This policy memo addresses the current and projected shortage of primary care health
professionals in light of population dynamics and health care reform. We identified three
different scenarios: worst, likely, and best, and made recommendations to encourage the “best”
result. Those recommendations include:

1. Lowering tuition or offering tuition reimbursements for those who enter primary care
fields or practice in poor urban and rural communities

2. The adaptation of electronic medical records and “medical home” style delivery of
coordinated care

3. Adopting a model of primary care in underserved areas that would effectively be a
smaller medical home comprised of nurses, nurse practitioners, physicians, and others
who manage care on a coordinated basis.

4. Working with organizations such as the AMA and ANA to work with the Centers for
Medicare and Medicaid Services (divisions of the Department of Health and Human
Services) to increase health insurance primary care reimbursements and to make clearer,
more logical distinctions about the scope of practice of different types of providers.

5. A competitive grant model for primary care incentives similar to “Race to the Top” in
PPACA where, essentially, the federal government could solicit proposals for reforms
and projects from states and educational institutions and then evaluate these proposals
based on a specific rubric. Even though the government would only be able to fund the
top few applications, many states and schools would be committing to changing existing
practices and implementing innovative new programming.

With specific, practical, evidence-based policy recommendations the primary care needs of
Americans can be adequately met, but it will require a great deal of preemptive effort on behalf
of medical educators, policymakers, and health care providers in order to provide quality care
and better patient outcomes.

The US Supreme Court this week has heard one of the most important appeals to reach it in more than a decade. The nine justices heard six hours of oral arguments over three days concerning the constitutionality of the Affordable Care Act, giving more time to this case than any other in the last forty-five years. As they did so, the message wars heated up reached heights reminiscent of the original 2009 debate in Congress.  And there is some indication that the ruling of the Court could have huge implications for the 2012 election, given that health care reform is President Obama’s signature achievement.

Law professors and journalists around the country have now begun to speculate about the various ways the Court could rule on the four key arguments of the case: 1) the constitutionality of the individual mandate, 2) whether the mandate is a tax, 3) whether the individual mandate is severable from the act or whether the entire legislation must be struck down, and 4) the federal vs. state conflict over the expansion of the cooperative Medicaid program. Nonetheless, there are many who argue that we just don’t know what the Court will do until they make their ruling.

The Most Important Number is Five

Obama’s Affordable Care Act needs five votes on the Supreme Court for a victory, since neither Justice Clarence Thomas nor Justice Elena Kagan have recused themselves from the case. Given the ideological divide on the Court, with five conservative justices and four liberal justices, getting to that magic number of five is easier said than done.

It is widely believed that Justices Ruth Bader Ginsburg, Elena Kagan, Stephen Breyer, and Sonia Sotomayor will all reach the conclusion that the ACA is constitutional. Two justices, Clarence Thomas and Samuel Alito, based on their observed understanding of the Commerce Clause, will almost certainly vote that the ACA is unconstitutional. That leaves Justices Antonin Scalia, Anthony Kennedy, and John Roberts in play.

To make things even more complicated, because arguments were made on day three of the case regarding the severability of the individual mandate from the rest of the bill, it is possible that the justices could vote to uphold the parts of the law that are not considered, as some on the Court put it, “tied at the hip.” And because it may be considered highly unnecessary  to strike down the whole 1,700  page bill filled with all kinds of reauthorizations of old bills, funding schemes, regulations, etc., a ruling which strikes down the individual mandate without striking down the rest of the law is a plausible, and perhaps likely, outcome.

Obama Not on Good Terms with the Court

But if anything complicates the math the most, it is perhaps that President Obama is not on the best terms with some of the members of the Supreme Court. On day one, President Obama was embarrassed after he and Chief Justice Roberts misspoke the words of the presidential oath of office at his inauguration, which resulted in a repeat swearing in the next day. Then, some members of the Court, particularly Roberts and Alito, were not happy with the President’s attacks on the Citizen’s United ruling during his State of the Union Address two years ago. And to top it all off, then-Senator Obama actually voted against the nominations of Roberts and Alito. All of this is in addition to the fact that Obama is an ideological liberal and a majority of the Court is ideologically conservative.

Clearly, the five conservative justices of the Court do not owe Obama any favors. But that does not mean that the ACA has no hope of survival.

The Brief of the Federal Government

The Federal Government will be arguing before the Court that the ACA is a proper exercise of the commerce powers of Congress. These powers stem from Article 1, Section 8 of the Constitution which says that Congress shall have the power “To regulate Commerce with foreign Nations, and among the several States, and with the Indian Tribes.”

The crux of the argument made by Federal Government is that the law was enacted for the purpose of protecting those who do have insurance from the cost shifting that occurs when uninsured individuals get care. The government’s brief to the Court states, “As a class, the uninsured shift tens of billions of dollars of costs for the uncompensated care they receive to other market participants annually. That cost shifting drives up insurance premiums, which, in turn, makes insurance unaffordable to even more people.”

The brief then quotes United States v. Darby (1941) saying that the Court has “many times held that the power of Congress to regulate interstate commerce extends to the regulation through legislative action of activities intrastate which have a substantial effect on the commerce or the exercise of the Congressional power over it.”

In response to the argument that Congress does not have the authority to regulate the actions of individuals who have not entered the market for health care, the government cites Wickard v. Filburn (1942). In this case, the Supreme Court ruled that Congress had the power under the Commerce Clause to regulate how much wheat a man could harvest, even if that person was not selling their wheat in the marketplace. Furthermore, the argument being advanced is that even persons claiming to be outside of the marketplace can be regulated because of the aggregate effect they have on commerce.

This leads to the conclusion that Congress has the authority under the Commerce Clause to regulate the health insurance market such that it mandates health coverage for all individuals, for as it states in United States v. Wrightwood Dairy Co. (1942), where Congress has the authority to regulate interstate commerce, “it possesses every power needed to make that regulation effective.”

The Brief of the 26 States

Naturally, the twenty-six states that have taken this issue to Court have viewed the individual mandate of the ACA as a violation of the Constitution on two grounds both related to liberty.

The first has to do with the sovereignty of the states and issues of federalism. It is the contention of the states that the federalism structure exists such that there are two different governments that rule in different spheres. The idea is that this system of federalism protects the people and their liberty because it prevents the tyranny of any one government. Insomuch as the federal government is encroaching on the boundary of state authority, the federal government is also threatening the liberty of the American people.

The second claim of liberty relates to the following excerpt from the brief of the states to the Supreme Court: “The individual mandate rests on a claim of federal power that is both unprecedented and unbounded: the power to compel individuals to engage in commerce in order more effectively to regulate commerce. This asserted power does not exist.” The argument being made in this case by the states is that the federal government has no right to force individuals to buy goods or services in the marketplace, and that any such mandate is a violation of one’s liberty. The brief of the states goes on to say, “If Congress really had this remarkable authority, it would not have waited 220 years to exercise it.”

The conclusion that the states reach is that “The power to compel a person to enter into an unwanted commercial relationship is not some modest step necessary and proper to perfect Congress’ authority to regulate existing commercial intercourse.  It is a revolution in the relationship between the central government and the governed.” Thus, unlike the federal government, which is trying to argue that such actions by Congress are normal and have been upheld by the Court in the past, the states are arguing that this is completely unprecedented and unrelated to the broad interpretations of the Commerce power in the Court’s past.

The Road to Five Justices

Given these arguments, the federal government will have the burden of convincing at least one of the conservative justices to vote with Breyer, Ginsburg, Sotomayor, and Kagan. To accomplish this goal, they have tailored their arguments in an attempt to convince Kennedy, Roberts, and Scalia.

Earning Kennedy’s Vote

Most legal scholars tend to agree that Justice Kennedy is the primary swing vote in this case, as in many other cases. In fact, in the past five terms, Kennedy has been in the majority in more than eighty percent of the Supreme Court’s five to four decisions, more so than any other justice. Indeed, it has been mentioned by some that they would have even put a picture of Justice Kennedy on the cover of the brief if they could.

Where they think they can get Kennedy is by reminding the Court of his prior statements on the Commerce power of Congress. For instance, in United States v. Lopez (1995), Kennedy stated in his concurring opinion that, “Congress can regulate in the commercial sphere on the assumption that we have a single market and a unified purpose to build a stable national economy.” Clearly, the federal government will try to make the argument that the goal of the ACA is to build a stable national economy by regulating the market for health care.

Where they might lose Kennedy is on the issue of federalism, something that Kennedy is known to take very seriously. As Kennedy stated in Alden v. Maine (1999), “Congress must treat the States in a manner consistent with their status as residuary sovereigns and joint participants in the governance of the Nation.” Kennedy later argued in Bond v. United States (2011) that “State sovereignty is not just an end in itself: Rather, federalism secures to citizens the liberties that derive from the diffusion of sovereign power.”

What we do know is that Justice Kennedy has not written many opinions for the Court as of late. There is some speculation that he may be holding out to write one of the most important opinions the Court will have in a while on the constitutionality of the ACA.

Earning Robert’s Vote

Another potential swing vote on the Court is that of Chief Justice Roberts. Some believe that Roberts may chose to vote with the liberal justices in this case so that he can write the opinion, particularly one that is narrow, leaving open the door to further cases to come before the Court challenging Congress’ commerce authority.

Another reason why it is believed that Roberts may vote to uphold the ACA is because he is particularly sensitive as the chief justice to the perception that the Court’s decisions are politically motivated and the toll that this has on the Court’s reputation. Surely, a five to four ruling along liberal and conservative lines will only reinforce the ideological divide and the idea that the members of the Court are making political, rather than constitutional, decisions.

Thomas Goldstein of scotusblog.com has also shed some light on this concern saying, “We’re in a little bit of a political death spiral for the Supreme Court, as ideologues on the left and the right attack justices with whom they disagree, maybe decreasing the public’s confidence in the Supreme Court.”

Finally, while Roberts has not had to make any commerce power decisions during his time on the Court, there is some evidence that he would support Congress’ commerce power claims given his vote in United States v. Comstock (2010) in which he voted to grant Congress authority not explicitly delegated to it in the Constitution.

Given these possibilities, however, it is unlikely that he would be the fifth vote to save health care reform if Kennedy decides with states.

Earning Scalia’s Vote

Of the three, Scalia is definitely the most difficult to convince, mainly because he defines himself as an originalist and often finds himself in agreement with Justice Clarence Thomas concerning the roles of federal government. Having said that, Scalia’s opinion in Gonzalez v. Raich (2005) has certainly given the federal government a chance at winning him over.

Specifically, Scalia wrote in Gonzalez that Congress may “regulate activities that substantially affect interstate commerce.” Scalia argued that “marijuana that is grown at home and possessed for personal use is never more than an instant from the interstate market,” making it subject to federal regulation. Therefore, the brief of the federal government cleverly adopted his language stating, “Because of human susceptibility to disease and accident, we are all potentially never more than an instant from the ‘point of consumption’ of health care.”

In the end, while the Gonzalez case is mentioned ten times in the federal government’s brief, it is unclear whether Scalia will view these cases as substantially similar such that he will view his opinion in Gonzalez as binding on him in some way.

Invoking the Name of Judge Sutton

The final trick up the sleeve of the federal government is to invoke the name of Judge Jeffrey Sutton of the 6^th Circuit Court of Appeals. Judge Sutton may be a very well-known conservative judge, a possible candidate for the Supreme Court in the future, and a former clerk for Justice Scalia. But he also ruled in favor of upholding the individual mandate on constitutional grounds. It’s no wonder why the federal government’s brief mentions Sutton more than twenty times.

In fact, the brief argues that, “As Judge Sutton recognized, ‘[n]o one must pile “inference upon inference” (Lopez, 1995) to recognize that the national regulation of a $2.5 trillion industry, much of which is financed through health insurance…sold by national or regional insurance companies is economic in nature.” It then continues to cite United States v. Morrison (2000) saying that “‘Where,’ as is clearly the case here, such ‘economic activity substantially affects interstate commerce, legislation regulating that activity will be sustained.’”

In the end, it is clear that Judge Sutton’s decision could be the saving grace that makes at least one of the conservative justices more comfortable with making an otherwise uncomfortable decision affirming a broad understanding of Congress’ commerce power.

Conclusions

Thinking through the farm bill more carefully.

Every five years, Capitol Hill authorizes funding for American agricultural policy through a concoction of tax credits, regulation, and developmental programs. Most recently, in 2008 Congress passed a 700 page farm bill, whose contents impacted food prices paid by American consumers and global commodities markets. Though originally narrow in scope, the bill evolved into a monolith encompassing everything from food stamps and school lunches to direct subsidies and conservation initiatives. While contentious, farm bills have historically benefited many American farmers and stabilized food prices. Nevertheless, the farm bill has potentially negative international consequences, something the United States must consider as changing global demographics strain our agricultural system.

The 2008 Farm Bill

The modern farm bill dates back to 1933, when Congress passed the Agricultural Adjustment Act amidst the Great Depression and Dust Bowl. Corn prices plummeted and demand became almost non-existent, leading President Franklin Roosevelt to implement farm assistance “to rescue American agriculture.” The bill reduced crop surpluses by paying farmers to leave their fields fallow and destroy crops and livestock to raise prices. Since then, the Farm Bill has evolved into a complex legislative item and provides the basis for America’s agricultural dominance.

Its most recent edition, the Food, Conservation, and Energy Act of 2008, allocated $288 billion over a five-year period. Over 70 percent of funding was directed towards nutritional programs like food stamps and school lunches, and more than half of remaining funds were subsidies for commodities.

Yet, because farmers have high amounts of capital invested in every growing season, crop insurance has become the most vital program of the farm bill. Before the advent of federally subsidized crop insurance, farmers’ livelihoods were subject to the whims of nature. Fluctuating weather patterns could render a farmer’s entire yearlong effort useless. According to Food Fight: The Citizen’s Guide to a Food and Farm Bill, many farmers “can’t buy enough insurance” because private insurers are often unwilling to take on such risk, leading the federal government last year to spend $5.2 billion on crop insurance.

However, the future of federal spending on agriculture programs is far from certain in the midst of deficit reduction efforts. The new Republican majority in the House has sought to cut government spending across many programs. The current farm bill will expire this September and some farm interest groups are even worried Congress will not renew the bill and that programs will see automatic funding cuts. According to a statement given exclusively to the HPR, Congressman Collin Peterson (D-Minn.), the ranking member of the House Agriculture Committee, said “it’s going to be a tough year” to pass the farm bill. Peterson and other committee leaders already proposed $23 billion in farm bill cuts to the failed debt Super Committee, but there is still a lingering concern that election year politics will prevent renewal. Peterson acknowledges, “we’ve passed a farm bill in an election before, but it is difficult.”

The Modern Farmer

Tracing the evolution of the American farmer reveals much about the parallel development of American agricultural policy. In 1950, there were 5.38 million farms in the United States, and the average farm was 213 acres. Since then, the number of farms has been slashed to around two million, while the average size has doubled. Today, truly profitable farms are generally larger than 2,000 acres, capital which most Americans cannot afford.

According to the Department of Agriculture, “fewer than two percent of Americans farm for a living today, and only 17 percent of Americans live in rural areas.” This statistic is indeed a far cry from Jefferson’s ideal of a republic where the yeoman farmer constituted the bedrock of American society. Many economists attribute this trend to technological growth and increased productivity with scale.

Some denounce this trend. Hilde Steffey, program director for Farm Aid, a group dedicated to supporting family farms, tells the HPR that Farm Aid’s mission is to, “keep every farmer we can.” Farm Aid issued a report to Congress stating that, “far from Wall Street, family farms are creating real wealth, producing real value, [and] growing from seeds and sunlight a product that nourishes us both psychically and economically.” They argue that supporting decentralized family farms is essential to vibrant rural communities.

However, the modern agricultural system has transformed the perspective farmers take on their livelihood. To compete in an increasingly complex domestic and global market, the contemporary farmer has become a technocratic businessman that stays abreast of recent advances in farming technologies. Jonathan Piekarski runs a 1,600 acre family farm in Fergus Falls, Minnesota, and his encyclopedic knowledge of global commodity prices and agricultural news underscores this development. For example, Piekarski observes how the current drought in Argentina, a large corn producer, has raised the global price of his crop.

He explained to the HPR how agricultural policies from Washington affect his daily life. When Piekarski was involved with Future Farmers of America during high school, the farm bill’s programs were touted as keeping, “rural America vital.” Since then, the farm bill has done little but slow the consolidation of America’s family farms. Yet he remains an advocate for a strong farm bill, acknowledging the stabilizing effect on prices and supply, and highlighting the benefits of the crop insurance program. He notes, “U.S. farmers feed the world… [and] the goal is global food security.”

The International Take

However, farmers from other countries rarely commend U.S. agricultural policy, viewing subsidies as anti-competitive. Indeed, some argue that subsidies have allowed American farmers to pursue dumping policies where they flood developing countries with cheap crops in a monopolistic fashion. In 2002, some of these issues came to the forefront when Brazil charged the United States with violating World Trade Organization guidelines and other multilateral trade agreements with its cotton subsidies.

A recent rise in global commodity prices has tempered these disputes, but also created problems of another kind. Randy Schnepf, an economist and specialist in agricultural policy for the Congressional Research Service, told the HPR that, “third world countries are facing high prices because a lot of them are importers of food.” Moreover, he added that many governments “don’t allow global prices in rural areas, so farmers can’t benefit from the high prices.” This mismatching of supply and demand creates an imperfect pricing system, and even slight changes in prices are calamitous for people living on mere dollars per day.

Possible Reforms: A Food Bill?

Many different proposals have arisen to reform the farm bill. Subsidies have generally declined over recent years, but the government still protects niche industries like sugar and rice. Furthermore, because some food policy items may violate international trade agreements, policymakers have additional incentive to make reforms. Direct payments, sums of money paid to farms regardless of the year’s profits, are among the most controversial programs in the farm bill, and cost the federal government $4.9 billion last year. According to Congressman Peterson, “Direct payments are tough to defend, especially now when the agricultural economy is doing so well…[they] will be gone” in the next farm bill.

Some have argued for progressive subsidies, which would involve subsidizing poorer and smaller farmers instead of agribusiness. This aligns more closely with the goals of the original farm bill, but would also face challenges. Overall, many agriculture policymakers and farmers agree that an adequate safety net must exist for farmers, which stabilizes agricultural supply for the American public.

Policy recommendations put forth by Farm Aid emphasize, “Family Farm-Centered Food Systems,” postulating that food should be grown and consumed locally. Steffey claims that beef cattle are often transported from Maine to Colorado for slaughter and processing before being sent back to Maine for consumption. By enforcing stricter anti-trust laws against large meat-packers and providing funds to rebuild local granaries and processing facilities, the farm bill could help communities eat more of what they grow. Another step in the right direction would be amending federal farm loan programs that prevent organic farmers from accessing credit because they are classified as “risky.” These reforms would perhaps enable large-scale and local agricultural production to successfully coexist.

Domestically, the farm bill has many positive consequences, providing a safety net for America’s farm communities, nutritional programs for the hungry, and a steady food supply for consumers. However, the farm bill hearkens back to what we eat, and writer Daniel Imhoff argues, the farm bill is really a “food bill.” America’s farmers are the most productive, innovative agricultural specialists in the world. We place our food orders to them through the farm bill, which will shape the future of farming, and the food and prices we find at local grocers.

HR 2306:

HR 2306 is a rare example of bipartisan collaboration in a particularly divided Congress. Congressmen Ron Paul (R-Texas) and Barney Frank (D-Mass.), both prominent members of their respective parties, are cosponsors.  But the fact that the bill tackles a seemingly untouchable issue, federal marijuana regulation, is even more interesting.

During the previous two Congresses, Frank introduced legislation curbing federal enforcement of marijuana usage laws.  Both times, the bills had bipartisan support, but never made it beyond committee, and its latest incarnation will likely meet that same fate.  Since its introduction last June, HR 2306 has been recommended to both the House Judiciary and the Energy and Commerce Committees, but neither has acted.

Regardless, the topic is certain to galvanize groups seeking drug law reform, and the two prominent cosponsors add greater legitimacy to the marijuana legalization movement. Indeed, there are already proposed ballot initiatives in California, Colorado, and Washington state to decriminalize marijuana. Victories there could encourage the federal government to seriously examine the issue, as supporters of legalization are increasingly encouraged to advocate on both the state and federal level.

Currently, little discussion exists regarding this legislation, but as November approaches, accompanied by the aforementioned ballot initiatives and a Presidential campaign, HR 2306 will likely gain additional attention.  ¶

HR 3806: “One Subject at a Time Act”

While pundits are criticizing Congress for its inaction, Congressman Tom Marino (R-Pa.) is claiming legislators are doing too much simultaneously.  HR 3806 states, “Each bill or joint resolution shall embrace no more than one subject,” but this seemingly simple bill could have serious repercussions if signed into law.

The practice of attaching riders, or typically irrelevant legislative items attached to popularly supported bills, would be prohibited.  Indeed, many controversial bills have been attached as riders in recent years, and the most famous one was the Patient Protection and Affordable Care Act.  In reality, the Democrats introduced it as an amendment to the “Service Members Home Ownership Tax Act of 2009”.

HR 3806 has yet to pass the House Subcommittee on the Constitution, and has only received five cosponsors.  However, the importance of this bill lies not in its potential passage, but in its implications. Assisted in its drafting by the Williamsport, Pa. Tea Party, the bill’s focus is very appealing to small government conservatives and libertarians.  While HR 3806 may not become law, any discussion indicates sincere thoughts about restructuring the way Congress conducts its business. ¶

HR 1981: “Protecting Children from Internet Pornographers Act of 2011”

The Stop Online Piracy Act (SOPA) stole the legislative spotlight for January, but the bill’s sponsor, Rep. Lamar Smith (R-Tex.), has another bill, the “Protecting Children From Internet Pornographers Act of 2011” under discussion.  While the title suggests possible bipartisan support, HR 1981 would significantly change the federal government’s role in monitoring the Internet.

Among the new punishments for possessing or creating child pornography are mandates for Internet service providers to maintain databases tracking convicted perpetrators’ IP addresses for one year at minimum. The goal is to locate individuals exchanging child pornography, but the implications extend well beyond that.  Essentially, information the government previously required a warrant for, Internet service providers would have to submit to authorities upon request.

The online community has remained silent, however, and because this legislation affects users rather than major service providers, few are protesting the bill.  Service providers have expressed disagreement with the expansion of federal authority, but the lack of outrage is most likely a product of minimal opposition from major online organizations. HR 1981 has passed the House Judiciary Committee, and is awaiting discussion by the full chamber. Expect for this bill to dominate discussion about civil liberties in the upcoming months.

Sherbaz Khan Mazari

650 pp. Oxford University Press. $64.

Sherbaz Mazari’s journey to disillusionment begins as early as 1948, after the creation of Pakistan. Hopes were running high and he was eager to serve his country when he took a group of tribesmen to fight for the liberation of Kashmir. An idealistic young scion of a Baloch tribe, he had an interest in politics and national events at an early age. Hearing stories of the Maharajah’s unlawful treaty granting the state to India and the oppression of Kashmiri Muslims, he gathered volunteers from the Mazari tribe and rode on horseback to the border of Kashmir to join the rebels, some of whom were supported by the Pakistan government.

Upon their arrival, they were refused entrance by the Pakistani army. He remembered, “It was here that I received the bitter news of the true state of affairs in Kashmir.” The rebels, much to the embarrassment of the Pakistani government, indulged in so much rapine and plunder that they even turned the Kashmiri Muslims against them. The soldiers at the border, assuming that Mazari’s tribesmen wanted to join the plunder, turned them away. Seeing what the liberation of Kashmir had become, Mazari returned to his village, disillusioned and disheartened.

His foray into Kashmir was short lived, unlike his long-standing struggle against the major forces that contributed towards Pakistan’s disintegration. Mazari’s memoir A Journey to Disillusionment pulls us into major events in Pakistan’s history through his active involvement in the struggle for democracy and his position as an astute judge of the political game and its major players.  The memoir is rich with detail on all the intrigues behind each shift in power. Using passages from old articles, direct quotes from major commentators and political figures and even documents obtained from intelligence reports, Mazari provides a candid account of the creation of Bangladesh, the many wars with India and the later conflict in Afghanistan. At the heart of all this is the story of another ongoing colonization in Mazari’s home province of Balochistan, comparable to the tragic situation that led to the separation of East Pakistan.

Balochistan borders Iran and Afghanistan and has historically been Pakistan’s major source of gas and minerals. Despite being the largest province, it has the smallest population, which consists mainly of large tribes living in a barren and underdeveloped part of the country. Due to Punjabi dominance from the federal government over Baloch resources, fewer funds allocated to the province and tribal suspicions with the federal government, Balochistan has long remained an alienated part of Pakistan.

Sherbaz Mazari spent a significant amount of his political career as an independent politician, refusing to align himself with major political parties until he formed the National Democratic Party to challenge Bhutto’s autocratic rule in the 70’s. He maintained his career by operating on his own principles, despite his acquaintance with the major politicians and army chiefs he encountered over the years. These included Bhutto and Zia ul Haq, who carried out systematic oppression of him and his fellow politicians. Mazari still maintained cordial and respectful personal relationships, an interesting conundrum when his life was under threat.

“Such is the uniquely peculiar nature of our social culture,” he states when the first democratically elected Prime Minister Bhutto invited him for a private dinner to talk about the political situation. Bhutto he described as “an old acquaintance whose minions were engaged in persecuting me and my supporters […] to the extent of trying to have me killed by members of my extended family.” Aided and abetted by the central government, factions were created within the Mazari tribe and Sherbaz Mazari himself, faced intrigue and opposition.

Yet, he started his public service trying to improve the system in his tribe. The tribe that once prided honor and loyalty above everything was losing its old ways to feudalism, where land ownership became a symbol of respect, thus allowing exploitation of tenants and their families. Interestingly, traditional Baloch culture accords immense respect to the tribal leaders who are given the final say in all matters. Historically, this has meant widespread oppression by these leaders.

However, Mazari outlines traditional Baloch laws as being democratic in principle. The Council resolved disputes and if the heirs to the titles were deemed ineffective, the tribal elders would choose a member of the family who displayed leadership qualities. Mazari’s son Sherazam Mazari told the HPR that the major responsibility of the tribal leader is to arbitrate in disputes. In this way, the head’s word is inscribed into the tribal laws over the years. While in many tribes this led to extensive oppression, Mazari established himself as a rebel, moving away from his family and settling in the village of Sonmiani, starting a private school and advocating for change in the traditionally backward system. Today, his efforts are still ongoing in his district.

From Mazari’s perspective, despite his developments in his village, circumstances prevented the province from ever reconciling with the central government. Bhutto sent the army into Balochistan in the 70’s after differences emerged between him and the provincial government. According to Mazari, a cache of arms was found in the Iraqi embassy in Islamabad and the Inter-Services Intelligence (ISI) immediately warned Bhutto. The ISI suspected this was to be sent through Balochistan to destabilize Iran. Since this coincided with the military imposition on Balochistan, Bhutto immediately placed the blame on the provincial government and dismissed them. This dismissal galvanized opposition leaders against him, but also increased the number of disappearances and torturing of political dissidents as well as the murder and rape of thousands of Baloch citizens. Mazari recalls one particular incident with palpable sorrow. He cites Selig Harrison, a foreign writer’s description of the army’s massacre in Mali, a small village in Balochistan. For Mazari this event “would soon become a part of Baloch folklore” when men and women were lined up and shot by invading forces. Throughout the 70’s and 80’s Mazari appealed in the National Assembly for a solution, but to no avail. An insurgency began in Balochistan that persists today.

All the subsequent elected and unelected leaders failed to grant the Balochi community their rights. Mazari predicted the dire consequences of the situation in this memoir, written over a decade ago. Today, his predictions are not far off the mark. Disappearances and target killings of ethnic minorities are a common occurrence in Balochistan. According to the independent Human Rights Commission of Pakistan mutilated bodies of 225 missing persons were found between July 2010 and November 2011, while in 2011 alone another 107 missing persons have been reported. In Balochistan today, ill will towards the predominantly Punjabi central government is palpable, especially after the army attacked and killed a respected tribal leader and alleged head of the insurgency Akbar Bugti (incidentally Sherbaz Mazari’s brother in law and friend) in 2006.

Mazari makes no claim to greatness, nor does he assume he was the last hope for Pakistan. He recounts how he was offered the position of governor of Balochistan a number of times during his years in the opposition but turned it down because his fellow politicians and supporters were still languishing in jails on various charges. Most of the politicians disappoint him, however, as is apparent in his dedication, “To the people of Pakistan– leaderless and betrayed.” His principled struggle to uphold the rule of law and his continuous protest against undemocratic governments fell on deaf ears until he retired from politics. As chairman of the Movement for the Restoration of Democracy (MRD), his was the loudest opposing voice to the post-Bhutto Zia ul Haq government. However, his efforts were hampered by party infighting and his journey reached its lowest point, when his own brothers turned against him in the 1988 elections in order to shift support to their seats. He retired, knowing that he “had come full circle, “ back to the day he faced his first disappointment at the Kashmir border.

In the beginning of his book Sherbaz Mazari remembers a friend who once told him that political memoirs in Pakistan are largely exercises in fiction. Keeping this in mind, he says, “I have made every attempt to be as honest and candid as humanely possible.” With these memoirs, it is hard to doubt him.

As America’s economic recovery crawls forward, its states suffer from depleted revenues and large spending commitments. Experts project between $30 billion and $40 billion in combined state budget deficits for fiscal year 2012. Though the federal government runs deficits during recessions to fund expansionary policies, many states are constrained by constitutional balanced budget requirements. They must close deficits by cutting spending and raising taxes, choking recovery with behaviors that compound macroeconomic problems.
Policymakers should not seek to eliminate balanced budget amendments, an important federalist measure to prevent states from amassing enormous debts. Rather, the federal government should offer short-term deficit relief to states and enable them to better project revenues and outlays, as well as making rising pension costs more transparent.

Balanced Budgets and Pro-Cyclical Policies

While every state but Vermont has a balanced budget requirement, deficits still occur because the regulations usually only cover operating budgets, comprising about half of state spending. Compounding the problem, this requirement applies only to projected budgets, where states foresee higher revenues and smaller expenditures than reality might suggest. As Harvard Law School professor Howell Jackson told the HPR, states “formally comply with balanced budget rules but do not fulfill the spirit of the amendments.”

As a result of their evasions, many states stand in dire fiscal condition. Periodic deficits are manageable, but Brookings Institute’s Tracy Gordon explains that states have been running deficits for the past five years because of the recession. Now states seek to cut spending, but Gordon adds, “If states run out of money, there are a lot of people who are hurt, and these are often the most disadvantaged people in our society.” The Obama administration, recognizing the threat presented by state statutes, offered fiscal relief in the 2009 economic stimulus. This money prevented some layoffs and spending cuts, but now funds are drying up. Gordon points out, “State governments are continuing to lay off about 30,000 employees per month. This is not only bad for the macroeconomy; it also means a lower quality of services that state and local governments are able to provide.”

As Gordon’s example illustrates, aid proposals such as the American Jobs Act are important steps toward alleviating state budget crises. With spending cuts continuing, the federal government should continue to offer aid to the states. Harvard Kennedy School Professor Daniel Shoag asserts, “State spending can be a real driver” for the economy. Thus, Jackson says, “A revenue- sharing mechanism [between the federal and state governments] can be appropriate.” Devising that mechanism to disperse aid to states remains complicated, because aiding states with the worst fiscal crises merely increases the moral hazard that states will spend frivolously. Awarded assistance based on other measures, like the unemployment rate, might prove a better bet.

Short-Term Crisis

When states make emergency cuts, they often proceed without carefully considering the long-term consequences. Most budget yearly, which, when coupled with balanced budget requirements, offers little incentive for long-term focus. Gordon points out, “There is a lot of push now to improve forecasting on the state level and engage in longer- term planning.” Additionally, state revenues vary considerably between years and work poorly under short-term restrictions. The income and capital gains taxes prove substantially cyclical, plunging states into deficits during recessions. Thus, to prevent shortsighted emergency policies, states should project both revenues and outlays over longer periods. As Elizabeth McNichol of the Center for Budget and Policy Priorities maintains, “Long-term, multi-year forecasting on both the spending and revenue sides… gives the states the opportunity to figure out the impact…on spending programs or tax systems for the long-term balance of their budget.”

One particularly effective mechanism may be the pay-as- you-go rule. This method, which the federal government followed from 1991-2000, would require every spending increase or tax cut to be financed by a tax increase or spending cut of equal size within five years. This policy helped create budget surpluses during the 1990s, and should be pursued as a structural fix to prevent budget crises from reemerging, at both the state and local level.

Unsustainable Costs

Even when the current crisis ends, however, states will still face the prospect of disaster in their pension funds. Pensions for public employees are funded by collecting taxes from workers and investing them in diversified portfolios. Shoag states, “It’s sort of like borrowing from the workers to invest in the stock market.” While these funds have typically earned high returns, approximately eight percent annually, the investments are highly susceptible to downturns, and have suffered greatly recently. Yet states continue to discount their obligations to pension funds without taking risk into consideration.

Funds’ behavior exposes taxpayers to substantial liabilities. Economists Joshua Rauh and Robert Novy-Marx estimate that state pensions are currently underfunded by about $3.23 trillion, assuming the eight percent discount rate. Considering that pension obligations are, as Jackson states, “very difficult to adjust due to legal and contractual arrangements,” many question whether pension obligations should be calculated at such high, risky rates. Given the volatility of pension funds, taxpayers will likely have to bail out public pensions, unless they are reformed.

Experts suggest various solutions. Shoag offers, “Pension obligations probably should fall under a balanced budget amendment.” This would prevent states from underfunding pensions, and would specify how exposed taxpayers actually are. Still, the underfunding itself is not an immediate crisis for the states. According to McNichol, 40 states have taken action recently to either reduce benefits or increase employee contributions. She adds, “It is important to separate out the immediate problems that the states are facing as a result of the impact of the recession on their budgets…from some of the longer-term issues, like pensions, which they don’t have to resolve tomorrow.”

Nevertheless, given the growing burden of pension obligations, especially health benefits, states should not take these problems lightly. Jeff Miron, Harvard economics professor, offers some structural solutions, which include creating defined contribution plans similar to 401Ks found throughout the private sector. Miron claims the benefit as that “[States] don’t have to do the fancy accounting and make those projections because… the employer is never on the hook.” Further, Miron believes the federal government should offer block grants to states for Medicaid expenses, rather than reimbursing states for half of all health care costs. According to Miron, “[States] would be forced to allocate [Medicaid funds] in ways that were affordable.”

In this weak economy, states should not drastically adjust pension or health care benefits. Over the longer term, they should still make the necessary projection and accounting changes. Ultimately, there are no easy answers, and states face complex constraints, often misunderstood in public discourse. But the solutions outlined can, with the right political will, mitigate the current situation and protect against future crises.

Daniel Backman ’15 is a Staff Writer.

Photo Credit: kenteegardin, Flickr

On June 14^th of this year, President Obama appointed a commission of seven men and women to evaluate the events that contributed to the Deepwater Horizon spill. The commission, organized less than two months after the spill began but a full month before the oil stopped flowing, released its initial reports this week. In one report, a working paper titled “The Amount and Fate of the Oil,” the staff of the commission issues a withering criticism of the federal government’s own estimates of the amount of oil in the Gulf after the spill and throughout the clean-up process:

“…the federal government created the impression that it was either not fully competent to handle the spill or not fully candid with the American people about the scope of the problem.”

The aforementioned report challenges administration estimates of the amount of oil that was initially flowing into the Gulf and the amount of oil that remained in the Gulf at the end of August, after extensive clean-up efforts. Crucially, a NOAA scientist reported a flow rate of 5,000 barrels-per-day on April 26^th. This number was used by Admiral Mary Landry, who was the ranking on-scene official at the time. While this number was still being used, a number of credible, non-government scientists estimated flows between 10,000 and 50,000 barrels-per-day, with some internal BP estimates placing the flow above 100,000 barrels-per-day. The danger in the government’s initial reliance on the 5,000 barrels-per-day statistic? The response to the spill was organized based on estimated oil flow.

The commission has also challenged the conclusion of Carol Browner, the White House climate advisor, that “three-quarters of the oil is gone,” a statement she made in early August.

The commission is chaired by two former government officials: Bob Graham, formerly a senator for and governor of Florida, and William Reilly, who served as the director of the Environmental Protection Agency under President George H.W. Bush. The remaining five members are all academics, including Cherry Murray, who is Dean of the School of Engineering and Applied Sciences at Harvard.

It is important to note that these reports do not represent the official opinion of the commission, which will be released in a final report next year. It is highly unlikely, however, that these working papers would have been posted to the commission’s website if the members of the commission did not agree with their analysis.

The report is a direct challenge to an administration that has prided itself on its relationship to science. President Obama pledged to maintain a new attitude of transparency in the sciences, in light of President George W. Bush’s perceived neglect of scientific knowledge and method. While President Obama made a series of very public appointments of top scientists to advisory positions, this report reveals the dilemma faced by any politician when the diligence of scientific reporting challenges political expediency.

In a heartbreaking account on NPR’s Science Friday in early June, the renowned oceanographer Sylvia Earle (“the sturgeon general”) described the lack of scientific knowledge about oceans. And yet, the administration condoned the release of dispersants into the Gulf post-spill. Earle and her on-air counterpart, the physicist Lawrence Krauss, lamented the public’s expectation that science provide immediate answers to massive crises. This desire, in the eyes of these two scientists and this blogger, is juxtaposed with a general unwillingness to fund scientific endeavor at a federal level.

President Obama has rightfully tried to involve scientists in decision-making, and his administration has demonstrated its belief that science can play a great role in the resolution of national problems, particularly at an environmental level. This willingness, however, needs to be met in practice. President Obama has made a noble effort, but the reports of the Commission show reluctance on behalf of the administration to listen to independent scientists even when an issue of grave national crisis is unfolding. President Bush often did exhibit an outright disregard for science, but proclaiming a love for science but failing to heed its warnings may be downright dishonest.

Photo attribution: NASA

Many of the government and independent estimates of oil flow were made using satellite technology and imagery.

Count me among the people that regard politics as primarily the art of getting things done — of deliberating on and then distributing out public goods to people, and trying to do this at the lowest costs possible, in the appropriate time horizons, with the greatest impact, and so on. Politics is not poll numbers; it’s not, ultimately, about feelings or even theories. Politics is about doing things.

Adopt this perspective, and the media-wide consensus that Obama has been “weak” on the BP Spill starts to look rather absurd:* the standard for success is a strictly material one; Obama should be judged, in the final analysis, by whether he succeeds at mitigating the effects of this crisis to the fullest extent possible — by whether he helps us plug that (goddamn) hole and then, afterwards, whether he goes to changing the material conditions that allowed the hole to burst open in the first place, the corrupt MMS regulatory regime and our insatiable appetite for crude oil. That is the standard we judge him by.

Theoretically, to judge Obama’s success by the standard of “is he getting it done” you’d need to create “counterfactuals,” where you test his choices against all other conceivable ones. (Note: not stopping the spill doesn’t mean failure; if we had counterfactuals, we might find out that even the best course of action conceivable wouldn’t have allowed the president to stop the spill sooner than he has.) But in practice, the fact of theoretical unknowability doesn’t mean we say “screw it” and decide, instead, to report on people’s perceptions of reality, on feelings or moods or zeitgeist or whatever it is Maureen Dowd is doing. No, it means we work a little harder, investigate the administration’s actions, use our analytical skills to make arguments (with evidence!) for or against them, and then draw conclusions. As it happens, I’ve seen embarrassingly little of that coming out of our press corps.

At the same time, this conception of politics as the material fact of getting goods to people in need helps give us perspective on the political back-and-forths of our moment. There’s a brilliant article out in Slate subtitled “What if political scientists covered the news?” It reads:

Obama now faces some of the most difficult challenges of his young presidency: the ongoing oil spill, the Gaza flotilla disaster, and revelations about possibly inappropriate conversations between the White House and candidates for federal office. But while these narratives may affect fleeting public perceptions, Americans will ultimately judge Obama on the crude economic fundamentals of jobs numbers and GDP.

Chief among the criticisms of Obama was his response to the spill. Pundits argued that he needed to show more emotion. Their analysis, however, should be viewed in light of the economic pressures on the journalism industry combined with a 24-hour news environment and a lack of new information about the spill itself.

Recast Obama’s popularity as a function of the structural forces at play at any given moment — as the result of the slumping economy, the progress of his agenda through Congress, and the fact that a blowout preventer a few thousand feet under the water has been spewing oil for a month — and you start to realize that the narratives about his “feelings” and “leadership” and “tone” are just ex post facto rationalizations. You realize that these narratives, as Jon Chait explains, are most properly understood as “bullshit.”

I think our pundit class would be a whole lot better if they acknowledged these simple truths: first, things happen to countries; then, presidents respond to those things that happen; those responses are bounded by the nature of those things that are happening (say, how much expertise the federal government has on offshore drilling), and, moreover, by the conditions of the world we live in. While the president steers the ship of state, he can’t be held responsible for the conditions of the water.

After all, isn’t this perspective what drew us to Obama in the first place? At the center of his campaign was a promise: to move us beyond the theatrics of politics — beyond the cynical new left/new right vocabulary of our parents, and beyond the erratic “suspend my campaign to fix the financial crisis!!” cowboy politics of his opponent — and towards a politics of reason, deliberation and decency, even when that doesn’t play so well in the media. Towards the politics of getting things done. That was the “change you can believe in” and it is perhaps the man’s deepest conviction: that we can be responsible and civic even in times of great urgency.

So let the guy be calm in crisis. That’s why we elected him, right?

-

* Adopt this perspective and you see why racism is best understood as what you choose to do not what you feel and claim. (Re: Rand Paul.)

Photo credit: U.S. Coast Guard

More than two-thirds of Americans are overweight or obese. Childhood obesity has tripled in the last thirty years. For the first time since the Civil War, Americans’ life expectancy may be declining. These facts paint a depressing, and by now familiar, picture.

After decades of failed attempts to convince individuals to make healthier eating choices, it is evident that reducing obesity will require changes in the food industry. Some recent initiatives undertaken by the Obama administration and the Food and Drug Administration will try to contribute to this effort by changing the way people think about food.

Forcing the Industry to Change

Many cities and states have taken the initiative in the fight against obesity by passing laws which put pressure on companies to make their food healthier. New York was the first major city to order a trans-fat ban in its restaurants, after a failed public education campaign. Other cities and states have followed suit and many are now also considering soda taxes and calling for reductions in salt content.

Kelly Brownell, director of Yale’s Rudd Center for Food Policy and Obesity, told the HPR, “You simply can’t do enough education to begin to compete with the food industry. We need to change the fundamental drivers of the obesity problem such as food marketing and the cost and content of food.” Local initiatives have been effective so far and have also had some positive unintended consequences: after facing trans-fat bans in major cities, nearly all fast food chains have removed trans fats from their national products. When faced with restrictions in large markets, it is often more efficient for companies to implement changes across the board.

But the most effective way to force the industry to change may be to create federal laws similar to those passed by lower levels of government. The food lobby, however, stands in the way. As Brownell explained, “The tobacco experience might be very informative here. The federal government had its hands tied because of lobbying by tobacco companies, and early on real action took place in cities and states.” But, she continued, “once enough victories occurred there, the federal government had cover and was able to take action.” Food companies will only change “if there is a threat of national government action or if these companies have to make changes for public relations reasons,” said Brownell.

Mobilizing the Public

The latter strategy is also being explored. The Obama administration has made fighting obesity a priority, with First Lady Michelle Obama’s “Let’s Move” campaign encouraging young people to exercise. The First Lady has worked with the FDA to increase public awareness, and a major focus has been nutritional labeling.

Siobhan DeLancey, a spokeswoman for the FDA, explained in an interview with the HPR that the FDA “has partnered with the First Lady … to make sure nutrition labeling is accurate and informative for people to rely on and make healthy choices in their day-to-day lives.” But she also acknowledged that even with this improved information available, consumers may not necessarily follow it. “With a busy lifestyle, it is difficult to spend the necessary energy and time to really comprehend food labels,” DeLancey said.

While improved food labels and the First Lady’s information campaign are potentially parts of the solution, an important—and often overlooked—step in the fight against obesity is getting the public to understand how much power the food industry has. For example, Pepsi recently announced that it will remove all sugared beverages from secondary schools in the United States. While this is a welcome move, Brownell cautioned that we have to make sure companies “don’t simply take their marketing muscle and apply it elsewhere like the Internet or store displays through which they can still encourage children to drink sugared beverages.” In order to ensure that companies such as Pepsi make and market healthier products, the public will have to confront them head-on and pressure them to take the correct action.

With the support of the Obama administration, the fight against the obesity epidemic is making strides. Nevertheless, it is important to realize that continued progress depends on changing the culture of food in the United States. As Brownell concluded, “We need to create the public sentiment to encourage change and then force companies to change.”

Neil Patel ‘13 is the Graphics Editor.

The Tea Party movement attracted a lot of attention with its vocal opposition to the Democratic health care legislation, but it took shape at the very beginning of the Obama presidency. It arose out of widespread libertarian and populist outrage over the federal government’s intervention in the economy. While opposing the Obama administration, the Tea Party movement has remained independent from the Republican Party, sometimes openly confronting the GOP establishment. Yet the two organizations are united by their opposition to the Democratic agenda. What will ultimately determine the future of the Tea Party movement, then, is how successfully Republicans can incorporate elements of the Tea Party’s doctrine into their party platform. And how effectively they can prevent the Tea Party from bringing down more electable, establishment candidates.

The Origins of the Tea Party

When CNBC commentator Rick Santelli railed against the “homeowner bailout” at the Chicago Mercantile Exchange in February 2009, he tapped into a widespread frustration with government “handouts.” Santelli famously declared that he wanted to oppose Obama’s economic agenda with a “Chicago Tea Party” in July. Within weeks, anti-tax groups had sprung up across the country. Zephyr Teachout, a professor of public policy at the Harvard Kennedy School, emphasized the importance of these early events in an interview with the HPR. “While right-wing media and politicians fueled the anger around health care reform and other programs,” she said, “I suspect that some of the organic growth of the Tea Party movement came from extraordinary anger at the bank bailouts.” Indeed, the bailouts—combined with the stimulus package’s $787 billion price tag—were major instigators for the Tea Party movement.

Kate Zernike, national correspondent for the New York Times, told the HPR that “the motivating grievance for most [Tea Partiers] was when Congress passed TARP—under President Bush.” TARP, which provided emergency assistance for major financial institutions, was maligned by populists on both the left and right. Furthermore, many Ron Paul supporters, devoted libertarians, provided an organizational structure for the nascent movement. A loose populist-libertarian coalition arose that sought to limit federal spending and roll back newly acquired government powers. The stimulus bill, Zernike said, was just fuel on the fire.

Tea and GOP

The Tea Party movement has repeatedly rebuffed the GOP establishment’s attempts to co-opt it, which has alarmed some Republicans. Richard Parker, a professor at the Harvard Kennedy School, observed, “The RNC remains concerned about three things: the impact of Tea Party primary challengers on the electability of general election candidates, how Tea Party voters will vote in November, and the potential political damage that negative perception of the Tea Party can cause.”

Overall, though, the Tea Party movement has chosen to operate as a wing within the Republican Party in the upcoming midterms, recognizing that fielding candidates against Republicans in general elections would be counterproductive. Indeed, Rasmussen Reports has found that in three-way contests between Democrats, Republicans, and Tea Party candidates, the anti-Democratic vote is split down the middle. Zernike explained, “Tea Party leaders generally boil their issues down to three things: fiscal responsibility, constitutionally limited government, and free markets.” These issues comprise the core values of fiscal conservatives, and Tea Partiers generally recognize that Republicans are better aligned with their interests than Democrats. Still, there is no doubt that the Republican establishment should be concerned, as it has seen a number of preferred candidates receive strong challenges from the Tea Party movement.

Tea Futures

As the economy recovers, the anger and frustration driving the Tea Party could abate. The principles behind the movement, however, will survive. If the Republican establishment adopts Tea Party planks and refrains from voting for new spending programs, Tea Party leaders will feel more incorporated into the political mainstream. The Republican caucus has already unanimously opposed numerous Democratic proposals, most notably President Obama’s health care initiative. As long as Tea Partiers believe that Republicans are listening to their concerns, the Tea Party is likely to function as “an outside advocacy group” that “works for Republican candidates, but does not uniformly support them,” Zernike predicted.

The Tea Party, originally a reactionary movement against what was perceived as unnecessary federal intervention in the nation’s economy, has become an organized political force. Although the Tea Party movement has not outright endorsed the Republican Party, it can exert significant pressure on the GOP to maintain a platform of strict fiscal conservatism, as seen in such primary challenges as Marco Rubio’s in Florida or J.D. Hayworth’s in Arizona. Though the economic conditions fueling the Tea Party’s growth will dissipate, the movement itself may have a long-term impact on American politics.

Alexander Chen ’13 is a Staff Writer.

Photo Credits: Flickr (Caveman 92223 and bisongirl)