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Friday, December 31, 2021

Opinion: Most evangelical objections to vaccines have nothing to do with Christianity

Opinion: Most evangelical objections to vaccines have nothing to do with Christianity

A woman holds a sign during a protest at the State House in Trenton, N.J., on Jan. 13, 2020. Religious objections, once used only sparingly in the United States for exemptions from required vaccines, became a more widely used loophole in the pandemic. (Seth Wenig/AP)

“Some of this rapid spread has come from breakthrough infections, caused by the insidiously transmissible omicron variant. But after a ghastly year of rumor, alarm and needless death, nothing is going to erase the harsh verdict against Americans in 2021: They were granted a miracle drug, and tens of millions refused to take it (or take enough of it).

In the grab bag of reasons for vaccine resistance, the religious exemption claimed by evangelicals is perhaps the most perplexing. The default ethical stance of Christianity is the Golden Rule: “Do to others as you would have them do to you.” This principle was developed in a variety of other religious and moral traditions. (See the Babylonian Talmud: “What is hateful to you, do not do to your neighbor. That is the whole Torah.”) In the New Testament, the Golden Rule is the moral culmination of the Sermon on the Mount. And it is clear from the text that Jesus is not encouraging a calculating ethic of reciprocity. His goal is to inspire a kind of aggressive, preemptive generosity. “If anyone would sue you and take your tunic, let him have your cloak as well. And if anyone forces you to go one mile, go with him two miles.”

The proper application of this principle can be difficult, particularly when it comes to Christian participation in a just war. But the case of vaccination is not really a hard one. Here the tunic is the prick of a needle and a minuscule risk of a bad reaction. The result is a significant benefit for the vaccinated and the community they live in.

U.S. airlines canceled hundreds of flights for a third day in a row on Dec. 26, as spiking coronavirus cases grounded flight crews. (Reuters)

Many have come to a very different view. White evangelical Christians have resisted getting vaccinated against the coronavirus at higher rates than other religious groups in the United States. Some initial resistance came in the context of a familiar ethical debate: Did the creation of coronavirus vaccines involve cell lines produced from aborted fetuses?

The short answer is: no. A slightly longer answer is that the Johnson & Johnson vaccine is grown in fetal cell line PER.C6, which was derived from an elective abortion in 1985. “But contrary to social media claims,” Francis Collins, former director of the National Institutes of Health, told me, “there are no fetal cells or fetal DNA in the Johnson & Johnson vaccine.” The Vatican has indicated that Catholics can take the Johnson & Johnson vaccine.

“The Pfizer and Moderna mRNA are synthesized without the need for a cell line,” Collins said. “The only possible objection against those is that their effectiveness was tested in certain lab experiments that used fetal cell lines. But if that is sufficient reason to decline them, that would also need to apply to a very long list of current medicines, including aspirin and statins.”

The main resistance of evangelicals to public health measures does not concern abortion. Having embraced religious liberty as a defining cause, they are now deploying the language of that cause in opposition to jab and mask mandates. Arguments crafted to defend institutional religious liberty have been adapted to oppose public coercion on covid. But they do not fit.

More than that, the sanctification of anti-government populism is displacing or dethroning one of the most basic Christian distinctions. Most evangelical posturing on covid mandates is really syncretism, a merging of unrelated beliefs — in this case, the substitution of libertarianism for Christian ethics. In this distorted form of faith, evangelical Christians are generally known as people who loudly defend their own rights. They show not radical generosity but discreditable selfishness. There is no version of the Golden Rule that would recommend Christian resistance to basic public health measures during a pandemic. This is heresy compounded by lunacy.

It is worth recalling, as a matter of law, that someone does not need a good or theologically coherent religious-liberty claim to make a religious-liberty claim in court (absent fraud or opportunism). To deny such a claim, government needs a compelling interest advanced in the least restrictive manner. But it is hard to imagine a clearer, more fundamental example of a compelling state interest than preventing the spread of a virus that has already taken the lives of more than 800,000 Americans.

And when Christians are asserting a right to resist basic public health measures, what is the actual content of their religious-liberty claim? The right to risk the lives of their neighbors in order to assert their autonomy? The right to endanger the community in the performative demonstration of their personal rights?

This is a vivid display of the cultural and ideological trends of a warped and wasted year. It just has nothing to do with real Christianity.“

‘Crazy’ omicron surge could peak soon, but the virus is unpredictable as the pandemic enters its third year

Crazy’ omicron surge could peak soon, but the virus is unpredictable as the pandemic enters its third year

“Columbia University researchers estimate infections could top out during the week of Jan. 9

People wait in line for coronavirus testing in Annapolis, Md., on Dec. 30. Testing sites across Maryland have experienced long wait times as the omicron variant spreads. (Jonathan Newton/The Washington Post)

The idea of a rapid peak and swift decline has a precedent in South Africa, the country that revealed the presence of omicron in late November. Cases there spiked quickly and then dropped with unexpected speed after only a modest rise in hospitalizations. An especially transmissible virus tends to run out of human fuel — the susceptible portion of the population — quickly.

Some forecasts suggest coronavirus infections could peak by mid-January.

“Omicron will likely be quick. It won’t be easy, but it will be quick. Come the early spring, a lot of people will have experienced covid,” William Hanage, an epidemiologist at the Harvard T.H. Chan School of Public Health, said in an email Thursday.

But this has always been an unpredictable virus, going back to when it first appeared two years ago, on Dec. 31, 2019. The virus had probably been spreading for a month or more, but that was the day infectious-disease experts around the world began hearing by email and text about an outbreak of a mysterious pathogen causing pneumonia-like respiratory infections in Wuhan, China.

No one on that day could have known that this pathogen, initially called the “novel coronavirus” and later named SARS-CoV-2, would trigger the most brutal pandemic in a century. And no one today knows when it will be over.

Forecasts of how the pandemic will play out have repeatedly been incorrect, to the point that some modelers have stopped trying to make caseload projections four weeks out, instead limiting their forecasts to one week ahead.

Because beyond a week, who knows?

Omicron is the fifth coronavirus variant of concern and is spreading rapidly around the world. Here’s what we know. (Luis Velarde/The Washington Post)

Forecasts of the current winter wave, in which omicron has come riding in atop an existing delta wave, are somewhat more plausible. Columbia University researchers have a model that projects a peak in cases during the week beginning Jan. 9, with about 2.5 million confirmed infections in that seven-day period — and potentially as many as 5 million.

Columbia epidemiologist Jeffrey Shaman said the infection numbers reported in recent days are already at the high-end of projections, and the peak could come sooner. Omicron is setting new daily records for infections with the virus. The seven-day average of new, officially confirmed daily cases soared to more than 300,000 Wednesday. Then came the eye-popping Thursday numbers from state health departments and the Centers for Disease Control and Prevention — 562,000 new cases, pushing the seven-day average to 343,000.

The official number captures only a fraction of the true number of infections. People who use rapid tests at home may not report positive results. Many others never get tested when sick. And some people are infected but asymptomatic or pre-symptomatic.

Shaman estimates the number of infections is four to five times the official count. Given that people remain infected for many days, that translates to many millions of active infections across the United States.

“We’re talking somewhere up to maybe 10 million people,” Shaman said. “Maybe not all of them are contagious yet. Crazy numbers. Crazy, crazy numbers.”

When infections begin to drop, hospitalizations could still rise for a period as the disease progresses among those most vulnerable to a severe outcome. Forecasts posted Monday by the CDC show national hospitalization rates rising steadily in the weeks ahead, with daily new hospital admissions topping 15,000 by mid-January — although the projections from different research teams varied widely.

The predictions of a short omicron surge are reflected in hopes expressed at the highest level of the federal medical bureaucracy.

“My hope is that we get a sharp peak with omicron, and it goes down to a very, very low level, and it just sort of stays there, and we don’t have any more really problematic variants,” Anthony S. Fauci, President Biden’s chief medical adviser for the pandemic, told The Washington Post on Wednesday.

But Fauci and other experts have consistently been surprised by the mutability of the virus. Some scientists did not think a variant with the number of mutations evident in omicron could be an effective transmitter.

“We are dealing with a virus that has a completely unanticipated level of transmissibility,” Fauci said. “We thought delta was very transmissible. This thing is like something we’ve never seen before.”

In the United States, vaccinations — including boosters — have blunted much of the impact of the latest wave of infections from the omicron variant, which appears to be innately less capable of generating severe disease.

That has led to a shift in the Biden administration’s strategy, with a new emphasis on keeping the economy running and shying away from top-down restrictions. All the while, the administration continues to push the available tools for fighting the pandemic, including testing, indoor masking, vaccinations for those reluctant to get the shots and boosters for those eligible for another dose.

But a more spontaneous shutdown has been underway since just before Christmas.

Airlines have canceled thousands of flights because of staffing shortages. The Smithsonian closed a few of its smaller museums. Some college football teams decided not to attend their bowl games. Broadway shows have gone dark. Actor Hugh Jackman, mildly sick with covid-19, is not anticipated back onstage in “The Music Man” until Jan. 6.

This is a new phase of the pandemic, one with sweeping disruptions but probably not the same level of fear and anxiety as earlier periods. Omicron appears milder. For many vaccinated people, it appears to present itself more like a bad cold than something capable of crippling the world economy — although the ramifications of the phenomenon known as “long covid” remain not well understood.

Scientists don’t know precisely why omicron tends to cause less severe illnesses than delta or other variants of the coronavirus. It is likely that immunity plays a role, as so many people have been infected previously or have been vaccinated.

That appears to have been the case in South Africa, hard hit by the virus in advance of the omicron wave.

study of more than 7,000 people, posted online but not yet peer-reviewed, reported high levels of antibodies to the coronavirus in South Africa before the omicron wave. Omicron spread faster than previous variants, but rates of hospitalizations and excess deaths “did not increase proportionately, remaining relatively low,” the study found.

Research on mice and hamsters suggests that omicron is innately less dangerous, apart from population immunity. Although omicron appears to grow especially well in the nose and upper airways, leading to much higher viral loads and easier transmission, it may not invade the lungs as well as earlier variants.

“The dam has broken with a milder variant. Most people who made the correct choice to get vaccinated are protected from severe disease,” said David Rubin, director of PolicyLab at Children’s Hospital of Philadelphia.

Rubin predicts a swift recovery for much of the country in January but notes this is likely to vary geographically. The East Coast, including major cities along the Interstate 95 corridor, and the heavily populated states of Florida and Texas are seeing large spikes in cases, while parts of the country hit hard by delta, including the Upper Midwest, are already seeing improvements, he said.

“By the second week of January, we’re going to see the national declines, but there will be some areas struggling for sure,” Rubin said.

A model from the Institute of Health Metrics and Evaluation at the University of Washington puts the peak of this winter wave at Feb. 6, with 408,000 confirmed new daily infections.

Pandemic models are hampered by the difficulty of amassing reliable data. Testing is disrupted during the holidays. There are only rough estimates of how many people have already been infected.

The most urgent question is whether a spike in caseloads will lead to so many severe illnesses that hospitals are overwhelmed. Although some hospitals are stretched thin, the increase in hospitalizations has been modest so far compared with the rise in infections.

For now, the Biden administration is holding off on drastic measures to combat omicron, beyond common-sense efforts to get more tests in the hands of the public and to encourage vaccination. CDC has issued looser rather than tighter guidelines on the isolation time for people infected with the virus, reducing the recommendation from 10 days to five.

That covers people who are asymptomatic or are seeing their symptoms improve. The CDC’s guidance does not advise that people get a negative test before leaving isolation.

The virus has never been a static agent, nor is society a monolith, and so any forecast of what will happen in the coming weeks needs to be written with a pencil — not a pen.

Shaman, the Columbia epidemiologist, acknowledges that the model he and his colleagues have developed is based on incomplete data and must take into account a new variant that remains somewhat enigmatic.

And the virus itself may have new moves not yet anticipated.

“I’m not a betting person on this thing, ever,” Shaman said.

Jacqueline Dupree contributed to this report“

Crazy’ omicron surge could peak soon, but the virus is unpredictable as the pandemic enters its third year

Crazy’ omicron surge could peak soon, but the virus is unpredictable as the pandemic enters its third year

Thursday, December 30, 2021

Congresswoman Openly Advocates End To American Democracy

US sets new record for daily Covid cases as Omicron spreads across country | Coronavirus | The Guardian

US sets new record for daily Covid cases as Omicron spreads across country

"A startling 488,000 cases were reported Wednesday, but even that figure is likely an undercount of the true number

Cars line up at a drive-thru Covid-19 testing site at the Zoo Miami site on Wednesday in Miami, Florida.
Cars line up at a drive-thru Covid-19 testing site at the Zoo Miami site on Wednesday in Miami, Florida.Photograph: Joe Raedle/Getty Images

The United States set a new record for daily infections of Covid-19 after reporting almost half a million positive cases as the surge of the Omicron variant spreads across the country.

On Wednesday there were 488,000 cases of the virus in the US, according to a New York Times database. However, even that figure is likely a serious undercount of the true numbers of positive cases, due to the rising popularity of home tests and people who are infected but asymptomatic.

The seven-day rolling average of cases in America is also soaring to a new high of more than 265,000 per day on average, a surge driven largely by the highly contagious Omicron variant.

“It’s unlike anything we’ve ever seen, even at the peak of the prior surges of Covid,” Dr James Phillips, chief of disaster medicine at George Washington University Hospital, told CNN.

New cases per day have more than doubled over the past two weeks, eclipsing the old mark of 250,000, set in mid-January during the height of the last winter peak of the pandemic, according to data kept by Johns Hopkins University.

Record case counts are being logged in states and cities across the US, including New Jersey, New York and Chicago. In Georgia, 200 national guard troops are helping staff testing sites and hospitals and in Arizona and New Mexico, federal medical personnel have deployed to bolster the local health services.

The fast-spreading mutant version of the virus has cast a pall over Christmas and the new year, forcing communities to scale back or call off their festivities just weeks after it seemed as if Americans were about to enjoy an almost normal holiday season.

The number of Americans now in the hospital with Covid-19 is running at around 60,000, or about half the figure seen in January, the Centers for Disease Control and Prevention (CDC) reported.

While hospitalizations sometimes lag behind cases, the hospital figures may reflect both the protection conferred by the vaccine and the possibility that Omicron is not making people as sick as previous versions.

Covid-19 deaths in the US have climbed over the past two weeks from an average of 1,200 per day to around 1,500.

Public health experts will be closely watching the numbers in the coming week for indications of the vaccines’ effectiveness in preventing serious illness, keeping people out of the hospital and relieving strain on exhausted healthcare workers, said Bob Bednarczyk, a professor of global health and epidemiology at Emory University.

CDC data already suggests that unvaccinated people are hospitalized at much higher rates than those who have been inoculated, even if the effectiveness of the shots decreases over time, he said.

“If we’re able to weather this surge with hopefully minimal disruptions to the overall healthcare system, that is a place where vaccines are really showing their worth,” Bednarczyk said.

It’s highly unlikely that hospitalization numbers will ever rise to their previous peak, said Amesh Adalja, senior scholar at the Johns Hopkins Center for Health Security at the Bloomberg School Public Health. Vaccines and treatments developed since last year have made it easier to curb the spread of the virus and minimize serious effects among people with breakthrough infections.

“Its going to take some time for people to get attuned to the fact that cases don’t matter the same way they did in the past,” Adalja said. “We have a lot of defense against it.“

But even with fewer people hospitalized compared with past surges, the virus can wreak havoc on hospitals and healthcare workers, he added.

“In a way, those hospitalizations are worse because they’re all preventable,” he said.

The World Health Organisation reported that new Covid-19 cases worldwide increased 11% last week from the week before, with nearly 4.99m recorded December 20-26. But the UN health agency also noted a decline in cases in South Africa, where Omicron was first detected just over a month ago."

US sets new record for daily Covid cases as Omicron spreads across country | Coronavirus | The Guardian

Opinion | The omicron surge could be the worst public health challenge of our lifetimes - The Washington Post

Opinion: The omicron surge could be the worst public health challenge of our lifetimes

A health-care worker conducts a test at a drive-through coronavirus testing site in Miami on Dec. 29. (Joe Raedle/Getty Images) 

"The current omicron surge represents one of the greatest public health challenges not only of the pandemic but also of our lifetime. To deal with the surge over the next six to eight weeks, policymakers need to plan for the impact of what could be 1 million cases a day of new infections in the United States.

Such planning involves being realistic about the effectiveness of vaccination at this point; taking immediate steps to improve public health messaging, data collection and the availability of drug therapies; and doing whatever is possible to ameliorate the potentially devastating consequences for our health-care system.

Vaccines remain the best tool we have available for reducing the risk of symptomatic disease, hospitalization and death, and convincing more people to be vaccinated and obtain booster shots is imperative. But the reality is that most doses administered over the next few weeks will have little impact on the overall trajectory of this immediate surge. It takes 10 to 14 days for even a third dose to increase immune protection. For those receiving their first or second doses, there may be some limited protection provided against severe illness or death, but the window of time to act is closing quickly.

Likewise, masks can be helpful, but only if they are high-quality and used routinely. This means non-fraudulent N95, KN95 or KF94 respirators, all of which have satisfactory filtration efficiency. Cotton or surgical masks are more for show than effective protection, especially against omicron. Public health messaging is essential, not only on the benefit of masking but also on what constitutes effective masking.

Testing represents another problem area. For one thing, we cannot rely on over-the-counter tests for omicron. Many people, including those fully vaccinated, are negativeaccording to antigen tests days into their illness — but positive according to PCR tests. With the public using antigen tests every day and relying on their results before gathering with family, going to work or visiting public settings, the National Institutes of Health and the Food and Drug Administration must immediately research the performance of available rapid tests and advise people on their reliability and best practices for using them during this surge.

In addition, the inadequacy and unavailability of reliable testing means that data on omicron cases in the United States is incomplete and will be unreliable for several weeks. Most positive cases picked up by over-the-counter rapid tests are unlikely to be reported. And bottlenecks created by heightened demand for PCR testing means many cases will go untested and unreported. Pronounced increases in omicron cases will likely overwhelm reporting resources at state and local health departments, resulting in backlogs. As a result, instead of focusing on case counts to prognosticate about omicron, policymakers should follow more reliable metrics, particularly the number of hospitalized patients who are receiving oxygen.

Another area of urgent concern is that we have too few therapies to dent the surge. The two main monoclonal antibody cocktails appear ineffective against omicron. Meanwhile, a third monoclonal that retained effectiveness against omicron is in very short supply. Ditto for the much-heralded covid-19 oral drugs. There are less than 180,000 doses of the Pfizer drug, and it takes months to manufacture. These therapies must be rationed and allocated to those most likely to suffer severe cases: the elderly, younger patients with comorbidities and the immunocompromised. Expect shortages of these therapies in the next few weeks.

Finally, and perhaps most alarmingly, we must brace for the possible catastrophic impact of the omicron surge on the U.S. health system. The weakest link is not the number of hospital beds but the availability of highly trained workers. Approximately 9.8 million doctors, nurses and high-level medical technicians are employed throughout the country. It is possible that 10 or even 20 percent of health-care workers could be infected by omicron in the next eight weeks, as has been reported in South Africa.

Losing that many health-care workers from a system already severely strained by staff shortages would be an enormous challenge. Even with the Centers for Disease Control and Prevention allowing shorter isolation and quarantine periods to help mitigate risk, covid-related absences won’t be addressed by providing hospitals with a thousand more Defense Department health-care workers. Omicron has already caused wide-scale disruptions across the airline industry, in sports leagues and among essential workers. State and local officials must put in place crisis-management plans to account for a 20 percent reduction in the health-care workforces.

To ignore these issues puts our entire country in peril. The time to act is now."

Opinion | The omicron surge could be the worst public health challenge of our lifetimes - The Washington Post

A New Ban on Surprise Medical Bills Starts This Week - The New York Times

A New Ban on Surprise Medical Bills Starts This Week

"If you have a medical emergency, you will no longer need to worry about a large bill from a doctor you did not choose.

The new law does not prevent ground ambulance companies from billing you directly for their services.
Annie Mulligan for The New York Times

For years, millions of Americans with medical emergencies could receive another nasty surprise: a bill from a doctor they did not choose and who did not accept their insurance. A law that goes into effect Saturday will make many such bills illegal.

The change is the result of bipartisan legislation passed during the Trump administration and fine-tuned by the Biden administration. It is a major new consumer protection, covering nearly all emergency medical services, and most routine care.

“I think this is so pro-consumer, it’s so pro-patient — and its effect will eventually be felt by literally everybody who interacts with a health care system,” said Senator Bill Cassidy, a Republican from Louisiana, who was part of a bipartisan group of lawmakers who wrote the bill. He said he counted the bill as among his top achievements as a lawmaker.

Even with insurance, emergency medical care can still be expensive, and patients with high deductible plans could still face large medical bills. But the law will eliminate the risk that an out-of-network doctor or hospital will send an extra bill. Currently, those bills add up to billions in costs for consumers each year. 

“This is such an important consumer victory because it is going to protect consumers from an egregious and pervasive billing practice that has just grown over the years,” said Patricia Kelmar, the health care campaigns director at the consumer group U.S. PIRG.

Behind the scenes, medical providers are still fighting with regulators over how they will be paid when they provide out-of-network care. But those disputes will not interfere with the law’s key consumer protections.

What does the law mean if I go to the emergency room?

If you are having a medical emergency and go to an urgent care center or emergency room, you can’t be charged more than the cost sharing you are accustomed to for in-network services. This is where the law’s protections are the simplest and the most clear for people with health insurance.

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You will still be responsible for things like a deductible or a co-payment. But once patients make that normal payment, they should expect no more bills.

“We shouldn’t have to depend on people knowing minutia about insurance regulation in order for them to get care or not be unfairly billed,” said Anthony Wright, the executive director of Health Access California, a patient group that supported the federal law and that fought for a law that banned surprise bills in California starting in 2017.

Several studies found that around 20 percent of U.S. patients who had emergency care were treated by someone outside of their insurance network, including emergency room doctors, radiologists or laboratories. Any of those providers could send patients an extra bill after the fact, and some medical groups did so routinely. Such bills are now illegal.

There is one important exception.

What does the law mean if I need an ambulance?

The new law does not prevent ambulance companies from billing you directly for their services if they travel on roads. It does offer protections against surprise bills from air ambulances.

Ground ambulances were left out of the recent legislation because legislators determined they would need a different regulatory approach. Congress established a commission to study the issue and may consider reforms.

Eleven states prevent ambulances from sending out-of-network medical bills. Patients who live in the other states are quite likely to get a bill in the mail if they require an ambulance. Research shows as many as half of people who need an ambulance receive such a bill, though the amount is not always large.

What does the law mean for routine hospital procedures?

For scheduled services, like knee operations, C-sections or colonoscopies, it’s important you choose a facility and a main doctor that is in your insurance plan’s network. If you do that, the law bars anyone else who treats you from sending you a surprise bill. This also addresses a large problem. Surprise bills from anesthesiologists, radiologists, pathologists, assistant surgeons and laboratories were common before.

If, for some reason, you are having such a service and you really want an out-of-network doctor to be part of your care, that doctor typically needs to notify you at least three days before your procedure, and offer a “good faith estimate” of how much you will be charged. If you sign a form agreeing to pay extra, you could get additional bills. But the hospital or clinic can’t force you to sign such a form as a condition of your care, and the form should include other choices of doctors who will accept your insurance.

“People should really, really think carefully before they sign that form, because they will waive all of their protections,” Ms. Kelmar said. She recommended that patients skip right to the part of the form that lists covered alternatives.

Does this mean I will never be surprised by a medical bill?

No. When health policy experts discuss “surprise bills,” they are talking about a specific thing: extra charges from a medical provider whom patients didn’t choose. But there are still many parts of the U.S. health care system that remain perplexing.

If you have an insurance plan with a high deductible, or have a kind of cost-sharing known as “coinsurance” in which you have to pay a percentage of your medical charges, you could still get a big bill in the mail after any medical care. The government is taking steps to make the costs of medical care more transparent. But it is still not always obvious what medical care will cost in advance, and what insurance plans will cover. It is always worth understanding how your insurance benefit works so that you have a general sense of how much you could be asked to pay beyond your premium.

If you are going to a doctor for something that’s not an emergency, it is also still important to confirm that the doctor is part of your health insurer’s network. Visits to doctors who are out of network could result in extra bills. Mr. Wright recommends asking doctors whether they are “in network” and not whether they simply “accept my insurance.” That’s because some doctors who are out of network will accept insurance payments but still bill patients for additional fees.

What about lawsuits over the law?

Doctor and hospital groups have brought lawsuits challenging a part of the surprise billing law. But even if those lawsuits are successful, there will be little immediate impact on bills. (It is possible they will eventually cause insurance premiums to rise.)

The lawsuits relate to what happens after an out-of-network doctor treats a patient. The new law sets up an arbitration system for the provider and the health insurer to determine a fair payment. In the lawsuits, the medical providers say the regulations for that process are not consistent with the wording of the law and may cause their payments to fall. If they win, they want some of the instructions for the arbiter to be deleted, but they do not seek the ability to send surprise bills."

A New Ban on Surprise Medical Bills Starts This Week - The New York Times

Opinion | A.O.C. and Manchin Are in the Same Party. No Wonder Democrats Are Struggling. - The New York Times

A.O.C. and Manchin Are in the Same Party. No Wonder Democrats Are Struggling.

Tom Brenner for The New York Times

By Julia Azari

"Ms. Azari has taught and written extensively about the American presidency, political parties and political rhetoric.

The promise of Joe Biden’s candidacy for president was his potential to assemble a coalition of progressives, liberal and moderate Democrats, and even disaffected conservatives looking for an alternative to Donald Trump. In 2020, this meant that Mr. Biden won a solid, but not landslide, victory.

In 2021, it means he has to govern with that coalition. Like Franklin Roosevelt and Lyndon Johnson, he came in with an ambitious, even transformative agenda. And like those presidents, he leads a party that’s a jumble of interests and viewpoints. But those earlier Democratic presidents had numbers, and solid majorities, on their side.

After the latest twist by Senator Joe Manchin of West Virginia in the Build Back Better drama, Democrats are weathering a storm of accusations of being plain bad at politics. This is nothing new: As a party of representing many groups, Democrats have always struggled to nail down party priorities and deliver on their campaign promises. But what is new is that for the Biden administration, those challenges have been compounded by a very narrow majority, nationalized politics and new ideological currents.

Democrats, as ever, have to figure out how to represent a diverse group of voters with different interests and outlooks. It is even tougher in 2021 because they have to find a way to mend the disconnect between the party’s ability to assemble a broad coalition at the ballot box and the struggles it faces in legislating.

This combination of the old and new Democratic Party has left the Biden coalition in a holding pattern. What might look at first like problems with individual politicians is in fact several structural problems at once: the counter-majoritarian institutions in American government; the fuzzy balance of power among different forces within the party; and the difficulty of energizing a diverse set of interests around common goals.

Negotiating with pivotal senators who are more conservative than much of the rest of the party isn’t a new thing under Mr. Biden — it’s also the story of the New Deal. Roosevelt had to deal with several conservative Southern Democrats. Today, Mr. Manchin and Senator Kyrsten Sinema of Arizona are actually in line with many recent Democratic proposals, but they can still extract concessions that don’t necessarily reflect the bulk of the party’s priorities.

Nationalized party politics make it more difficult for these senators to cultivate a local, personal brand. As a result, they have to work harder to draw media attention to their performances of political independence and willingness to push back against the president and congressional leaders. Because it’s harder for them to distance themselves from the national party brand, they’re harder to negotiate with.

The second change is the emergence of a strong and cohesive left wing within the Democratic Party. It’s true that the party is more uniformly liberal than it has been in the past. But this means different things. The so-called Squad and the rest of the Progressive Caucus bring both a more economically left perspective and a different vision on issues like race and criminal-justice reform. The presidential candidacies of Bernie Sanders and Elizabeth Warren showed that there’s solid support for moving to the left on economic issues — even if it’s not a majority of the Democratic coalition. In addition to appeasing the more conservative wing of the party, the Biden coalition also features tensions between this new progressive faction and more traditional liberals represented by members like Speaker Nancy Pelosi.

It’s likely that a smaller, patchwork Democratic coalition is here to stay for a while. This means that they will still face some of the same problems Presidents Roosevelt and Johnson did — like risk-averse party members and vocal campaigns against expanding the welfare state — but without a key tool for getting things done: large majorities (or the possibility of regularly picking up Republican votes on major legislation).

As a result, Democrats might be doomed to more cycles of lengthy negotiations and under-delivering on progressive promises. But there are a few changes that could shake up which groups hold power within the party, making it more responsive to a broader range of its voters. One route is to strengthen social movements, which could both keep progressive issues like green energy and student debt on the public agenda and possibly help to elect more progressive Democrats. Such movements could also help to mobilize different groups of voters around shared priorities like health care and economic insecurity.

The other — which has drawn the most attention in the past year, though little progress — is institutional reform. This approach isn’t so much about enlarging the Democratic coalition as it is about reforming the rules of governance to allow a party that already regularly wins national elections to wield proportionate influence in governing. These proposals include filibuster reform and making Congress more proportional. Proponents argue that these changes would ease the veto power that less populated and more conservative areas of the country hold over the majority.

But the balance of power within the patchwork Democratic Party is not just about institutions, or even about narrow majorities. It’s also about the influence of wealthy interests over public opinion. The persistent inability of a majority party to enact policies that reflect the opinions of its constituents means that we ought to look at the forces at work. Mr. Manchin is an especially good example of this dynamic — powerful voices in West Virginia have come out in support of Build Back Better, but the senator has serious ties to the fossil-fuel industry. Ms. Sinema’s hesitance to support party priorities has also been linked to her ties to powerful industries rather than any ideology or what Arizona voters want.

These problems also require structural solutions — tightening regulations over conflicts of interest for members of Congress and enacting lobbying reform. The party’s survival may depend on its ability to represent its own voters and not the corporate interests that still have a powerful veto in the legislative process.

Finally, the party could scale back on its policy agenda. But recent history suggests that “change” candidacies — from Barack Obama to Donald Trump to Bernie Sanders — resonate with an electorate that craves change, even if they can’t agree on what kind.

Many of the Democrats’ problems in the legislative process are not of their own making. But, fairly or not, Democratic leaders will need to think differently about how power flows through their coalition if they want to see their successes in electoral politics turn into policy achievements.

Julia Azari (@julia_azari) is an associate professor of political science at Marquette University and the author of “Delivering the People’s Message: The Changing Politics of the Presidential Mandate.”

Opinion | A.O.C. and Manchin Are in the Same Party. No Wonder Democrats Are Struggling. - The New York Times