It is apparently not enough for America’s anti-tax crusaders that Congress just passed one of the most expensive and regressive tax bills in our history. The Washington Post reports that Grover Norquist’s Americans for Tax Reform and other conservative groups are now urging the Trump administration to change how investment profits are taxed—unilaterally, if need be—in a way that would overwhelmingly favor the wealthiest Americans. Sound familiar? Namely, they want to index capital gains to inflation. Suppose I bought $100,000 worth of Apple stock on July 10, 2020 and kept it. Today, I could sell that stock for $170,383—a tidy $70,383 profit. That’s a 74 percent overall return and an average annual return of 11.7 percent. Pretty good, right? Not good enough for Norquist et al. These players want to let me adjust the “cost basis”—the price I originally paid for the stock—for inflation. Using this inflation calculator, I could then tell the IRS that my initial $100k investment was in fact a $120,407 investment, and so my profit for tax purposes is only $40,976. This is insane—for several reasons. First, read the room. Congress just passed a megabill whose benefits are deeply skewed in favor of the wealthy. Its tax provisions and spending cuts, taken together, will result in a 4 percent increase in average after-tax income for the richest 1 percent of American households and a nearly 4 percent decrease for the poorest 20 percent, based on the Yale Budget Lab’s analysis. This is very, very unpopular. The bill will at least $3.3 trillion to the national debt—more like $5 trillion if expiring provisions are extended in the coming years. And indexing capital gains to inflation, according to 2018 estimates from the Tax Policy Center and the Penn Wharton Budget Model, would add yet another $100 billion to $200 billion to the tab—with the richest 1 percent reaping 86 percent of the benefits. > “I don’t think reducing [capital gains rates further] will change investor > behavior,” says billionaire Mark Cuban. Norquist told the Washington Post he recently spoke with President Donald Trump and recommended the president implement the change with an executive order. Indexing capital gains to inflation was considered during Trump’s first term, the Post‘s Jeff Stein reports, but Treasury Secretary Steve Mnuchin felt Congress should handle it—current secretary Scott Bessent may prove more complaint. “I said something like, ‘Mr. President, after we do the bill, we will need more economic growth,” Norquist told Stein. “The Big Beautiful Bill is very pro-growth, but with this, we can have even more growth.’” In reality, not one of the Republican tax packages enacted since Ronald Reagan became president has lived up to its sponsors’ economic promises. “The economy may well enjoy a sugar-high the next couple of years, as borrowing stimulates near-term consumption,” Maya MacGuineas, president of the nonprofit Committee for a Responsible Federal Budget, said in a statement after Congress passed the “One Bie Beautiful Bill” on July 3. “But a sugar-high won’t be sustained, it will do real damage, and often what comes next is the crash.” As for the notion of indexing fueling “more growth,” the billionaire investor Mark Cuban told me in an email that he thinks the current tax rates on capital gains are fair, and “I don’t think reducing it will change investor behavior.” Yet the fairness of those rates—and their justification—is the subject of fierce debate. Suppose I’m a wealthy investor and I sell assets I’ve held for at least 12 months—stocks, bonds, real estate, or even, say, a stud racehorse—netting my family $1,000,000 in profits. The federal tax on those capital gains ranges from zero for the first $94,000 to 20 percent for the portion that exceeds $583,750. Because my spouse and I have income of more than $250,000, we also have to pay a 3.8 percent “net investment income tax.” This all adds up to an effective tax rate of about 19 percent. But tax rates for wage income are much higher. A couple reporting $1,000,000 in salary income pays an effective rate of about 30 percent. That’s a huge difference, and part of why families whose money comes from primarily from asset growth have amassed wealth so much faster than working families have. It no lefty exaggeration to say America’s economic system is rigged against workers and in favor of investors. It’s right there in the tax code. > “This kind of proposal will only widen the economic inequality we’re facing.” So how do conservative policy wonks justify the low capital gains rates? A key argument, interestingly, is that inflation eats away at the value of long-term gains. One “solution” would be to index the gains to inflation, notes the libertarian Cato Institute, “but most countries instead roughly compensate” by offering reduced tax rates for investors. And now the anti-taxers want to have it both ways. Investors enjoy other economic advantages, too. Notably, their gains are counted as income only when the assets are sold. In practice, this allows people with a large portfolio of appreciated assets to borrow against their holdings at single-digit interest rates and live off those loans instead of selling assets and paying a double-digit tax. As ProPublica discovered, many of America’s wealthiest families have been doing precisely that. (As a result, from 2014 to 2018, Jeff Bezos paid an effective income tax rate of less than 1 percent.) Or say you have a $100 investment that grows by 10 percent a year during a period of 2 percent annual inflation. The first year’s profit, after inflation, is $8. “But I don’t pay tax on that $8 until I sell, which may be decades later,” says Bob Lord a former tax attorney and associate fellow at the Institute for Policy Studies. “I’m basically getting a free ride on the appreciation of that $8 portion of my investment.” Doesn’t that benefit, he asks, more than offset any detriment from inflation? And also, isn’t investing supposed to contain an element of risk management? Isn’t the ability to beat inflation part of what separates a savvy investor from a useless one? Indexing for inflation, combined with favorable tax capital gains rates and an exemption for unrealized gains—doesn’t that basically reduce investing to shooting fish in a barrel? It is worth noting, too, that most Americans work for a paycheck, and the ones who make their living via investing are by and large quite wealthy. More than half of Americans now own some stock, but not much. As of January 2024, per Federal Reserve data, 93 percent of US stock holdings were owned by the most affluent 10 percent of the population, and the richest 1 percent owned more than half of all public equities—not to mention private equities. Indexing gains to inflation “would really codify the notion that income taxes are only for people who work for a living,” says Morris Pearl, a former managing director at BlackRock and current chairman of the board of Patriotic Millionaires, a nonprofit that advocates for higher taxes on the rich. If the Trump administration were to attempt the change Norquist recommended—unilaterally or otherwise—its not even clear how it would work. You would presumably need to make changes on both the profit and loss sides of a balance sheet. Kyle Pomerleau, a senior fellow with the right-leaning American Enterprise Institute, has concluded that indexing is complex and unlikely to generate significant economic impact, and is therefore “more trouble than it’s worth.” “Indexing has been rejected in the past to avoid opening new tax shelters,” says Steven Rosenthal, a Washington tax policy expert and former legislation counsel for the congressional Joint Committee on Taxation. “If investors were permitted to index their assets, but not required to index their liabilities, debt-financed investments would explode. Investors could exclude profits and deduct interest. But indexing both assets and liabilities is a mess, which I, as a congressional staffer, discovered when we tried to draft it.” “This kind of proposal will only widen the economic inequality we’re facing,” adds Patriotic Millionaires’ Pearl. “It’s absurd that all I would need to do is buy property that I can rent out, and make a lot of money, and never have to pay taxes again!”

Just in time for the nation’s birthday, House Republicans have passed the most regressive legislation in recent memory, a bill that’s expected to cut more than $1 trillion from Medicaid and boot some 12 million Americans off their health insurance, even as it explodes the federal deficit—all to extend and expand tax cuts that favor the rich. The vote was 218-214. Republicans unilaterally shoved through their “One Big Beautiful Bill Act,” awkwardly named with President Donald Trump’s phrase, just in time to meet his demand that they deliver it for his signature by Independence Day. Their fealty to Trump helped House Speaker Mike Johnson overcome resistance among some GOP members, even though the measure flagrantly violates Trump’s many vows not to reduce Medicaid spending. Trump has addressed that contradiction by falsely claiming the bill doesn’t cut Medicaid or other benefits. No Democrat in either chamber voted for the bill, and the party is expected to make the cuts to Medicaid and other safety net programs, including food stamps, the center of their efforts to retake control of the House and Senate in next year’s midterm elections. Here are some of the aspects that have led critics to declare this “the worst bill in modern American history.” It’s incredibly regressive: The bill cuts taxes for rich people while reducing benefits for the poor. Broadly, it extends the 2017 tax cuts Congress passed during Trump’s first term while partly offsetting the cost with deep cuts to health care spending, food assistance, and other programs. Although it includes some tax cuts that would benefit lower-income Americans, the gains, in aggregate, flow to the rich, with the top 1 percent of families getting a break (according to an estimate from an earlier version of the bill) of $79,000 a year while families in bottom fifth would get $160. But that’s before you consider the lost benefits. When you factor in spending cuts to the aid programs, those wealthiest households end up with an average 4 percent increase in after-tax income, while the bottom 20 percent of earners are docked by nearly that same percentage, according to a Yale Budget Lab analysis. In a recent survey of 4,500 Americans by Yale political scientist Jacob Hacker and post-doc Patrick Sullivan, Republican respondents, when informed of these numbers, opposed the bill by a ratio of 3-t0-1, and overall support for it plummeted to just 11 percent. It blows up the deficit: The bill will increase the deficit dramatically over the next decade, according to the Congressional Budget Office (CBO), by extending the 2017 tax cuts and adding new ones aimed at fulfilling Trump promises. These include an extension of a home mortgage interest deduction and a “no tax on tips” provision, albeit with a $25,000 cap on the amount of tips workers can claim—which experts say means it will not help lower-income service workers. It slashes Medicaid: The bill includes both direct and indirect cuts to Medicaid spending. It limits so-called Medicaid provider taxes that states use to collect more matching funds from the program. (Those states are taking advantage of a loophole in the law, but by cutting it off, the bill leaves them with less Medicaid funding, likely causing many to reduce services.) The legislation also imposes a requirement that Medicaid recipients provide proof of employment to get benefits. This imposes a complicated bureaucratic burden on beneficiaries that CBO says will cut $280 billion in Medicaid spending over six years—in many cases because even many people who work (most recipients do) won’t be able to navigate the red tape the bill imposes. It ends health coverage for millions: Nearly 12 million Americans will lose coverage as a result of the bill, according to CBO, mainly due to the burdensome new requirements places on Medcaid recipients, and steps that make it harder to sign up, like limited enrollment periods and new paperwork requirements. It‘s an impediment for women’s health care: Of the 24 million women currently enrolled in Medicaid, 56 percent are of reproductive age and the majority are women of color. The bill excludes Planned Parenthood and some other providers from Medicaid, reducing access to birth control and other reproductive care. The cuts could also force more than 140 rural hospitals to shut down obstetrics services or drastically curtail them. It slashes food stamps: The bill will cut federal spending on the Supplemental Nutrition Assistance Program (SNAP), which helps poor people buy food, by an estimated $287 billion over a decade. It also includes a bizarre provision that rewards states with the highest error rates in awarding food stamps. That’s the result of legislative wrangling in the Senate where, in a bid to win over Sen. Lisa Murkowski of Alaska, GOP leaders—barred by procedural rules from simply exempting Alaska—instead exempted the 10 states with the highest error rates. (Alaska is the highest.) This actually gives states on the cusp of making the list an incentive to get worse. As with Medicaid, most of the cuts to SNAP and other aid programs will be done backhandedly, via onerous bureaucratic burdens. As the New York Times reported: “By including dozens of changes to dates, deadlines, document requirements and rules, Republicans have turned paperwork into one of the bill’s crucial policy-making tools, yielding hundreds of billions of dollars in savings to help offset their signature tax cuts.” Among the new requirements, “able-bodied” elders, ages 55 to 64, will have to submit documents verifying their citizenship. And rather than letting states use information already on hand to verify the citizenship of Obamacare subsidy applicants, the legislation requires people to track down and submit those documents. Republicans, who for years have railed against federal bureaucracy, claim these paperwork tasks would weed out only people who don’t qualify for benefits, but CBO and many experts say such hurdles will cause millions of people who qualify for Medicaid, food stamps, and health subsidies to lose them. It undermines clean energy development: The bill slashes spending on clean energy approved under President Joe Biden’s Inflation Reduction Act, likely leading to job losses and a capitulation to China’s domination of the sector. It removes tax incentives for wind, solar, and other renewable energy projects, though it delays some of the cuts until after the midterms. It also ends subsidies of up to $7,500 for electronic vehicles purchased this year. It greatly expands ICE detentions and enforcement: As masked ICE agents stir up neighborhoods around the country, the bill throws cash at the agency—more than $100 billion in new funding for US Immigration and Customs Enforcement through 2029. As my colleague Inae Oh reports, that would “fund the single largest increase in immigration enforcement in US history. It would ramp up mass deportations to an unprecedented scale; create hastily built, sordid detention centers across the country; and all but ensure that millions of people who haven’t been accused of crimes are disappeared.”

This story was originally published by Popular Information, a substack publication to which you can subscribe here. The Federal Communications Commission will no longer enforce a rule capping the price of prison phone calls, according to an announcement made Monday by FCC Chairman Brendan Carr. The move suspends a 2024 FCC decision that capped the price of in-state phone calls at 6 cents minute for prisons and large jails and 7 cents per minute for medium-sized jails. Before the decision, a 15-minute phone call could cost as much as $11.35 at large jails in some states. Under the 2024 rules, those same phone calls would cost 90 cents. This week’s FCC announcement states that the suspension of the 2024 rules will apply until April 1, 2027. But it also says that the FCC will use that time to consider making permanent changes to the rule. Carr claims that the 2024 rules, which started going into effect on January 1 on a staggered basis, are “leading to negative, unintended consequences.” > The current system incentivizes prison operators to award contracts to > companies that charge exorbitant fees. The 2024 FCC decision followed the passage of the Martha Wright-Reed Just and Reasonable Communications Act of 2022, which gave the FCC authority to regulate the price of in-state phone calls from prisons and jails. The legislation was named after Martha Wright-Reed, who spent two decades fighting for lower prices for prison phone calls as she struggled to afford spending over $100 per month to call her incarcerated grandson. At times, Wright-Reed had to skip medication payments and even cut back on groceries in order to afford the calls. In 2000, Wright-Reed sued CoreCivic, a private prison operator, arguing that the company’s exclusive contracts resulted in excessively high prices. Monday’s statement was blasted by FCC Commissioner Anna Gomez, who argued that not enforcing the 2024 rules violates the Martha Wright-Reed Act, as the law directed the FCC to “implement the statutory provisions not earlier than 18 months and not later than 24 months after the date of its enactment.” Gomez said that the FCC is making the “indefensible decision to ignore both the law and the will of Congress.” Incarcerated people have said that the high cost forces them to choose between spending money on phone calls or purchasing personal hygiene items, or even shoes. One mother told CBS News in 2020 that she and her husband spent “$14,268 over the past two years” so that their incarcerated son could make phone calls. On top of the exorbitant per-minute rates, incarcerated people are charged additional fees, including as much as $4 to connect the call, which could be charged multiple times if the call drops. In 2024, the FCC estimated that capping the price of phone and video calls “would save incarcerated people and their families, friends and legal teams about $386 million.” The Prison Policy Initiative estimated that the industry costs families of incarcerated people “nearly $1 billion a year.” Studies have shown that visitation and phone calls from family decrease the chances that an incarcerated person will commit another crime. So why is the FCC suddenly suspending the lowered price caps for prison phone calls? Follow the money. The high cost of prison phone calls is a cash windfall for the private prison industry, which spent vast sums to help elect Trump president. The companies that provide prison telephone services offer kickbacks, known as “commissions,” to prison operators to secure lucrative contracts. This means up to 50 percent of the money incarcerated people spend on telephone calls is routed back to the company or government that operates the prison. This system incentivizes prison operators to award contracts to companies that charge exorbitant fees, creating a larger pool of money for kickbacks. For private prison companies like GEO Group and CoreCivic, kickbacks from telephone service providers are a lucrative revenue stream. How much money do these companies make from commissions? The industry no longer discloses those figures. But in 2012, according to SEC filings, the GEO Group made over $600,000 in site commissions from phone services. That figure is likely much higher today. The FCC rule on phone rates would have ended this practice, banning kickbacks for prison operators. But, like the caps on phone charges, the kickback ban is now on hold. During the 2024 campaign, GEO Group, through its PAC, was the first company to make the maximum contribution to Trump’s campaign. The same day, two top GEO Group executives, CEO Brian Evans and board chairman George Zoley, each donated $11,600 to the Trump Save America Joint Fundraising Committee. Later, a GEO Group subsidiary, GEO Acquisition II, donated $1 million to Make America Great Again PAC, a pro-Trump super PAC. GEO Group used the subsidiary to evade a federal law that prohibits government contractors from making political donations. After Trump won, GEO Group and CoreCivic each donated $500,000 to Trump’s inauguration committee. Both Tom Homan, Trump’s border czar, and Attorney General Pam Bondi have previously been on the payroll of GEO Group. According to his federal financial disclosures, Homan received consulting fees from GEO Group in 2023 and 2024. Homan was not required to disclose the exact amount he was paid by the GEO Group, except that it was more than $5,000. Bondi worked as a lobbyist for GEO Group in 2019. In the order delaying the rule, the FCC explicitly cited the “financial burdens” imposed on prison operators through inhibiting their ability to collect commissions. The FCC claims that, without the ability to receive commissions or charge high prices, many facilities would stop allowing incarcerated people to make phone calls. This conclusion is largely based on claims made to the FCC by the corporations profiting from the existing system.

This story was originally published by the Guardian and is reproduced here as part of the Climate Desk collaboration. As she canvassed for Zohran Mamdani in New York City on Tuesday last week, Batul Hassan should have been elated. Her mayoral candidate—a 33-year-old state assemblymember—was surging in the polls and would within hours soundly defeat Andrew Cuomo on first preference votes in the Democratic primary election. But Hassan’s spirits were hampered by record-breaking temperatures. In Crown Heights, where she was the Mamdani campaign’s field captain, the heat index soared into the triple digits. “I couldn’t think about anything but the heat,” she said. “It was so dangerous.” Early that morning, Hassan had visited a public school polling site, where elderly workers sweltered without air conditioning. The city Board of Elections sent over paper fans, but they were no match for the heat. If Mamdani is elected mayor, that school could be retrofitted with air conditioning and green space to bring down temperatures as part of his green schools plan, or could even be transformed into a resilience hub for communities to shelter amid extreme weather events > “We need to expand mass transit to fight the climate crisis,” and also > “because we want to improve people’s lives right now.” “Seeing total infrastructural failure on Election Day emphasized the stakes of what’s happening with the climate crisis and the importance of the election,” said Hassan, who took time off from her day job at the leftist thinktank Climate and Community Institute to canvass. Mamdani’s green schools plan is just one of his schemes to slash carbon emissions and boost environmental justice. His plans for New York City would make residents “dramatically more safe” from extreme weather, said Hassan. But the democratic socialist, who was endorsed by the national youth-led environmental justice group Sunrise Movement and student-led climate group TREEAge, did not place the climate crisis at the center of his campaign, instead choosing to focus relentlessly on cost-of-living issues. The model could help build popular support for climate policies, supporters say. “Climate and quality of life are not two separate concerns,” Mamdani told The Nation in April. “They are, in fact, one and the same.” Over the past two decades, Democrats increasingly focused on the climate. But often, their proposed schemes have been technocratic, Hassan said. Carbon taxes, for instance, can be impenetrably complex, making them difficult candidates for popular support. They can also be economically regressive, with “working class people experiencing them as an additional cost,” Hassan said. More recently, Joe Biden coupled climate plans with green industrial policy and plans to boost employment. But even those projects can take years to effect tangible change, critics say. As president, for instance, Biden achieved historic climate investments in the Inflation Reduction Act. But its green incentives disproportionately benefited the wealthy, and its job creation remains invisible to most people around the country. One poll found only a quarter of Americans felt the IRA benefited them. “Now with Trump, we see the pitfalls of the IRA, where there is real difficulty in consolidating enough political support to defend those climate policy achievements,” said Hassan. Mamdani “learned from some of the mistakes” of the Biden administration, said Gustavo Gordillo, a co-chair of the New York City chapter of the Democratic Socialists of America, which supported Mamdani’s campaign. His housing plan, for instance, aims to lower planet-heating pollution by boosting density, but his signature promise is a rent freeze. That pledge could ensure residents are not priced out of New York City and forced to move to more carbon-intensive suburbs, and prevent landlords from passing the costs of energy efficiency upgrades or air conditioning installation to renters, preventing displacement, said Hassan. Similarly, Mamdani’s headline transit goal was to make buses faster and free, which could boost ridership and discourage the use of carbon-intensive cars. “Public transit is one of the greatest gifts we have to take on the climate crisis,” Mamdani said at a February mayoral forum. Biden’s IRA placed little focus on boosting public transit, said Gordillo. This was a missed opportunity to cut emissions and also lower Americans’ fuel costs, he said. “We need to expand mass transit to fight the climate crisis, which hasn’t been a priority for the Democratic establishment,” said Gordillo, who is an electrician by day. “But we also need to expand it because we want to improve people’s lives right now.” As a New York assemblymember, Mamdani has backed explicitly green policies. He was a key advocate for a boosting publicly owned renewable energy production. The effort aimed to help New York “live up to the dream of our state as being a climate leader,” he said in 2022. He also fought fossil-fuel buildout. He coupled that climate focus with efforts to keep energy bills low, consistently opposing local utilities’ attempts to impose rate hikes, said Kim Fraczek, director of the climate nonprofit Sane Energy Project. “His growing political influence is a clear win for communities demanding a just transition: renewable power, democratic control and relief from crushing energy costs,” said Fraczek. Progressive cities like New York are often climate leaders. But if they price out working people, only the wealthy get to see the benefits of their green policies, Mamdani’s backers say. By crafting popular climate policies, the Democratic nominee is also building a base of New Yorkers who will work to defend those plans in the face of threats from the Trump administration, they say. “New Yorkers want an affordable city, clean and green schools, fast and free buses, and a rent freeze,” said Daniel Goulden, a co-chair of the New York City Democratic Socialists of America ecosocialist working Group. “But most importantly, New Yorkers want a future—one where they can live and thrive in New York.”

This story was originally published by Grist and is reproduced here as part of the Climate Desk collaboration. The federal Weatherization Assistance Program is the oldest and largest energy efficiency initiative in American history. Born from the 1973 oil crisis, it helps low- and moderate-income households make a litany of upgrades to their homes, such as installing insulation, sealing windows, and wrapping water pipes. The program, known as WAP, is often free and saves residents an average of $372 annually on their utility bills.  But a report released today by the nonprofit American Council for an Energy-Efficient Economy (ACEEE) found that many homes need basic—but expensive—repairs before they can participate, something many residents can’t afford. Those households are placed on a deferral list until those improvements are made. Although some buildings are too damaged to fix up and some people manage to get off the list, the research showed that, in 2023, another 7,000 homes could have been repaired but weren’t due to lack of money. That’s a fifth of the 35,000 homes that the Department of Energy estimates WAP reaches each year. > “People are in really bad situations…There is a very big demand for this > no-cost program.” “We were the first to really figure out what the deferral rates are and why,” said Reuven Sussman, an expert in energy efficiency behavior change at ACEE and an author of the report. “I don’t think this problem is broadly known.” The Department of Energy, which administers the $326 million WAP budget, works with local companies to weatherize qualifying homes. ACEEE surveyed providers in 28 states about their deferrals. The top reason cited was the poor condition of the roof—an issue that undermines improvements such as attic insulation. Floor damage and outdated electric panels were the other leading justifications for deferring homes. The average cost of bringing a home up to WAP standards, the report found, was nearly $14,000.  “If you’re eligible for WAP you likely don’t have enough money to pay for it,” Will Bryan, director of research for the Southeast Energy Efficiency Alliance. “There are households that are falling through the cracks.” People facing deferrals have a few options, but they are limited and inconsistent. Depending on where these residents live, some public, private, or philanthropic funds are available for critical home repairs. Some states—like Pennsylvania, Delaware, and Vermont—have more specific programs targeting WAP deferrals. Starting in 2022, the federal government also provided money for the Weatherization Readiness Fund (WRF),  though it only backed it with about $15 million.  “The government has experimented with some pre-weathization funding, but that hasn’t happened at the kind of scale that it needs to,” said Bryan. And, he added, President Donald Trump’s administration and Congress are trying to pull what little money has become available in recent years. The “big, beautiful” budget bill that the House passed zeros out the budget for both WAP and WRF, as well as related assistance or incentive programs. The details of the Senate version are not yet clear, but the impacts of the rollback could be drastic.  “Elderly people, disabled people, small children—their energy burden is so much higher than other folks because they are on fixed incomes,” said Bryan Burris, vice president of energy conservation programs at projectHOMES, a WAP provider in Richmond, Virginia. The recent influx of state and federal funding has helped his organization cut its deferral rate from around 50 percent to about 20, but that progress is in peril. “People are in really bad situations,” said Burris. “There is a very big demand for this no-cost program.” ACEEE estimates that it would cost about $94 million per year to make the 7,000 preventable deferrals ready for weatherization. If all those homes were able to receive WAP services, it would save 49,236 megawatt-hours of energy annually and reduce carbon dioxide emissions by 153,000 metric tons over the lifetime of the measures. WAP projects also often pay for themselves many times over in lower utility bills. Evaluating the effectiveness of weatherization readiness programs is more complex. Although they may save homeowners some money on a monthly basis, the greatest gains of major repairs are often indirect boosts in health and quality of life. For example, fixing a roof could help a senior citizen age in place, rather than go to an assisted living facility. Removing toxic substances, like asbestos, from homes could prevent illnesses in children. “You can potentially save money in the long term by reducing the hazards that people are exposed to,” said Bryan, pointing to a substantial body of research supporting the idea. A 2021 study in the southeastern United States, for example, found that after weatherization, “respondents reported fewer bad days of physical and mental health. Households were better able to pay their energy bills and afford prescriptions.” While that line of inquiry was beyond the scope of the latest ACEEE report, Sussman said the logic makes sense. Avoiding even a minor trip to the hospital or doctor could save programs like Medicaid or Medicare thousands of dollars.  “People live with holes in the roof and asbestos and can’t get assistance,”  said Bryan. “It leads to health issues.”

This story was originally published by Grist and is reproduced here as part of the Climate Desk collaboration. Thomasville, Georgia, has a water problem. Its treatment system is far out of date, posing serious health and environmental risks. “We have wastewater infrastructure that is old,” said Sheryl Sealy, the assistant city manager for this city of 18,881 near the Florida border, about 45 minutes from Tallahassee. “It’s critical that we do the work to replace this.” But it’s expensive to replace. The system is especially bad in underserved parts of the city, Sealy said. In September, Thomasville applied to get some help from the federal government, and just under four months later, the city and its partners were awarded a nearly $20 million Community Change grant from the US Environmental Protection Agency to make the long-overdue wastewater improvements, build a resilience hub and health clinic, and upgrade homes in several historic neighborhoods. “The grant itself was really a godsend for us,” Sealy said.  In early April, as the EPA canceled grants for similar projects across the country, federal officials assured Thomasville that their funding was on track. Then on May 1, the city received a termination notice. “We felt, you know, a little taken off guard when the bottom did let out for us,” said Sealy. > “What is it about building a new health clinic and upgrading wastewater > infrastructure…that’s inconsistent with administration policy?” Thomasville isn’t alone.  Under the Trump administration, the EPA has canceled or interrupted hundreds of grants aimed at improving health and severe weather preparedness because the agency “determined that the grant applications no longer support administration priorities,” according to an emailed statement to Grist. The cuts are part of a broader gutting of federal programs aimed at furthering environmental justice, an umbrella term for the effort to help communities that have been hardest hit by pollution and other environmental issues, which often include low-income communities and communities of color.  In Thomasville’s case, the city has a history of heavy industry that has led to poor air quality. Air pollution, health concerns, and high poverty qualified the surrounding county for the Biden administration’s Justice40 initiative, which prioritized funding for disadvantaged communities. Thomasville has some of the highest exposure risks in Georgia to toxic air pollutants that can cause respiratory, reproductive, and developmental health problems, according to the Environmental Defense Fund’s Climate Vulnerability Index. The city’s wastewater woes don’t only mean the potential for sewage backups in homes and spills into local waterways but also the risk of upper respiratory problems, according to Zealan Hoover, a former Biden administration EPA official who is now advising the advocacy groups Environmental Protection Network and Lawyers for Good Government. “These projects were selected because they have a really clear path to alleviating the health challenges facing this community,” he said. Critics argue there’s a disconnect between the Trump administration’s attack on the concept of environmental justice and the realities of what the funds are paying for. “What is it about building a new health clinic and upgrading wastewater infrastructure … that’s inconsistent with administration policy?” Democratic Georgia Senator Jon Ossoff asked EPA Administrator Lee Zeldin at a recent hearing.  Zeldin repeatedly responded by discussing the agency’s review process intended to comply with President Donald Trump’s executive orders, particularly those related to diversity, equity, and inclusion policies, but Ossoff cut him off, pushing for a specific answer about Thomasville’s grant. “Is a new health clinic for Thomasville, Georgia, woke?” he asked. > “We spent $60,000 in local funding hiring people to write the grants” that now > have been terminated, noted a Athens-Clark County official. Thomasville’s Sealy said she understands that the federal government has to make hard funding decisions—that’s true locally too—but losing this grant has left her city in the lurch. In addition to the planned work on the wastewater collection system, the city needs to update its treatment plant to meet EPA standards. That overhaul will likely cost $60 million to $70 million, she said. “How do you fund that?” Sealy asked. “You can’t fund that on the backs of the people who pay our rates.” The funding cuts have left cities across Georgia—including Athens, Norcross, and Savannah—as well as nonprofit groups, in a state of uncertainty: some grants terminated, some suspended then reinstated, some still unclear. This puts city officials in an impossible position, unable to wait or to move forward, according to Athens-Clarke County Sustainability Director Mike Wharton.  “Do you commit to new programs? Do you commit to services?” he said. “Here you are sitting in limbo for months.”  Like Thomasville, Athens was also awarded a nearly $20 million Community Change grant. The city was going to use the money for backup generators, solar power, and battery storage at its public safety complex—ensuring 911, police, the jail, a domestic violence shelter, and other services could all operate during a power outage. That grant has been terminated. The problem, Wharton said, goes beyond that money not coming in; the city had already spent time, resources, and money to get the grant. “We spent $60,000 in local funding hiring people to write the grants,” he said. “Over a period of 14 months we invested over 700 hours of local personnel time. So we diverted our services to focus on these things.” These frustrations are playing out for grant recipients throughout the state and country, according to Hoover. He said it’s not just confusing—it’s expensive. “They are causing project costs to skyrocket because they keep freezing and unfreezing and refreezing projects,” he said. “One of the big drivers of cost overruns in any infrastructure project, public or private, is having to demobilize and remobilize your teams.” Thomasville and Athens officials both said they’re appealing their grant terminations, which require them to submit a formal letter outlining the reasons for their appeal and requesting the agency reconsider the decision. They’re also reaching out to their elected officials, hoping that pressure from their senators and members of Congress can get them the federal money they were promised. Other cities and nonprofits, as well as a group of Democratic state attorneys general, have sued, arguing that terminating their grants without following proper procedures is illegal. But that’s a difficult step for many localities to take. “Suing the federal government to assert your legal rights is very daunting, even if the law is on your side,” Hoover said.

This story was originally published by Grist and Street Roots and is reproduced here as part of the Climate Desk collaboration. On a Thursday morning in Portland’s Old Town neighborhood, two dozen people mill around a warehouse, waiting for the results of a lottery. At 7:45 sharp, a woman sitting in an interior office calls out three numbers in quick succession. She repeats the last one a few times before someone finally comes forward: “234?” she says into the crowd. “Who’s 234?”  Chris Parker is 234. He is tall and thin and wears Garneau cycling gloves and a baseball cap from the power tools company DeWalt. “Are you kidding me?” he says, happy and shocked. Across the room, one of the other selectees—number 237—does a kind of end-zone victory dance, shimmying with arms above his head. The lottery determines who will participate in that day’s waste collection program from Ground Score Association, a Portland-based collective for people who “create and fill low-barrier waste materials management jobs.” Through this particular program, called GLITTER (short for Ground Score Leading Inclusively Together Through Environmental Recovery), Parker will join a group of Ground Score employees on a four-hour walk around Portland, clearing sidewalks of plastic and other trash. At the end of the shift, he’ll get $80 in cash—$4.55 more per hour than the Portland metro area minimum wage. Participating in the lottery doesn’t require passing a drug or sobriety test or providing a social security number. It’s meant to provide low-barrier employment to people who might otherwise struggle to find or keep a job. Parker, for example, tells me he totaled his car last summer—the latest in a string of misfortunes. He says he used to work at a rail yard on the Columbia River, but he was laid off when he got Covid. It’s been difficult to find a stable job, he says, especially one that pays enough for the “affordable” apartments he sees advertised at $1,300 a month. For now he’s living in a small apartment near Ground Score’s headquarters. One of Ground Score’s GLITTER teams poses for a photo mid-route.Courtesy of Ground Score Most people are homeless when they start working with Ground Score. But after a year on payroll, there’s an 80 percent chance they will have secured housing, according to the organization. Terrance Freeman, one of the employees leading a GLITTER group on Thursday, wears wraparound sports sunglasses and a yellow scarf. He’s been working at Ground Score for six months. Previously, he worked at a nearby Chevron gas station and struggled with alcohol. Another member of his group, Dana Detten—a.k.a. Peanut—was homeless for eight years and worked various jobs at Dollar Tree and FedEx before joining the GLITTER program. Kevin Grigsby, the lankiest of the team, says he came to the organization while trying to overcome mental health issues and a “huge cocaine problem.” Now he’s splitting a $630-a-month garage apartment on Portland’s outskirts with his girlfriend.  “If Ground Score didn’t hire me I would be on a different path,” Grigsby says, using a long grabber tool to pinch up an Oreo wrapper.   Grigsby and the other people employed by Ground Score are “waste pickers,” a catch-all term for the 20 million people worldwide who make a living collecting, sorting, recycling, and selling discarded materials. In recent years, waste pickers have fought for their work to be recognized and formalized in the global plastics treaty being negotiated by the United Nations.  Ground Score, which sees its mission as building community while also “changing society’s perceptions of what and who is considered valuable,” shows what that recognition and formalization look like on a local level. It’s a model with huge potential, given the urgent global need to create stronger social safety nets and combat the growing plastic waste crisis. Could it work in other cities, too? Waste pickers tend to work outside of governments’ formal waste management programs, meaning the services they provide—keeping streets clean, ensuring high recycling rates, sifting hazardous e-waste out of landfills—are underappreciated and poorly remunerated.  The International Alliance of Waste Pickers, or IAWP, which represents unions, collectives, and organizations across 34 countries, says waste pickers manage as much as 80 percent of some cities’ municipal waste, with the highest percentages in developing countries that lack extensive waste management infrastructure. One study from 2020 estimated that waste pickers collect 58 percent of all the plastic that ever gets recycled. They boost recovery rates for cardboard, aluminum, and other metals too.  Members of the Asociación Cooperativa de Recicladores de Bogotá (Waste Pickers Association of Bogotá) work in a warehouse in Colombia’s capital city in 2015. Juan Arredondo / Getty Images via Grist Waste pickers also recover e-waste—often so they can sell the metals inside electronics—as well as textiles that can still be worn, repaired, or refashioned into new goods.  In some jurisdictions, including Oregon, waste pickers collect aluminum cans and plastic bottles in order to claim a rebate determined by a so-called “bottle bill”—a law that tacks an extra 5 to 15 cent deposit onto the containers’ purchase price. But these policies are a relative rarity.  Within the US, only nine other states and Guam have one, and the majority of similar laws internationally are concentrated in Europe, Canada, and Australia. Waste pickers in poorer countries often have to buy or sell their wares directly to recycling companies or brokers, and they can’t rely on a government-mandated return rate per item collected. These activities not only provide waste pickers with a living, they also help to address climate change. According to one study published in March, a subset of waste pickers in just one city—Salvador, Brazil—helped avoid more than 27,000 metric tons of greenhouse gas emissions between 2010 and 2022, mostly by enabling recycling that displaced the need for raw materials like aluminum and PET, the kind of plastic used in water bottles. (For context, that’s about the amount emitted by 6,300 gasoline-powered cars in a year.) Removing paper and cardboard from landfills also reduces emissions, because these materials would otherwise release methane—a potent greenhouse gas—as they decompose. Waste pickers’ services have recently gained attention thanks to negotiations for a binding United Nations treaty to “end plastic pollution,” which began in early 2022 and are ongoing. One paper published last year, quoting an unnamed negotiator, described waste pickers as “the human face” of the treaty, since they’re on the front lines of plastic pollution. In the negotiations, the IAWP has allied with many countries and environmental groups that want to put limits on global plastic production. But it’s also calling for the treaty to include a distinct article ensuring a “just transition” for waste pickers whose livelihoods could be at risk from greater formalization of the waste management sector. Broadly, IAWP wants countries to build better waste management systems around the work waste pickers are already doing, instead of bringing in private companies that would take their place.  Ground Score is showing how to implement that goal on a small scale—in part through partnerships with city, county, and state government, but also through a participatory organizational structure that gives waste pickers a sense of ownership over Ground Score’s activities. Workers in the program “feel like it’s a privilege that they can actually help their own community rather than just perpetuating this culture of, you know, giving and taking ‘handouts,’” says Taylor Cass Talbott, Ground Score’s co-executive director, who is also the advocacy director for the IAWP.  Cass Talbott, Laura Tokarski, and Barbra Weber co-founded Ground Score in 2019 as a “peer-led initiative,” meaning it would be organized by and for the city’s waste pickers. Weber had been collecting cans in Portland since 2015—she had previously worked in marketing, but a brain lesion affected her ability to speak and put her on the street. Tokarski had already founded the Portland-based Trash for Peace, a nonprofit that engagess with communities to reduce and reuse waste. Ground Score is now fiscally sponsored by Trash for Peace. In contrast to most waste pickers’ activities, Ground Score’s GLITTER program doesn’t focus on recovering and selling recyclable material. According to one of the organization’s co-directors, Nic Boehm, 26 percent of what participants collect is nonrecyclable “microtrash,” like cigarette butts. Much of the rest is food wrappers, containers, plastic bags, needles—things that can’t be recycled and are instead destined for landfills or incinerators.  Ground Score employees at The People’s Depot pay cash for the cans and bottles that canners drop off.Brodie Cass Talbott GLITTER’s workers are compensated thanks to funding from the City of Portland’s Homelessness and Urban Camping Impact Reduction Program, as well as contracts with local businesses associations. The Homeless Services Department, a partnership between Portland and overlapping Multnomah County, has also supported the program through funds raised by a 2020 “supportive housing services” tax, though a department spokesperson told Grist that funding for “employment programs” like GLITTER may be reduced in the 2026 budget.  GLITTER highlights the value that waste pickers provide outside the recycling value chain, by keeping city streets clean. “Trash attracts other trash,” Boehm tells me as his group sweeps up fast food containers and wrappers around an overflowing garbage can. The goal is to keep the buildup at bay. Ground Score also has another program that more closely resembles the type of waste picking that is common in other jurisdictions. It’s called The People’s Depot, and it serves as a dropoff point for those who collect and sell used cans and bottles, who are sometimes called “canners.” The people who visit the depot gather empty water bottles and aluminum cans, whether from the side of the road or from unsorted residential recycling bins, and then lug them to a small lot underneath the Morrison Bridge, in Portland’s Central Eastside neighborhood.  At the depot, canners sell their goods for 10 cents a pop—a value assigned to them by the current version of Oregon’s 54-year-old bottle bill. Ground Score’s payroll employees, some of whom are current or former canners, dole out more than $4,000 in cash each day. The money comes from beverage companies that pay into the Oregon Beverage Recycling Cooperative, a nonprofit that manages implementation of the bottle bill. Deposited bottles are hauled off at the end of each day to an Oregon Beverage Recycling Cooperative warehouse, where they’re weighed so that Ground Score can be reimbursed for their value. Kris Brown is the operational manager at The People’s Depot. He’s worked there since 2021, but before that, starting in 2016, he made a living collecting cans—one night a week in Portland’s Southeast quadrant, a couple nights a week near Willamette Park in Southwest. Apartment complex dumpsters were hotspots, he says, because many apartment buildings lacked a separate recycling bin, meaning there would be lots of cans and bottles to pull out. Brown lived in tent camps around town, and under Portland’s Tilikum Crossing bridge during the earliest days of the Covid pandemic. “There’s this stigma that if you’re homeless, then you’re useless. Like, ‘Why don’t you get a real job?’” he says. “But collecting bottles and cans — it is work. It wasn’t enough money to get a house or an apartment, but it was enough for me that I didn’t have to go begging or steal anything. I could be me and feel good about it.” Where deposit return systems do exist, the data suggests that they play a big part in boosting the number of containers that get reclaimed and recycled. According to an industry estimate, cans covered by deposit systems are recycled in the US at a rate of 74 percent, compared to the national average of 43 percent. Plastic bottles eligible for a deposit are returned at rates of up to 81 percent, compared to a national average of under 30 percent (although not all of what’s collected is ultimately recycled due to technological and economic limitations on plastic recycling).   Canners congregate at The People’s Depot in Portland’s Central Eastside neighborhood. Brodie Cass Talbott In Portland, The People’s Depot offers an alternative to deposit locations attached to supermarkets and convenience stores, where waste pickers say they’re treated with disdain by shoppers and passersby. Last year, hundreds of Portlanders blocked a new bottle dropoff location proposed in the neighborhood of St. Johns. They cited “safety” concerns and a “potential increase in crime or vandalism.” Brown, who regularly invites mutual aid groups and a mobile library to visit The People’s Depot so its patrons can benefit from free books and food, calls the program a “more humanizing experience.” He suggests it could be a model for scaling up waste picker-led recycling programs in other cities. “It becomes more of a community space for [canners] to show up to,” he says. “And the community shows that respect back to us.” Ground Score has had a presence at all five negotiating sessions for the global plastics treaty so far. Weber and Cass Talbott helped draft the IAWP’s 2023 report, “Vision for a Just Transition for Waste Pickers under the UN Plastics Treaty,” which describes the environmental importance of waste pickers’ work. The report calls for, among other things, the direct involvement of waste pickers in plastics-related policymaking, as well as “universal registration” of waste pickers in local and national databases, so they can be enrolled in social benefits programs and more formally included in the plastics recycling value chain.  In order to create more programs like Ground Score, Cass Talbott says waste picker collectives around the world should cultivate relationships with policymakers inside local and regional governments, who can help educate their peers on the benefits waste pickers provide. Ground Score has one particularly strong connection within Portland’s Homelessness and Urban Camping Impact Reduction Program, which has helped Ground Score negotiate nearly all of its contracts with the city, according to Cass Talbott. Waste pickers with the Nakuru County Waste Pickers Association in Kenya call for recognition and respect outside of a dump site in 2024. James Wakibia / SOPA Images / LightRocket via Getty Images via Grist Waste pickers and their allies often talk about a “just transition” for the waste sector, a concept that seeks to resolve the apparent tension between reducing plastic production and protecting waste pickers’ livelihoods: If oil and gas companies stop making so much plastic, waste pickers could have less work to do.  For their part, Ground Score’s employees and day workers are aware of that tension. Brown, at The People’s Depot, stresses that plastic production should be reduced and that companies should be “held accountable” for the waste they create. Detten, the GLITTER group member, says she wishes we could send a big laser up into space to “zap” away the world’s plastic pollution. Christine Alix is more reserved than some of her co-workers. She has dark blue hair peeking out from under her baseball cap, and wears bright yellow sunglasses despite the overcast day. She says that, before she started waste picking, she would get angry with people for throwing plastic onto the street. Her feelings are more complicated now: “Thanks for giving me a job,” she jokes. Alix says her bigger priority is trying to keep streets looking clean in order to “reduce the impacts of sweeps,” referring to the police clearing of tents and other shelters from parks, sidewalks, and other places.  Most of the team is effusive about Ground Score’s social mission and the way a simple, low-barrier job can change people’s trajectory. At least three people tell me Ground Score saved their life. Others say their work with the organization has given them a renewed sense of purpose and self-respect. “I love my job,” Detten says. “It’s fulfilling in a way that just expands my humanity.”

One day about 10 years ago, Alicia Mitchell-Mercer experienced one of those moments that change the course of a person’s life. She was a longtime paralegal in Charlotte, North Carolina, working for a consulting company that helps law firms with project management. In the lobby of a client firm that day, she overheard a troubling conversation. A receptionist was explaining the firm’s rates to a caller who was clearly in distress. Ray (a pseudonym) was a single father and fast-food manager with three girls between the ages of 7 and 12. His estranged common-law wife, struggling with addiction, had moved in with a man who’d done prison time. Ray had heard she was planning to leave town with him and take the kids, and he was desperate to prevent it. Despite the urgency of his situation, the receptionist was telling Ray the firm would be unable to help—he couldn’t afford their fees. Mitchell-Mercer reached out to Ray. It turned out he’d already been to the sheriff’s office and had consulted with a court advocate. Both said he needed an emergency custody order—and a lawyer. She knew how to help him, but she couldn’t do it on her own. Laws in all 50 states forbid what’s known as “unauthorized practice of law.” UPL statutes generally preclude the provision of legal services by nonlawyers, even old hands like Mitchell-Mercer, who, in addition to her decades as a paralegal, has served in state and national legal organizations and volunteered as a court-appointed child guardian. For Ray, she found a workaround. On her own time, she ghostwrote a complaint and had an attorney she knew review it. Ray filed the complaint as an unrepresented litigant and got his emergency order. But by the time his daughters were located, several weeks after Mitchell-Mercer reached out, the girls were living in another state and said they’d been assaulted and sexually abused. Mitchell-Mercer dreads to imagine how much worse things might have been had she not intervened. “This man had gone to everyone under the sun to try and get help and wasn’t able to,” she said. “That was one of the first times I realized how broken things were.”   With that realization, she would soon find herself drawn into an unusual coalition of left-leaning academics, grassroots activists, and libertarian lawyers, all striving to democratize civil legal services by suing states, including her own, to roll back their UPL laws. Strange bedfellows, to be sure, but their timing is impeccable. As the pendulum swings in favor of deregulation, even some progressive politicians and traditional fans of zealous government oversight have cast a skeptical eye on overbearing restrictions, like the zoning and environmental codes that are thwarting construction of desperately needed housing and clean energy projects. Depending on whom you ask, if Mitchell-Mercer and her allies can put their arguments before the Supreme Court, they could either smash barriers that have left millions of Americans helpless against abusive partners, bad landlords, and heartless corporations or usher in a bonanza of poverty predation—or both. Either way, their efforts have the potential to change the legal landscape profoundly.       The failings of America’s criminal justice system are common knowledge, but our civil legal system, which affects even more people, is no less compromised—and there’s no civil equivalent to the Sixth Amendment’s right to counsel in criminal cases. A 2022 report from the Legal Services Corporation (LSC), a nonprofit that Congress established during the 1970s to fund free civil legal aid for the poor, notes that “low-income Americans do not get any or enough legal help for 92 percent of their substantial civil legal problems.” More than 70 percent of low-income families encounter at least one such issue a year, the LSC reports. As in Ray’s case, these are often true emergencies—domestic violence, eviction, predatory debt collection—with life-altering stakes. A 2018 study found, for example, that tenants facing eviction in the Minneapolis area were four to five times more likely to be forcibly removed from their home if they lacked legal representation. But lawyers charge around $300 an hour on average, putting their services out of reach for even much of the middle class. State legal aid organizations, meanwhile, are independent nonprofits and, despite some government support, are badly underfunded. In Mitchell-Mercer’s home state, there is only one Legal Aid attorney for every 8,000 eligible people—those with annual household income of no more than $39,000 for a family of four (125 percent of the federal poverty level). The National Center for Access to Justice ranked North Carolina the third-worst state for access to civil attorneys—only Mississippi and South Dakota scored lower. About half of its counties are legal deserts, with fewer than one lawyer per 1,000 residents.       This dearth of affordable representation affects communities of color disproportionately, and Mitchell-Mercer, who is Black, is regularly approached by members of her church. A woman needs assistance getting a restraining order. A family facing eviction doesn’t know how to respond to court papers. The immediate solutions are often straightforward—a matter of properly filing standard legal documents—and well within her realm of expertise. But even such minimal assistance is verboten. In theory, the UPL laws are in the public interest—conceived, in part, to protect people from predatory charlatans and incompetent practitioners. But they’re also the primary mechanism by which lawyers maintain their monopoly on legal advice. Even as Americans have grown used to receiving basic medical care from physician assistants and nurse practitioners—including diagnoses, treatment, and prescriptions—UPL rules ensure that no equivalents exist for legal services. Most of the statutes are extremely broad, encompassing everything from giving legal advice to drafting documents and appearing in court. They are vigilantly policed by the state bars, and violating them exposes nonlawyers like Mitchell-Mercer to sanctions, even including jail time. Which is why, when someone comes to her for help, there’s often little she can do.       To a degree unmatched by other professions, American law is a self-governing fiefdom. There are no federal rules for lawyers. Officially, state supreme courts act as industry overseers, but as a practical matter, regulation is largely delegated to state bars. These are the licensing bodies that lawyers join upon passing the bar exam, as opposed to bar associations, which are professional groups. State bars determine not only who may practice law but what constitutes that practice—including tasks that people without a law degree are quite capable of handling.      Stanford law professor Nora Freeman Engstrom and researcher James Stone trace the current regime back to the 1930s, when bar associations launched a fusillade of litigation against unions, homeowners associations, and auto clubs that provided legal services to members, accusing them of violating incipient UPL laws. “In state after state,” Engstrom and Stone wrote in the Yale Law Journal, the bar associations prevailed, eliminating competition and decimating “a once-thriving system for the provision of group legal services to ordinary Americans.”     The industry’s evolution over the past half-century has only made access to lawyers more exclusive, said James Sandman, a Penn Law School lecturer and former LSC president. In 1973, less than half of law firm revenue came from corporate clients, as opposed to individuals; by 2023, the figure was nearly 75 percent. “They’re going after the clients that can afford to pay,” Sandman said. “Individuals who don’t have lawyers have to navigate an unbelievably complicated, opaque system designed by lawyers for lawyers.” He continued, “But the image people have of what goes on in a courtroom, where both parties have lawyers arguing facts on behalf of their clients, is a fiction in more than three-quarters of civil cases.” > “I’m not going to jail for you or anybody else,” says a social worker who > helps with visitation and custody issues at a free legal clinic. “People say, > ‘What would you do?’ Well, I can’t tell you.” The legal industry fiercely resists incursions onto its turf. In response to a 2008 proposal to loosen UPL restrictions in Washington, the state bar association claimed the move would create “second class, separate but unequal, justice” and deprive less-affluent lawyers of work. The North Carolina bar issued a cease-and-desist letter that year to LegalZoom, saying the tech firm’s document-creation service violated UPL law. (The company, which has faced similar challenges elsewhere—most recently in New Jersey—then sued the North Carolina bar and later settled, agreeing to have lawyers vet all of its documents.) Meanwhile, a 2015 proposal to relax California’s UPL rules would, one foe argued, be “detrimental to the honest attorneys who are trying to make a living.” But the image of a general-practice lawyer hanging a shingle on Main Street is largely a relic of the past. Today’s median lawyerly income is roughly $150,000, and law is increasingly a business of corporate specialists. From 2013 to 2023, the number of lawyers working at firms that have more than 500 attorneys increased by 36 percent. The bar’s proposed solutions to the affordability crisis—increasing legal aid funding and expanding pro bono requirements—are woefully inadequate. “Providing even one hour of attorney time to every American household facing a legal problem would cost on the order of $40 billion,” legal scholars Gillian Hadfield and Deborah Rhode wrote in 2016—almost 30 times the overall legal aid expenditures in 2013. To provide even this minimal level of counsel, they calculated, every licensed attorney in the United States would have to clock more than 200 pro bono hours a year. To make a dent in the problem, legal aid organizations would need a massive increase in support. Last year, Congress approved only $560 million for the Legal Services Corporation, about a third of its budget request. And even if LSC were fully funded, lots of low-income litigants would be stuck on the sidelines. Those who are ineligible for financial or other reasons, and who can’t find other pro bono legal help, are left to navigate a patchwork of free clinics and courthouse services that vary greatly in quantity and quality. Concentrated in urban areas, these clinics are generally staffed by nonlawyers who cannot offer clients any actual legal advice.  Daniel Stolle On a recent morning at a courthouse in downtown Raleigh, employees of the Wake County Legal Support Center were helping people fill out standard forms and offering instructions on how to serve court papers. The center, one of the few of its kind in North Carolina, opened in January 2023. A local judge had estimated that 2,000 people might use it each year. In 2024, it served almost 14,000.  Seated at a long plastic table, a court advocate who specializes in domestic violence issues was especially busy. “Does she have a concealed carry permit?” she asked a bearded Black man in an orange construction shirt and mud-caked boots. The man shook his head. He was filing for an emergency protective order against his partner for himself and his child. Still, he said, “she could tweak out at any moment.” He left the center visibly relieved, an envelope of completed forms tucked under his arm. But the two young women who came next couldn’t decide how to proceed. They wanted the advocate to advise them, but she wasn’t allowed. Both left empty-handed.    This happens all the time, Norma Boyd, who was sitting at an adjacent table, told me. Boyd, a veteran social worker whom everyone calls Ms. Norma, handles questions about child custody and visitation. Often, she said, people have difficulty understanding basic legal terms. “I ask, ‘Are you the plaintiff or the defendant?’ They don’t know.” Even if they file initial paperwork, their cases are frequently dismissed when, without further guidance, they miss follow-up steps such as serving documents and filing certificates of service. For people without an attorney, the courtroom is an intensely frustrating, alienating place. “I felt like this street rat showing up to a cocktail party uninvited, and everybody knows what’s going on except me,” one North Carolinian who’d represented himself in a custody trial against a lawyered-up former partner told me. Boyd, with her proximity to family law, often knows perfectly well what the center’s clients ought to do. But “I’m not going to jail for you or anybody else,” she said. “People say, ‘What would you do?’ Well, I can’t tell you. I tell people, ‘These are your options.’ People want you to tell them what to do, and I can’t.”       Mitchell-Mercer’s quest to reform the system took shape in 2020, when she and another paralegal, S.M. Kernodle-Hodges, founded a nonprofit called the North Carolina Justice for All Project. They were inspired by policy changes in a handful of other states, notably Arizona, Utah, and Washington, that permit nonlawyers who’ve undergone special licensing programs to provide limited legal assistance. In Utah, they can work on family law matters, including domestic abuse, child custody, and divorce, plus eviction and debt collection cases. In Arizona, they can handle certain criminal and juvenile law issues. In both states, they can give advice; review, draft, sign, and file documents; and accompany clients to court. (Similar programs are now under consideration in about a half-dozen other states.) Kernodle-Hodges, a former deputy sheriff who calls everyone by their last name—she goes by “Kernodle”—had been thinking about bringing such a program to North Carolina. On a colleague’s recommendation, she reached out to Mitchell-Mercer, who had served a stint in the Army and written her master’s thesis on legal services. They proved a good fit. Kernodle, too, is Black and a court advocate. Both women are extraordinarily disciplined and scheduled to the hilt with professional and volunteer obligations. Both have a precise, punctuated way of speaking and a kind of regal poise. In January 2021, they proposed a program comparable to those in Arizona and Utah to the North Carolina bar. At more than 100 pages, their plan was deeply researched, with rigorous citations. The bar’s Subcommittee Studying Regulatory Change, of which Mitchell-Mercer and Kernodle were members, held a series of meetings and hosted outside experts to vet the proposal. > “When you have this many disparate parties involved, the Supreme Court is > going to have to resolve it…It’s going to be one of the first big economic > regulation cases of our era.”   In January 2022, the subcommittee issued a report fully endorsing it. But the authors weren’t convinced they would get a fair shake. “What we were hearing was that there was some hesitancy to move forward,” Mitchell-Mercer recalled. “Our ideas were getting explained to other bar committees, and not necessarily being well received.” Indeed, the bar went on to create another subgroup, supposedly to address the access question, from which the two women were excluded. When that committee first met, in October 2022, they posted a message to the Justice for All Project’s website: “We are concerned that this new committee was formed solely to appear that state bar leaders are doing something about the access to justice crisis and to appear empathetic to the plight of North Carolinians,” they wrote. And “there is reasonable concern that North Carolina State Bar officers have no serious intention of acting on previously discussed initiatives.”   A prominent lawyer sympathetic to Kernodle and Mitchell-Mercer told them that bar leaders were describing them as “angry and aggressive,” an offensive stereotype. Mitchell-Mercer tried to take it in stride. Kernodle was upset. “Mercer is a look-at-the-bright-side person,” Kernodle explained. “She will give you the very proper language about everything. My thing is: What’d you say?!” But they had been careful not to frame their proposal in racial terms. “No matter how cordial we were, it was still upsetting to them,” Kernodle said. The bar took no further action, in any case. And so, in 2023, the women submitted a similar proposal to the state legislature, backed by more than a dozen legal entities, including the US Department of Justice, whose antitrust division commended their “thoughtful analysis and policy recommendations and looks forward to reviewing any related bills that ultimately are introduced to the North Carolina legislature.” None were forthcoming. Kernodle and Mitchell-Mercer had encouraging talks with several lawmakers, but their proposal, which asserted that UPL laws gave attorneys “no meaningful incentive to provide affordable services,” clearly ruffled some feathers.  Amy Galey, a Republican state senator and an attorney, sent the women a blistering email that March, copying her Republican colleagues: “So you want to create a two-tiered system of legal representation, one of well-educated licensed lawyers for people who can afford them, and a second tier of unlicensed, unregulated people of questionable education for low income people,” she wrote. “If your response would be no, they would be licensed, and we would regulate them, and they would be required to have a certain education—yes we have that already, and they are called attorneys.” She went on: “Your proposal would create an A-team and a B-team…and ultimately solve nothing.” Asked for further comment, Galey replied, “That’s a really good quote, glad I said it, and I don’t have anything to add.” Her message effectively ended the discussion. Kernodle and Mitchell-Mercer heard nothing more from the legislature.         Even as they contemplated defeat, the women were introduced to an unexpected ally, Paul Sherman, a senior attorney with the Institute for Justice, an influential libertarian public-interest law firm. Founded in 1991 as a nonprofit with a $350,000 grant from Charles Koch’s foundation, the IJ now spends about $44 million a year, much of it litigating in federal courts to “protect the constitutional rights of Americans” against what its funders and principals view as regulatory overreach. Professional licensing laws are among the firm’s favorite targets. In Louisiana, Florida, Kentucky, and elsewhere, the IJ has successfully challenged what it argued were onerous licensing laws for engineers, diet coaches, florists, and tour guides. Since the late 2000s, it has increasingly framed professional licensing as a violation of the First Amendment, relying on a series of Supreme Court decisions that eroded the right to limit certain kinds of speech. In one 2015 case, Reed v. Town of Gilbert, the court held that an Arizona town’s attempts to restrict public signage based on its content were unconstitutional. In another, National Institute of Family and Life Advocates v. Becerra, in 2018, the justices rejected the idea that professional speech and commercial speech enjoy less protection than personal speech. “There’s never been a better time in American history to be litigating free speech cases,” Sherman told me. “The court has adopted a more or less libertarian interpretation of the speech clauses of the First Amendment.” > Without adequate guardrails, “there can be consumer fraud. There can be a > whole variety of issues…We need to be focused on: What’s good for the public?” In January 2024, Sherman filed a First Amendment lawsuit on behalf of the Justice for All Project that challenges the scope of North Carolina’s UPL prohibitions. Naming five local district attorneys and the president of the state bar as defendants, it builds on the IJ’s suit against New York state—where the firm represents a pastor and a legal-tech nonprofit called Upsolve, arguing that they should be able to advise clients battling debt collectors—and a similar case brought by the NAACP in South Carolina that centered on eviction. The Upsolve case is under review by the 2nd Circuit after a lower court issued a preliminary injunction in the nonprofit’s favor, and the South Carolina Supreme Court has granted the NAACP permission to train nonlawyers to provide eviction-related advice.    But the North Carolina claims are substantially broader, asserting the right of nonlawyers to advise clients on a spectrum of issues and charge for their services. This is by design. “The goal is for the Supreme Court to make clear that advice, no matter what the topic, is protected by the First Amendment,” Sherman said.  Legal experts figure this case, or a similar one, has a good shot at getting in front of the high court, and soon. “It’s not going to stop in North Carolina,” said Lucy Ricca, executive director of the Deborah L. Rhode Center on the Legal Profession at Stanford. “These cases have the potential to blow through” the political morass. “When you have this many disparate parties involved, the Supreme Court is going to have to resolve it,” concurred Dan Rodriguez, a professor at Northwestern Law School. “It’s going to be one of the first big economic regulation cases of our era.”   Sherman acknowledges that taking on the bar is, well, a high bar. “We tried to think of occupations that are composed largely of speech, and of course, one of the first that occurred to us was our own: the practice of law,” he said, but “before we could challenge that system, we had to have some victories involving other occupations to establish the legal principles in a setting that would be less scary to judges.” He now believes the Institute for Justice has the precedents it needs. It doesn’t hurt that at least one Supreme Court justice has expressed displeasure with the status quo. Lawyers “have used the expansive UPL rules they’ve sought and won to combat competition from outsiders seeking to provide routine but arguably ‘legal’ services at low or no cost to consumers,” Neil Gorsuch wrote in a 2016 article. “It seems well past time to reconsider our sweeping UPL prohibitions.”   A Supreme Court ruling favoring the IJ in the North Carolina case could greatly expand access to civil justice for the people whom Mitchell-Mercer and Kernodle aim to help. But even some access-to-justice proponents are wary. If you wipe out all restrictions on providing legal advice, “there’s no logical stopping place,” Northwestern’s Rodriguez told me. That’s part of why more than a dozen civil legal services and rights groups in New York oppose the IJ’s suit there, including Legal Services NYC, the nation’s largest provider of free civil legal assistance. > “When we started making these arguments, people laughed at the idea that the > First Amendment could apply to professional speech…People aren’t laughing at > these arguments anymore.” “Plaintiffs would immediately relegate low-income New Yorkers, including low-income New Yorkers of color, to receiving questionable legal advice,” the groups wrote in an amicus brief. “The consequences,” they argue, “can be disastrous.” Incompetent legal guidance could pave the way for “creditors and debt collectors to secure an unaffordable settlement agreement or an easy judgment that they can then use to freeze bank accounts and garnish wages.” Critics also fear that artificial intelligence would unleash a firehose of dubious counsel. Without adequate guardrails, “there can be consumer fraud. There can be a whole variety of issues,” Andrew Perlman, the dean of Suffolk University Law School, told me. It’s not hard to imagine entrepreneurs akin to payday lenders and skeezy tax preparers opening outlets in low-income neighborhoods to peddle legal help. “We need to be focused on: What’s good for the public?” Perlman said. The fact that Sherman’s group takes money from dynasties like the Kochs and the DeVoses doesn’t exactly ease liberals’ concerns. “Open their books and it’s a cornucopia of ProPublica’s worst nightmares!” Rodriguez quipped. “There are going to be people drafting on these sympathetic plaintiffs, looking for economic advantage. You think you’re protecting access to justice, but actually, you’re feeding the Koch brothers’ wildest fever dreams!”   Hadfield, who teaches at Johns Hopkins University and is an influential voice on the access issue, is skeptical of the First Amendment framing. “I don’t think that [just] anybody should be able to say anything to anybody about legal matters,” she told me, and merely empowering competent nonlawyers to provide advice isn’t enough, given the scope of the problem. She dreams of a future in which large nonprofits and businesses harness technology, including AI, to furnish reliable, ethical, low-cost legal assistance on a massive scale. Many academics who study civil legal access share a similar vision. You could have Amazon get in on the act, and also retailers like Walmart, whose customers might one day obtain a simple will or even a divorce while picking up their prescriptions. “We’re worried about the impact of these companies in communities, but they’re also just better at serving consumers than lawyers are,” said Stanford’s Ricca. “Lawyers think we’re really, really special—a privileged class. But we’re just not serving regular people anymore.” Qualms aside, Hadfield does hope the First Amendment cases succeed, “because we need to break open a very, very harmful set of practices: this stranglehold that the legal bar has.” There’s no evidence that litigants have been harmed in the states that have relaxed UPL rules, she added—and a scorched-earth approach may well be a necessary first step in creating a more equitable and thoughtfully regulated industry.             The Justice for All Project hit a snag in December, when a federal judge dismissed its case. The court ruled that North Carolina’s UPL statutes regulate “conduct”—the practice of law—with only “an incidental impact on speech,” and thus do not violate the First Amendment. The decision relied, in part, on a recent appellate ruling against another IJ client, a drone photography company that North Carolina targeted for the “unlicensed practice of land surveying.” The December ruling is “disappointing but not surprising,” Sherman told me, arguing that both decisions clearly misapply Supreme Court precedent. He is appealing the Justice for All case while the high court considers whether to review the drone case. For Sherman, both losses are merely temporary setbacks: “We’ve been litigating these cases for 15 years. What’s amazing is when we started making these arguments, people laughed at the idea that the First Amendment could apply to professional speech. The Supreme Court agreed with us. People aren’t laughing at these arguments anymore.” Mitchell-Mercer, too, was skeptical of Sherman’s strategy at first. “I had never thought of this as a First Amendment issue,” she told me. But she’s come around, even adopting some of the language of her libertarian allies. “People should be trusted to know that they’re gonna get what they pay for,” she said. “Prohibiting people from even having a conversation is almost a weaponizing of paternalism. Telling people that we’re going to control who you can talk to about your issue, who you can hear from, is not benefiting the public. It benefits the lawyers.” 

Homelessness in America reached the highest level on record last year, according to new data released by the Department of Housing and Urban Development—and it will likely only get worse, in light of both a Supreme Court decision issued in June and President-elect Donald Trump’s forthcoming presidency. The annual report—which estimates the number of people staying in shelters, temporary housing, and on the streets on a single night—found more than 770,000 people experiencing homelessness on a single night this past January, up 18 percent from a night in January 2023. The increase in the rate of families experiencing homelessness was even steeper, rising 39 percent from 2023 to 2024. And there was a 33 percent increase in children experiencing homelessness, bringing the amount recorded earlier this year to nearly 150,000 kids. (Experts say the numbers are likely an undercount.) HUD attributes this rise to “significant increases in rental costs, as a result of the pandemic and nearly decades of under-building of housing,” as well as natural disasters—such as the deadly August 2023 Maui wildfires—that destroyed housing. Other factors include “rising inflation, stagnating wages among middle- and lower-income households, and the persisting effects of systemic racism [that] have stretched homelessness services systems to their limits,” the report says. (Black people remain overrepresented, accounting for 12 percent of the US population but 32 percent of those experiencing homelessness, according to the report.) California and New York had the highest numbers of people experiencing homelessness. Some of the nationwide increase, the report notes, was also due to “a result of [communities’] work to shelter a rising number of asylum seekers.” In New York City, for example, asylum seekers accounted for almost 88 percent of the increase in sheltered homelessness. HUD points out that the counts were conducted after Republicans in Congress blocked a bipartisan Senate deal that would have funded border security and before President Joe Biden’s border crackdown via executive action—a reference Sen. John Cornyn (R-Texas) aimed to use to his advantage. https://twitter.com/JohnCornyn/status/1872996093543522435 Balakrishnan Rajagopal, the UN Special Rapporteur on the right to adequate housing, responded on X that this was a “misdiagnosis of its causes,” adding that he has a report forthcoming on “this easy scapegoating of migrants for the homelessness crisis.” Despite the bleakness of the data, there were some signs of progress: Homelessness among veterans dropped to the lowest number on record: 32,882—an 8 percent decrease from 2023. The report also spotlights a few places (Dallas, Los Angeles, and Chester County, Pennsylvania) that saw significant decreases in people experiencing homelessness thanks to targeted efforts to increase the availability of housing and other supportive services. Still, it’s hard not to see the data as an indictment of one of the world’s wealthiest nations, where basic necessities—housing, food, and healthcare—are out of reach to many low- and middle-income families. And, as the report intimates, it is likely that people experiencing homelessness will face even greater challenges in light of Grants Pass v. Johnson, the June Supreme Court decision that essentially greenlit the criminalization of homelessness. (As I have reported, domestic violence prevention advocates expect the ruling will be catastrophic for survivors, given the role abusive relationships can play in driving victims to homelessness.) Ann Olivia, CEO of the National Alliance to End Homelessness, said in a statement she hopes the data will spur lawmakers “to advance evidence-based solutions to this crisis.” (Vice President Kamala Harris made new housing construction a key part of her campaign.) Some Democrats agree that politicians have to act—and fast: https://twitter.com/BernieSanders/status/1872743695721828828 “As housing prices increase, homelessness increases,” Rep. Maxwell Frost (D-Fla.) posted in response to the same AP article. “Homelessness is a housing problem.” But don’t hold your breath: Trump’s acolytes have signaled their desires to slash the social safety net and enact mass deportations of undocumented people, which experts have said will likely exacerbate the housing crisis given the role immigrants play in the construction industry. The closest his budding administration has come to offering a solution is VP-elect JD Vance’s claim that mass deportations will solve the housing shortage by freeing up units.

Amid the frenzied coverage of UnitedHealth CEO Brian Thompson‘s assassination and the public’s troubling reaction to it were references to various polls, including one conducted in 2016 by the Kaiser Family Foundation, whose results suggested that Americans were content with their private health plans. Similar stats had crept into the debate over Medicare for All—a proposed national health insurance program to cover all Americans, and with which private insurers would have to compete. A few weeks before Thompson was murdered, AHIP, the primary trade group for commercial health insurers, published a new survey it had commissioned. About three-quarters of respondents, a “strong majority,” the group said, were satisfied with their employer-provided plans and preferred getting their coverage this way, as opposed to through any government program. > “We’re living in a country where we have people who literally can’t afford to > breathe.” I found these numbers hard to square with the nonchalant—even celebratory—response to Thompson’s death. Until, that is, I spoke with Ed Weisbart. A veteran medical doctor, now retired, Weisbart serves as national board secretary for Physicians for a National Health Program (PNHP), a nonpartisan organization of some 25,000 doctors founded in 1987 to advocate for a public health insurance program. (Disclosure: My late mother was a member.) So long as you’re healthy, he told me, it is in your insurer’s best interest to keep you happy by delivering on small claims. It’s only when it looks as though you’re going to cost them lots of money that the denials start coming—and maybe by then you’re too sick to fight. This interview was edited for length and clarity. What compelled you to join PNHP? I was a practicing physician for decades and got fed up with seeing patients unable to afford health care—not in the broad, abstract way, but in the very real, nitty-gritty way. The Type 1 diabetic who has uncontrolled disease, and I prescribe insulin for him, and it would make a huge difference in his life expectancy, but he comes back a month later and his blood sugars are no better. And I ask him why, and he would say, “Well, because I’m taking my insulin every other day. It’s all I can afford.” I know he’s barreling toward dialysis. A patient with end-stage emphysema came into the office without her oxygen, huffing and puffing, unable to breathe. She’s had portable oxygen at home and we know this because she had it previous visits. And I said, “Where’s your oxygen? Why are you so short of breath?” She says, “Oh, I can’t afford my oxygen anymore.” We’re living in a country where we have people who literally can’t afford to breathe. I’ve got hundreds if not thousands of stories like that. It just drives me crazy, realizing you have to advocate for patients outside of the exam room as well, and then understanding that the reason it’s like this is because of the profiteers just leeching the blood and soul of everyday human beings so they can have the best returns on Wall Street. What did you make of the reaction to the Brian Thompson killing? It’s obviously a tragedy and a very wrongheaded move. I was aghast. And yet it was also not hard to understand the dynamics, when there are tens of thousands of people dying because of the profiteering—people constantly running into having some bureaucrat say they can’t get the lifesaving care they need. So, I was not surprised, but I was surprised. What do you consider the biggest flaws of our health system? As a medical director at various places, I'd say the biggest problem is that the system is designed to return profits rather than to improve health. And the programs that you would want to design to improve health are contrary to the business model of the people that could put those programs in place. Related to that is the fragmentation of the system. That's a consequence of the first problem. It means comprehensive solutions can't be put in place. It means people are thrust into gaps in between care. So it creates its own set of expenses and driving up the cost. The third piece is our inability to negotiate prices on behalf of Americans, which other countries do. Those costs are borne all across the system in ways that are obvious, like the overhead of the insurance industry—13 percent to 18 percent depending on where you look. But then they hide more than that by transferring some of the overhead onto hospitals, hospital infrastructure, and medical practices. Milliman estimated the average physician pays $100,000 for office staff to deal with the insurance industry, and where does that money come from? It comes from jacking up prices. All the fee schedules have to be adjusted so physicians can afford to pay this overhead. This is unique to America. In Canada, the overhead of running a practice to deal with the national health insurance they have there is more like $20,000 or $25,000 per doctor. In any other industry, auto repair for instance, you get an estimate in advance of what it'll cost you. Why isn’t that the case with health care? Well, I would argue that's not the correct solution, anyway. Because in the auto repair industry, you can shop around and make an intelligent choice, and you know whether the car is going to work right afterward. In healthcare, it's the exact opposite. > “We spend roughly a third of the health care dollar propping up the bloated, > Byzantine insurance industry.” You can shop for prices for [commodity services like LASIK], but that kind of thing is a tiny fraction. In healthcare, a very large percentage [of the total cost of care] is spent in the last six months of life by people who are desperately sick, and they are not in a position to start shopping around. And even if you had the prices, how do compare that to quality? If an insurance company with six floors full of actuaries can't do the price-versus-quality equation so that you they can direct you to the best quality care for the price, how is the person who works at the gas station on the corner supposed to make that determination? I'm also curious about situations in which a patient gets a crazy bill, just totally unrealistic, and they kick up a fuss and the insurer suddenly reduces the cost or even wipes it out entirely. Is the whole system premised on people giving up and not fighting claim denials? Yes. There's data about this for Medicare. If Medicare denies a claim, it's usually because the claim is for something that's legally not a covered benefit. It's extraordinary for it to be any reason other than that, and so when Medicare denies claims—which they almost never do—and someone appeals, there's about a 1 percent chance that appeal will get reversed. Now, with Medicare Advantage, which is the for-profit, typically proprietary, insurance industry version of Medicare, its the exact opposite. If somebody appeals a denial, I think around 80 to 85 percent of those denials get reversed, because when Medicare Advantage does a denial it's because it wasn't in the company's business interest to pay for it. But nobody appeals it because they don't know that they can—or that it would work. Fascinating. So it's actually easy—well, not easy, because it's a total headache—but you can get these things reversed if you persist. I wouldn’t call it easy by any means. The patient has to spend significant time collecting things and going through the process. And you need a physician who's willing to help, and who's going to pay the physician for that? That's a chunk of the physician’s time that is not reimbursed. Plus, most people in a situation where they need to do that are sick. They're not at their best to begin with. It's really hard, really time-consuming. And there's a long delay from when you do the appeal to when you get a favorable decision. Tell me more about the for-profit model, and how delaying and denying claims plays into it. The commercial insurance industry collects a premium. So that's a prepayment. The Medicare Advantage industry is prepaid by the government. That's money in their pocket, and every time they pay a claim, that's money that they're spending. They have this term, “medical loss ratio,” which is a carryover from the fire loss ratio and property loss ratio, but they call it a loss when they pay. So, they don't want to pay, and it manifests in a couple of ways. First, if they don't pay the claim, that's money they can retain. Secondly, even if they just delay the care, they have sophisticated systems managing how they invest the money they're not paying. I once worked in a part of the insurance world where they did exactly that. They had contracts that required them to pay their bills within a certain timeframe, and if they paid long after they were contractually obliged to, there was a penalty, and they had sophisticated systems to analyze the return on their investments in the market vs. how big the penalties are for delaying the payment for care. And they would delay until they hit the right point on the curve where it was more sensible financially to pay the claim than to keep investing it in the market. So basically you collect a big pile of money and invest it and then avoid paying claims so you can keep that money invested as long as possible to maximize your returns in the market? That's exactly right. What are the kinds of procedures insurers are most likely to deny or delay, and the most common reasons people fall into medical debt? I can't give you a quantitative answer, but the more expensive a procedure is, the more likely they are to want to put in a barrier to payment. Insurers typically don't want to put barriers to things that low-expense patients get, like a blood pressure medication that's very inexpensive and that healthier populations use. It's to their advantage to get you to use the insurance a little bit because the people that are the most likely to disenroll from a specific company are the people who never use it. They want you to maybe get your eyeglasses or something. But if you're sick and you need home oxygen, or you need a CT scan or an MRI, or something that's both expensive and predictive that you're probably a higher risk person—that you're going to be a more expensive patient to take care of—they don't want to spend that money. So if you call them and say, “I'm so mad at you. You got in the way of my CT scan. I'm thinking of going to different insurance company,” the company has a win! They don’t want you in their plan. You mention CT scans. I know imaging is among the things medical practices tend to overprescribe because it’s a cash cow, and you get a fair bit excessive testing and overtreatment. Can certain denials then be to a patient's benefit? There is obviously a significant percentage of what we do in medicine that is not evidence-based and could probably be avoided. But if you compare the United States to other modern nations, our utilization of those kinds of services is roughly average. The problem with the high cost of care in the US is not overutilization. Is there overutilization? Absolutely. Is that the driver of healthcare costs? No, it's not. The driver of health care costs is two things: It's the overhead, the managing, the cost of the complexity of administering this. Most estimates are that we spend roughly a third of the health care dollar propping up the bloated, Byzantine insurance industry. The second piece is the failure to negotiate prices effectively because we're so fragmented. That's where the money is. How big a cost is the failure to negotiate prices? I can’t tell you overall, but the average prescription drug in the United States is about twice as expensive as it is in the rest of the modern world. How does the cost of a public insurance bureaucracy compare with the cost of a private one? The commercial insurance industry has a roughly 15 percent overhead. Traditional Medicare, parts A and B, operates with a roughly 2 percent overhead. Wendell Potter, a former Cigna PR guy, just wrote a Bloomberg piece on the role of Wall Street, and how executives at giants like UnitedHealthcare and Cigna go to these investor conferences where there’s no mention at all of patient care. It's all about the returns, and that's what's driving a lot of the misery we're seeing. Oh, that's exactly right. I mean, the root issue is greed. But don't public systems also have their drawbacks? The Veterans Administration has weathered scandals. And I saw a CTV News piece from last fall about how Canadians fed up with long wait times for surgeries in their public system were turning to private providers. If you go down the street in Canada and ask people, they all have a story like that. But then they'll say, “But there's no way I would change to the United States system where I have to have a bake sale to have my knee replaced.” They don't want this system. More importantly, US life expectancies were the same as Canadian life expectancies within a few months up until the early 1970s. That's when we passed the HMO Act, creating managed care, and Canada finally finished implementing their national health insurance plan, and then there was a fork in the road. Our costs continued to go up along the same curve. Their costs started to really flatten out, and our life expectancy did not begin to keep pace with the improvements in life expectancy in Canada. Fifty-some years later, they live three to five years longer than we do and spend half as much. Have you seen any notable pivot points for the United States in terms of the cost of care and deterioration of quality? They've been on a steady, relentless curve. There's a whole list of things that we have tried, and none have really bent the curve. There's one obvious solution. You mean single-payer? Correct. But I'm not stupid enough to say that sometime in the next four years or six years that's going to magically pass. One of the things PNHP has been really good about the last three or four years is thinking about a strategy of how do we pave the road to that? What has to happen? Our strategy to get the bills passed is far more robust than just pass the bill. The single-payer community five years ago, 10 years ago, would literally say you can only cross a chasm in a single leap. You know, I've looked at the bottom of chasms and there's dead people who couldn't make the jump. You cross the chasm by building a bridge slowly. Do you think for-profit insurers play any positive role in our system, or would you like to see them go away entirely? I would like to see them go away entirely. I mean, it's probably never going to happen here. Everything looks impossible until it's already happened. My skepticism comes from watching Obama try to implement single-payer and having it demonized as socialism—and "death panels" and so forth. I don't think people care whether it's single payer or quadruple payer. Those words mean nothing to people. You know, Medicare for All. That's not what they care about. People want health care. They don't care about health insurance. They're angry at the profiteering, the outrageous prices. They're angry they can't afford their care. They're much more focused on solve this problem than they are on which exact tool or mechanism you go to. That's what I think, too. What I care about is that everybody in the country has unfettered access to high-quality health care that they control the decisions for. I think single-payer is the smartest way to do it. But if we went to an "all payer" or some other model that accomplished that, I'm fine. I just don't want people dying like they are today.