language,” says Curtis, the author of biographies of W.C. Fields and Spencer Tracy. Sahl excelled at gallows humor (Soviet leader Nikita “Khrushchev says he can bomb any American city. And I want to

know if he’s taking requests”), and his barbs could be prescient.

In 1966, Sahl helped develop an innovative, if short-lived, satirical news show. The set of “Mort Sahl,” broadcast in Los Angeles, included “a world map and three clocks suggesting the stern surroundings of a small newsroom,” Curtis writes.

Sahl’s belief that he “was on the job to save America,” as Curtis puts it, was evident in his preoccupation with President John F. Kennedy’s murder. “Mort Sahl” was dominated by assassination theorizing. “The comedy had almost entirely given way to outrage,” Curtis says. Ultimately, Sahl’s incessant Kennedy coverage “was the downfall of the show,” recalls a behind-the-scenes colleague.

“Mort Sahl” was canceled in 1967.

To Sahl, this and other setbacks were evidence of something more insidious.

Aside from Curtis’s sensitive handling of the overdose death of Sahl’s son, the final chapters of “Last Man Standing” are laden with wearisome discussions of unproduced screenplays and other abandoned projects. Not for nothing did GQ, in 1984, ask, “Whatever Happened to Mort Sahl?” These years could’ve been dispatched in a few pages.

By many accounts, Sahl was once a singular performer. Woody Allen said, “He was the greatest thing I ever saw.” The last chapter might’ve been the place to tally his accomplishments. Instead, Curtis quotes from a news release about a college-teaching gig Sahl had a decade ago, and then wraps up with a half-dozen of his tweets. #Why? For a book about a man who claimed that “anybody can act, but the only one who can do what I do is me,” it’s an awfully feeble curtain-closer. n Canfield has written for Bookforum, Film Comment and other publications.

This was written for The Washington Post.

SUNDAY, JULY 9, 2017

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KLMNO WEEKLY

OPINIONS

The ongoing terrorist attack in Ohio: Opioids GARY ABERNATHY Abernathy is publisher and editor of the (Hillsboro, Ohio) TimesGazette. This was written for The Washington Post.

HILLSBORO, Ohio

There is an ongoing terrorist attack happening in Ohio.

It has nothing to do with the Islamic State or political anarchists. The weapons in this case come in the form of heroin and other opioids, and the terrorists are the pushers who spread the deadly poison.

From the Columbus Dispatch this spring: “At least 4,149 Ohioans died from unintentional drug overdoses in 2016, a 36 percent leap from just the previous year, when Ohio had by far the most overdose deaths in the nation. . . .

Many coroners said that 2017’s overdose fatalities are outpacing 2016’s.”

Consider that number — 4,149 overdose deaths in Ohio in one year, more than the number who died on 9/11.

The worst of the state’s opioid problems are here in southern Ohio. The Highland County coroner provided our newspaper, the Times-Gazette, with a recap of cases from 2016 showing at least 16 overdose deaths in this small rural county. He also pointed to 50 deaths during the year from other causes where drug use or a history of drug use were present.

Even non-fatal overdoses are taxing local resources. During the first three weeks of May, emergency responders answered calls to at least 18 overdoses around the county, almost three times as many as during the same period a year ago. The public information officer for the local fire and emergency medical services department called it “the new normal.”

This is all happening around little Hillsboro, a town often compared with television’s idyllic Mayberry. With the FBI reporting that most heroin enters the United States from Mexico, and local officials saying that it then makes its way here through metropolitan drug rings, it’s no wonder that few

people in Hillsboro think President Trump’s border security plans are extreme.

Like other forms of terrorism, the opioid attack will have a generational impact, in this case in a foster-care crisis being left in its wake. In December 2015, our newspaper reported that “a focused crackdown on drug abuse by local law enforcement — a focus applauded by nearly everyone — has led to the unintended consequence of more children who are left homeless.”

Our most recent article on the subject, in April, reported that there were more than 100 children in foster care, costing our county about $1.9 million annually. With just 15 foster parents in all of Highland County, “many children must be placed in other counties, incurring higher costs.”

The drug crisis is leading to some controversial initiatives.

Our local health commissioner recently unveiled a program to supply free naloxone, an opioid inhibitor, to people who attend training on how and when to administer it to overdose victims. Many residents oppose

DAVID DERMER/ASSOCIATED PRESS

From a recovery center in Youngstown, Ohio, Paul Wright shows a 2015 picture of himself in the hospital after a near-fatal overdose.

the idea, arguing that the same users are being revived time and again, but the commissioner responds that his agency is charged with saving lives.

Opioids come in legal form, too, and Ohio’s attorney general, Mike DeWine, recently sued the pharmaceutical industry, accusing drugmakers of contributing to the problem through misleading marketing campaigns.

After I briefly mentioned the overdose epidemic in a recent op-ed for The Washington Post about our region’s support for Trump, I heard from readers claiming that Trump’s 2018 budget does little to fight the opioid problem. Maybe, but the statistics show that what we have been doing is not working, which indicates we should not just keep doing more of it.

Some local officials have begun tackling the heroin crisis more aggressively, especially since recent batches have been laced with fentanyl, an even deadlier drug. Fentanyl is largely a Chinese export, which presents Trump with an opportunity to insist on a crackdown as a bargaining chip in what appears to be his effort toward better trade relations with China.

Our local prosecutor has

begun charging those accused of supplying fentanyl-laced heroin to overdose victims with involuntary manslaughter, rather than treating these simply as accidental deaths. If that approach is more widely adopted, drug pushers who are arrested but typically back on the streets in short order will instead find themselves behind bars under stiffer charges more representative of the death and carnage they are causing.

In southern Ohio, the opioid problem is beyond mere fodder for partisan budgetary debates.

We’re dealing with purveyors of poison carrying out a real-time assault on our communities.

When it comes to the flow of deadly drugs into the United States and communities such as Hillsboro, we have to combat it outside the scope of typical drug abuse prevention programs.

Our vaunted “war on drugs” has long represented little more than benign phraseology. But it has become a real war, and the drug cartels and pushers here and abroad are enemy combatants. Until we respond as we would to any terrorist attack, the casualties will continue to mount. That may sound extreme, but the rising death toll suggests otherwise. n

SUNDAY, JULY 9, 2017

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OPINIONS

KLMNO WEEKLY

TOM TOLES

Trump’s wasted opportunity FRED HIATT is the editorial page editor of The Washington Post.

He writes editorials for the newspaper and a biweekly column.

President Trump is giving outsiders and drain-the-swampers a bad name.

A president who comes to power with little dependence on either party and wins election by running against the special interests, could, in theory, do a lot of good work. He could use his popular support to push reforms that are in the national interest but have gotten stuck in Washington. Three examples come to mind — none of which has, at least so far, inspired the president to action.

The first, and in some ways most obvious, is a carbon tax linked to infrastructure modernization.

This would be a win-win-win for the country. The tax would encourage conservation, which would be good for the environment and for slowing climate change. Republicans would have reason to cheer a market-friendly approach, as opposed to government picking energy winners and losers.

Some of the proceeds could be used to augment the earnedincome tax credit, to counter its regressive nature. That would give Democrats reason to cheer.

The rest of the revenue could be distributed to states to spend on infrastructure. The federalism would make Republicans happy.

Blue states could spend more on mass transit, making Democrats happy. This makes such sense that you might think it would

pass even without a push from an above-the-fray president, but it won’t. Republicans are too bound to their no-tax ideology.

Democrats might object to the loss of federal control.

Presidential leadership would be needed to keep special interests in check and the deal on track.

Then there is immigration reform. This is another case where the shape of a compromise is well-known, but where neither side can say yes without a strong push. A deal would offer undocumented immigrants a path to legalization, in theory cheering Democrats, while stepping up enforcement to block further illegal immigration, in theory cheering Republicans. Congress could then work out how many

legal immigrants, and of what sort, the country should accept in the future. Easy, right?

Well, no. Most undocumented people would welcome such a deal to bring them out of the shadows, but their professional advocates, and therefore many Democrats, would object to anything short of citizenship.

Republicans who clamor for strict enforcement would, in many cases, object to the most efficient method: holding employers accountable for hiring undocumented workers.

Trump would be wellpositioned to push such a deal.

Though he called for deporting the 11 million undocumented people in the United States, he also said that the “good” ones could quickly return. The makings of a deal are there — and could include some segments of his wall.

For tax reform, too, the outlines of a deal are in theory universally admired: cap or abolish the deductions that taxpayers can claim — the “loopholes” — and then lower the rates that everyone must pay. The universal admiration quickly wanes, however, under special-interest assault. Realtors in every congressional district explain why the mortgageinterest deduction can’t be

disturbed. Hospitals, churches and universities remind Congress that opposing the charitable deduction is unAmerican. Folks from financial services recount how the elderly will go hungry without taxadvantaged 401(k) accounts.

Realistically, the best hope would be not to abolish any of these deductions but to cap how much relatively wealthy people could claim in any given year.

You may think the president is on board for this one, because he talks a fair bit about tax reform. But so far, what he seems to have in mind is only tax cuts, which might be popular in the short term but would send the already sky-high national debt into outer space.

Which is in keeping with the policy predilections Trump has shown, to the extent he has shown any so far: conventional, down-the-line Republican, from tax cuts for the rich to the far more difficult, and politically fraught, push to repeal, and possibly replace, the Affordable Care Act. Meanwhile he leaves on the table the opportunities his unconventional path to the presidency had opened for him.

He’s missing a chance to show the good that a leader unbeholden to party orthodoxy really could do in this town. n

SUNDAY, JULY 9, 2017

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KLMNO WEEKLY

OPINIONS

BY SHENEMAN

Why you need to see a total eclipse RAY JAYAWARDHANA is an astrophysicist and dean of science at York University in Toronto and the author, most recently, of “Neutrino Hunters.”

This was written for The Washington Post.

Surreal doesn’t begin to describe the scene. There we were, on a scorched, rubble-strewn plateau in the Altai Mountains of western Mongolia. A shaman in a colorful cloak made of yak hair paced around an impromptu rock shrine, beating a drum and chanting. A hundred or so people stood in a semicircle nearby. Groups of three took turns kneeling in front of the shaman for a blessing, which consisted of a mouthful of alcohol spit on their foreheads and a lash from a whip on their backs.

Suddenly, the wind picked up, and I felt a chill. The shaman’s assistant lit a bonfire as the sun started to wither. The shaman turned his back on the disappearing sun, while the visibly terrified crowd roared and screamed. These age-old rituals were meant to dissuade the monstrous deity Rah from gobbling up the life-sustaining sun.

We had arrived at this remote dusty outpost after a 16-hour offroad trek (with vomit stops!) that nearly killed us when our exhausted driver nodded off at the wheel, to observe a total solar eclipse on Aug. 1, 2008. The rare astronomical event made for a wondrous experience, worthy of almost risking our lives, though the spectacle on the ground was equally mesmerizing on this occasion. The dual sights of the

eclipse in the sky and the rituals in the desert reminded me of the enduring links between the celestial and the human realms.

On Aug. 21, people across the United States, from Oregon to South Carolina, will have the opportunity to witness a total eclipse of the sun. The path of totality will sweep from the Pacific coast to the Atlantic for the first time in 99 years, prompting some to revive the moniker “the Great American Eclipse.”

For the last such event, in 1918, the U.S. Naval Observatory, with a special $3,500 grant from Congress (the equivalent of approximately $60,000 now), dispatched a scientific expedition to Baker City, Ore. Researchers planned to measure the deflection of starlight by the sun’s gravity when the sky got dark and stars became visible during

BY NICK ANDERSON FOR THE HOUSTON CHRONICLE

totality, thus testing a key prediction of Albert Einstein’s theory of general relativity, which had been published three years earlier. It was seen as a chance for American scientists to upstage their then-dominant European counterparts, representing an intellectual coup for a nation ascendant. Such hopes were dashed, however, because thin clouds covered the sun during the critical moments, obscuring faint background stars in its vicinity.

Team member Howard Russell Butler, a physicist-cum-artist, did capture the corona and prominences of a moon-blocked sun in a historic painting.

Stunning vindication of Einstein’s theory came a year later, from English scientists who traveled to the island of Principe, off the west coast of Africa, and to Brazil for the next total solar eclipse.

This summer, the stakes are much lower, though a number of researchers aim to conduct studies of the sun and the Earth with support from NASA and the National Science Foundation.

Besides, with dazzling images of intricate nebulae from Hubble and splendid portraits of ringed Saturn from Cassini popping up on our screens nearly every week, we have become quite blasé about celestial sights. Compared with

those color-enhanced visuals, our glimpses of astronomical objects with the naked eye, or through binoculars or a backyard telescope, tend to leave us feeling underwhelmed.

A total eclipse of the sun is different. No photograph can do it justice, in my opinion, because it is a truly immersive experience.

Seeing a partial eclipse doesn’t prepare you for the real McCoy, either.

To appreciate the phenomenon fully, you need to see (safely) the fleeting spectacle of the sun gone dark behind the passing moon, while a few bright stars appear in daytime. You need to hear the birds rushing to their nests, confused by the fading light. And you need to feel the chill in the air as an eerie darkness engulfs the land.

Luckily, the Aug. 21 eclipse will be among the most accessible in recent history. Some 10 million Americans live along its arc of totality, and tens of millions more could reach it within a few hours’ drive from home.

Even in this age of Instagram and live-streaming, it is worth making the effort to experience a total solar eclipse in person, in all its splendor. Totality will last just a couple of minutes, but it is one heavenly sight that you’re likely to remember for a lifetime. n

SUNDAY, JULY 9, 2017

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KLMNO WEEKLY

FIVE MYTHS

Health insurance BY

A LEXIS P OZEN

It is no wonder so many myths about health insurance persist. The U.S. health insurance system is opaque and labyrinthine, and at times purposely so. The current debate over whether to repeal major provisions of the Affordable Care Act (ACA), otherwise known as Obamacare, comes down to whether consumers should subsidize services they never expect to use. But who pays for what, and how, is not straightforward.

MYTH NO. 1 The ACA has forced millions to buy insurance they don’t want.

House Speaker Paul D. Ryan (R-Wis.) deployed this myth when defending repeal — which the Congressional Budget Office estimated would increase the number of uninsured people by 22 million by 2026.

But both before and after the ACA, most of the uninsured consistently have reported that they want insurance. In a 2009 Department of Health and Human Services report, 48 percent of uninsured people under age 65 said they didn’t have health insurance because of the cost, 38 percent cited life changes (they had lost their jobs, left school or changed their marital status), and 12 percent said their employers didn’t offer it or they’d been denied coverage.

MYTH NO. 2 Expanding health insurance coverage saves money.

The Obama administration sold the ACA to skeptics on the promise that it would limit health-care cost growth over time. Healthier people need less care, the argument goes. If a lack of insurance is a barrier to health care, and if health care improves health, then expanding coverage should improve health. If poor health is costly, then expanding insurance should also lower costs.

The myth that insurance expansion will save money

highlights the fallacy that a program must save money to be valuable. Expanding health insurance is costly, and perhaps costs even more than it saves, but it is also valuable, because it improves people’s access to care, financial stability and overall well-being.

MYTH NO. 3 Health insurance companies make massive profits by cheating consumers.

To strengthen the case for reform, proponents of the ACA scapegoated private insurers in the debate leading up to its passage, blaming outsize premiums and skimpy coverage on unethical behavior.

Insurers, however, were not earning particularly high profits then. A 2010 Congressional Research Service study showed that among large, publicly traded health insurers, profits averaged 3.1 percent of revenue. In comparison with other healthcare players, that put them in the middle of the pack — well below pharmaceutical and biotech companies and medical-device manufacturers, on par with pharmacy companies, and above hospitals.

In 2013, when GDP growth was slower, insurers on average operated at a loss; but they recovered by 2014 when growth picked up. Moreover, the bulk of insurer profits were from investments rather than enrollees.

SAUL LOEB/AGENCE FRANCE-PRESSE VIA GETTY IMAGES

Women dressed as characters from “The Handmaid’s Tale” protest the Senate health-care bill outside the Capitol on June 27.

MYTH NO. 4 People are free-riding on Medicaid.

The White House’s Kellyanne Conway is among those who have promoted this myth, telling Fox News recently that Medicaid has expanded beyond the truly needy.

“If you’re able-bodied and you would like to go and find employment and have employersponsored benefits, then you should be able to do that” and not rely on Medicaid, she said.

Historically, Medicaid has not required recipients to work, but most Medicaid recipients who can work, do. Almost two-thirds have full-time or part-time jobs, and more than three-quarters come from families where someone has a job. (These jobs, though, tend to be in low-paying sectors, such as agriculture and food service, where employersponsored health insurance is generally not an option.)

MYTH NO. 5 Job-based insurance means your employer pays — and the government doesn’t.

Although firms may boast about offering generous healthcare benefits, the costs of coverage are largely borne by

employees, in the form of lower wages than a competitive market would otherwise support. That helps explain why inflationadjusted wages have remained flat, even while productivity has increased — it’s all going to cover rising health-care costs.

By exempting employee and employer premiums from income and payroll tax, the government forgoes hundreds of billions of dollars in tax revenue each year. In 2016, this subsidy was worth $275 billion. The government subsidy is what ties employment to insurance.

As with any policy, there are disadvantages to taxing health insurance. For example, it may discourage younger, healthier workers from joining their jobbased plans and prod them to seek insurance in the individual market, where they would not be pooled with older and sicker coworkers. Presumably, the benefit savings would be passed on in the form of faster wage growth, but this transition could be slow. n Pozen is a professor of economics at CUNY School of Public Health and a coauthor of the textbook “Navigating Health Insurance.” This was written for The Washington Post.

SUNDAY, JULY 9, 2017

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GREAT WINE. GREAT FOOD. GREAT FUN.

It’s the largest gathering of wineries in the region, and the only professionally-judged wine event dedicated to wines produced in Chelan, Douglas, Grant and Okanogan counties. And this year it’s bigger than ever—more food, wine, beers, ciders, distilleries and eateries.

Saturday, August 26, 2017

6pm to 9pm

Town Toyota Center, Wenatchee

Tickets $45 each • A limited number of VIP tickets available for $75 each Available online at wenatcheewineandfood.com or at the door Presented by Foothills Magazine

oothills

Interested in having a booth at this event?

E-mail us at info@wenatcheewineandfood.com

WENATCHEE ❆ LEAVENWORTH ❆ CHELAN AND ALL OF NORTH CENTRAL WASHINGTON

Sponsored by

Port of Chelan County • Banner Bank • Tastebuds Coffee & Wine • Spokane Industries • Port of Douglas County • Moss-Adams, LLP • Great Northwest Wine Visconti’s Italian Restaurant • Blue Horizon Insurance & Financial Services • Haglund’s Trophies • Wenatchee Valley Museum & Cultural Center • Town Toyota Center