Day: February 27, 2024

A cyberattack on a unit affiliated with UnitedHealthcare, the nation’s largest insurer, has disrupted drug prescription orders at thousands of pharmacies for nearly a week.

The assault on the unit, Change Healthcare, a division of United’s Optum, was discovered last Wednesday. The attack appeared to be by a foreign country, according to two senior federal law enforcement officials, who expressed alarm at the extent of the disruption on Monday.

UnitedHealth Group, the conglomerate, said in a federal filing that it had been forced to disconnect some of Change Healthcare’s vast digital network from its clients, and as of Monday, had not been able to restore all of those services.

Change handles some 15 billion transactions a year, representing as many as one in three U.S. patient records and involving not just prescriptions but dental, clinical and other medical needs. The company was acquired by UnitedHealth Group for $13 billion in 2022.

This latest attack underscores the vulnerability of health care data, especially patients’ personal information, including their private medical records. Hundreds of breaches at hospitals, health plans and doctors’ offices are being investigated, according to federal records.

In this case, the disturbance has been widespread, including for U.S. military overseas. Change acts as a digital intermediary to helps pharmacies verify a patient’s insurance coverage for their prescriptions, and some reports indicate that people have been forced to pay in cash.

Last week, after UnitedHealth found what it described as “a suspected nation-state associated cybersecurity threat actor” targeting Change, the company shut down several services, including those allowing pharmacies to quickly check what a patient owes for a medication. Some hospitals and physician groups that rely on Change for billing to get paid may also be affected.

Large drugstore chains like Walgreens say that the effects have been limited, but many smaller outfits say that they rely on Change whenever they handle a prescription for someone with insurance.

“For the last week, it has been hit or miss about whether we can take care of patients,” said Dared Price, who operates seven pharmacies in Kansas. While patients can pay cash if the medication is inexpensive, he says that some of his customers have been unable to obtain more costly treatments for flu or Covid because their insurance status is unclear.

“It’s a debacle,” he said.

Tricare, which covers the U.S. military, said its pharmacies in the United States and abroad are being forced to fill prescriptions manually. It continued to warn people this week of possible delays in getting medications.

Details about the attack, including whether any personal patient information has been stolen, are limited. Change has been making brief periodic updates on its website. On Monday, the company reiterated that the affected services would likely be unavailable for at least another day. It also emphasized that it had a “high-level of confidence” that other parts of United’s businesses were not targeted in the attack.

But there’s little question that United, whose sprawling businesses touch nearly every aspect of health care, made for a particularly rich target.

“If you’re going to go after stealing records, you want to go after the biggest pot of records you can get,” said Fred Langston, the chief product officer for Critical Insight, a cybersecurity firm. “You’re literally hitting the jackpot.”

The motives of the attacker are not yet known, Mr. Langston said. It may involve ransomware, allowing culprits to demand some sort of ransom. The intent may also have been to throw the health care system into disarray by making it harder to fill prescriptions or to bill for care in a timely manner.

“You have a concentration of mission-critical services for the entire sector, which represents a concentration of risk,” said John Riggi, the national adviser for cybersecurity and risk for the American Hospital Association. It has been advising hospitals to be careful about connecting to Change or affiliated businesses.

The industry has seen an increasing number of these kinds of assaults, said Cliff Steinhauer, director of information security and engagement at the National Cybersecurity Alliance, a nonprofit group.

According to federal officials, large breaches of health care data have nearly doubled from 2018 to 2022, including a spike in the number involving ransomware. Patients have had to go to different facilities, resulting in delays in care, according to a recent report.

Under federal law, patients must eventually be notified if their information is the subject of some sort of breach, Mr. Steinhauer said. People will be alerted even if their information does not appear to have become publicly available.

“It is worse if we find out that information is for sale on the dark web,” he said.

Glenn Thrush and Helene Cooper contributed reporting from Washington.

Will technological progress lead to mass unemployment? People have been asking that question for two centuries, and the actual answer has always ended up being no. Technology eliminates some jobs, but it has always generated enough new jobs to offset these losses, and there’s every reason to believe that it will continue to do so for the foreseeable future.

But progress isn’t painless. Business types and some economists may talk glowingly about the virtues of “creative destruction,” but the process can be devastating, economically and socially, for those who find themselves on the destruction side of the equation. This is especially true when technological change undermines not just individual workers but also whole communities.

This isn’t a hypothetical proposition. It’s a big part of what has happened to rural America.

This process and its effects are laid out in devastating, terrifying and baffling detail in “White Rural Rage: The Threat to American Democracy,” a new book by Tom Schaller and Paul Waldman. I say “devastating” because the hardship of rural Americans is real, “terrifying” because the political backlash to this hardship poses a clear and present danger to our democracy, and “baffling” because at some level I still don’t get the politics.

Technology is the main driver of rural decline, Schaller and Waldman argue. Indeed, American farms produce more than five times as much as they did 75 years ago, but the agricultural work force declined by about two-thirds over the same period, thanks to machinery, improved seeds, fertilizers and pesticides. Coal production has been falling recently, but thanks partly to technologies like mountaintop removal, coal mining as a way of life largely disappeared long ago, with the number of miners falling 80 percent even as production roughly doubled.

The decline of small-town manufacturing is a more complicated story, and imports play a role, but it’s also mainly about technological change that favors metropolitan areas with large numbers of highly educated workers.

Technology, then, has made America as a whole richer, but it has reduced economic opportunities in rural areas. So why don’t rural workers go where the jobs are? Some have. But some cities have become unaffordable, in part because of restrictive zoning — one thing blue states get wrong — while many workers are also reluctant to leave their families and communities.

So shouldn’t we aid these communities? We do. Federal programs — Social Security, Medicare, Medicaid and more — are available to all Americans, but are disproportionately financed from taxes paid by affluent urban areas. As a result there are huge de facto transfers of money from rich, urban states like New Jersey to poor, relatively rural states like West Virginia.

While these transfers somewhat mitigate the hardship facing rural America, they don’t restore the sense of dignity that has been lost along with rural jobs. And maybe that loss of dignity explains both white rural rage and why that rage is so misdirected — why it’s pretty clear that this November a majority of rural white Americans will again vote against Joe Biden, who as president has been trying to bring jobs to their communities, and for Donald Trump, a huckster from Queens who offers little other than validation for their resentment.

This feeling of a loss of dignity may be worsened because some rural Americans have long seen themselves as more industrious, more patriotic and maybe even morally superior to the denizens of big cities — an attitude still expressed in cultural artifacts like Jason Aldean’s hit song “Try That in a Small Town.”

In the crudest sense, rural and small-town America is supposed to be filled with hard-working people who adhere to traditional values, not like those degenerate urbanites on welfare, but the economic and social reality doesn’t match this self-image.

Prime working-age men outside metropolitan areas are substantially less likely than their metropolitan counterparts to be employed — not because they’re lazy, but because the jobs just aren’t there. (The gap is much smaller for women, perhaps because the jobs supported by federal aid tend to be female-coded, such as those in health care.)

Quite a few rural states also have high rates of homicide, suicide and births to single mothers — again, not because rural Americans are bad people, but because social disorder is, as the sociologist William Julius Wilson argued long ago about urban problems, what happens when work disappears.

Draw attention to some of these realities and you’ll be accused of being a snooty urban elitist. I’m sure responses to this column will be … interesting.

The result — which at some level I still find hard to understand — is that many white rural voters support politicians who tell them lies they want to hear. It helps explain why the MAGA narrative casts relatively safe cities like New York as crime-ridden hellscapes while rural America is the victim not of technology but of illegal immigrants, wokeness and the deep state.

At this point you’re probably expecting a solution to this ugly political situation. Schaller and Waldman do offer some suggestions. But the truth is that while white rural rage is arguably the single greatest threat facing American democracy, I have no good ideas about how to fight it.

The Democratic Party has had no shortage of argument and dissent over the years. Internal battles and backbiting are part of what it means to be a modern-day Democrat.

But over the past few months, Democrats have been distinctly inhospitable to the public airing of concerns about President Biden — particularly the question of whether, at age 81, he is too old to run for president again, but also criticisms of the day-to-day strategic decisions by his campaign.

This has played out on platforms large and small, most recently after Jon Stewart, on his return to his former Comedy Central show after a nine-year hiatus, mocked the “objectively old” President Biden. “Please make it another nine years,” Keith Olbermann, the former MSNBC host, said on X.

Prominent Democratic strategists like David Axelrod and James Carville who criticize Biden are facing a barrage of pushback on social media and from the White House — and sometimes, reportedly, from Biden himself. They are accused of lifting the prospects of Donald Trump, and of being disloyal alarmists (or, in a phrase from the 2008 campaign that has come back in vogue this year, bed-wetters).

There are critics of Trump on the Republican side, too, but they have been relegated to the sidelines, more likely to be ignored than seriously engaged, reflecting the party’s devotion to Trump and to the increasing conviction among his supporters that he will win.

What is happening among Democrats should not be a surprise. The political environment has changed starkly. Politics is more of a team sport — you are with me or against me. Olbermann assailed Stewart as a “bothsidesist fraud.” Mary Trump, the former president’s niece and one of his biggest critics, called Stewart “a potential disaster for democracy.” And platforms like X have grown into organizational tools, halls for rallying attacks on anyone who might be viewed as a heretic.

But it also goes to the particular dynamics of this election. Biden is almost certain to be his party’s nominee, despite concerns that have been raised by Democrats. But he is viewed unfavorably by much of the electorate, and is struggling against Trump in swing states like Michigan. “Democrats Have a Better Option Than Biden,” my colleague Ezra Klein in Times Opinion said in a 4,000-word audio essay, devoted to why Biden should step aside. (“No. Ezra Klein Is Completely Wrong. Here’s Why,” read the response from Talking Points Memo.)

Biden supporters argue that Democrats should not do anything that might be perceived as contributing to a second Trump term. That includes raising questions about any Biden shortcomings or the decisions of the Biden campaign command. The memories of 2016, when some Democrats piled onto Hillary Clinton in the weeks leading up to her loss, remain raw.

“Privately, there are a tremendous amount of misgivings about Biden running again,” said Douglas Sosnik, who was a senior White House adviser to Bill Clinton. “But there are some reservations, at least for some people, about publicly voicing the concerns about Biden.”

Axelrod, who was the chief strategist for Barack Obama, has been dragged by the White House and on X for questioning the way the campaign has been run, particularly how it has addressed Biden’s age.

“There’s this sense that this is a hugely consequential election and Biden is the guy and everybody should march unquestioningly behind him and don’t mention the things that they see,” Axelrod said. “I don’t think that’s helpful to him.”

“Everybody knows the score,” he said. “This is not a challenge you can wish away. I’d rather tell the truth and take my chance.”

Carville, who was a lead strategist to Bill Clinton when he was elected to the White House in 1992, has also come under fire for his critiques of Biden’s re-election team.

“Look, if I were in the White House, I wouldn’t like me right now either,” he said. “But that’s just part of the territory.”

And for what it’s worth, the pushback against critics like Stewart, Axelrod and Carville doesn’t seem likely to keep them quiet. Stewart used his second television appearance to eye-roll his critics. “I have sinned against you, I’m sorry,” Stewart said. “It was never my intention to say out loud what I saw with my eyes and then brain.”

Carville said it was important for Democrats to acknowledge the reality of Biden’s age as he seeks re-election.

“I haven’t said anything that is wrong,” Carville said. “I think some people think if you don’t mention it, it will solve itself on its own. I don’t think that is viable.”

Trump’s primary results are not matching expectations

It’s still early in the primary season, but a whiff of a possible polling error is already in the air: Donald Trump underperformed the polls in each of the first three competitive contests.

• In Iowa, the final FiveThirtyEight polling average showed Trump leading Nikki Haley by 34 points with a 53 percent share. He ultimately beat her by 32 points with 51 percent. (Ron DeSantis took second.)

• In New Hampshire, he led by 18 points with 54 percent. In the end, he won by 11 points with 54 percent.

• In South Carolina, Trump led by 28 points with 62 percent. He ultimately won by 20 points with 60 percent.

In the scheme of primary polls, these aren’t especially large misses. In fact, they’re more accurate than average.

But with Trump faring well in early general election polls against President Biden, even a modest Trump underperformance in the polls is worth some attention.

So what’s going on? We can’t say anything definitive based on the data at our disposal, but three theories are worth considering.

Theory No. 1: Undecided voters

One simple explanation is that undecided voters ultimately backed Haley, the former South Carolina governor.

This is plausible. Trump is a well-known candidate — even a de facto incumbent for his party. If you’re a Republican who at this point doesn’t know if you support Trump, you’re probably just not especially inclined toward the former president. It’s easy to see how you might end up supporting his challenger.

Theory No. 2: The electorate

Another possibility is that the polls simply got the makeup of the electorate wrong. In this theory, pollsters did a good job of measuring the people they intended to measure, but they were measuring the wrong electorate. In particular, they did not include enough of the Democratic-leaning voters who turned out to support Haley.

For many pollsters, the problem is baked in from the start: They don’t even interview prior Democratic primary voters.

The decision to survey prior Republican primary voters is understandable — it makes the poll much cheaper and homes in on the respondents likeliest to vote — but it will obviously miss any previous Democratic voters who hadn’t voted in a Republican primary and now choose to do so.

Theory No. 3: A hidden Biden vote

If you’re a Democrat hoping that the polls are underestimating Biden in the general election, your best-case scenario is the polls are wrong because there’s a Hidden Biden vote, or at least a Hidden Anti-Trump vote.

In this theory, the polls did well in modeling the electorate while undecided voters split between the candidates, but anti-Trump voters simply weren’t as likely to take surveys as pro-Trump voters. If this theory were true, then the general election polls might be underestimating Biden by just as much as they’ve underestimated Haley.

There is one reason the anti-Trump turnout might have relevance for general election polling: It’s consistent with other data showing Biden with the edge among the most highly engaged voters. This could yield a slight turnout advantage, even in a general election. It may also mean that the current polls of all registered voters slightly underestimate Biden compared with the narrower group of actual voters.

This wouldn’t mean the polls today are vastly underestimating Biden, but it could make the difference in a close election.

—Nate Cohn

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