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Derrien Murry, an 11-year-old boy from Mississippi, was tragically shot in the chest by an Indianola Police Department officer early in the morning last Saturday while responding to a domestic disturbance call. The call was made by Derrien himself after his mother, Nakala Murry, had requested him to do so when her other child’s father showed up to the home in a rage.

Upon entering the residence, the officer immediately had his gun drawn and told those inside to come out. According to Nakala Murry, it was at this moment that her son was shot as he was around the corner of a hallway into the living room. Desperate and shocked, the mother quickly applied pressure to her son’s gunshot wound while the officer attempted to give first aid afterward.

Derrien was brought to the University of Mississippi Medical Center in Jackson, where he endured an emergency chest tube, fractured ribs, a lacerated liver, and a collapsed lung. Fortunately, he was released from the hospital after recovery.

The event has prompted an outcry from the community and Derrien’s family. A press conference mentioned on Carlos Moore’s Twitter page was held in response to the incident, featuring a declaration for justice and a sign that said, “Your ‘best’ cop shot my baby.” Carlos also demanded that the officer, Greg Capers, be “terminated!” and “prosecuted to the fullest extent of the law.”

The Indianola Police Department is yet to comment on the shooting, though Officer Capers is currently on paid administrative leave while an investigation continues. The public still awaits to see what further action will be taken.

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The practice of “salting,” covertly getting a job with the intention of organizing a workplace, is receiving renewed attention lately. During the Vietnam War, activists used this tactic to build the antiwar movement within the ranks of the US military.

A group of American Army soldiers from the group “GIS for Peace” stand arm-in-arm during a protest demonstration against the Vietnam War, Washington, DC, April 24, 1971. (David Fenton / Getty Images)

The tactic of “salting” — getting a job with the specific intention of organizing your workplace — has recently been grabbing news headlines.

In a recent Bloomberg story, labor journalist Josh Eidelson showed how the Starbucks union drive, which began in Western New York and continues across the country, was started by salts. Eidelson, as well as labor journalist Luis Feliz Leon and scholar Mie Inouye, emphasized the critical role salts also played in the successful Amazon union drive in Staten Island. During recent Senate hearings on union busting at Starbucks, ex-CEO Howard Schultz referred to salting as a “nefarious act,” and industry groups are backing Republican efforts to crack down on the practice.

Salting helped build the labor movement over the past century and is clearly making a comeback in the new surge of union organizing. Right now, there are likely hundreds, if not thousands, of salts or salts-in-training who are driving new organizing efforts that will surface in the months and years ahead.

But while the tactic of salting in the workplace is getting attention, much less well known is the crucial role that salting played in building antiwar resistance in the US military during the Vietnam War.

From the mid-1960s through the mid-1970s, dozens of left-wing organizers entered the armed forces with the explicit intention of organizing antiwar resistance within the ranks. Some of them adamantly enlisted, but many were drafted and then decided to report to induction with the goal of talking to fellow GIs about the war, imperialism, and racism. Some were secretive about their military salting, while others were bolder and more open. Many soldiers who were politicized after entering the military were influenced by GI salts.

These GI salts played a crucial role in kickstarting and sustaining the massive wave of soldier protest during the Vietnam War. They established some of the most high-profile GI antiwar groups and drove some of the most notable cases of troop dissent, providing inspiring models for thousands of other servicemembers who doubted the war. They helped convert latent troop discontent into organized resistance. These were the “militant minority” of antiwar GIs, with radical visions of peace and equality, willing to take risks against military authority because they were driven by a higher mission to end the war.

The GI Movement Against the US War in Vietnam

The GI movement against the US war in Vietnam involved thousands of active-duty soldiers and threw the US military into crisis. It may have been the cutting edge of the wider antiwar movement. Yet, the history of the GI movement is little known to many.

In 1965, President Lyndon B. Johnson announced a massive escalation of the US war in Vietnam, which included the start of a three-year bombing campaign and a huge troop buildup. Almost immediately, soldier dissent began brewing in the armed forces. In November 1965, Lieutenant Henry Howe was arrested for attending an antiwar rally in El Paso, Texas, outside of Fort Bliss. In June 1966, Privates Dennis Mora, James Johnson, and David Samas, who were stationed at Fort Hood, Texas, held a press conference to announce their refusal to ship to Vietnam. In late 1966, Captain Howard Levy, an army medic, refused orders to train Green Berets headed to Vietnam because he did not want to be party to war crimes.

Acts like these — and many more — inspired the rise of the GI movement. By 1968 and 1969, new antiwar soldier groups were forming. Off-base antiwar coffeehouses aimed at GIs, often staffed by sympathetic civilians, were spreading from coast to coast. A growing number of subversive GI antiwar newspapers were circulating around the barracks. Soldiers were openly refusing orders on political grounds. For example, dozens of black troops — known as the “Fort Hood 43” — refused orders to suppress protests at the Democratic National Convention in 1968.

By the turn of the 1970s, all this had exploded into a full-fledged, global movement of GI resistance to the war. From military bases in West Germany and Hawaii to Mountain Home, Idaho, and Fayetteville, North Carolina, GIs openly protested the war, imperialism, racism, and military authority. In 1970 and 1971, hundreds of troops staged antiwar protests across military bases on Armed Forces Day, which they dubbed Armed “Farces” Day. Thousands of GIs stationed in the United States, the Philippines, and Japan turned out to see Jane Fonda’s FTA show in 1972, cheering as it mocked the war and military brass (“FTA” was the acronym for the army’s recruitment pitch of “Fun, Travel, Adventure,” which GIs reworked into a protest slogan, “Fuck The Army”).

This spirit of resistance carried over into Vietnam. US troops wore peace signs, grew their hair out, and freely used drugs. Many avoided combat and some outright refused orders to fight. A shocking article published in the Armed Forces Journal in June 1971, authored by Col. Robert D. Heinl Jr, conveyed the scope of the crisis. “The morale, discipline and battleworthiness of the US Armed Forces are, with a few salient exceptions, lower and worse than at any time in this century and possibly in the history of the United States,” Heinl declared. “By every conceivable indicator,” he continued, “our army that now remains in Vietnam is in a state approaching collapse, with individual units avoiding or having refused combat, murdering their officers and non-commissioned officers, drug-ridden, and dispirited where not near mutinous.”

“It Was the GIs Who Could Bring a Sudden Halt to the War”

What’s less known about the history of the GI movement is that dozens of left-wing organizers — socialists, communists, anti-imperialists, Black Power advocates — entered the military with the conscious intent of building resistance to the war. These GI salts — driven by deeper political motivations, with links to civilian and legal support networks — played a pivotal role in galvanizing the rise of organized antiwar dissent from within the armed forces.

One of the most famous GI salts was Private Andy Stapp, who joined the army in May 1966 with the explicit goal of organizing antiwar resistance from within. Stapp, who grew up in a suburb of Philadelphia, had grown critical of US imperialism as a college student and plunged himself into the growing peace movement. But he felt he needed to go beyond burning his draft card and attending street protests “to end the slaughter” in Vietnam. He had to enter the very machine that was waging the war.

“It was the GIs who, if they refused to fight, could bring a sudden halt to the war,” he later wrote.

In late 1966, Stapp arrived at Fort Sill, Oklahoma, where tens of thousands of troops were stationed. He quickly set about discussing the war with his fellow soldiers in barracks “bull sessions” and shared radical literature that he kept in his locker. Stapp’s rebelliousness against military authority — he snagged not one, but two courts-martial in 1967 — earned him respect from rank-and-file GIs. He soon recruited a tight-knit circle around him to help spread antiwar resistance on base. They linked up with several off-base supporters from Youth Against War and Fascism, a youth group connected to the communist Workers World Party.

On Christmas Day, 1967, Stapp’s group formed a new organization, the American Servicemen’s Union (ASU). Its eight-point program included demands like “The Right of GIs to Collective Bargaining,” “An End to Racism in the Armed Forces” and “The Right to Disobey Illegal and Immoral orders.” The organization acquired its own newspaper, the Bond, that would go on to print dozens of issues.

News of the ASU quickly spread, and chapters formed across the world. The ASU was loose and decentralized — essentially, anyone could join by declaring themselves a member. During its run, the Bond printed hundreds of stories of protest and letters from GIs who claimed to be ASU members or were sympathizers. Stapp was eventually kicked out of the army in the spring of 1968, but he became a minor celebrity, with Esquire magazine running a cover story on Stapp and the ASU.

The ASU’s vision of a radical soldier’s union inspired innumerable others to join the resistance movement in the armed forces. One of them was David Cortright, who participated in the GI movement and later authored the classic history, Soldiers in Revolt. Upon Stapp’s death in 2014, Cortright told the New York Times about the impact that Stapp had on him. “To me, it was like a light going off, like a flash of illumination, that maybe I could do the same,” Cortright remembered.

Another famous example of GI salting involved Private Joe Miles, a socialist from Washington, DC, who had been radicalized by Malcolm X and was active in the civil rights and antiwar movement. When Miles was drafted into the army in 1968, he was a dedicated member of the Young Socialist Alliance (YSA), and he intended to organize his fellow GIs against the war. He read the Uniform Code of Military Justice from cover to cover so that he could try to avoid punishment.

When Miles got to Fort Jackson, South Carolina, in early 1969, he began organizing barracks “rap sessions” with his fellow black GIs where he’d play tapes of Malcolm X speeches and they’d talk about war and racism. Together, the circle around Miles, which grew into a multiracial group of black, white, and Puerto Rican troops, formed a new organization called GIs United Against the War in Vietnam that demanded an end to the war and to racism in the military while calling for GIs to be allowed to freely express their antiwar opposition. Among other things, GIs United organized a petition to hold an on-base meeting about the war.

The army eventually transferred Miles to Fort Bragg, and it cracked down on GIs United after the group staged an impromptu on-base rally in March 1969 that attracted dozens of soldiers. The arrested leaders became known as the “Fort Jackson 8,” a major cause célèbre of the GI movement. The YSA and prominent left-wing attorneys came to the GIs’ defense, and the case grabbed national headlines. Like the ASU, GIs United spread to several other bases, and the group’s story emboldened others to resist.

“I Did Something That Other People Knew About and It Tempted Them to Do Stuff”

Howard Petrick was one of the earliest GI organizers against the war. He served in the army from 1966 to 1968 and was at the center of a high-profile defense campaign after the military cracked down on him for his dissent. Petrick, now seventy-seven years old and living in San Francisco, spoke to Truthout about his motivations and experiences in organizing against the war from within the army.

Petrick grew up near Erie, Pennsylvania, but moved to the Twin Cities in the mid-1960s, where he was radicalized and mentored by Ray Dunne, a Trotskyist who helped lead the famous 1934 Teamsters strike in Minneapolis. By the time Petrick was drafted in 1966, he was a dedicated antiwar activist and, as a YSA member, a socialist. He knew fellow YSA member Joe Miles “pretty well” before Miles went into the army.

Petrick did not want to get drafted — it “was one of the worst days of my life,” he said — but he was determined to use his time in the army to talk to other soldiers about the war. When he arrived at Fort Leonard Wood, Missouri, he was struck by how much doubt toward the war he observed among GIs. “A lot of them were questioning the war,” he said. “It was a fertile situation” for antiwar organizing.

Petrick began quietly talking about the war with fellow GIs and soon hit it off with a few kindred spirits. One of their first acts was to tack up “a little petition” on one of the base’s bulletin boards demanding the military justify the war. Petrick says around twenty GIs signed before it was taken down.

Petrick was soon assigned to the 2nd Armored Division at Fort Hood, Texas, right when the trial of the Fort Hood 3 was taking place, which instilled in him the need to avoid arrest even as he organized from within. “I was going to be a good soldier and follow all my orders, but I was going to speak up whenever I could,” he said.

Petrick was assigned to be a cook, and he started befriending GIs on base, forming a “pretty good group” around him. “I learned right away the guys who were against the war,” he told Truthout.

Petrick shared radical literature that his friends sent him. “We were having meetings of ten, fifteen, twenty guys about the war” a few times a week, he remembered. They debated with pro-war GIs to try to persuade them against the war. “We just looked for any angle that would open up people’s minds,” Petrick said.

Meanwhile, Petrick was attending antiwar rallies in nearby Austin and staying in touch with the YSA. In April 1967, the army searched his locker, confiscated his radical literature, and questioned Petrick on his political beliefs, beginning a months-long ordeal where he was threatened with court-martial. His YSA comrades and the wider antiwar movement came to his defense, forming a “Committee to Defend the Rights of Pfc. Howard Petrick.” He was eventually given an undesirable discharge in March 1968 (which was later overturned), but continued to organize against the war, speaking at antiwar rallies and meeting with GIs.

Petrick’s story filled the GI press and his example inspired other GIs to oppose the war. “The thing I’m proudest of is that I did something that other people knew about and it tempted them to do stuff,” he said. “I got letters from guys all over the country, and when I got out of the Army, I made a tour and I went to Army bases all over the country and talked to these guys in coffeehouses or sometimes in the barracks” and tried “to help them from my limited experience.”

Organizers like Petrick, Stapp, Miles, and others not only helped lay the groundwork for the rise of the Vietnam War–era GI movement, but also left an enduring legacy for organizing dissent and resistance in the military. To be sure, the US military today is in some ways worlds away from the days of the Vietnam War. There is no official draft, which contributes to the larger isolation of the armed forces from civilian society. The US is not fighting an unpopular war that mobilizes hundreds of thousands of soldiers and directly touches the lives of millions of people.

At the same time, a de facto “economic draft” continues to fill the army’s ranks with poor and working people. Indeed, if the United States achieved Medicare for All, free higher education, and a $20 minimum wage tomorrow, military recruitment would lose much, if not most, of its appeal. The armed forces remain ridden with racism and poverty, as well as sexual assault that overwhelmingly impacts the growing number of women in the military. Day by day, the United States lurches further into inter-imperialist conflict with Russia and China.

Together, these factors will likely intensify the feelings of entrapment, injustice, and impending disaster that motivated GI resistance to the Vietnam era. The job of the Left is to relentlessly shine a spotlight on how US militarism and the bipartisan foreign policy establishment threatens the welfare of working people, women, and people of color. If the Left takes this project seriously, it may not be long before the resurgence of salting in the labor movement, and the new mood of labor militancy more generally, also shows up in military spaces.

The US hospice system is supposed to provide compassionate end-of-life care. But private equity firms have swallowed up the industry: 7 out of 10 hospice agencies are now for-profit, putting profit maximization over patient well-being.

In recent years, private equity has exploited both fragmentation in the hospice sector and gaping holes in oversight left by federal agencies. (Justin Paget / DigitalVision via Getty Images)

Though the majority of Americans spend the final weeks of their lives in hospice care, the United States only got its first hospice, the Connecticut Hospice, in 1974. Today, just under a half century later, over 5,500 hospices provide services for the dying; in 2020, 1.72 million Americans received care through hospice services, whether in brick-and-mortar inpatient facilities or in the comfort of their homes. (Most people on hospice do pass away at home.)

The United States’ heavily for-profit hospice system would be unrecognizable to Florence Wald and the group of patient-minded nurses, doctors, and clergy who founded the Connecticut Hospice. As of 2020, over 72 percent of hospices are for-profit and approximately 24 percent are nonprofit. Less than 3 percent are publicly owned.

In a new report by the Center for Economic and Policy Research (CEPR), Preying on the Dying: Private Equity Gets Rich in Hospice Care, researchers examined the outsize role that private corporations, and specifically a small but growing group of private equity firms (PEFs), play in the administration of US hospice care. They found that in recent years, private equity has exploited both fragmentation in the sector and gaping holes in oversight left by federal agencies, including the Centers for Medicare & Medicaid Services (CMS) and the Federal Trade Commission (FTC). And though groundbreaking investigations from the Los Angeles Times, the New Yorker, and ProPublica have sounded the alarm on hospice fraud in recent months, too little attention has been paid to issues inherent to the system — in particular, how private equity can so exploit regulatory holes.

These days, the authors of Preying on the Dying write, the hospice industry is dominated by “Wall Street players driven by the logic of profit maximization.”

The Hospice Landscape

Until the early 2000s, the majority of hospices were nonprofits. But in the wake of the financial crisis, most nonprofit hospices and palliative care facilities were bought out — first by publicly traded companies, and now by private equity. Over 70 percent of hospice agencies acquired between 2011 and 2019 were previously nonprofit, and private equity ownership of hospices has doubled since 2011.

William Lazonick, professor emeritus of economics at the University of Massachusetts and cofounder and president of the Academic-Industry Research Network, tells Jacobin that he believes private equity has moved into the health care arena writ large because the sector is largely unregulated and consumers are highly dependent on its products, including hospice services. And given the inherent stress of end-of-life situations for patients and their families, they may also be hard pressed to push back against poor quality or high costs of care.

The hospice industry is dominated by ‘Wall Street players driven by the logic of profit maximization.’

The hospice industry is especially vulnerable to private equity intrusion because it is fragmented, giving companies the opportunity to “buy up small agencies . . . consolidating local health care markets.” Between 2011 and 2020, private equity deals soared by almost 25 percent. Eileen Appelbaum, coauthor of Preying on the Dying and codirector of CEPR, tells Jacobin that the number of takeovers also remains obscure. “When private equity is involved, it looks like one deal. But they’re picking up many locations. When one deal happens, that might mean two hundred locations.”

For now, the details of the hospice locations involved in these deals are kept private, as they are proprietary. No nationally representative data exists on what these PEFs are doing: “They’re not required to report anything,” Appelbaum says. Since buyouts don’t necessarily lead to company name changes, locals may also not be aware of takeovers. And because deals primarily occur with “little or no disclosure or public scrutiny,” a March 2023 Public Citizen study reported, regulators and watchdogs struggle “to monitor the effects of private equity ownership.”

How Does Private Equity Acquire Hospices?

Private equity firms use “leveraged buyouts” to obtain a company and borrow money in that company’s name to pay themselves dividends. In the meantime, acquired companies are saddled with debts that they must eventually repay. “They get their money up front,” Lazonick explains, “by loading the company up with debt.” Debt-burdened companies are then forced to lay off workers, cut costs, or go bankrupt. Though it’s difficult for researchers to pin down how many private equity deals eventually trigger bankruptcy, leveraged buyouts undoubtedly increase the likelihood of a company going belly up.

In the wake of the financial crisis, most nonprofit hospices and palliative care facilities were bought out — first by publicly traded companies, and now by private equity.

The CEPR report is the first to look at how private equity operates in the hospice industry. Though many of the roughly four thousand PEFs in the United States are small firms that don’t load up companies with massive debt, Appelbaum and her coauthors, Rosemary Batt and Emma Curchin, find that hospice acquisition by some of the larger, more predatory private equity firms can do terrific damage to the quality of care for the dying. They argue that the “drive for high returns for investors” leads to extreme wealth extraction on the part of PEFs: “Private equity’s debt-financed acquisition of agencies, its prioritization of profits, and the short time frame before it plans to sell them for much more than it paid to acquire them creates unique pressures to quickly increase revenue and operating profits.” Even publicly traded companies generally hold onto acquisitions longer than private equity funds; the median holding time for private equity–owned companies is just over four years. Those acquisitions can generate as much as a 25 percent return for a PEF and its investors.

Private equity is particularly good at exploiting the public payment system for hospice care. The Centers for Medicare & Medicaid Services have provided a hospice benefit to Medicare and Medicaid recipients since 1983, and from 2000 to 2017, Medicare outlays to hospice providers ballooned from $2.8 billion to $17.7 billion. Medicare contracts other organizations to provide hospice services and reimburses them through a fixed payment system, using a per-diem rate for each patient regardless of what kind of care the patient needs. This means that the “longer a patient stays, the more money the provider makes” — a model that leaves room for abuse, Appelbaum says. She argues that CMS needs to pay a higher fee for patients with higher acuity cases, rather than a flat fee.

For now, the fixed payment system means that privately owned hospice providers are more inclined to take on both ineligible patients who clearly have more than six months to live and healthier patients who require less expensive care. People with dementia, for instance, may have few acute medical needs and live for more than six months, giving providers more time to collect their daily reimbursement and allowing providers to goose their profit margins.

‘When private equity is involved, it looks like one deal. But they’re picking up many locations. When one deal happens, that might mean two hundred locations.’

By contrast, cancer patients or patients with heart conditions who are being released from the hospital typically have shorter life expectancies and require more skilled nursing care. Refused by privately owned providers, they frequently wind up in nonprofit hospices. Those providers may struggle to provide for panels comprised of sicker patients, while privately owned companies thrive off relatively healthier, longer-living patients.

Private equity–owned providers find additional ways to boost their profit margins, like slashing the number of days or hours of care a patient receives or using poorly paid, less experienced workers in inappropriate or dangerous circumstances. Researchers have found that Medicare beneficiaries enrolled in for-profit hospice agencies are “more likely to receive a narrower range of services” than beneficiaries getting care from nonprofit agencies. And since CMS lacks standards for what dying patients actually require — especially in the few days before death, “when the patient’s need for pain relief and treatment to improve their comfort are most acute” — patients in for-profit settings are vulnerable to real neglect in the twilight of their lives.

What Can Be Done?

Last December, four leaders of the bipartisan Comprehensive Care Caucus sent a letter to the inspector general and to CMS administrator Chiquita Brooks-LaSure requesting that they initiate an investigation of allegations — made public by the Los Angeles Times, the New Yorker, and ProPublica — of widespread Medicare and Medicaid fraud in hospice care. Around the same time, four preeminent national hospice organizations wrote a joint letter to Brooks-LaSure urging her to fortify federal oversight to safeguard hospice patients and their families. A spokesperson for one member of the Comprehensive Care Caucus, Sen. Tammy Baldwin (D-WI), said that Baldwin’s office had no record of a response from CMS to their December letter.

When approached for comment for this article, Administrator Brooks-LaSure said:

The Centers for Medicare & Medicaid Services (CMS) takes our oversight role of the Medicare program seriously. Effective oversight and enforcement are important to protect the integrity of the Medicare program, especially when it comes to end-of-life care. We are concerned about increased reports of program integrity concerns surrounding the hospice benefit and are working on further strategies to prevent fraud, waste and abuse while making sure that people with Medicare get the care they need.

In the meantime, the coauthors of the CEPR report propose a three-pronged approach to policy reform: strengthening and enforcing existing policies; developing new measures to close loopholes in the system; and enhancing merger review by the Department of Labor and the FTC. Currently, under the Hart-Scott-Rodino Act, the FTC automatically reviews acquisitions valued at over $110 million. But hospice acquisitions rarely hit that trigger threshold, leaving “regulators blind to the scale at which private equity owned hospice chains are growing.” The failure of oversight by antitrust agencies leaves PEFs free to form ever-larger for-profit hospice empires.

New regulations for private equity in other areas of health care offer clues as to what kinds of reforms might work for hospice. Under pressure over concerns about private equity in nursing homes and hospitals — including reports that PEFs often don’t appear in ownership reports for providers in which they are invested — the Biden administration has introduced new transparency requirements. Last December, the administration published ownership information for seven thousand hospitals, and in February, the Department of Health & Human Services (HHS) issued a proposed rule to compel nursing homes to disclose information about their beneficial ownership and management. Just last month, HHS put out ownership data for more than six thousand Medicare-certified hospices and eleven thousand home health agencies.

‘Private equity gives so much to Republicans and to centrist Democrats. Any bills that crack down on [it] are facing an uphill battle.’

On the legislative side, US representative Pramila Jayapal (D-WA) reintroduced the Healthcare Ownership Transparency (HOT) Act this March, which aims to combat private equity in health care. The HOT Act would set up bodies to better understand the role of private equity in health care, and require disclosure of ownership stakes in health care facilities — including nursing homes, home health agencies, and hospice providers — ensuring that that information is publicly available even if a facility is in a shell company’s name.

But the bill will most likely “struggle in a Republican House,” says Eagan Kemp, a health care policy advocate at Public Citizen. “Private equity gives so much to Republicans and to centrist Democrats. Any bills that crack down on [it] are facing an uphill battle.” Still, there is certainly a “growing awareness,” he added, including within the Biden administration, “that something needs to be done.”

CMS is ultimately responsible for reining in private equity behavior and enforcing rules that are already on the books, Appelbaum says. But she and others believe the agency’s regulations are deficient. A CMS spokesperson told Jacobin that to participate in Medicare, hospices must meet federal standards for health and safety and are then surveyed at least once every three years to verify their compliance. But Appelbaum notes that if a provider is owned by private equity, it could be sold before it is even due for its next inspection. She argues that CMS needs to carry out more consistent and careful inspections to guarantee that hospice providers are aboveboard before they become eligible for government payments.

Even when problems are found, Applebaum tells Jacobin, “agencies are required to do little more than develop a plan to correct deficiencies. Notably, the agencies are not booted from the Medicare program and continue to collect generous payments while providing substandard care.” Except in egregious cases, CMS rarely revokes a provider’s certification: only nineteen hospices had their Medicare funding revoked between 2014 and 2017.

A spokesperson from CMS said the agency takes appropriate administrative action to recover improper payments and refers cases to law enforcement in instances of suspected fraud. According to the spokesperson, the agency also recently launched a nationwide project to conduct site visits for hospices enrolled in Medicare, focusing on hospices that are colocated at one address; it plans to nix any nonoperational hospices from the Medicare program. This project has helped CMS single out fifteen hospices that the agency is currently removing from billing privileges.

Finally, there is the option to expand the small fraction of hospice agencies that are currently government owned.

Yet many experts believe that to reduce false claims and improve the quality of hospice care, the entire payment structure for hospice care needs reforming. The National Hospice and Palliative Care Organization has urged CMS to move away from the flat-fee model toward one based on patient needs. Though CMS regularly changes its payments to physicians based on advice the agency receives from its advisory bodies, it’s unclear whether it has a similar authority to change the way that hospice payments are set and distributed. Appelbaum, for one, hopes that a congressional office will pursue the question with CMS. If CMS is unable to make these shifts to the payment structure, then Congress may need to intervene.

A new model would dole out reimbursements based on the services required by individual patients, linking payment to a patient’s diagnosis, the frequency of care services, and to the skills of those who provide the services — in essence, providing incentives to “provide more and higher quality care to patients.”

Finally, there is the option to expand the small fraction of hospice agencies that are currently government owned. According to Preying on the Dying, “Economists argue that when the quality of a service is ill-defined and enforceable contracts cannot be written” — as with hospice — “it may be preferable to have the service publicly provided.” But the authors stop short of defining how that horizon might be achieved, instead acknowledging that it is “not often possible” to provide these services publicly. In the absence of publicly provided hospice services, heightened regulation — including the changes described above — is paramount.

But though they are few and far between, publicly owned hospices do exist. They remain the clearest path forward if the United States is intent on bringing the hospice industry closer to its roots in compassionate caregiving for the dying.

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Motivated by fears of the existential risks posed by advanced AI falling into the hands of authoritarian regimes, longtermists have for years been quietly pressing the White House to pursue a more aggressive policy toward China.

President Joe Biden meeting with business leaders at the White House on March 9, 2022. (Doug Mills / the New York Times via Getty Images)

The philosophy of “longtermism” is having a moment. Once a fringe ideology among Silicon Valley’s doomsayers, it has come to receive widespread and favorable media coverage, motivate heavily funded runs for congressional office, and attract many millions in philanthropic donations and investments. And, with the surge of interest in GPT-4 and other AI programs, formerly niche longtermist opinions and worries about a future with advanced artificial intelligence have started to gain mainstream adherents, even among some socialists.

Of course, not all the treatment has been positive. The Sam Bankman-Fried scandal last year shone a spotlight on the darker side of the movement by allowing journalists to point to FTX and Alameda Research’s deep entanglement with longtermist charities. And its biggest talking points have been met with criticism and ridicule from many onlookers. But, for good or for ill, it is no longer the obscure intellectual brand of a few tech futurists.

Most media attention so far, however, has focused on the philosophy’s role in the tech industry and philanthropic world. This coverage omits a crucial facet: longtermism’s political interventions and ambitions, beyond those immediately touching on its charitable and scientific projects. Perhaps most strikingly, public documents reveal evidence that longtermists were key players in President Joe Biden’s choice last October to place heavy controls on semiconductor exports, a policy many commentators have been willing to ascribe to more conventional protectionist and anti-China elements in Washington. With this kind of political weight and determination, the movement deserves greater public scrutiny going forward.

Existential Risks

Longtermism emerged as a school of thought within the wider “effective altruism” (EA) movement. This movement attempts to design and assess charities and charitable contributions with an eye to maximum positive impact on the dollar. While the most publicized and best received EA work has focused on near term, immediately pressing cause areas like global poverty and disease prevention, there has long been a controversial contingent within the community more interested in futurist concerns.

Much of this longtermist work in EA has been on “existential risks,” potential cataclysms that (allegedly) threaten the existence of humanity as a whole. These “x-risks,” as they are called, run the gamut from the sci-fi-esque (giant meteor impacts) to the prescient (pandemic readiness and prevention). Among the theoretical doomsdays studied by longtermists, however, one topic has consistently stood to the fore: AI safety.

Advocates of AI safety as a cause area generally fear that, one way or another, an advanced artificial intelligence could pose a risk to human survival. Some argue that, with aims at even slightly cross purposes with ours, a superintelligent AI would be willing and able to quickly eliminate us to achieve its goals.

Biden’s export controls have, incidentally, failed spectacularly at achieving their stated ambitions.

Others suggest, more conservatively, that AI could prove dangerous in much the same way as nuclear weapons: easy to accidentally misuse, hard to predict in detail, and with far-reaching consequences if handled ineptly. But they are united in their belief that bungled advances in artificial intelligence could spell disaster for humankind, potentially to the point of extinction.

With stakes this high, it is only natural that longtermist proponents of AI safety would seek influence in national (and international) politics. Future Forward, a pro-Democratic super PAC with an explicitly longtermist outlook, was among the most munificent donors in the 2020 presidential election, and in 2022, Carrick Flynn made a congressional bid openly running on longtermist issues. Electoralism has come for the Cassandras of AI doom.

Going purely by its (rather widely covered) electoral contributions, however, one might reasonably judge the movement a side attraction at best in the broader American political landscape. While Future Forward’s 2020 donations were extensive, few pundits have suggested they on their own turned the tide against Donald Trump, and Flynn’s campaign two years later ended in overwhelming defeat.

It would be a mistake, however, to assess the political reach of longtermism purely by its electoral influence. Beyond campaigns, it has with little fanfare made its way high in the realm of think tanks, congressional commissions, and bureaucratic appointments, where it has been vocal on issues of the utmost national and global significance. Perhaps the most notable, to date, has been US policy on microchip infrastructure.

Long Term Planning for a Cold War

The Biden administration’s decision, in October of last year, to impose drastic export controls on semiconductors, stands as one of its most substantial policy changes so far. As Jacobin‘s Branko Marcetic wrote at the time, the controls were likely the first shot in a new economic Cold War between the United States and China, in which both superpowers (not to mention the rest of the world) will feel the hurt for years or decades, if not permanently.

Already the policy has devastated critical supply chains, upset markets, and roused international tensions, all with the promise of more to come. Semiconductors, the “oil of the 21st century,” are an essential component in a huge range of computing technologies, and the disruption emerging from the export controls will inevitably affect the course of their future production and innovation, for the worse.

The idea behind the policy, however, did not emerge from the ether. Three years before the current administration issued the rule, Congress was already receiving extensive testimony in favor of something much like it. The lengthy 2019 report from the National Security Commission on Artificial Intelligence suggests unambiguously that the “United States should commit to a strategy to stay at least two generations ahead of China in state-of-the-art microelectronics” and

modernize export controls and foreign investment screening to better protect critical dual-use technologies  —  including by building regulatory capacity and fully implementing recent legislative reforms, implementing coordinated export controls on advanced semiconductor manufacturing equipment with allies, and expanding disclosure requirements for investors from competitor nations.

The commission report makes repeated references to the risks posed by AI development in “authoritarian” regimes like China’s, predicting dire consequences as compared with similar research and development carried out under the auspices of liberal democracy. (Its hand-wringing in particular about AI-powered, authoritarian Chinese surveillance is ironic, as it also ominously exhorts, “The [US] Intelligence Community (IC) should adopt and integrate AI-enabled capabilities across all aspects of its work, from collection to analysis.”)

These emphases on the dangers of morally misinformed AI are no accident. The commission head was Eric Schmidt, tech billionaire and contributor to Future Forward, whose philanthropic venture Schmidt Futures has both deep ties with the longtermist community and a record of shady influence over the White House on science policy. Schmidt himself has voiced measured concern about AI safety, albeit tinged with optimism, opining that “doomsday scenarios” of AI run amok deserve “thoughtful consideration.” He has also coauthored a book on the future risks of AI, with no lesser an expert on morally unchecked threats to human life than notorious war criminal Henry Kissinger.

Also of note is commission member Jason Matheny, CEO of the RAND Corporation. Matheny is an alum of the longtermist Future of Humanity Institute (FHI) at the University of Oxford, who has claimed existential risk and machine intelligence are more dangerous than any historical pandemics and “a neglected topic in both the scientific and governmental communities, but it’s hard to think of a topic more important than human survival.” This commission report was not his last testimony to Congress on the subject, either: in September 2020, he would individually speak before the House Budget Committee urging “multilateral export controls on the semiconductor manufacturing equipment needed to produce advanced chips,” the better to preserve American dominance in AI.

Congressional testimony and his position at the RAND Corporation, moreover, were not Matheny’s only channels for influencing US policy on the matter. In 2021 and 2022, he served in the White House’s Office of Science and Technology Policy (OSTP) as deputy assistant to the president for technology and national security and as deputy director for national security (the head of the OSTP national security division). As a senior figure in the Office — to which Biden has granted “unprecedented access and power” — advice on policies like the October export controls would have fallen squarely within his professional mandate.

Far from securing US dominance in the area, export controls on semiconductors have accelerated the fracturing of the international AI research community into independent and competing regional sectors.

Just as importantly, in January 2019, he founded the Center for Security and Emerging Technology (CSET) at Georgetown University, a think tank on national issues that friendly analysts have described as having longtermism “baked into their viewpoint.” CSET has, since its founding, made AI safety a premier area of concern. Nor has it been shy about tying the matter to foreign policy, particularly the use of semiconductor export controls to maintain US advantage on AI. Karson Elmgren, a CSET research analyst and former OpenAI employee specializing in AI safety, published a research paper in June of last year once again counseling the adoption of such controls, and covered the October rule favorably in the first issue of the new EA magazine Asterisk.

The most significant restrictions advocates (aside from Matheny) to emerge from CSET, however, have been Saif Khan and Kevin Wolf. The former is an alum from the Center and, since April 2021, the director for technology and national security at the White House National Security Council. The latter has been a senior fellow at CSET since February 2022 and has a long history of service in and connections with US export policy. He served as assistant secretary of commerce for export administration from 2010–17 (among other work in the field, both private and public), and his extensive familiarity with the US export regulation system would be valuable to anyone aspiring to influence policy on the subject. Both would, before and after October, champion the semiconductor controls.

At CSET, Khan published repeatedly on the topic, time and again calling for the United States to implement semiconductor export controls to curb Chinese progress on AI. In March 2021, he testified before the Senate, arguing that the United States must impose such controls “to ensure that democracies lead in advanced chips and that they are used for good.” (Paradoxically, in the same breath the address calls on the United States to both “identify opportunities to collaborate with competitors, including China, to build confidence and avoid races to the bottom” and to “tightly control exports of American technology to human rights abusers,” such as… China.)

Among Khan’s coauthors was aforementioned former congressional hopeful and longtermist Carrick Flynn, previously assistant director of the Center for the Governance of AI at FHI. Flynn himself individually authored a CSET issue brief, “Recommendations on Export Controls for Artificial Intelligence,” in February 2020. The brief, unsurprisingly, argues for tightened semiconductor export regulation much like Khan and Matheny.

This February, Wolf too provided a congressional address on “Advancing National Security and Foreign Policy Through Sanctions, Export Controls, and Other Economic Tools,” praising the October controls and urging further policy in the same vein. In it, he claims knowledge of the specific motivations of the controls’ writers:

BIS did not rely on ECRA’s emerging and foundational technology provisions when publishing this rule so that it would not need to seek public comments before publishing it.

These motivations also clearly included exactly the sorts of AI concerns Matheny, Khan, Flynn, and other longtermists had long raised in this connection. In its background summary, the text of one rule explicitly links the controls with hopes of retarding China’s AI development. Using language that could easily have been ripped from a CSET paper on the topic, the summary warns that “‘supercomputers’ are being used by the PRC to improve calculations in weapons design and testing including for WMD, such as nuclear weapons, hypersonics and other advanced missile systems, and to analyze battlefield effects,” as well as bolster citizen surveillance.

Biden’s export controls have, incidentally, failed spectacularily at achieving their stated ambitions. Despite the damage the export controls have wrought on global supply chains, China’s AI research has managed to continue apace. Far from securing US dominance in the area, the export controls on semiconductors have accelerated the fracturing of the international AI research community into independent and competing regional sectors.

Longtermists, in short, have since at least 2019 exerted a strong influence over what would become the Biden White House’s October 2022 semiconductor export rules. If the policy is not itself the direct product of institutional longtermists, it at the very least bears the stamp of their enthusiastic approval and close monitoring.

Just as it would be a mistake to restrict interest in longtermism’s political ambitions exclusively to election campaigns, it would be shortsighted to treat its work on semiconductor infrastructure as a one-off incident. Khan and Matheny, among others, remain in positions of considerable influence, and have demonstrated a commitment to bringing longtermist concerns to bear on matters of high policy. The policy sophistication, political reach, and fresh-faced enthusiasm on display in its semiconductor export maneuvering should earn the AI doomsday lobby its fair share of critical attention in the years to come.

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