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Germany, the UK and Canada offer additional models for health care insurance that vastly improve results for dollar spent over the dysfunctional U.S. model. Here Jamie Daw take a look at the German social health insurance system which dates back to hte period of Bismarck in 1884. The German system is funded through progressive taxation which charges for healthcare based on incomes not on health needs.

About 100 nonprofit health insurers provide insurance and all Germans are required to have health insurance. Contributions to sickness funds are centrally pooled and allocated using a formula to insurers. Insurers can only charge small out of pocket fees limited to 2% of income annually. Sickness funds combine market power to negotiate lower prices.

Administrative and governance costs are 3% in Canadian system and 5% in the German system. 

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The Medicare for All movement in the U.S. gathers momentum after the U.S. midterm elections with states. Governor Newsom of California says he will seek federal authority to setup a state single payer plan for health insurance. An expert at Georgetown University says there is a new burst of energy for broader coverage or universal health coverage. States with new governors or seeing this momentum are California, Washington, New Mexico, Maine, Nevada, Delaware, Oregon, Connecticut, Wisconsin, Michigan, Illinois. Polls show a large majority of Americans now support Medicare for All as a form of universal health coverage for all Americans, a system that prevalent in Canada for the last 50 years. Two hearings will be held in Congress on Medicare for All in 2019.

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After the 2008 election of president Obama rural whites left the Democratic Party, Following the election of president Trump educated suburbanites left the Republican Party. These two trends have accelerated as seen in the 2018 U.S. Congressional elections. Democrats won in and around major cities, and Republicans won in rural and small town America. Democrats won 27 GOP Republican COngressional seats to win the majority. Republicans added 2 seats to their Senate majority.  The electorate is sharply divided in terms of education in a way that is regressive and not good for America, and in a way that has never happened before. Republicans share of of House districts with lowest shares of college education bachelors degrees increased from 44% in 1998 to 60% in 2018. Democrats share of House districts with the highest share of Bachelors degrees went up from 50% in 1998 to 81% in 2018. Much of the Democrats support from educated suburbanites comes from lopsided support from educated women. The result is that the Republican Party is trading faster growing counties for slower growing smaller counties and now has a base of older voters. The Democrats have to find a leader who can rally support from this new combination of educated suburbanites, younger voters, and minorities. And big issues are at stake. About 77% of people in recent polls now support a national health care insurance like than in the UK and Canada. Poor reading skills and reading comprehension in school tests show a need for greater investment  in education. Infrastructure investment is a big priority for a decade that has yet to be tackled directly. Of the 50 new Democrats in the House of Representatives 24 campaigned on a promise for a national health insurance like that in Canada or UK. The focus on economic issues would move the Democratic Party back to where it was in all the post war years till the distractions from cultural issues  in the last decade shifted its focus from its historical base support of working class voters. ...

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The total government expenditure of the US including the individual states spending is 37% of US GDP (IMF). Musk $2 trillion cuts is 92% of the 2.17 trillion excluding defense, veterans benefits, interest on debt, Social Security, Medicare. The simple math means he plans to shut down the government. US  37.5%  Germany 48% France 57% UK and Canada 43% Japan 42% This shows that the US that has no universal health insurance and  subsidized public transportation, spends less than the developed OECD countries as a percentage of its GDP. Of the Budget of $6.75 trillion in 2024 Social Security $1.46 trillion   22% Medicare            $874 billion   13% Interest on Debt  $880 billion    13% Trump plans to remove tax on Social Security which would take this from 48% to over 50% meaning half of the Budget is off limits. If defense spending goes up not down then $874 and $325 for Veterans benefits are $1.2 trillion also off limits.  This means cuts of $2 trillion on $2.17 trillion or 92%. Do the simple math and this would shut down the government. ...

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Allan Blakeney was health minister of the Canadian province of Saskatchewan, and later premier of the province. Blakeney, as health minister in premier Woodrow Lloyd's government expanded a program in 1962 to cover the costs of doctor provided medical care. Earlier in 1946, the Saskatchewan government of Tommy Douglas setup a program of universal insurance coverage for hospitalization. This program of universal healthcare was extended to all of Canada in 1966. He later headed the provincial New Democratic Party and was premier of Saskatchewan from 1971-1982. During this period he introduced a New Deal for People, which included a dental program for children, prescription drug program, subsidized housing and a guaranteed income supplement for the elderly poor.

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The Washington Post survey of 1200 readers on how the Republican healthcare plan of Speaker Ryan and the House of Representatives looks to them, how it affects them in their lives. Here Somasekhar of the Post gives the stories of 5 Americans. Some see the prospect of losing their insurance under the Republican plan even as they reach an older age, others a smaller segment says the Post, whose premiums jumped under the Affordable Care Act say they faced high premiums and high deductibles. The Post says the large majority of opinions have expressed anxiety over the proposed Republican Ryan House plan for healthcare. One of them is an uninsured poor farmer, Mr. Woosley,  income about $18000 who gained benefit from expanded Medicaid under the Affordable Care Act,  one Mr. Smith, 32 years, a personal injury attorney who faces paying $10,000 if he did not take insurance and $10,000 if he took insurance because of high premiums so a wash either way deciding to do without it, one a tech worker Mrs. Powers, 62 years, income $22,000 on year and $4000 the next, from middle class during the tech boom but facing fewer opportunities and uncertain income from part time work, hit by the deep recession facing fewer opportunities as she gets older and now the prospect of losing insurance without government subsidies, one who is from the middle class who sees little benefit from the Affordable Care Act and is forgoing insurance because of the high premiums yet faces a penalty for not being insured under the ACA, another Mr. Blanchard, 52 years, is from the middle class, a computer programmer who lost his job in downsizing, earns $100,000 as a consultant self-employed, pays $767 in premium a month and relies on the Affordable Care Act which helps him gain freedom from working at a company that could downsize,  another is a middle class programmer Mr Riffle,age 44, and his wife, who does not qualify for a subsidy with a $71,000 family salary from working 4 jobs between himself and his wife- this person finds it too expensive for his salary to buy insurance $900 a month and $14,000 deductible under the Affordable Care Act. His views are worth listening to as they go to the crux of the problem- he says he may not be any better with the Republican plan. He sees the real problem as the high cost of health care in the U.S. and the only way this can be fixed is for members of Congress to be asked to use the insurance exchanges they create. If this sample is representative it shows that there are real problems with both the Affordable Care Act and the Republican plan, that the high cost of health care the problem lurking behind every plan that does not squarely address this, and till that happens and members of Congress experience what ordinary people face, this problem can never by fully solved.   Woosley, Smith, Powers, Blanchard, Riffle, and their personal experience is at the crux of what is right and wrong  with the Affordable Care Act, and also with the new Republican plan of Speaker Ryan and the House of Representatives. For every Woosley, Powers and Blanchard who benefit, there is a Smith and a Riffle who are indifferent or are affected by the high cost under Affordable Care Act and the current system of medical care with its high cost. The Affordable Care Act does not  tackle high cost, for that to happen the culture in America that makes it possible and acceptable to charge high prices must change. Another problem apart from bringing health care costs is that any solution needs to have the whole country behind it. If the notion that all people are entitled to basic health care is to stand, the whole country needs to believe it as they do in countries like France, Britain, Germany and Japan. If this has to be made a workable proposition health care has to be offered at a price that makes this possible to achieve, and that idea also needs the deep and broad sense of support from the culture in America similar to that in these other countries. Until that happens politicians in America will get elected and turned out of office in turns on issues such as health care, based on which side they take and which problems they choose not to face squarely and responsibly. ...

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A health care practitioner says the real problem is the high cost of medical care in the U.S. when compared to other countries. She points out that the Obama bill in 2008 did not take effective steps to bring down the cost of health care before enacting legislation to cover the uninsured, leading to higher premiums for the middle class. The link between healthcare and profits is seen as the main problem. 

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Friedman reviews Acemoglu and Robinson's new book, "Why Nations Fail." Acemoglu says that nations fail when wealth and opportunities are concentrated in the hands of few people, that a condition for societies to succeed is to create opportunities for more people. For this to happen it is important to create inclusive political and economic institutions. This is an important insight, but for Western society this is an insight as old as Adam Smith when he pointed out the importance of this aspect of western societies after the feudal period in his "Wealth of Nations." For Smith it was the failure to create inclusive societies that led to the gradual unravelling of societies in the river valleys of the Yangste and the Ganges, in China and India, of increasing poverty and the gradual disappearance of what constituted the middle class in India and China. Chapter 8 titled "Of Wages and Labor" in the "Wealth of Nations" makes specific reference to this.

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The health care system is designed to encourage procedure based specialist practices and discourages the patient understanding education and monitoring that occurs with a well designed preventive family physician practice. As a result a patient only spends 30 minutes ayear on average with family physician compared to one hour in other developed nations. In the USA there has been a steady decline in the level and quality and extent of family care and the close one on one rapport with well trained family physicians who enjoyed their work and understood their patients and kept up with their health conditions and provided good and regular advice on these conditions. There is no money in this care as a result first you provide an environment where a whole range of medical conditions can flourish and expand, and then you hit them with a whole series of tests to rule out specific medical conditions. It is a perfect way to expand the testing and let testing flourish, so it would appear that if someone had wanted to start with a goal of letting testing proliferate unhindered then this would be the perfect way to design it. ...

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John Cochrane, professor at the Booth School of Business, University of Chicago points to the simple truths about U.S. healthcare- out of control pricing because of the pathologies created by previous laws and regulations. He points out that costs are high in healthcare because regulations keep them high. Supply of new doctors is controlled because Congress and the AMA made it that way with a cap on residency programs and AMA opposing the expansion of medical schools. In a system of open competition new hospitals and health care businesses would challenge old ones which is not happening in a regulated market with regulations working to limit competition for the firms already in the business and with the influence to limit competition. Insurance costs for major expenses in an open and deregulated competitive market without the regulations would be so much lower than todays costs that its likely we would not even need a mandate such as the one the Obama healthcare law imposes.

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Estimates show the 50 million Americans enrolled in Medicare today will increase to 80 million by 2030, according to the program's actuaries. Simple demographics as the baby boom generation ages is making controlling the deficit without controlling increase in health care costs as both sides in the fiscal cliff negotiations are attempting to do can only lead to defunding critical areas such as education, R&D and infrastructure, and breaching the safety net for lower income Americans. Health care spending took up 7% of GDP in 1960, increasing to 17.9% of GDP in 2010. Federal spending on healthcare has grown to about 25% in 2012 from 10% in 1960, and is projected to increase to about 33% in ten years by the Congressional Budget Office.

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An average of major opinion polls compiled by Real Clear Politics website shows 50.5% of Americans opposed to the Obama U.S. health care law.

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This report in the Economist points to the improved situation for Mexico after the scare from Trump's plans to build the wall and deport large numbers of immigrants. The peso dropped by 15% between mid November 2016 and January 2017, but has since recovered, and non-oil exports were up 5.5% in February 2017 over prior year with the manufacturing growth in the U.S.  Growth forecasts are now up from about 1% GDP growth previously to 2% for 2017, close to the 2.3% in 2016. Much of the change in mood in Mexico is a result of the failure of the early travel bans being blocked in the courts, the failure to get health care legislation through Congress, and the effort by the trade advisers and economic advisers around Trump to move Trump's positions more to the centre and closer to traditional Republican party positions. Wilbur Ross, the Commerce Secretary, says " a sensible agreement" can be reached with Mexico. Peter Navarro, trade adviser, talks about making "a mutually beneficial regional powerhouse." Robert Lighthizer, a veteran from the Reagan days, is likely to be made the new U.S. Trade representative. Still as the Economist points out the "20% border adjustment tax" continues to be supported by Paul Ryan in Congress to pay for tax cuts. But certainly the mood has lifted in Mexico in the first 100 days. This is true for economic policy in relation to China and Germany, and the close circle of Ross, National Economic Council head Gary Cohn, and Secretary of State Tillerson is moving Trump to the centre in policy statements to get things done. Mexico is faced with internal challenges of reestablishing the rule of law, improving infrastructure, reducing red tape and corruption, addressing problems in the education system, to promote economic growth. These challenges may prove to be as large as the external challenges were once thought to be. ...

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Krauthammer cites Congressional Budget Office numbers that show the Obama U.S. health care law continues the spiralling costs of health care with new government mandates at a time of severe budget cuts in education and other areas- for 2013-2022 the costs come to $1.76 trillion. The initial Obama administration figures of 10 year costs of $938 billion announced in 2010 reflected the fact that the new U.S. health care law would take 4 years to fully go into effect. Costs after 2021 are shown to be $250 billion each year in the CBO figures. The law is now before the Supreme Court in 2012, which has to decide on the basis of the limits of the Commerce Clause.

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Pearlstein quotes Dickens in "Oliver Twist," about the law being an ass, and the constitutional law exercize in the Supreme Court of the U.S. giving a sense of a failure of the so-called best and brightest in reasoning out the issues. He points out that a serious problem is that American business which is burdened with high health care costs for employees is seriously missing in this debate after years of complaining about high costs. The National Federation of Independent Businesses is actually one of the plaintiffs questioning the constitutionality of the Obama health care law. Pearlstein says business wanted an end to the fee-for-service medicine that increases consumption of medical services and pushes up cost relentlessly, and that Obama's health care law does this. This is not the case as both Democrats and Republican administrations have failed to resolve this side of the cost issue, and this is the hidden reason for the loss of credibility for both sides in this debate, leaving health care problems to be resolved in future administrations. ...

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A recent book "The Spirit Level" has become popular in Britain. It says that countries with greater disparities in income also do worse in a number of social indicators, from higher murder rates to lower life expectancy. It also affects the consensus in society which is a necessary underpinning for sustained economic development and economic growth. Inequality when it affects the middle class and reduces the size of incomes in the middle, or creates stagnation in incomes, poses large risks for society and affects economic growth. In the US the home foreclosure crisis and the lack of bargaining power of wage earners in the middle class has created this problem. This is exacerbated by the banking crisis and bad loans in the banking system. Studies show that slow growth in college graduating rates in the USA after 1970 compared to the period 1900-1970, has increased inequality, especially with today's knowledge economy. Germany is also affected by this problem as wages for workers have remained stagnant with the labor reforms. Interestingly a combination of economic growth and payments to the poor have increased the size of the middle class and its incomes in Brazil. The austerity policies in Britain will affect incomes and income growth in Britain for the middle class. In China the gap is widening quickly between the urban areas and the rural areas. And the policy of residency permits- the hukou system-which limits internal mobility from rural areas to the cities and towns, makes the inequality all the more glaring. The lack of democratic election makes the situation worse in China compared to Brazil, because free elections in Brazil enabled leaders from the working classes such as Luiz Inacio Da Silva and Ms. Rousseff to emerge as heads of government. These leaders pursued policies that would explicitly bring a more shared prosperity in Brazil compared to the leadership in China. In China policies are determined by entrenched interests in its model of development- the state-owned companies and banks and their managers, local and government officials of the Communist party, and businesses with the networks and connections with the Communist party and local governments. This is why the ginni coefficient which measures inequality has dropped significantly in China, putting it in the rank of developing countries with poor records in equality. Inflation in China, India and Africa also affects the poor and lower middle classes to a greater extent. Current trends suggest that rebuilding the middle class in the developed countries and providing fairer distribution in developing countries will be of serious importance in coming years. Especially with the likelihood of more economic crises which tend to adversely affect the middle and lower classes disproportionately....

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Jerry Muller, professor of history at the Catholic University of America, offers some useful insights into the nature of inequality in advanced capitalist societies and other parts of the world, and a clear eyed way to tackle the problem of inequality. Tackling the problem should be done in a way that preserves the economic protections for the middle class and the poor which are needed for capitalism to work- unemployment insurance, Medicare, Medicaid, Social Security, Earned Income Credit, and the Affordable Care Act. Much of this system is already in place in advanced capitalist societies. Incremental gains in this area will be much smaller and it is important to recognize the need for strengthening the economic engine that supports these benefits, says Muller. Economic dynamism has to be preserved and nurtured with human capital deployed in the best possible way, and competitiveness of countries increased. Each country and society has to find its own way of achieving this. The family matters, and matters a lot in taking advantage of educational opportunity, says Muller. The culture of different ethnic, immigrant groups, also matter. These differences were present in earlier periods in the nineteenth and twentieth century and are likely to remain. Strengthening the pool of human capital and deploying it is essential to progress. In an earlier book "Adam Smith In His Time and Ours- Designing a Decent Society," Muller emphasized the importance Smith placed on the civic duty of citizens to promote the welfare of the whole society, and the importance of education, family and moral character, with no substitute for the "general prevalence of wisdom and virtue." ...

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Zombrun describes the effect of low interest rates on savings for the bottom half of households in the U.S., the pressure to invest in stocks without the skills and experience of the better educated part of households in the top 20% of households by wealth and income. This resulted in a negative effect, a depletion of savings compared to an increase under a higher interest rates scenario with less pressure to take risks in a volatile stock market. This is the direct cost of the crises in stock and financial markets of 2000 caused by a internet bubble, and the larger crisis of 2008-2009 caused by the bubble in mortgages and housing. The secondary effects of the mortgage price bubble and faulty mortgage securities was in the millions of homeowners who went into foreclosure in 2009-2013, which further depleted wealth and savings of households in the bottom half lacking the experience and skills to navigate this type of housing market. The failure of the Obama administration to stem the foreclosures with practical steps which would have helped not hurt the banking sector, as suggested by FDIC's Sheila Bair and Harvard economist Martin Feldstein in many WSJ op-eds in 2010-2012, added to the erosion of savings and wealth of the bottom half. Minorities in particular were hit hard. A third effect is of communities across America that are feeling the effects of job migration to emerging markets such as China that has been underway as part of the globalization of the last three decades. A fourth effect in the rising cost of education, particularly since 2000, has reduced the opportunities for struggling working class people to enter the middle class and enjoy the higher incomes in precisely the very period when the divergence of incomes between less educated, less killed people and the more educated and better skilled people was taking place. The last two effects were neutral as part of the overall process of emergence of a globalized economy with a premium on more skills and education, requiring action by the government, universities and business for a concerted effort to mitigate in some places the negative effects and enhance in other places the positive effects. The first two effects were man made crises which required managing in constructive and positive ways for the entire American people, taking risks where necessary such as fears about the financial system if foreclosures did not go through. The risks of a long period of extremely low interest rates for savers and the middle as well as working class were poorly understood by the Fed since 2000. A similiar crisis is being faced in Europe with extremely low interest rates. Janet Yellen was only doing the honest thing by acknowledging how far and how different the situation is now compared to the period of three decades following 1945- a question not just of values cherished in America, also of the need for societies to advance through creation of wealth across all sectors of society or regress, as described by Smith in the Wealth of Nations....

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A report released by the Organization for Economic Cooperation and Development (OECD) shows growing income inequality in 34 OECD countries. OECD Secretary General, Angel Gurria says: "The social contract is starting to unravel in many countries. This study dispels the assumptions that the benefits of economic growth will automatically trickle down to the disadvantaged and that the greater inequality fosters greater social mobility. Without a comprehensive strategy for inclusive growth, income inequality will continue to rise." Countries with the largest ratios between incomes at the top and the bottom, are the United States, Turkey and Israel, roughly 14 to 1. Germany, Denmark and Sweden have ratios of 6 to 1, with their ratios up from the 1980's. Gaps in Chile and Mexico are at 25 to 1. The study covers the period from 1980 to 2008. Overall inequality went up by 25% in the U.S. from 1980. In 2008 the top ten percent in the U.S. earned $114,000, 15 times than incomes for the bottom 10%. The top 1% of Americans saw incomes go up from 1980 to 2008, increasing from 8 percent to 18 percent. The richest 1% having $1.3 million in after tax income, and the lowest 20% making $17,700. The trends have accentuated an increase at the highest end- the top 1% and top 10% of the people- and a sharp decrease for the bottom 20%, which can be grasped from the $17,700 and the $1.3 million, both at extreme ends. The study attributes the rise in inequality to a growing gap in wages for highly skilled workers as technology advances, a surge in foreign direct investment and a looser regulatory regime that reduces employee protections leading to wage premiums for financial jobs and smaller incomes for workers at the bottom. Income groups and professions and sectors that had the greatest influence in government were able during this period to get the greatest protection for incomes, and able also to maximize their incomes. Incomes in the financial sector increased dramatically in the last decade, as a result of deregulation leading to higher risk and speculative activities in the financial sector, leading to the financial crisis of 2008-2009. Financial crises further depress incomes at the lower end. Similiar income inequality trends can be seen for India and China. China has a Ginni coefficient of 0.5 according to researchers at Beijing Normal University, up from 0.3 three decades ago- a Ginni Coefficient above 0.4 is considered destabilizing. Another factor that played a part in these countries is corruption and lobbying by special interests for favored treatment of sectors or groups. Austerity measures taken in Europe and in the U.S. are likely to widen income gaps by depressing the lower end income groups, creating social unrest, especially in the absence of efforts to stimulate growth....

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President Obama's speech announcing the details of his executive order on immigration on Nov. 20, 2014, starts by saying he is not bypassing Congress or the Republicans. He says Republicans had the opportunity to pass legislation in the House that passed the Senate, or come up with their own bill. And still have an opportunity to come up with a bill he could sign into law that address the shortcomings of the current immigration system. In selling the bill to Americans he points out that this is not an amnesty, that the current system which allows immigrants here to stay illegally without paying taxes or any accountability is an amnesty. He points to deportation of millions as not an option, an out of the character of America. That deportation of criminals will continue and is up 80% in his administration, without mentioning that deportation under his administration for ordinary undocumented immigrants without any criminal record had reached a high of 400,000 a year under his administration, higher than under the Republican Bush administration. In fact it had reached such levels that Hispanic groups stated they would sit out the midterm 2014 elections and not vote for Democrats or Republicans, after providing a significant part of the winning margin for Obama in the 2012 presidential election. President Obama says he has the legal authority to prevent deportation, and that this is essentially what this executive order does- providing a temporary right to stay and work in this country to undocumented immigrants here living in the shadows who are here for more than 5 years, not a permanent status or citizenship. He cites other presidential decisions of the last 50 years, Republican and Democratic, that have integrated large groups of undocumented immigrants, including an executive order by President Reagan. And he refers to the Bush presidencies 41 and 43, where both father and son, considered Hispanic Americans "a part of American life," as good hard-working people deserving a chance to be Americans. The speech ends with an appeal to the compassion of Americans urging them to look at their own individual stories going back one, two or several generations, or Ellis Island where the early waves of European immigrants entered the country in the 19th century, and to immigrants from the period after the early British settlements in the 18th century. This is typical Obama, as much as the calculated decision to pursue a aggressive deportation policy was for the first 6 years of his administration, including the decision for "Dreamers" or young people before the 2012 election. "Scripture tells us, we shall not oppress a stranger, for we know the heart of a stranger. we were strangers once, too. And whether our forbears were strangers who crossed the Atlantic, or the Pacific, or the Rio Grande, we are here because this country welcomed them in." Over 2 million deportations in one of the most aggressive deportation policies of any administration, followed by an effort to stop deportations before the next presidential election, when the NYT had called his deportation policy "infuriating." ...