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Black Americans see a health-care system infected by racism



This story was produced in partnership with
The Undefeated, an ESPN website that explores the intersection of race, culture, and sports. ESPN and National Geographic are both owned by The Walt Disney Company.

African Americans have a dim view of the nation’s health care system, which they see as infected by the same racism they encounter on the job, out shopping, in the classroom or interacting with the police.

A new nationwide poll by The Undefeated and the Kaiser Family Foundation (KFF) found that 7 in 10 African Americans believe that people are treated unfairly based on race or ethnicity when they seek medical care. It’s a feeling born of unequal history and intensified by the coronavirus pandemic, which is disproportionately ravaging Black lives both physically and economically.

The poll, which included interviews with 777 African Americans, is the most comprehensive survey of Black attitudes and experiences with health care since the start of the pandemic. Among the findings:

  • About four out of 10 Black adults said they knew someone who has died from the coronavirus, almost double the rate for white people.
  • One-third of Black adults and nearly half of Black parents are struggling to pay their bills as a result of the pandemic. Two out of 3 Black parents have either lost jobs or had their incomes interrupted since the pandemic struck in February.
  • While a sizable minority of Americans of all races are deeply skeptical of the nation’s byzantine health care system, the feeling is more pronounced in the Black community. Fifty-five percent of African Americans said they distrust it.
  • Despite the horrific toll of the pandemic, African Americans are doubtful about the promise of a coronavirus vaccine that public health officials hope to begin deploying in the coming months. Just half of African Americans surveyed said they would be interested in taking a vaccine, even if it were determined to be safe and were provided at no cost. By comparison, 2 in 3 white people said they would definitely or probably get vaccinated, as did 6 in 10 Hispanics. The vast majority of African Americans who said they would not take a coronavirus vaccine did not think that it would be properly tested, distributed fairly or developed with the needs of Black people in mind.

Public health experts called the misgivings around a vaccine an outgrowth of the discrimination many African Americans endure, not only as they attempt to access health care, but also as they go about their daily lives.

“We have a centurieslong legacy in this country of basically Black people, in particular, and other people of color as well, being treated poorly,” said Dr. Lisa A. Cooper, an internist who directs The Johns Hopkins Center for Health Equity. “So why should Black people trust any institution? It has gone on for so long.”

A majority of Black adults, 58 percent, said they had experienced discrimination in just the past year. One in 4 said they were discriminated against dealing with police in traffic and other incidents. Twenty-eight percent said they experienced racial bias on the job, while 40 percent said they were treated unfairly while shopping. One in 5 said they experienced it while seeking health care.

A large majority of Black Americans cited implicit bias as a major factor, both in preventing racial equality and as an obstacle in their own lives. At the same time, 7 in 10 Black respondents who said they were treated unfairly because of their race saw the discrimination as deliberate. (There are large gaps between attitudes of Black and white people over bias and discrimination.)

“They treat Black people different than they do white people when I go to the hospital,” said Eugene Lawrence, 73, a retired waiter who lives in Hartford, Connecticut. “It’s petty, little things. When they call the nurse, they rush to come see the white people. They don’t rush to see the Black people. I think it’s racist. It’s been that way from the beginning in this country, and it is going to be that way to the end.”

The survey found scant trust among African Americans in fundamental American institutions. Only 1 in 4 trusted police to do the right thing for their communities all or most of the time. Less than half trusted local schools.

The poll was taken as the country has been gripped by a monthslong racial reckoning prompted, in part, by the death of George Floyd in May under the knee of a Minneapolis police officer. While a majority of African Americans, 57 percent, are hopeful that the ongoing protest movement and push for racial equality would produce meaningful change, 53 percent of white people expected no meaningful change.

Still, the ongoing disparities have Black people pessimistic about their current standing in American society. Just over four years ago, then-President Barack Obama told Howard University graduates, “If you had to choose a time to be, in the words of Lorraine Hansberry, ‘young, gifted and Black’ in America, you would choose right now.”

The survey, however, found that only 1 in 4 Black men and 1 in 3 Black women agreed that it was a good time to be Black in America. That is a far cry from 2006, when 60 percent of Black men agreed with that statement, or 2011 when 73 percent of Black women thought it was a good time to be Black.

“It’s a challenging time to be Black,” said Eddie Singleton, 76, a retired Army lieutenant colonel who lives in Goldsboro, North Carolina. “Just look at all the things going on, and the tone of the election. We need to get together and get this country headed in the right direction.”

Widespread disparities

As demonstrators have taken to the streets across the country to protest police violence and systemic racism, the nation’s attention has been directed to the stark disparities that continue to separate Black and white people in nearly every walk of American life.

African Americans are more likely than white folks to be arrested. Once arrested, they are more likely to be convicted. One in 3 Black men born in 2001 can expect to go to prison in their lives, as opposed to 1 in 17 white men.

At $188,200, the net worth of a typical white family was nearly eight times greater than that of a Black family in 2019. A typical Black worker earns $805 a week, according to the U.S. Department of Labor, which is 79 percent of the median white wage of $1,017 a week.

Gaping racial disparities also characterize American health outcomes, which experts call a consequence of other social inequities. Black people suffer more frequently than white people from diabetes, obesity, high blood pressure, maternal mortality and infant mortality. In 2017, 12.6 percent of Black children had asthma, compared with 7.7 percent of white children. Overall life expectancy for Black people is 75.5 years, 3.4 years shorter than it is for white folks.

Asked to name the biggest driver of those disparities, Dr. Leo Moore, a public health physician in Los Angeles, offered a one-word answer: racism. “Redlining, pollution, the fact that we have fewer parks and recreational activities in our neighborhoods. Our schools not receiving as much funding, all plays a role,” he said. “And racism and white supremacy is at the root of it all.”

Those disparities are compounded by the differences in the health care received by Black and white people, the survey found. One in 5 Black adults said they have been “personally treated unfairly” in the past year when trying to get health care for themselves or a family member because of their race. (COVID-19 unveils an America that always sees itself in Black and white.)

Verlisa Taylor, 49, an IT project manager who lives in Waldorf, Maryland, has been helping to manage the care of both her cancer-stricken brother and her mother, who has suffered a stroke and other ailments.

In each case, she has been dissatisfied. Her brother, Thomas Mason, 60, was diagnosed with throat cancer in 2007. When he was treated, she always suspected something was off, and she frequently felt cut out of the decision-making.

That notion was confirmed last year when cancer returned, and the doctors this time said it probably was a result of excessive radiation during his first round of treatment. She often believes that if they were wealthy, or perhaps white instead of Black, that would not have happened.

“You can never know, but when all of your doctors are white, you can come to the conclusion that is about race,” she said.

She gets the same feeling when she goes to the doctor with her 78-year-old mother, Shirley Taylor, who, among other things, suffers from chronic stomach problems. “When she goes to the doctor, it is always, ‘Take this medication,’ ” she said. “It seems like there is never any conversation or dialogue to try to get at what might be the underlying problem.”

Black Americans were more likely than white people to cite specific negative encounters with the health care system, including feeling that providers didn’t believe they were telling the truth, being refused a treatment or test they thought was necessary, and being denied pain medication.

It is a feeling Camellia Moses Okpodu, dean of the college of arts and sciences at Xavier University of Louisiana in New Orleans, knows personally. Two years ago, she received a frantic call: her 88-year-old mother had been stricken with a ruptured aneurysm in Wilmington, North Carolina. She hopped into her car for the nearly 900-mile drive to be by her mother’s side. When she got there, she was stunned by the attitude of her mother’s doctors. At first, they were reluctant to perform the surgery that she believed offered the best chance to save her life.

“They kept saying she was 88 years old,” recalled Okpodu, a biochemist. “Yes, she was 88. But she had never lost consciousness, was not in terrible health or had some extenuating circumstance that would not allow her to withstand the operation. It was like they were looking at some actuarial table and not at my mother.”

The doctors relented once Okpodu insisted that her mother undergo surgery. The procedure proved to be successful. She said her mother is now 90 and going strong. “I wonder what the outcome would have been had I not been there to advocate for her,” Okpodu said. “Would she have died?”

Looking back, “I can’t say what is in their hearts,” Okpodu said. “I just know it was some horrible decision-making seeming based on some sort of table they had. I just think it was ignorance.

A legacy of discrimination

Black people were used as medical research subjects during slavery. It was long before medical ethics developed as a discipline and “Black bodies often found their way to dissecting tables, operating amphitheaters, classroom or bedside demonstrations, and experimental facilities,” according to a 1982 paper (PDF) by Todd L. Savitt, a professor at East Carolina University’s College of Medicine.

That kind of medical exploitation (which sometimes included white people, too) continued for more than a century. Most famously, the Tuskegee syphilis study began in 1932 with the goal of tracking the damage the disease does to the human body. Without informed consent, the study enrolled 600 Black men, including 399 who had syphilis. The men were told they were being treated for “bad blood,” but they did not receive any treatment for their illness — not even after penicillin was found to cure syphilis in the mid-1940s. The study did not end until it was exposed to the press in 1972, and has gone down as one of the nation’s most egregious examples of medical racism.

But disparate treatment did not end there. Researchers have documented many ways that Black patients are treated differently from white patients. In 2002, the Institute of Medicine’s groundbreaking report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, found higher rates of diseases, including diabetes, heart disease, hypertension and HIV, among Black and other people of color. Yet, minority patients were less likely to receive critical medical interventions such as bypass surgery or antiretroviral therapy. At the same time, people of color were more likely to receive extremely invasive treatments, such as amputations.

Different treatment contributed to mistrust, which only compounded medical problems, the report found. “Minority patients are more likely to refuse recommended services, adhere poorly to treatment regimens and delay seeking care,” it concluded. The report helped move the issue of racial disparities in health care into the mainstream of medical thinking. But rooting out the disparities, which are tightly bound to the nation’s other social inequities, remains a problem.

The Undefeated/KFF survey found that Black people tended to have much more confidence in doctors than they do in the overall health care system, with its impenetrable billing models, slow-moving waiting rooms and multitude of insurance plans. Yet, Black patients had much less confidence in doctors and local hospitals than white folks.

In her own research, Cooper has found that doctors have poorer communication with Black patients than white ones. Doctors tended to dominate visits with Black patients by talking, rather than listening and connecting with patients, she found. With white patients, the conversation more often flowed two ways. The result is that Black patients often are reluctant to share whatever ails them and, more often than white patients, leave doctor’s visits feeling unheard.

“Physicians tend to dominate the conversations when they are seeing African American patients,” Cooper said. “African American patients get to ask fewer questions, they get less opportunity to explain themselves or to offer their opinions or their preferences.”

She also found that communication improves when Black patients see Black doctors. Other researchers have documented a host of benefits when Black doctors see Black patients. They include more shared decision-making, improved medication adherence and better patient perception of treatment decisions.

But in a nation where just 45,000 of the more than 900,000 physicians are Black, that is not always possible. A quarter of Black respondents said they’ve never seen a doctor who is Black. Doctors of all races can do an effective job treating Black patients, and while the survey found that 24 percent of Black adults would prefer to see a Black doctor, most said their doctor’s race did not matter.

Cooper said research like hers is slowly changing how doctors think about their profession. Once concerned mostly with the hard sciences such as biology, she said more physicians are becoming open to ideas springing from the social sciences and are mindful of how best to communicate with patients and understand the many forces that may be impacting their health.

In Los Angeles, Moore said he is careful not to lecture his patients, even when he disagrees with their choices. In recent weeks, he has been encouraging patients to take the flu vaccine and to be ready for the coronavirus vaccine once it is ready and proven safe. But some patients don’t want to hear it. They insist the vaccine will be unsafe, or that they previously contracted the flu from a vaccine. (Half of Black adults say they won’t take a coronavirus vaccine.)

“I try to explain that you cannot get the flu from the vaccine, that you are being exposed to the antigen within that virus,” Moore said. “So you’re being exposed to particles that will help you create antibodies and in that process, you might have some cold symptoms, but it is not the flu.”

Moore acknowledges that he is not always convincing. So he looks for other ways to educate. He is active on Instagram, and he has launched a YouTube show called The Practical M.D., in which he uses short videos to share information in plain language about health and self-care.

“I was taught early on about patient autonomy. So, the importance of telling my patients the risks and benefits and letting them make the best choice for themselves,” he said. “We as providers have to accept that sometimes what a patient views as their best choice would not be the choice that I would choose, but it’s the best choice for them at that time. And we accept that and move on, but continue to have conversations about it to ensure that they’re the best informed to continue to make the best decisions for themselves.”



U.S. Records 100,000 Cases in a Day for the First Time



U.S. Records 100,000 Cases in a Day for the First Time


A bicyclist passing the New York Stock Exchange on Wednesday.
Credit…Jeenah Moon for GFN

The United States on Wednesday recorded over 100,000 new coronavirus cases in a single day for the first time since the pandemic began, bursting past a grim threshold even as the wave of infections engulfing the country shows no sign of receding.

The total count of new infections on Wednesday was more than 107,800, according to a New York Times database. Twenty-three states have recorded more cases in the past week than in any other seven-day stretch.

Five states — Maine, Minnesota, Indiana, Nebraska and Colorado — set single-day case records. Cases were also mounting in the Mountain West and even in the Northeast, which over the summer seemed to be getting the virus under control.

North and South Dakota and Wisconsin have led the country for weeks in the number of new cases relative to their population. But other states have seen steep recent increases in the last 14 days.

Daily case reports in Minnesota, on average, have increased 102 percent over that time, while those in Indiana have risen 73 percent. For months, Maine had among the lowest levels of transmission anywhere in the country, but new cases there have more than tripled. In Wyoming, new cases are up 73 percent, while in Iowa they have more than doubled.

Deaths related to the coronavirus, which lag behind case reports, have increased 21 percent across the country in the last two weeks.

Hospitals in some areas are feeling the strain of surging caseloads. More than 50,000 people are currently hospitalized with Covid-19 across the country, according to the Covid Tracking Project, an increase of roughly 64 percent since the beginning of October.

Dr. Anthony S. Fauci, the country’s top infectious disease expert, predicted in June, when new cases were averaging roughly 42,000 a day, that the rate would eventually reach 100,000 a day if the pandemic were not brought under control. His blunt assessments of the country’s failure to control the virus drew attacks from Trump administration officials, including the president, who called him alarmist.

In an interview on Friday, Dr. Fauci told The Washington Post that the country would most likely hit the 100,000 mark soon.

“We’re in for a whole lot of hurt,” he said.

Dr. Fauci said that the country “could not possibly be positioned more poorly” as winter approaches and colder temperatures lead people to gather indoors.

States report new cases unevenly from day to day, so seven-day averages are a more reliable gauge of trends than an individual day’s figures are. But Wednesday was bad by that measure as well, with the seven-day average exceeding 90,000, the highest since the pandemic began.

During the early days of the pandemic in March and April, testing in the United States was very limited, so it is not possible to say with certainty that the virus is spreading faster now than it did then.

But the pattern of infection has clearly changed.

Dr. Bill Hanage, an associate professor of epidemiology at Harvard’s T.H. Chan School of Public Health, said this week that while the surges in the spring and summer were concentrated in specific regions — the Northeast in the spring and the Sun Belt in the summer — the current one reflects transmission increases in nearly all parts of the country.

Dr. Hanage called Wednesday’s milestone “the completely foreseeable consequence of not taking pandemic management seriously.” And he said the country would see “hospitalizations and deaths increase in due course.”

“This is desperately concerning,” Dr. Hanage said, “because uncontrolled transmission will end up compromising health care, and in order to preserve it, we will almost certainly end up needing to take stronger action to prevent the worst outcomes.”

“Look to Europe to see the consequences of leaving it too late,” he said. “The longer you leave it, the harder it will be to control.”

Lombardy is one of the regions in Italy that will be going into lockdown.
Credit…Alessandro Grassani for GFN

The Italian government announced Wednesday night that it would lock down a significant portion of the country, including the northern regions that are its economic engine, in an effort to stop a resurgent wave of coronavirus infections.

Prime Minister Giuseppe Conte said the measures, the most drastic since the nationwide lockdown in March, would take effect on Friday and will seal off six regions in the country’s deeply infected north and highly vulnerable, and poorer, south.

“The situation is particularly critical,” Mr. Conte said at an evening news conference. He said the virus was moving at a “strong and even violent” pace.

Across Europe, efforts to halt a second wave of cases with piecemeal measures are being replaced by far stricter rules — and hurried efforts to bolster health systems that could quickly reach capacity in the coming weeks.

Starting Thursday, England will be under a second lockdown. Poland will shut schools and shops this weekend, and Lithuania will enter a full lockdown. Switzerland has called in the army to bolster hospitals. And France’s health minister is pushing to extend a state of emergency until February.

In Italy, the new measures will ban residents of the six regions from crossing borders except for work, health or other “situations of necessity,” Mr. Conte said. Movement within the regions will also be strictly limited. Bars and restaurants will be closed in all of the regions and shops selling nonessential goods will be closed in most of them.

Three of the regions span the country’s northwest and include Lombardy, which is the home of Italy’s financial capital, Milan, Piedmont and Aosta Valley. The southern regions are Calabria, Puglia and the island of Sicily.

Mr. Conte said the restrictions, which have triggered fierce opposition from business groups, restaurants and many citizens exasperated with government limits on their freedom, were being put in place because “there is a high probability that some regions will exceed the critical limits in intensive care units” in the coming weeks.

“We necessarily have to intervene,” he said.

The country will be essentially divided into three zones: red, orange and yellow, each with its own restrictions. The government will make those assessments on a weekly basis.

The announcement adds specifics to a new government decree, announced earlier on Wednesday, which imposed a 10 p.m. curfew around the country and closed museums, high schools and, on the weekend, shopping malls. Mr. Conte also “strongly recommended” that Italians stay home during the day, but deferred the decision to establish local lockdowns to the country’s health minister and the regional governors.

Mr. Conte said he had chosen a more targeted approach rather than a blanket lockdown because nationwide measures might be ineffective for the most infected areas and too draconian for places with fewer cases.

In Britain, Mr. Johnson spoke before Parliament on Wednesday, saying there was no alternative to a monthlong lockdown if a “medical and moral disaster” was to be avoided. For weeks, Mr. Johnson had resisted such drastic measures, rejecting calls from scientists who advise the government, and from the opposition Labour Party, for an earlier but shorter lockdown.

Lawmakers voted 516-38 to approve the rules, despite a rebellion from within Mr. Johnson’s Conservative Party.

Britain has been the worst-hit country by the pandemic in Europe, with more than 60,000 deaths.

London was bustling with shoppers hours before the new rules took effect. Stores, restaurants, pubs and other nonessential businesses must close for a month; schools will remain open. People will be asked to stay home unless they are needed at work, or out to buy food or exercise.

Germany and France, which had failed to contain the virus with piecemeal measures, have also reimposed nationwide lockdowns.

Switzerland called on the army to support its medical services on Wednesday as the daily number of virus cases hit a new peak. The Swiss cabinet said it agreed to deploy up to 2,500 military personnel to support testing, care and transport services. Switzerland recorded more than 10,000 cases on Wednesday, a single-day record, and 73 deaths.

Lithuania said it would impose a nationwide lockdown as of Friday, after the number of new cases tripled in recent weeks, while the prime minister of Denmark, and most of the government, went into quarantine after the justice minister tested positive for the virus.

Poland stopped short of a national lockdown, but announced new restrictions on Wednesday. Cultural institutions and nonessential shops in commercial centers must close on Saturday, and the number of customers allowed into other shops will be limited. Hotels will only be allowed to accept business travelers, and all schools starting at first grade will switch to online learning.

Counting votes in Milwaukee on Tuesday.
Credit…Chang W. Lee/GFN

Across the United States on Tuesday, voters cast ballots in a presidential election in which the uncontrolled coronavirus pandemic was both a top issue and a threat.

As millions of Americans turned out to vote, the nation was facing a rapidly escalating pandemic that is concentrated in some of the very states seen as critical in determining the outcome of the presidential race. From Wisconsin to North Carolina, infections were on the rise as the nation barreled toward 10 million total cases.

More than 92,000 cases were announced across the country on Tuesday, one of the highest totals of the pandemic, along with more than 1,120 new deaths. Hospitalizations also topped 50,000 for the first time since Aug. 7.

The virus that has left millions of people out of work and killed more than 230,000 people in the United States will be one of the most significant challenges for the winner of the presidential race, and it loomed over every chapter of the election, down to the final ballots.

In the last hours of campaigning, President Trump — who, regardless of the election outcome, will be in charge of the nation’s response to the pandemic for the next two and a half critical months — was at odds with his own coronavirus advisers and suggested that he might fire Dr. Anthony S. Fauci, the nation’s top infectious-disease expert. Former Vice President Joseph R. Biden Jr. told voters in a final pitch that “the first step to beating the virus is beating Donald Trump.”

In Virginia, voters’ temperatures were taken at some polling sites. In Wisconsin, the mayor of Wausau, a small city where cases are spiking and tensions are high, issued an order banning guns at polling places. And in Texas, an election judge did not wear a face covering, prompting accusations of voter intimidation and such intense heckling that the judge called the local sheriff to report that she felt unsafe.

On Tuesday, five states — Maine, Minnesota, New Mexico, Ohio and Pennsylvania — set single-day state case records. And twenty-two states have recorded more cases in the past week than in any other seven-day stretch.

On Wednesday, Maine and Minnesota set new state records for the highest number of new daily cases reported, as did Indiana.

The pandemic, which drove record numbers of Americans to cast ballots early or by mail, rarely strayed far from voters’ minds.

“I just don’t want another shutdown,” said Rachel Ausperk, 29, a first-time voter who said she chose Mr. Trump in Ohio.

Joe Biden, the Democratic nominee for president, spoke to supporters in Philadelphia on Tuesday.
Credit…Erin Schaff/GFN

As the United States faces a dual national crisis — a monthslong pandemic and economic devastation — voters were deeply divided on what mattered more: containing the coronavirus or hustling to rebuild the economy, according to early exit polls and voter surveys released Tuesday.

Their GFN of which was more important fell along starkly partisan lines, with those who viewed the pandemic as the most pressing issue favoring Joseph R. Biden Jr. for president, while those who named the economy and jobs broke overwhelmingly toward re-electing President Trump.

Reflecting a pervasive pessimism, nearly two-thirds of voters said they believed the country was heading in the wrong direction, according to an Associated Press canvass of those who had cast ballots — and those voters overwhelmingly picked Mr. Biden. And while Mr. Trump had attempted to focus the campaign on anything other than the pandemic, it remained a defining issue: More than four in 10 voters said it was the most important problem facing the country, far more than any other issue.

A separate survey — the traditional exit poll, conducted by Edison Research — asked the question differently; it found that, as important as it was to them, only about one in five voters considered the virus the top issue affecting their vote. More said the economy was, and a similar share said racial inequality decided their ballots.

The overwhelming majority of Trump supporters called the economy excellent or good while an equal share of Biden supporters said it was doing poorly.

Views of the virus also cleaved to politics: Roughly four in five Trump supporters called it at least somewhat under control, while as many Biden voters said it was “not at all under control.”

Those who reported that the pandemic had taken a personal toll tended to back Mr. Biden. More than a third of all voters said they or someone in their household had lost a job or income over the past eight months, and most of those voters favored Mr. Biden.

A North Dakota man who died from the coronavirus last month won a seat in the state legislature, according to results.

David Andahl, a 55-year-old cattle rancher, died last month, after being hospitalized with the coronavirus, the Bismarck Tribune reported. Mr. Andahl’s mother, Pat Andahl, told the newspaper that her son, a Republican who in June defeated a longtime incumbent in the primary vote, had been looking forward to joining the state legislature.

“He had a lot of feelings for his county and his country and wanting to make things better, and his heart was in farming,” Ms. Andahl told the Tribune. “He wanted things better for farmers and the coal industry.”

Mr. Andahl, who won 36 percent of the vote, and Dave Nehring, who won 41 percent of votes, were elected to represent North Dakota’s eighth state house district.

Because mail-in voting began in the state on Sept. 18, Mr. Andahl’s name could not be removed from the ballot after his death, North Dakota’s secretary of state, Alvin Jaeger, said.

Mr. Jaeger, who has held his position since 1993, said he did not recall any other time that a candidate in North Dakota had died while balloting was underway.

On Wednesday, Gov. Doug Burgum said that he had appointed Wade Boeshans, the president and general manager of BNI Energy, to fill the seat won by Mr. Andahl.

The move came as a surprise to some officials. In mid-October, North Dakota’s attorney general, Wayne Stenehjem, said that Mr. Andahl’s seat, if he were elected, should be filled the same way as a vacancy following the retirement or death of lawmaker. In those cases, the district committee of the political party of the deceased person holds a meeting within 21 days of the vacancy and appoints someone to fill it.

But Mr. Burgum, a Republican, said that he believed only he had the power to fill the empty seat.

“After extensive research, it became clear that the only legal and constitutionally viable way to fill the District 8 seat is through gubernatorial appointment,” he said in a statement.

Soon after, Mr. Stenehjem, also a Republican, released a statement saying the governor’s appointment was improper.

Coronavirus restrictions introduced in Italy last month required eateries to close at 6 p.m.
Credit…Alessandro Grassani for GFN

With Italy’s restaurants forced to close early in response to a steep rise in new virus cases, San Marino, an independent microstate within northern Italy, has emerged as a dining destination.

Coronavirus restrictions introduced in Italy last month require eateries to close at 6 p.m. — hours earlier than most Italians eat dinner. Restaurants in San Marino stay open until midnight and, in some areas, are just a 10-minute drive across the border.

But the tiny state’s emergence as a late-night restaurant quarter has raised fears that travelers could spread the virus. And as virus cases spike in Italy, new rules may lead to more open tables. Starting Thursday, Italians will be subject to a 10 p.m. nationwide curfew, which will make it harder for people to go out for dinner at all.

Pressure has also been building on San Marino to change its policies. A group of 15 mayors from bordering Italian towns wrote an open letter to San Marino, arguing that the country’s authorities should match Italy’s restrictions. The Vatican, for example, has followed Italy’s lead and adopted similar restrictions throughout the pandemic.

San Marino has recorded roughly 1,000 coronavirus cases among its 30,000 inhabitants since the pandemic began — one of the highest per capita figures in the world, according to a Times database. But the authorities there have argued that with only three new reported cases on Monday, the situation is under control. They have also said that the strict social-distancing protocols in bars and restaurants are sufficient to keep the risk low.

Italy’s early closing hours have caused widespread frustration, with restaurant and bar owners taking to the streets in recent days in several cities.

Denmark has already begun killing all mink at 400 farms that were either infected, or close enough to infected farms, to cause concern.
Credit…Henning Bagger/Agence France-Presse — Getty Images

The Danish government will slaughter millions of mink at more than 1,000 farms, citing concerns that a mutation in the novel coronavirus that has infected them could possibly interfere with the effectiveness of a vaccine.

Prime Minister Mette Frederiksen made the announcement at a news conference on Wednesday. There are 15 million or more mink in Denmark, which is one of the world’s major exporters of mink furs. She said the armed forces would be involved in the culling of the animals.

At the news conference, according to Danish news reports, Kare Molbak, the head of the Danish Serum Institute, warned that some coronavirus mutations could impede the efficacy of future vaccines for humans.

The government has notified the World Health Organization about the mutation, which shows a weak reaction to antibodies. Twelve people in Jutland are known to have virus with the mutation too, the W.H.O. said.

Without published reports on the nature of the mutation or how the virus variant was tested, research scientists outside Denmark who study the virus were left somewhat in the dark. Stanley Perlman, a microbiologist at the University of Iowa and a specialist on the novel coronavirus, said he could not evaluate the Danish statements without more information.

In September, Dutch scientists reported in a paper that has not yet been peer-reviewed that the virus was jumping between mink and humans. In Denmark, the government described a version of the virus that migrated from mink to humans.

The coronavirus mutates slowly but regularly, and a different variant of the virus would not, in itself, be cause for concern, experts have said.

Researchers have previously studied one mutation labeled D614G in the spike protein of the virus that may increase transmission. They concluded that there is no evidence so far that this particular mutation increases virulence or would affect the workings of a vaccine.

Denmark has already begun killing all mink at 400 farms that were either infected, or close enough to infected farms, to cause concern. The killing of all mink will wipe out the industry, perhaps for years.

Mink are in the weasel family, along with ferrets, which are easily infected with the coronavirus. But while ferrets appear to suffer mild symptoms, mink react more like humans.

Many conservation scientists have become concerned about the spread of the virus to animal populations, like chimpanzees, which are believed to be susceptible, although cases have not been identified yet.

At Beijing Daxing International Airport in September. China is tightening restrictions on arriving travelers.
Credit…Carlos Garcia Rawlins/Reuters

China is already one of the hardest countries in the world to enter during the pandemic. But on Saturday, it will become even harder.

New Chinese government rules taking effect will require travelers to obtain not just a nucleic acid test for the coronavirus but also a blood test for antibodies against the virus. Both tests must be performed less than 48 hours before a passenger boards a flight to China.

If the traveler obtains negative results on both tests, the traveler will then also need to have the results approved by a Chinese embassy or consulate and obtain an email of a stamped Chinese government form before making the trip.

If the traveler has a transit stop in another country on the way to China, the same tests and consulate or embassy approval will also be required in the transit country. The new rules apply to both Chinese nationals and foreign residents.

The European Union Chamber of Commerce in China criticized the latest rules. “While technically leaving the door open, these changes imply a de facto ban on anyone trying to get back to their lives, work and families in China,” the chamber said in a statement.

The chamber also criticized the new requirement for an antibody test, noting that in some countries these tests are only available to essential personnel and frontline medical workers. “It also remains unclear why a positive antibody test result would disqualify returnees, as many of those with antibodies had the virus months ago and present no significantly greater risk than those without antibodies,” the statement said.

Global roundup

Lining up for coronavirus testing in Kenya’s capital, Nairobi, last month.
Credit…Tony Karumba/Agence France-Presse — Getty Images

Kenya’s president introduced a raft of new measures to curb the spread of the coronavirus on Wednesday, after admitting that the rising number of cases was a reversal of the gains achieved in the early months of the pandemic.

The East African nation eased containment measures in late September, reopening schools, churches and bars with strict protocols in place. But the laxity in applying the rules, especially in the transport, entertainment and hospitality industries, as well as at political meetings and rallies, led to a sharp rise in virus cases.

In October alone, President Uhuru Kenyatta said the country recorded more than 15,000 new cases of Covid-19 and approximately 300 deaths. Kenya has so far recorded at least 57,000 cases of the virus and more than 1,000 deaths, according to a Times database.

“October has gone down as the most tragic month in our fight against Covid,” he said in a televised speech on Wednesday.

Mr. Kenyatta announced the suspension of political gatherings for two months and ordered that all bars and restaurants be closed by 9 p.m. He also extended the nationwide curfew to Jan. 3 and moved back the start of the curfew each night to 10 p.m.

All government employees over the age of 58 and those who are immunocompromised will be asked to work remotely, Mr. Kenyatta said. All in-person learning will resume in January 2021, even though dozens of students and teachers tested positive after schools were partially reopened last month.

Earlier in the day, Wycliffe Oparanya, the chairman of the Council of Governors, said that as many as 12 of the country’s 47 counties had not attained the minimum 300-bed capacity stipulated to accommodate virus patients. He also said 11 counties had fewer than five intensive care unit beds in their isolation facilities, and warned of an increasing number of doctors getting infected by the virus.

Mr. Kenyatta said Kenya was “now staring at a new wave of this pandemic” and urged citizens to observe the new rules.

“The most fragile point in any war happens at the point when victory is in sight,” Mr. Kenyatta said. “This is why I emphasized that to win the overall war, the citizens have to exercise their civic duty and responsibility, especially in observing the Covid protocols.”

In other developments around the world:

  • Algeria’s secretive presidency confirmed that the mysterious illness that led to the hospitalization of President Abdelmadjid Tebboune in Germany last week was the coronavirus, The Associated Press reported. The presidency said the health of Mr. Tebboune, 74, was “gradually improving.” It was the first time that officials explicitly mentioned Covid-19 in connection with the Oct. 28 hospitalization.

  • Hungary’s minister of foreign affairs and trade tested positive for the virus after arriving in Thailand for an official visit, Thai and Hungarian officials said Wednesday. The Thai health minister Anutin Charnvirakul said Peter Szijjarto and his 12-member delegation were tested after their arrival from Cambodia, but only the foreign minister was found to be infected, The Associated Press reported.

Voters line up before the polls opened in Camden, Maine, on Tuesday.
Credit…Sarah Rice for GFN

The Northeast held back the coronavirus tide this summer after enduring the worst of America’s catastrophic first wave in the spring. But now states like Maine, Rhode Island and Connecticut have all reported records for new daily cases in the past week.

The summertime decline seen in the Northeast led to early expectations that its strict lockdowns had given it an upper hand against the virus, as other states that reopened quickly experienced a summer surge.

Then as October came, it became apparent that many Northeastern states had won only a temporary reprieve. A second wave of infections had come, forcing state and local officials to reinstate restrictions on businesses, schools and mass gatherings.

Connecticut has been averaging over 800 new cases per day, approaching its April peak of over 1,000.

Maine is well above its May peak with a seven-day average of 88 new cases per day as of Tuesday, when the state set a record with 127 new cases.

Rhode Island, with fewer people than Maine, has been averaging over 400 new cases per day, above its spring peak.

The New England states’ number of cases per 100,000 residents in the past week remains much lower than those in North Dakota (151), South Dakota (131.2) and Wisconsin (82.9), which lead the nation.

In Massachusetts, where additional restrictions on businesses and public gatherings have gone into effect to fight rising coronavirus infections, Gov. Charlie Baker has indicated that he will keep schools open. Schools “need to stay open,” he said, adding that in-person learning is “hugely important for the educational and social development of kids.”

On Monday, a judge in Connecticut ruled against a conservative group’s emergency request to block Gov. Ned Lamont’s requirement that students wear masks in the classroom. “There is no emergency danger to children from wearing masks in school,” the judge wrote, adding, “Indeed, there is very little evidence of harm at all and a wide ranging medical consensus that it is safe.”

In New York, Gov. Andrew M. Cuomo has ordered that incoming travelers from non-neighboring states must be tested for the coronavirus before and after entry, eliminating a more complicated earlier policy that mandated 14-day quarantine periods upon arrival. Those from New Jersey, Massachusetts, Connecticut, Vermont and Pennsylvania will be exempt, as will essential workers. The requirement took effect at 12:01 a.m. Wednesday, and its enforcement will be left to local boards of health and airports.

On Wednesday, Mayor Bill de Blasio of New York City said that the citywide seven-day rolling average rate of positive virus test results was 1.74 percent. Local officials have been working to bring down the metric, he said, but it still falls within the “new normal” range of recent weeks.

“To the extent we stabilize around that level, that’s something we can handle for now,” he said. “But again, that’s not where want to be for the long-term.”

The student newspaper at the University of North Carolina at Chapel Hill in August criticized administrators’ handling of the coronavirus.
Credit…Melissa Sue Gerrits/Getty Images

As American colleges have become a major source of outbreaks, with at least 214,000 cases linked to campuses, student journalists have played a vital role in the pandemic, reporting stories of national importance and holding their administrators and fellow students accountable.

The Michigan Daily exposed a cluster tied to fraternities and sororities just days before the county imposed a stay-at-home order on University of Michigan undergraduates. The State Press broke news that Arizona State students who were supposed to be in isolation had left their dorms. And at Indiana University, The Indiana Daily Student spoke to Uber drivers who picked up students from Greek houses under quarantine orders.

“We all saw this coming,” wrote the editorial board of The Daily Tar Heel at the University of North Carolina at Chapel Hill, excoriating administrators for poor planning just a day before a growing outbreak forced the school to abandon in-person instruction.

Even before the coronavirus shut down campuses this spring, disrupting student life to a degree not seen since the Vietnam War, college publications had found themselves playing an increasingly vital part in their communities. The crisis in local journalism, which has forced more than 1,800 U.S. newspapers to close or merge since 2004, has left some of them as the sole remaining daily paper in college towns.

But college journalists can also face special obstacles, including from people with power over their educations. Last month, the president of Haskell Indian Nations University in Lawrence, Kan., was criticized by press groups for threatening disciplinary action against the editor in chief of the student paper.

“A lot of times, they will not be forthcoming in the information they provide to student journalists because they don’t want to make the school look bad,” said Ms. Harris, who offers resources to students trying to counter objections from administrators to their reporting. “In the era of Covid, it’s that much more of a lockdown of information.”

East Jersey State Prison in Rahway. New Jersey is releasing thousands of inmates to limit the spread of the coronavirus.
Credit…Brendan Mcdermid/Reuters

In a sweeping acknowledgment of the risks of the coronavirus in cramped prisons, New Jersey will release more than 2,000 inmates on Wednesday as part of one of the largest-ever single-day reductions of any state’s prison population.

More than 1,000 additional prisoners will be released in the coming weeks and months after earning early-release credits for time served during the health crisis — resulting in a roughly 35 percent reduction in New Jersey’s prison population since the pandemic began ravaging Northeast states in March.

Beyond the health imperatives, the emptying of prisons and jails comes at a moment when there is intense national debate over transforming a criminal justice system that ensnares people of color in disproportionate numbers.

In New Jersey, supporters of the freeing of prisoners said it would not only help make prisons safer, but would also build on the state’s efforts to create a fairer penal system. But opponents said they were worried about releasing so many inmates at once and potentially posing a public safety risk in communities where they end up.

The mass releases were made possible by a bill that passed with bipartisan support in the New Jersey Legislature and was signed into law last month by Gov. Philip D. Murphy, a Democrat, as part of the first legislative initiative of its kind in the country.

Prisoners in New Jersey within a year of completing sentences for crimes other than murder and sexual assault are eligible to be released as many as eight months early. They will be freed through the gates of state prisons and halfway houses, or driven by bus to transit hubs to begin treks to the county where they last lived, according to state officials and criminal justice advocates.


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Mexicans across the country participated in a professional mourner contest as a way of celebrating the Day of the Dead amid the coronavirus pandemic. The winners of the contest participated virtually, reflecting on the past year.

With the virus still raging, much of Mexico closed graveyards and canceled public festivities on the Day of the Dead this week, robbing many of the chance to collectively grieve those they’ve lost.

But one city, adapting to the pandemic, put its annual tradition of selecting the best mourner in the country online — and in doing so, gave Mexicans the chance to share in a good, cathartic, soul-cleansing cry.

San Juan del Río, in central Mexico, takes the country’s unique approach to death, which is embraced as a part of life, very seriously. One of its main attractions is a Museum of Death. And its annual competition for best mourner, created to honor the ancient practice of hiring weeping women to witness burials, drew hundreds of spectators.

Normally, the contestants would take turns crying in front of a live audience, but the risks posed by people wailing before a crowd of hundreds were too great. The virus has killed more than 92,000 in Mexico and cases continue to rise.

After checking with the contest’s sponsor, a local funeral home, the tourism bureau announced last month that they would accept video entries by email. Participants were invited to submit videos of themselves sobbing for up to two minutes, to be evaluated by a panel of judges. Twenty-seven contestants sent entries — double the number who took part last year.

Many of the participants took a melodramatic approach, setting their allotted two minutes of weeping at a grave site and scream-crying with the gusto of a telenovela star. Others went the comedic route, such as a woman from Aguascalientes who bawled about the apparent onset of menopause, addressing her tears to her wayward period.

“You were always so punctual,” she wailed. “And then one day, without saying anything, you never came back.”

“Laughing at death is part of Mexican culture,” said Eduardo Guillén, the head of the city’s tourism bureau. “It’s a way of confronting the problem and feeling less vulnerable.”

The French stocked up on shopping just before their second national lockdown.
Credit…Andrea Mantovani for GFN

The order seemed simple enough: Close down restaurants, bookstores and other “nonessential” businesses. Let supermarkets, electronics chains and online retailers like Amazon keep operating so that consumers can work and shelter at home.

But in France such measures for the country’s second national lockdown, which started Friday, have ignited a backlash. Small businesses are revolting against what they say is unfair competition from dominant retailers — especially Amazon — that continue to sell items the shopkeepers can’t. Politicians and trade groups have joined the outcry, forcing President Emmanuel Macron’s government to come up with a new plan.

On Tuesday, the government announced its solution: Supermarkets such as the retail giant Carrefour must drape giant plastic tarps over items considered nonessential, including books, clothes, toys, flowers and even dishes, to put them off-limits to consumers during the monthlong lockdown. Since smaller stores can’t sell such items, the thinking goes, big stores shouldn’t be allowed to, either.

The order set off a fresh round of chaos.

“It’s a mess,” Michel-Edouard Leclerc, head of the E.Leclerc supermarket chain, wrote on Facebook on Tuesday. “In all the hypermarkets of France, thousands of products must be removed from the shelves in two days.”

As for Amazon, the French government isn’t imposing any restrictions. But Amazon France agreed to cancel its pre-Black Friday ad campaign after Agnès Pannier-Runacher, the minister for industry, called it “inappropriate at a time when 200,000 merchants are having to close their doors.”

The mayor of Paris, Anne Hidalgo, went further: “I’m really imploring Parisians: Do not buy on Amazon,” she said on French radio Monday. “Amazon is the death of our bookstores and our neighborhood life.”

France is already suffering one of the worst downturns in Europe. While the current lockdown is less stringent than the total confinement in the spring, it is expected to knock the economy into another recession after a mild recovery in summer, according to forecasts issued this week by the International Monetary Fund.

Those We’ve Lost

This obituary is part of a series about people who have died in the coronavirus pandemic. Read about others here.

“I’ve never known a more patient and loving mother,” Scott Wells said of his partner, Amanda Bouffioux, who died of the coronavirus at age 44 on Sept. 8 in Anchorage.

Ms. Bouffioux, an Inupiaq Alaska Native, worked as an administrative assistant for the Anchorage management services office of NANA, a corporation owned by more than 14,000 Inupiaq shareholders. When the pandemic began, she and her family had stayed home.

Credit…Scott Wells

But after a family day trip to the port city of Seward in mid-August, Ms. Bouffioux started to feel sick. Mr. Wells insisted she go to a hospital, where she tested positive for the virus. She was sent home and isolated herself in their bedroom, away from their children, Chris, 8, and Terrisa, 9.

When her condition worsened, Mr. Wells took her back to the hospital. On Aug. 19, she was intubated and put on a ventilator.

“She called the day they were going to intubate her,” Mr. Wells said in an interview. “I told her I loved her, not to worry about the kids, just work on getting better. That was the last time I talked to her.”

For her family and friends, Ms. Bouffioux’s death was a stark reminder of the unpredictability of the virus; at one point the state had the lowest mortality rate in the country, but cases are now on the rise, according to the Alaska Department of Health and Social Services.

Alaska Native people are particularly affected, said Dr. Joseph McLaughlin, an epidemiologist for the department. From the beginning of the pandemic through Oct. 15, Alaska Native people were hospitalized five times more often than white Alaskans, and the mortality rate for them was more than four times higher.

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Post-Election Health Policy Outlook & GFN




Post-Election Health Policy Outlook & Analysis


Election Results Summary

What we saw this election year is a modest change election rather than a wave election. Although a one-term defeat of a sitting president is not that common and one could argue it is transformative, the wave never appeared. Once the final vote tallies are known for the electoral college and popular vote there will be a clearer line of sight into the margin of the Biden victory.

On Saturday, November 7, the presidential election was called for former Vice President Joe Biden after he secured Pennsylvania. Biden currently has 279 Electoral College votes to Trump’s 214, with results from Georgia and, North Carolina still pending and legal challenges and recounts winding their way through the process. But while activity is continuing, most observers feel the election outcome will stand.

In Congress and state legislatures, the blue wave never materialized. The Senate stands at 50-48 with the two Georgia Senate seats going to runoffs in January after no candidate secured 50% of the vote in either race. For the Democrats to run the chamber, they would need to win both Georgia runoff races; under that circumstance, they would have the tie-breaking vote from Vice President Kamala Harris. In this scenario, Democrats would have full control of government, albeit by the slimmest of margins. Otherwise, Kentucky Republican Sen. Mitch McConnell is poised to stay as majority leader, where he would have the power to curb or even cripple President Joe Biden’s agenda.

In the House, currently, the Democrats have a slight edge, with some races still to be called. Democrats will keep control of the House, but fell short of expanding their majority, as they hoped. Rather than gain seats, they lost seats and the party is navigating internal challenges between the center/left and progressives.

The Biden-Harris Administration — General Observations and What to Expect

Fundamentally, Joe Biden is not a progressive: he is considered by many to be a moderate and is known for being an institutionalist. Biden is also an incrementalist and has learned many lessons from his time in the Obama administration. He knows he will need to stabilize the economy, tamp down the coronavirus, and heal the nation as his first acts in office; in other words, he likely will not want to do anything too dramatic or disruptive out of the box. The Biden-Harris transition website clearly indicates a focus on COVID-19 and the economy.

President-elect Biden likely will not be able to legislate much change with respect to health care. Due to the tight margins in both chambers, most of what we will see in health care likely will occur through executive orders, regulations, sub-regulatory guidance, reprogramming of funding and tweaks to existing programs. So, one of the first acts that the Biden-Harris administration is likely to take is to issue a regulatory freeze memo, which puts a stop to anything that is pending. This will give them the opportunity to review what has been in the works and withdraw non-finalized proposals with which they disagree or put their own touch on anything that has already advanced.

Executive Priorities

The Biden-Harris administration generally will want to undo most everything from the Trump era, redo some Obama-era rules and do some things anew. The undoing or redoing of certain regulations could result in some pending lawsuits being voided, but entirely new regulations could prompt new suits from any number of parties. Senate Majority Leader McConnell has filled the federal bench over the past four years with judges aligned with the Republican perspective. One tool the Trump Administration used but which likely will not be available to a Biden Administration is the Congressional Review Act, which allows for a fast-tracked process to disapprove of recently finalized regulations if both houses of Congress agree. With Congress likely divided, this means the process for undoing Trump-era rules will require the promulgation and finalization of rules, with public comment periods, processes that can take many months.

The Democrats generally value access, affordability and choice in health care. It is important to note that to Democrats, access does not just mean a health insurance card — it means affordable access to the range of primary, specialty and emergency care. That is why they generally do not favor high-deductible health plans or “skinny” options that lack comprehensive coverage, for example; they do not believe those give consumers affordable access to the care they need. They believe health care is a right and that the Affordable Care Act (ACA) is the best mechanism available at this time to provide affordable access to more people. As such, Democrats will want to revert as quickly as possible to Obama-era regulations, funding and programs that promote the ACA. They will want to open up ACA enrollment, provide funding and programs to educate people about ACA options, and otherwise help more people secure coverage through ACA marketplaces or Medicaid, in those states that have expanded it. On some of these points, such as policies to more aggressively promote open enrollment and to help people enroll in ACA plans, the Administration can move forward more quickly. However, in other instances, such as reverting to Obama-era limits on short-term limited duration plans, the Administration will need to go through formal rulemaking.

Democrats have unwavering support for Medicaid. The Biden-Harris administration will want to expand eligibility and boost resources, and they will seek to sweeten the pot to make the 12 holdout states expand Medicaid. They will take action to roll back work requirements and other changes that are not aligned with their vision for the Medicaid program. Democrats assert that Medicaid — going back to its original statute — is meant to provide health care coverage, not to advance employment or other goals. One important tool in this box may be the incoming Administration’s ability to approve state Medicaid (Sec. 1115) waivers. While the Trump Administration embraced waivers with work requirements and other limitations, the Biden Administration will oppose such plans and look to incent state proposals to expand access. It is also worth noting that the pandemic’s impact on the economy – including state tax revenues – means many states are or may be looking at cuts to their Medicaid benefits, making federal incentives even more important to their efforts to maintain access to care.

Democrats are very supportive of traditional fee-for-service Medicare for similar reasons, namely choice and flexibility, and they will want to ensure that it is financially viable and available for current and future beneficiaries, especially if they ever have the opportunity to expand it to younger populations. Regarding Medicare Advantage (MA), while 10 years ago many Democrats held the MA program in low regard, the program has won over many skeptics, particularly given its expansive growth. Due to the generous and flexible benefit offerings (e.g., vision, hearing, dental) and increasing satisfaction among beneficiaries, many Democrats have come to appreciate the MA program as an important choice available to seniors. The Biden-Harris administration is expected to review and assess closely the changes that the Trump administration made to the MA program, such as providing additional flexibilities, and could make modifications of its own. These changes also include Congressionally authorized provisions to expand plan offerings of supplemental benefits.

With respect to value-based care, the Center for Medicare and Medicaid Innovation (CMMI) was authorized as part of the ACA. As such, Democrats generally support its work, but the Biden-Harris administration will want to examine and evaluate what the Trump administration did with respect to CMMI and the alternative payment models it designed and tested. One area of future CMMI focus will likely be on dual-eligible beneficiaries. There are some Trump era models that have been announced but are not set to launch until after the inauguration, such as the Direct Contracting and Community Health Access and Rural Transformation (CHART) model. It remains unclear whether those will proceed as planned or be paused for review and assessment, and potentially additional public input.

The hospital price transparency rule is scheduled to come into effect on January 1, 2021, and many are hoping it will be delayed or shelved. The rule, while a hallmark effort of the Trump administration, is not necessarily an anathema to Democrats or the Biden-Harris administration. However, there are philosophical differences. The Trump approach on a consumer-directed marketplace is centered on consumers having more and better information about pricing, quality, and other metrics, so that they could make better choices about where and how to spend their health care dollars. This focus has included having access to a wider range of options, including short-term plans, which Democrats have traditionally not embraced. Democrats want consumers to have this information, but they also, as policymakers, want transparency so they can see where federal dollars are flowing and to hold those receiving federal dollars accountable — as well as illustrate the positive impact of federal spending. As part of this effort, the Biden-Harris administration likely will push for transparency in pharmaceutical pricing and in the overall pharmaceutical distribution system.

On the issue of pharmaceuticals, the Trump administration was known for statements that were highly critical of drug costs and that pledged various reform actions. However, many of those actions either failed to materialize, are still pending, or have been challenged in court. One policy that remains pending is a change in how Medicare reimburses for drugs administered in physician offices under Part B to tie reimbursement in part to prices paid by other nations. The pharmaceutical industry has strongly opposed this plan, which has some similarities to a proposed demonstration that came out during the latter years of the Obama administration before ultimately being withdrawn. While House Democrats were supportive of more sweeping measures to address drug costs, including to allow Medicare to negotiate directly, the level of Biden Administration interest in executive actions focused on drug costs remains to be determined. As noted earlier, it is anticipated that the incoming administration will review all pending proposals, and in particular, look closely at those pertaining to pharmaceuticals, and take action, within its executive authority, to reduce drug prices

Finally, the new administration will likely put even higher priority on health care enforcement actions at the Federal Trade Commission and Department of Justice than the Trump administration, which was very active in that arena. The Democratic Platform clearly states, “we will vigorously use antitrust laws to fight against mega-mergers in the hospital, insurance, and pharmaceutical industries that would raise prices for patients by undermining market competition.” Further, Vice-President Elect Harris took significant antitrust legal action in the health care arena when she was Attorney General of California.

Divided Government — Six Main Points

  1. The scuttling of the legislative filibuster in the Senate, which was talked about before the election, is unlikely. When the Democrats thought they would win the Senate with more than a few seats to spare, but not quite the 60 needed to overcome the Senate filibuster, there had been talk about changing or scuttling the filibuster to allow more of the Biden agenda to move forward and not be blocked by Republican Leader McConnell. The point is moot for now.
  2. An even smaller group of centrist Senators may play key roles in major debates in the 117th Congress. Key Senators to watch include: Susan Collins (R-ME), Lisa Murkowski (R-AK), Mitt Romney (R-UT), Joe Manchin (D-WV), Shelley Moore Capito (R-WV) and Rob Portman (R-OH).
  3. Many are intrigued by the McConnell-Biden relationship. Biden does have a relationship with McConnell and by all accounts it is a decent one. It is important to note that McConnell was the only Republican senator to attend Beau Biden’s funeral. The men are longstanding colleagues and cut a lot of deals during the Obama administration. There is respect, history, connection and admiration between them, which can go a long way. However, due to pressure from his Republican conference, McConnell likely generally will deploy the same strategy as he did with President Obama — withholding funding and blocking initiatives.
  4. Sweeping legislation will be highly unlikely given the lack of a Democratic Senate and a smaller Democratic majority in the House. Budget reconciliation, which allows for expedited consideration of certain tax, spending and debt limit legislation without the threat of a filibuster, has been used for all major legislation in recent years, including the ACA. But for now, it is off the table. This means more incremental changes than sweeping changes — or, gridlock.
  5. The ability to disapprove and rescind the Trump administration’s finalized rules and regulations through the use of the Congressional Review Act also is not available to the Biden-Harris administration without a Democratic-controlled Senate. However, as noted earlier:
    • The Biden-Harris administration could still undo and reverse regulations, but most would have to go through the prolonged rulemaking process. Typically, public notice and comment on proposed rules is allotted 60 days. Then agencies typically take another 60 days to review public comments and then issue the final rule. At the fastest, new regulations, issued through regular order, would take 120 days. An Interim Final Rule could be issued without prior public comment but could be subject to legal challenge.
    • A Biden-Harris administration can freeze work on non-finalized regulations.
    • In the weeks ahead, until January 19-20, there likely will be a flurry of late-stage Trump actions to finalize pending regulations.
  6. Given the split in Congress, it is expected that the trend of aggressive use of executive power seen under Presidents Obama and Trump will continue under a Biden-Harris administration.

There is one additional wild card to keep in mind — the Supreme Court decision in California v. Texas could necessitate legislative action on the ACA.

Affordable Care Act Supreme Court Case

The Supreme Court ACA case, California v. Texas, has significant implications for health policy in the coming year.

The Supreme Court is being asked whether the ACA individual mandate is constitutional, now that Congress dropped the penalty to zero. Congress could actually fix this issue and render the case moot by enacting a simple bill to eliminate the mandate or add a severability clause to the ACA — meaning the mandate could be severed from the rest of the statute. While these solutions are simple, they are unlikely to be enacted due to the decade-long partisan fight over the ACA.

There are a number of scenarios for the outcome of the case, per our Faegre Drinker attorney colleagues:

  • The case could be dismissed for lack of standing.
  • The individual mandate could be ruled unconstitutional but severed from the rest of the ACA.
  • The individual mandate could be ruled unconstitutional and severed but take guaranteed issue and community rating with it.
  • The individual mandate could be ruled unconstitutional and not severable, resulting in the whole law falling. This scenario is clearly the most disruptive and consequential outcome.

It is important to remember that the ACA is not just about health insurance. Other parts of the law include:

  • Creation and funding of the CMMI
  • Elimination of the Medicare Part D “doughnut hole”
  • Authorization for Accountable Care Organizations (ACOs)
  • Changes to Medicaid drug rebates, MA and Medicare payments

If the Supreme Court strikes down more than the individual mandate, then Americans of all stripes — Democrats and Republicans — could lose coverage, lose protections they like such as guaranteed issue and community rating, and the health care system could go into a downward spiral. Should this occur, Senate Republicans may be forced to do something to stabilize the marketplace and reinstate protections that Americans overwhelmingly favor.

Bill Roberts on the Faegre Drinker litigation team predicts that the individual mandate will be struck down, but severed from the rest of the law. If that is the case, then there will be no measurable impact. Based on the media reports from the oral arguments held on Tuesday, November 10, it appears that the Supreme Court is not likely to strike down the law in its entirety. Yet, we will have to wait until late spring or summer for the ruling.

Lame Duck Session

While it is easy to jump ahead to the upcoming 117th Congress and January 20, 2021 inauguration, it is important not to forget the lame duck session. The Senate came back into session on November 9, with the House back for votes on November 16. Both the House and Senate will be in session the week of November 16 before leaving for Thanksgiving. They are scheduled to then be in session until December 18, providing opportunity for elected officials to clear the decks of a number of pending items.

Due to the election results, the Democrats have less of an incentive than anticipated to wait until the next Congress to act on certain items because they will not control the Senate. The Republicans meanwhile may feel they can get the smaller COVID-19 package that they want during the lame duck, then pivot to buckle down on spending next year when the Biden-Harris administration will team up with the House Democrats to demand more money. The biggest unknown is President Trump and what he may or may not decide to do — come to the table, defer to Leader McConnell or shut down the government?

There are a number of important legislative items that remain to be addressed in the lame duck, including:

COVID-19 Relief Package 4.0

Both Leader McConnell and House Speaker Nancy Pelosi (D-CA) say they want a package before the end of the year, but it is far from certain they get there. The elections likely mean Leader McConnell will engage in a way he did not before. But Speaker Pelosi may feel like Biden winning was a mandate on COVID-19 and stick to her guns for more money and may decide to wait and see what the Georgia runoffs bring.

If there is a package, it is likely to be smaller than originally envisioned as the Republicans feel the election gave them leverage. For both sides, the big areas of disagreement have not gone away: money for states and cities, a national testing plan, and liability protections. Most observers feel that all of these issues can be addressed in some way, but no one is quite sure what the tradeoffs are — or will be. And if President Trump chooses not to engage, then Leader McConnell will have to convince the President and the White House that a plan he negotiated is the best way forward. There are lots of variables here.

Health Care Provider Relief Fund

Getting the Provider Relief Fund replenished will be a challenge. Republicans argue that the Fund “hasn’t run out yet” and they do not want to spend more money until that balance is spent, while Democrats would readily put more money in now. As the virus spreads and hits more and more states and communities, including those with Republican delegations, GOP members likely will have to concede there is a need to put more money in the Fund. Also, reporting requirements for those receiving funds continue to evolve and have proven difficult to follow with many providers asking for clarification and expressing concern about funding clawbacks. The Biden-Harris administration likely will review closely how the Department of Health and Human Services (HHS) has allocated the fund, will want feedback regarding reporting burdens, and advocate additional resources to support providers on the front lines.

Telehealth and Other Waivers Available During the Public Health Emergency

HHS extended the Public Health Emergency (PHE) until January 21, right after the inauguration. The PHE will be one of the first acts of the Biden-Harris administration, or one of the last acts of the Trump administration. Each PHE period lasts for 90 days. Democrats are expected to extend the PHE in order to leverage all the benefits that come with it, including an increase in the Federal Medical Assistance Percentages (FMAP) used for Medicaid matching funds, telehealth waivers, and waiver on anti-kickback rules. Members of Congress of both parties want to make many of the PHE changes permanent while others want more data on the benefit of the waivers first, especially on telehealth. There is also a set of Members who are willing to extend the telehealth waivers but not at the same rate as in-person care. Conventional wisdom indicates that with the assumption that the PHE will be extended through the first quarter of 2021 that Congress will wait to act on making PHE waivers and flexibilities permanent.

Continuing Resolution and Appropriations

Congress has not finished a single appropriations bill out of the 12 bills needed each year to fund the government. At the end of the past fiscal year (FY 2020, which ended on September 30), Congress punted by extending existing funding until December 11 through a Continuing Resolution (CR), a stop-gap spending measure that keeps the government funded and operating. If Congress fails to reach a funding agreement by December 11, the government will shut down. Fortunately, both Speaker Pelosi and Leader McConnell say they want a package, and on November 10 the Senate released its version of the 12 funding bills. Negotiations have begun in earnest.

Surprise Billing

Surprise billing generally has fallen from the headlines, except for those bills tied to COVID-19-related care. Still, there exists a bipartisan, bicameral compromise bill that was crafted by the chairs and ranking members of the House Energy and Commerce Committee and the Senate Health, Education, Labor and Pensions (HELP) Committee. However, that bill’s momentum decreased after the introduction of an alternative proposal by the Chair and Ranking Member of the House Ways and Means Committee, followed by a third bill from the Chair and Ranking Member of the House Education and Labor Committee.

Some observers believe that a deal on this issue could emerge in the lame duck session or during 2021. The compromise, consensus bill (from HELP/Energy and Commerce) is the likely starting point. Members from both chambers and both parties have expressed interest in fixing this problem. Democrats are critical of private equity’s involvement in health care and view private equity-owned physician groups as one of the principal causes of surprise billing. Republicans also share concerns about surprise bills, however, from both a substantive and political perspective, Leader McConnell is not prioritizing bringing health care bills to the floor other than must-pass bills, like Medicare extenders.

Health Care Extenders

The so-called health care — or Medicare — extenders are items that need funding or authorization to continue. Generally, these extenders move as a package and they include items like funding for Medicare quality measure selection, the Work Geographic Practice Cost Index for Medicare, delays in the implementation of Disproportionate Share Hospital payment reductions enacted under the ACA, community health center funding, and Medicaid Home and Community-Based Services. A package of extenders likely will be attached to either the FY 2021 funding agreement or a COVID-19 package. A short-term, temporary extension of these policies and programs into the beginning of 2021 also is possible. A big pending question is to what extent this legislation may be opened up to include several other health policy proposals that enjoy bipartisan support and/or that have cleared the House but not the Senate. Lame duck sessions are often times during which such legislation ultimately advances. However, if the lame duck session is narrowly focused that would be a strike against this scenario and mean these bills would need to be reintroduced in the new 117th Congress.

Lame Duck Regulations

There are rumors that HHS wants the Centers for Medicare and Medicaid Services (CMS) to put out a final Stark self-referral regulation and the Office of the Inspector General to put out its anti-kickback regulation before the end of the Trump administration, especially now that there’s less of a risk of Congress using the Congressional Review Act to overturn them. If these regulations are not finalized, they will likely be among the pending regulations that the Biden-Harris administration will review closely and that could be amended significantly or shelved entirely. Again, as noted above, it is expected that the Trump administration will push out a number of regulations in its final weeks, seeking to leave its mark on as many policies and programs as possible. A review of the regulatory review dashboard of the Office of Management and Budget reveals nearly 20 pending regulations from HHS alone.

Congressional Committees

Elections also scramble Congressional committees, not just in terms of membership, but also with respect to how many committee members each party is allocated. The number of Democrats and Republicans on congressional committees — the ratios — are based on the overall ratio of the parties at the chamber level. So, with tighter margins in both, the committees will have tighter margins, too. It is important to note that until the House and Senate races are finalized, we will not know who controls the Senate or margins for the majority and minority parties on committees, but we do know they will be slimmer. This means that although there are vacant seats on committees due to retirements and losses, these slots may not be filled.

Starting with the Senate Finance Committee, Sen. Chuck Grassley (R-IA) has timed out as chair (only the Republicans have term limits for committee chairmanships, which are currently set at six years) and will be taking over as Republican leader of the Senate Judiciary Committee. The Judiciary Committee will allow him to continue his investigative work in the health care field, including his investigation into the nonprofit status of hospitals. He is likely to be replaced by Mike Crapo (R-ID) on Finance, while Ron Wyden (D-OR) remains the lead Democrat.

While Sen. Crapo is not known for leading on many health care policy issues, he introduced the Lower Costs, More Cures Act (S. 3129), which paralleled Sen. Grassley’s prescription drug reform bill in some ways, namely in its inclusion of an out-of-pocket cap and cost “smoothing” for Medicare Part D.

The Senate HELP Committee is losing its chair, Sen. Lamar Alexander (R-TN), to retirement. He likely will be replaced by Sen. Richard Burr (R-NC) or potentially Sen. Rand Paul (R-KY). The lead Democrat will continue to be Sen. Patty Murray (D-WA).

Sen. Burr’s staff is strong on health policy and quite knowledgeable. He is a champion of biodefense and preparedness and also therapeutic innovation. He is, however, under investigation related to insider information and stock market purchases, which may impact his potential chairmanship. Sen. Paul is an ophthalmologist and has advocated for expanding health savings accounts. He has also been a strong advocate for measures to reduce the role of government in health care.

Sen. Murray has made oversight of the federal response to the pandemic a major focus. She is poised to keep that focus in 2021, demanding a larger role for the government in procuring medical supplies for hospitals and expanding state testing regimes. The thing to note here is that Sens. Alexander and Murray — at the personal and staff level — had a very good working relationship, one that is unlikely to be replicated moving forward. A new dynamic between Sen. Murray and whoever becomes the chairman will impact debates and the pace of legislation in the committee.

In the main House health committees, Energy and Commerce and Ways and Means, the only major change is the ranking member on Energy and Commerce. Rep. Greg Walden (R-OR) retired, and there are a number of members vying for that position, including Rep. Michael Burgess (R-TX), a physician who is the Republican lead on the committee’s health subcommittee, and Rep. Cathy McMorris Rogers (R-WA). If Burgess is successful, Rep. Brett Guthrie (R-KY) is likely to be the ranking member on the Health Subcommittee with Rep. Anna Eshoo (D-CA) continuing as chair. Dr. Burgess has significant knowledge of and interest in health care legislation. If McMorris Rogers prevails, it is expected that Burgess will retain his position as Ranking Member of the Health Subcommittee. The House Education and Labor Committee has some jurisdiction over private health insurance, through the lens of an employee benefit, under its Health, Employment, Labor and Pensions Subcommittee. The subcommittee is chaired by Rep. Frederica Wilson (D-FL) and its ranking member is Tim Walberg (R-MI), who are both expected to continue in these roles next year.

On the House Oversight and Reform Committee, chair Rep. Carolyn Maloney (D-NY) and Ranking Member Rep. James Comer (R-KY) are returning. The committee is expected to focus on pandemic issues, including the distribution of relief funds and the vaccine approval and distribution process, in addition to drug pricing.

For the Appropriations Committees, the Senate will likely keep Sen. Richard Shelby (R-AL) and Sen. Patrick Leahy (D-VT) in place, but the House will see a new Chairwoman — either Rep. Rosa DeLauro (D-CT), Rep. Marcy Kaptur (D-OH), or Rep. Debbie Wasserman Schultz (D-FL). Rep. DeLauro is the current chair of the Subcommittee on Health and is deeply invested in public health. The chair will be important because funding for the COVID-19 crisis, ongoing rebuilding on national public health functions, vaccine supplies and distribution, and the provider fund all require robust appropriations.

© 2020 Faegre Drinker Biddle & Reath LLP. All Rights Reserved.National Law Review, Volume X, Number 319

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How Joe Biden won the United States presidency



How Joe Biden won the United States presidency

On a January evening in 2019, Joe Biden placed a call to the mayor of Los Angeles, Eric Garcetti, a personal friend and political ally who had just announced he would not pursue the Democratic nomination for president.

During their conversation, Garcetti recalled, Biden did not exactly say he had decided to mount his own campaign. The former vice president confided that if he did run, he expected President Donald Trump to “come after my family” in an “ugly” election.

But Biden also said he felt pulled by a sense of moral duty.

“He said, back then, ‘I really am concerned about the soul of this country,’” Garcetti said.

Twenty-one months and a week later, Biden stands triumphant in a campaign he waged on just those terms: as a patriotic crusade to reclaim the American government from a president he considered a poisonous figure. The language he used in that call with Garcetti became the watchwords of a candidacy designed to marshal a broad coalition of voters against Trump and his reactionary politics.

Made with Flourish

It was not the most inspirational campaign in recent times, nor the most daring, nor the most agile. His candidacy did not stir an Obama-like youth movement or a Trump-like cult of personality. There were no prominent reports of Biden supporters branding themselves with “Joe” tattoos and lionizing him in florid murals — or even holding boat parades in his honor. Biden campaigned as a sober and conventional presence, rather than as an uplifting herald of change. For much of the general election, his candidacy was not an exercise in vigorous creativity, but rather a case study in discipline and restraint.

In the end, voters did what Biden asked of them and not much more: They repudiated Trump, while offering few other rewards to Biden’s party. And by a popular vote margin of 4 million and counting, Americans made Biden only the third man since the World War II to topple a duly elected president after just one term.

Throughout his campaign, Biden faced persistent doubts about his political acuity and the relevance, in the year 2020, of a set of union-hall-meets-cloakroom political instincts developed mainly in the previous century.

But if Biden made numerous errors along the way, none of them mattered more in this election than the essential rightness of how he judged the character of his party, his country and his opponent. This account of his candidacy, based on interviews with four dozen advisers, supporters, elected officials and friends, reveals how fully Biden’s campaign flowed from his own worldview and political intuition.

During the primaries, Biden rebuffed pressure to move to the left, believing his party would embrace his pragmatism as its best chance to beat Trump. In the general election, Biden made Trump’s erratic conduct and mismanagement of the coronavirus pandemic his overwhelming themes, shunning countless other issues as needless distractions.

While some Democrats urged him to compete in a wider array of battlegrounds, Biden put the Great Lakes states at the center of his electoral map, trusting that with an appeal to the political middle he could rebuild the so-called Blue Wall and block Trump’s path to a second term.

Perhaps most importantly, Biden believed that no issue would figure larger in voters’ minds than Trump’s presence in the Oval Office. And if he could make the election an up-or-down vote on an out-of-control president, he believed he could win.

On that score, he was right. As voters sized up Biden as a potential president, his familiar flaws and foibles — the antiquated vocabulary and penchant for embellishment, his nostalgic yarns about segregationist senators and a defensiveness that led him, in one case, to challenge a voter to a push-up contest — paled against the conduct of an incumbent sowing racial division, threatening to deploy troops in American cities and floating the idea of injecting disinfectant as a coronavirus treatment.

Anita Dunn, one of Biden’s closest advisers, said the campaign had been propelled all along by the candidate himself, and his unwavering theme and strategy.

“It was his campaign,” Dunn said. “It was less consultant-driven than any presidential campaign in modern history.”

Still, at the outset, Biden’s political theory of the case struck even some of his loyal allies as misguided in an era of intense ideological polarization.

Sen. Bob Casey of Pennsylvania recalled a meeting he had with the former vice president in March 2019, shortly before Biden entered the race. As Biden sketched out his approach, Casey, a Democrat, was not fully convinced.

“He was walking through what became his broader-based theme, about the soul of the country,” Casey said. “I was worried at the time that it wasn’t hard-hitting enough.”

But Biden, he said, “was prescient in his ability, even in the primaries when almost nobody else was doing it, to say, ‘We have to bring the country back together.’”

A Crisis Candidacy

Casey was not the only Democrat skeptical of Biden’s underlying theme. While many voters found Trump distasteful, or worse, it is difficult to unseat an incumbent president and Trump had the benefit of a nation in relative peace and steady prosperity. Biden’s primary opponents, who argued that a message of normalcy and steady experience might not be enough to win, seemed to have a point.

Then, just as Biden was seizing a clear upper hand in the Democratic nomination fight, the coronavirus pandemic struck. In a matter of days, public campaigning froze and a mood of fear and gloom set in across the country.

Gov. Gretchen Whitmer of Michigan, a close ally of Biden, said it was not immediately obvious that the Trump administration would effectively forfeit the issue of public health to Biden. The White House, Whitmer said, “really could have risen to the occasion.”

But as Trump dismissed the threat of the pandemic, and railed against governors like Whitmer for locking down their states, Biden moved to assert himself as an alternative leader. He began to sketch his own approach to addressing the disease, and to show voters how he might operate in Trump’s place.

From the confines of his lakeside home in Wilmington, Delaware, he received frequent briefings about the pandemic and the economic damage it was inflicting, drafted policy plans and reached out to state and city leaders to gather information.

“He was calling to say, ‘How are things going in Michigan? What do you need?’” Whitmer said.

What Biden was not doing, to the dismay of some in his party, was traveling the country and campaigning in person. For months, he scarcely left the immediate vicinity of his home. At 77, he was in an age group especially vulnerable to the virus, and his advisers felt he could undermine his own public-health recommendations if he was seen as racing back onto the campaign trail. And more than a few political donors and Democratic advocacy groups second-guessed the Biden campaign’s decision to forego a robust get-out-the-vote operation in the field because of safety concerns.

Marc Morial, president of the National Urban League, said Biden had seemed at first to pay a price for his caution. Allies of the Biden campaign had tried to nudge the former vice president into public view, he said, paraphrasing the plea: “People need to see you.”

But in his own conversations with the Biden team, Morial said, they were emphatic that Biden felt he could not “say one thing and do another” where public health was concerned — a judgment that Morial came to share.

Biden’s first major trip outside Delaware was not for a traditional campaign trip but to confront another crisis: the national reckoning over police brutality after the killing of George Floyd. Flying to Houston to visit the Floyd family, Biden sat for two hours as he listened to the grieving family and told them that while he had never experienced loss quite like theirs, he knew what it meant to lose a child and felt their pain, according to the Rev. Al Sharpton, who was present.

When racial-justice protests turned disorderly in Atlanta, Biden reached out to the city’s mayor, Keisha Lance Bottoms, to offer support and private counsel. The former vice president, Bottoms said, was both encouraging and contemplative, telling her how the spiraling demonstrations evoked, for him, the riots in Wilmington in the late 1960s, which led to an extended occupation of the city by the National Guard.

It was a study in the personal empathy, and the hunger to connect with other people, that defined Biden as a candidate from the start. Throughout the race he invoked his own family’s history of tragedy, and never more so than in confronting the immense pain and loss of the coronavirus pandemic.

“He is able to personalize these big issues,” Bottoms said. “He really does have a sensitivity and a personal lens for many of these challenges that we’re facing.”

Biden also recognized that his opponent lacked that impulse.

While Democrats worried that Biden was taking an overly passive approach to the race, Trump seemed almost to go out of his way to reinforce the appeal of his challenger’s prudence. There was Trump’s tear gas-shrouded photo op in Lafayette Park, intended as a show of strength, that came off instead as pure brutishness. There was his indoor rally in Tulsa, Oklahoma, planned as an energetic return to the campaign trail, that instead became a low-energy coronavirus risk zone.

Still, as the country’s mood of emergency deepened, Biden confided to allies that he was already feeling the weight of the challenges that would lie ahead if he won.

Sen. Tammy Duckworth of Illinois said she told Biden in a conversation earlier this year that the political moment seemed to cry out for a candidate with formidable governing experience. According to Duckworth’s recollection, Biden responded, “Tammy, I need people around me that understand that, and that we need to hit the ground running.”

Biden reacted in a similar fashion last Monday in Cleveland, when Sen. Sherrod Brown of Ohio told Biden he would soon have the chance to be “one of the great presidents of my lifetime.”

“He grabbed my shoulder,” Brown said, “pulled me in as much as you can when you’re wearing a mask and said: ‘I really need you to help me.’”

Biden also expressed pointed anxiety after delivering a pair of speeches about national unity and healing at Gettysburg, Pennsylvania, and Warm Springs, Georgia — two landmarks associated with the crisis presidencies of Abraham Lincoln and Franklin Roosevelt.

If Biden found those backdrops politically resonant, he suggested to an adviser that he was less comfortable with the implied comparison between himself and those men. Biden had a difficult time, he said, seeing himself as the next Lincoln or Roosevelt.

Party Unity, of a Kind

The pandemic alone might not have shifted the political landscape in Biden’s favor had he not managed a feat the previous Democratic nominee, Hillary Clinton, could not: persuading Democrats to lock arms with him after a bruising primary.

Biden, however, had advantages that Clinton did not, starting with a genial relationship with his chief opponent, Sen. Bernie Sanders of Vermont.

As the Democratic contest neared its end, Biden quickly took steps to accommodate his former rivals on the left. Days after Sen. Elizabeth Warren of Massachusetts ended her campaign in early March, Biden called to tell her he was adopting one of her key proposals on bankruptcy reform. And when Sanders withdrew from the race, Biden agreed to create a set of policy task forces to formulate a shared governing agenda.

Rep. Kathy Castor of Florida, a Democrat who sat on Biden’s climate task force, said the difference from 2016 was stark: “That was just so divisive back then, from the Democratic convention in Philadelphia through the election,” she said. “You can’t have Democrats fighting Democrats.”

But Biden did not budge on the overall ideological thrust of his campaign. On the contrary, he and his close advisers felt vindicated in their assessment of the Democratic Party as a center-left coalition, rather than one of the activists left. Though he added a handful of progressive policy hands to his campaign staff, Biden’s inner circle was dominated by relative centrists for whom the Sanders ethos of democratic socialism held little appeal.

Perhaps most prominent among those advisers was Valerie Biden Owens, Biden’s sister and longtime counselor, who stressed during internal deliberations that the campaign should be careful about attacking the wealthy as a political tactic. After all, Owens argued, many working-class people aspire to be rich.

“The Democratic Party is not what people may think it is on Twitter,” said Rep. Brendan Boyle of Pennsylvania, a Biden supporter from day one who recalled telling the former vice president as much last year. “It’s still working-class African Americans, whites and Latinos. And he was always true to that.”

Over the summer, Biden chose a running mate who he hoped would reconcile the competing pressures on his candidacy: to excite his own party without creating new vulnerabilities that Republicans might be able to exploit. He settled on Sen. Kamala Harris of California, completing his ticket with a choice that was at once groundbreaking and cautious — a younger woman of color who largely shared his own pragmatic political instincts.

He wound up with a message and policy agenda that left Trump with only limited avenues for attack, and benefited from the president’s lack of interest in learning details. When Trump sensed vulnerabilities in the Democratic platform, he never devised a critique deeper than one-liner jibes seemingly made for Fox News. His attacks on Biden’s climate plans, for instance, included claims that Democrats would force buildings to have tiny windows.

If Biden’s approach held up throughout the campaign, it left enormous unanswered questions for him to confront later on. In some cases, Biden and his advisers deliberately opted to suppress rather than resolve Democratic disagreements until after the election.

The most prominent example was Biden’s evasive response to Justice Amy Coney Barrett’s elevation to the Supreme Court. As other Democrats raised a cry of support for overhauling the federal judiciary, Biden spent weeks refusing to state his own position, eventually proposing a commission to study judicial reforms as a temporary salve.

The rush to seat Barrett opened his eyes more to the hardball tactics of today’s Senate Republicans, said one adviser. But in private, Biden has continued to express unease about trying to expand the high court, and he is still more intrigued by broader judicial reforms than simply adding justices.

One lawmaker said Steve Ricchetti, a former chief of staff to Biden, had been candid last summer about the campaign’s dilatory approach to the party’s internal divisions. Asked privately how Biden intended to handle the left, Ricchetti acknowledged that it would be a challenge over the long term.

For the moment, he said, getting through Nov. 3 was the only goal.

The Blue Wall and the Blue Line

The most perilous moment of the race for Biden may have come in late August, when a season of racial-justice protests had given way to spasms of vandalism and arson in a handful of politically important states. In Wisconsin, after the shooting of Jacob Blake, a Black man, by a police officer in Kenosha, rioting erupted in the suburban city — and Trump went on the attack.

At the Republican nominating convention, the president and his allies pounded Biden for a week with false or overstated attacks, linking him both to outright criminals and to left-wing activists who had taken up “defund the police” as a slogan. Biden had disavowed the idea, but Republicans persisted.

The onslaught posed a distinctive challenge to Biden, threatening to weaken his coalition of racial minorities, young liberals and moderate whites. Trump began a scare campaign aimed in part at white women, telling them he would “save your suburbs” from what he portrayed as looting mobs that Biden would not control.

Like other liberals of his generation, Biden saw danger in the Kenosha riots. Recalling the riots in American cities after the assassinations of the 1960s, he telephoned an adviser, saying he wanted to denounce the violence and asking a question: What had Robert F. Kennedy said to cool tempers in the aftermath of the Rev. Dr. Martin Luther King Jr.’s murder?

Biden flew to Pittsburgh the following Monday to head off Trump’s attacks. In a 24-minute speech, he reaffirmed his support for police reform while sternly denouncing civil unrest. “Looting,” he said, “is not protesting.”

“We need justice in America. We need safety in America,” Biden said.

The Biden campaign turned a clip from the speech into a television ad and ran it at saturation levels across the electoral map, countering Trump’s claims that a Democratic administration would unleash violent anarchy.

“Joe has always been someone who was able to hold two thoughts together at the same time about law enforcement and racial justice,” said Sen. Chris Coons of Delaware.

And once again, Biden benefited from his opponent’s impulse toward incitement and division. At the very moment Democrats feared voters might see Trump as a fearless steward of public safety, the president also spoke out in defense of people sowing chaos on the right.

Trump would do so again in his first debate with Biden, marring his law-and-order message by declining to denounce an extremist group on the far right.

Counting to 270

That moment after Kenosha was all the more important to Biden because of its resonance across the Midwest, the region he prized above all others. It was the band of states stretching from Minnesota across to Pennsylvania, Biden believed, that was likeliest to make him the next president.

His top lieutenants shared that assessment.

During a marathon Zoom session in May, after the campaign’s first major round of polling in the general election, Biden and his high command spent hours poring over the electoral map. By the end, they had hammered out their priorities. They would focus on three Great Lakes states Trump flipped in 2016 — Wisconsin, Michigan and Pennsylvania — plus Arizona, Florida and North Carolina. The campaign was skeptical of its chances in Florida and saw two other Sun Belt states, Georgia and Texas, as intriguing — but difficult and expensive to compete in.

When Biden and Harris returned to the campaign trail, that map guided their activities and their advertising strategy. They lunged at a few longer-shot targets, sending Harris on a last-minute trip to Texas, while Biden returned to Ohio, where polls showed him being competitive. Neither state wound up being close on election night.

More fruitful was an aggressive late play for Georgia, a rapidly diversifying state where suburban voters appeared to be swinging hard toward Democrats. In October, Biden’s pollster, John Anzalone, determined that the former vice president had a better chance to win there than in North Carolina and even Florida, and Biden embarked on his trip to Atlanta and Warm Springs. Harris visited the state repeatedly, and on the eve of the election the campaign decided to send former President Barack Obama to Georgia rather than North Carolina to make one last push there.

As the results began coming in on Tuesday, a tense mood took hold across much of the Biden campaign. In the first states to report, Florida and North Carolina, Trump was faring several points better than Democratic polling had forecast, and considerably ahead of most surveys conducted by the media.

The Biden campaign publicly projected composure, in contrast to Trump’s erratic behavior on Twitter and during late-night remarks from the East Room. Greg Schultz, Biden’s former campaign manager during the Democratic primaries, held a call with key supporters to offer reassurance, insisting that the early returns in the suburbs of Ohio were a good omen for the nearby swing states. But to some agitated listeners it was not a convincing presentation.

Biden’s inner circle grew increasingly unnerved as the night wore on and it became clear that the president was running stronger than expected. Jill Biden, former Sen. Christopher Dodd of Connecticut and an array of Biden advisers telephoned Democrats around the country to learn more about the vote count and whether Joe Biden was in danger of losing.

Within a matter of hours, Biden’s fortunes had improved as the big cities of the North reported their votes. It would take until Saturday, when Pennsylvania was called in his favor, to confirm that Biden had won more than the 270 Electoral College votes required to claim the presidency. The Blue Wall was standing again for Democrats.

For all the Democratic jubilation at Trump’s demise, Biden may not entirely share that feeling of pure delight. Rahm Emanuel, who served as Obama’s chief of staff during the Great Recession, said he warned Biden recently that his reward for winning would be fleeting.

“You’re the dog that caught the car,” Emanuel said, alluding to what awaited Biden in the Oval Office.

The man who would soon be president-elect responded: “Ain’t that the truth.”

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