Saturday, May 06, 2017

Fact Check: It's a Lie That the GOP Healthcare Bill Abandons People With Pre-Existing Conditions

By Guy Benson
May 5, 2017
FILE - In this Friday, March 24, 2017, file photo, protesters gather across the Chicago River from Trump Tower to rally against the repeal of the Affordable Care Act, in Chicago. The Republican push to replace the Affordable Care Act was revived by a small change to their plan designed to combat concerns over coverage for those with pre-existing health conditions. But experts say the change, which helped the bill squeak through the House of Representatives, Thursday, May 4, 2017, may be too small to make much difference in the hunt for affordable coverage for these patients. (AP Photo/Charles Rex Arbogast, File)
In this Friday, March 24, 2017, file photo, protesters gather across the Chicago River from Trump Tower to rally against the repeal of the Affordable Care Act, in Chicago.  (AP Photo/Charles Rex Arbogast, File)
As we described yesterday, there are some concerning policy elements of the House-passed American Health Care Act, which the Senate would be wise to explore and rectify over the coming weeks. The bill -- and that's all it is at this point: a work in progress -- repeals and alters significant portions of the Democratic Party's failing experiment in "affordability."  But based on rhetoric from elected Democrats and the Left generally, one might assume that Obamacare was called the "Pre-existing Conditions Coverage Act" (side-stepping the whole "choice and affordability" fairy tale they peddled), and that the Republican bill obliterates those protections. The proposed law would be a "death warrant" for sick women and children, they shriek, casting Obamacare opponents as the moral equivalent of accessories to murder. This is demagogic, hyperbolic, inaccurate nonsense. To review the actual facts, even under an exceedingly unlikely scenario in which the Senate passed the House bill without making a single alteration, people with pre-existing conditions are offered several layers of protection:
Layer One: Insurers are required to sell plans to all comers, including those with pre-existing conditions. This is known as "guaranteed issue," and it's mandated in the AHCA. No exceptions, no waivers. I spoke with an informed conservative news consumer earlier who was stunned to learn that this was the case, having been subjected to 24 hours of unhinged rhetoric from the Left.

Layer Two: Anyone with a pre-existing condition and who lives in a state that does not seek an optional waiver from the AHCA's (and Obamacare's) "community rating" regulation cannot be charged more than other people for a new plan when they seek to purchase one -- which, as established above, insurers are also required to sell them.
Layer Three: Anyone who is insured and remains continuously insured cannot be dropped from their plan due to a pre-existing condition, and cannot be charged more after developing one. So if you've been covered, then you change jobs or want to switch plans, carriers must sell you the plan of your choice at the same price point as everyone else. Regardless of your health status. This is true of people in non-waiver and waiver states alike.
Layer Four: If you are uninsured and have a pre-existing condition and live in a state that pursued (and obtained after jumping through hoops) a "community rating" waiver, your state is required to give you access to a "high risk pool" fund to help you pay for higher premiums. The AHCA earmarks nearly $130 billion for these sorts of patient stability funds over ten years.
It is simply a lie to say that the AHCA guts protections for people with pre-existing conditions. One can argue that perhaps $130 billion (not $8 billion, as some are dishonestly pretending) might at some point prove insufficient to covering the people described in layer four, but I think any such assessment is at best hypothetical and premature.  Either way, it's a very different critique than the scare-mongering going around right now.  Also, I'll repeat: The number of "uninsurable" Americans with pre-existing conditions within the individual market represents a tiny sliver of the overall population.  Helping these people was one of the few credibly-popular selling points and actual achievements of Obamacare.  But the existing law's track record on this front helps illustrate how limited the scope of that particular problem is:
The peak enrollment in Obamacare's Pre-existing Condition Insurance Plan was less than 115,000 people. 

Obamacare created a "bridge" program that allowed previously-uninsurable consumers with pre-existing conditions to get coverage in between the law's 2010 passage and full implementation a few years later. At its peak, it attracted less than 115,000 takers. Those people matter, and they were helped. But that statistic helps contextualize the problem, especially compared to Obamacare's overriding flaw: Unaffordability, leading to lack of participation, leading to unsustainable risk pools, leading to insurers pulling out and hiking premiums, leading to unaffordability, leading to further lack of participation, etc.  As for the moral bullying about the AHCA supposedly leading to thousands of deaths (with these pronouncements coming from the very same people who lied incessantly and made spectacularly wrong predictions about Obamacare, by the way), consider this data-based evidence:
Public-health data from the Centers for Disease Control confirm what one might expect from a health-care reform that expanded Medicaid coverage for adults: no improvement. In fact, things have gotten worse. Age-adjusted death rates in the U.S. have consistently declined for decades, but in 2015 — unlike in 19 of the previous 20 years — they increased. For the first time since 1993, life expectancy fell. Had mortality continued to decline during ACA implementation in 2014 and 2015 at the same rate as during the 2000–13 period, 80,000 fewer Americans would have died in 2015 alone. Of course, correlation between ACA implementation and increased mortality does not prove causation. Researchers hypothesize that increases in obesity, diabetes, and substance abuse may be responsible. But thanks to the roughly half of states that refused the ACA’s Medicaid expansion, a good control group exists. Surely the states that expanded Medicaid should at least perform better in this environment of rising mortality? Nope. Mortality in 2015 rose more than 50 percent faster in the 26 states (and Washington, D.C.) that expanded Medicaid during 2014 than in the 24 states that did not.
If conservatives wanted to turn liberals' demagoguery against them, they could cite these numbers to claim that Obamacare is killing tens of thousands of people -- especially in Medicaid expansion states -- and that Democrats have blood on their hands. Murderers! Let's not match their repugnant hackery. But we should make them aware of evidence that could build that deeply uncharitable and specious narrative. And speaking of Medicaid, I've seen a lot of hyperventilating about "deep cuts" to the program, which was already suffering poor health outcomes and restricted accessbefore Obamacare's huge expansion of it. The AHCA does eventually transition to a major reform of the dysfunctional program, but it does so via a gradual tapering and eventual halt of Medicaid's expansion several years from now, with existing recipients (including new additions under the continued expansion) grandfathered in. May I repeat: There are flaws in the bill that need to be addressed. But the fact-challenged, emotional, manipulate meltdown on the Left is designed to scare people, not inform them. And it has the side effect of distracting from the spiraling betrayals of Obamacare, a program the Left put in place last time they were in charge. I'll leave you with this strong editorial from the Wall Street Journal:

Ending ObamaCare, Part One

House Republicans take a giant step toward better health care.

The Wall Street Journal

May 4, 2017
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Pete Caster (
The media template for covering the 115th Congress apparently goes like this: When Republicans fail to pass a bill, they’re doomed. But when they succeed, they’re also doomed. Thus the same media sages who said the House could never repeal ObamaCare are now saying that the replacement the House passed Thursday can’t pass the Senate.
The wish is the mother of this analysis, and predictions about the Senate are worth about as much as the guarantees of President Hillary Clinton. The reality is that the House success, however narrow the 217-213 vote, is the first essential step toward fulfilling the GOP’s top campaign promise.
While the job was messier than it should have been, the result shows that Republicans can hold a governing majority despite unprecedented media, interest-group and Democratic hostility. The majority spanned the GOP conference from Michigan libertarian Justin Amash to moderate Carlos Curbelo, who deserves special notice for political courage considering his swing Miami district. If you doubt this is a big moment, imagine the media obituaries for Republicans if they had failed.
Credit goes to House leaders for sticking with their essential product and working around the edges to cajole a majority. The bill that passed is remarkably similar to the one that GOP leaders first introduced. The changes demanded first by the Freedom Caucus and then some moderates are tweaks that don’t alter the reform’s core architecture.
The bill includes deregulatory steps to pave the way for a variety of insurance coverage that more people can afford; the largest entitlement reform in decades by devolving control over Medicaid to the states; a $1 trillion spending cut over a decade; tax credits for individual insurance that begin to equalize the tax treatment of health care for individuals and businesses; and the repeal of ObamaCare taxes totaling $900 billion over 10 years.
The bill doesn’t repeal all of ObamaCare because it can’t without Democratic help under the Senate’s budget rules. But the bill marks a giant step away from the Democratic march to government-run health care, which is why the political and cultural left have been so vitriolic in their denunciations.
The Senate will now put its stamp on the policy, and no doubt there will be many perils of Rand Paul-ine moments with only a 52-seat GOP majority. The House bill will change, but reporters who think it is doomed should get off Twitter and make some calls. Majority Leader Mitch McConnell has been counting votes and calculating necessary compromises for some time.
House Republicans should be prepared that some of their planks may not survive Senate budget rules. They’ll have to be flexible enough to accept the compromises that are inevitable in a bicameral legislature. The trump card, so to speak, is that this process will yield a binary political choice: Either Members vote for what emerges from the House and Senate, or live with the status quo of ObamaCare.
That status quo is deteriorating as this week’s decision by Aetna to withdraw from Virginia’s health exchanges shows. Republicans need to act within weeks to clarify the rules of the individual insurance market for 2018. The lobby for the insurance industry issued a generally supportive statement on House passage, which offers some hope that congressional action can forestall a market collapse. Republicans will be blamed for that collapse whether or not they pass repeal and replace.
A word about the legislative process and political hypocrisy. Democrats and the media are howling that Republicans passed their bill before the Congressional Budget Office issued its final score of the budget and insurance impact. They have a point, but anyone voting Thursday had ample time to understand the policy choices.
As for CBO’s score, really? We don’t recall the same media concern for budget exactitude when Democrats rammed through ObamaCare on a partisan vote with more gimmicks than a traveling carnival. Remember the Class Act on long-term care that gilded the deficit numbers until it was quickly repealed? And don’t forget the government takeover of the student-loan market that was packaged with ObamaCare because CBO said it would save taxpayers money. Now loan defaults are bleeding red ink.


Which brings us to the main Republican weakness, which has been the failure to make the public case for this reform. House leaders have been preoccupied with twisting arms, leaving critics unrebutted.
President Trump deserves credit for his inside game of persuasion, and the bill wouldn’t have passed without his one-on-one lobbying. But a President also has a unique public platform, and Mr. Trump needs to use it to make a sustained case for the benefits and necessity of this reform. Tweets aren’t enough. He needs to make speeches that include persuasive details beyond superlative adjectives.
But these challenges wouldn’t matter if House Republicans had failed this week. Now it’s the Senate’s turn to fulfill seven years of promises to replace ObamaCare.
Appeared in the May. 05, 2017, print edition.

Friday, May 05, 2017

Health Care, from the Top

We cannot vote away scarcity.

By Kevin D. Williamson — May 5, 2017
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Our ongoing troubles with health care stem from an unwillingness to deal with certain facts. One of those facts is scarcity.

“Scarcity” is a term from economics, and it refers to the fact that there is never enough of anything to satisfy every possible desire — the universe holds only so much, and human desire has a way of outgrowing whatever we have. So we have to come up with a way of dividing up that which is scarce. We have tried many different ways of doing that — war, caste systems, central planning — though mostly we’ve relied on the fact that everybody wants lots of different things, which makes it possible to trade. But buying and selling stuff is not, to be sure, the only way to divide up that which is scarce.

Medical care is scarce: There are only so many doctors and hospital rooms; the pill factories can make only so many pills, and there are real limitations on the raw materials used to make those pills; heart stents don’t grow on trees, but, even if they did, they would be scarce, like apples and oranges and pears and avocados.

An example: A few years ago, a friend of mine was deathly sick with a chronic cardiac condition. He learned that a doctor in another country — on another continent — had developed an experimental treatment for his condition. The chances of its working were not very high, but it had worked on others. The problem was, there were something like three doctors in the world who did that procedure, and approximately one who had done it with a great deal of success. His insurance would not pay for it, and the public-health system in his country would not even think of paying for it. But my friend was vastly wealthy, so he called up that doctor, offered him what I assume was a very large sum of money, put him on an airplane, and rented out space in the finest private hospital money could buy. Unhappily, the procedure was not successful, and he died.

We cannot offer the same level of care to everybody with the same condition. They number in the millions, and the doctors who can perform that procedure number about three. (Or, at least they did ten years ago.) Even if they worked 16-hour shifts, seven days a week — even if we pressed them into slavery — they could see only so many patients and perform so many procedures, and those would amount to a tiny fraction of the number of people who might benefit from their attention.

Because of scarcity, medical care eventually reaches the point where one of three things happens: Somebody puts out his hand and says “Pay me,” an officer of the government or an insurance company refuses to approve some treatment, or you die.

Because we are a largely cooperative species, we do not like that very much. It seems unfair and unkind. So we try to make an end run around scarcity with things such as health insurance and government medical plans, both of which are based on the same economic principle: Someone else pays. But scarcity does not care who is paying: Scarcity is scarcity. In the most monopolistic public-health systems (e.g., the ones in the United Kingdom and Canada), there is a lot of saying “No,” though it is what we might call a “Japanese no” — saying “no” without actually saying it. They put you on a waiting list and hope you die before they actually have to say “No,” or they simply expect you to accept that some services and treatments are categorically unavailable. There is a reason New York City’s hospitals are full of rich Canadians who cannot afford the free health care at home.

But a polite, indirect “No” is still a “No.” No means no.

Insurance companies say “No” all the time, and we hate them for it. That is because of another fact that we refuse to deal with like mature, responsible adults: Insurance is not a medical product — it is a financial product. Most of us do not need to spend a great deal of money on health care during any given year for most of our lives. I myself pay for most of my medical expenses out-of-pocket, and, in any given year, they rarely add up to what my health-insurance premiums cost. But I do not have health insurance, and pay premiums for that health insurance, in order to have somebody else pay for my annual check-up or routine dental work. I have insurance because I might get hit by a bus or cancer or a heart attack, and, secondarily, because one day I will be old, if I am lucky, and old people have lots of medical expenses.
Scarcity exists because of the nature of the physical universe, not because insurance executives are big meanies.
Scarcity exists because of the nature of the physical universe, not because insurance executives are big meanies. (It’s okay to hate insurance executives — everybody hates insurance executives.) Insurance companies have to say “No” a great deal, whether they are run by nice people or by the sort of people who ordinarily run insurance companies. The Canadian government health-care system is in essence a big, generous insurance company owned by its customers and perfectly happy to run large losses indefinitely, and it still has to say “No” pretty often.

Putting mandates on insurance companies is not a cure for scarcity. Sometimes, it makes things worse. Insurance companies operate by making a very careful study of actuarial information, which allows them to make remarkably accurate predictions about the medical needs of large populations with known demographic characteristics. Nobody knows whether any given 60-year-old man will have a heart attack this year, but stack up 10 million of them, and the pointy-headed actuarial nerds can tell you with a high degree of accuracy how many of them will. But we want insurance to be something different: We want it to be the conqueror of scarcity. So we do things like mandate coverage of preexisting medical conditions, which is to say, we demand that they place bets against things that already have happened. The usual metaphor here is offering fire insurance after the house already has burned down, and that is apt. We are asking them to bet against the Patriots in the 2017 Super Bowl after the fact, in 2018, in 2019, 2020, etc.
What might a health-care program that deals with reality look like?

We could probably lower the cost of prescription drugs significantly by making the approval process less cumbrous and expensive, and maybe by tweaking a few intellectual-property procedures. We could do the same with medical devices and the like, though the so-called Affordable Care Act took the opposite approach, taxing those devices and making them scarcer. 
If we want more doctors, there are probably 1 million top-shelf physicians from around the world who would immigrate to the United States yesterday if we gave them the go-ahead. (Yes, that probably would lower the incomes of native-born doctors; we are going to be adults for the moment, and this is a question of trade-offs.) We could reduce the regulatory burden on insurance companies in an effort to lure more of them into the market, whereas the ACA added to their burdens and drove many of them from the marketplace.
We could try to make ordinary, non-emergency medical care more of an ordinary product, one that people pay for the way they pay for food and housing and cars and World of Warcraft expansion packs.
We could try to make ordinary, non-emergency medical care more of an ordinary product, one that people pay for the way they pay for food and housing and cars and World of Warcraft expansion packs and the other necessities of modern life, allowing insurance to be insurance: a financial product that helps to mitigate certain risks related to unexpected health-care costs. This would allow for the emergence of robust, competitive, consumer-oriented markets like we have in cellphones and pornography and other innovative markets where choices abound and prices keep going down because the consumer is king.

But there will be scarcity. Somebody will put his hand out and say, “Pay me.”

This brings up something economists call “elasticity of demand.” That is a fancy way of saying that when you roll into the local BMW dealer and find out that that i8 costs $150,000, you say, “No, thanks,” and you get a Honda Civic instead, but when you are rolled into the emergency room with a broken leg or a non-functioning heart, you don’t talk about prices at all, and, even if you did, you aren’t normally going to say “No” to any price when the alternative is sickness and pain and death. But not every medical procedure is a life-and-death matter, and, even in the matter of serial chronic conditions such as diabetes, there is opportunity for comparison shopping and negotiating. The other kind of medical problem is why you have insurance.

We have perfectly functional markets in all sorts of life-and-death goods. They expect you to pay up at the grocery store, too, but poor people are not starving in the American streets, because we came up with this so-crazy-it-just-might-work idea of giving poor people money and money analogues (such as food stamps) to pay for food. It is not a perfect system, but it is preferable, as we know from unhappy experiences abroad, to having the government try to run the farms, as government did in the Soviet Union, or the grocery stores, as government does in hungry, miserable Venezuela. The Apple Store has its shortcomings, to be sure, but I’d rather have a health-care system that looks like the Apple Store than one that looks like a Venezuelan grocery store.

There is a certain libertarian tendency to look at messes such as the Affordable Care Act and the American Health Care Act and throw up one’s hands, exclaiming: “Just let markets work!” We should certainly let markets work, but not “just.” We aren’t going to let children with congenital birth defects suffer just because they might have stupid and irresponsible parents, and we are not going to let old people who have outlived their retirement savings die of pneumonia because we don’t want to spend a couple of thousand bucks treating them. But we also do not have a society in which everybody is on Section 8 and food stamps, nor do we want one. Developing sensible, intelligently run, reasonably generous welfare programs for those who cannot or simply have not done it for themselves is a relatively small project, but trying to have government impose some kind of political discipline on the entirety of the health-care system — which is as explicit a part of the current daft Republican health-care program as it is of Obamacare — is a different kind of project entirely.

Scarcity is not an economic theory. You can experience it for yourself any time you like, on a desert island or the streets of New York City. It is an aspect of reality, and the health-care reformers eventually will have to get around to taking reality into consideration.


— Kevin D. Williamson is National Review’s roving correspondent.

Thursday, May 04, 2017


By Ann Coulter
May 3, 2017

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Paul Ryan (Photo by Gage Skidmore / Flickr.)

If this is the budget deal we get when Republicans control the House, the Senate and the presidency, there's no point in ever voting for a Republican again. 

Not only is there no funding for a wall, but -- thanks to the deft negotiating skills of House Speaker Paul Ryan -- the bill actually prohibits money from being spent on a wall. 

At a CYA press conference on Tuesday, Trump's ridiculously chipper budget director, Mick Mulvaney, described the bill's prohibition on building a wall as a MAJOR win. (At least Mulvaney said it in English, unlike his all-Spanish 2014 townhall.) 

True, there will be no wall. But the Democrats graciously agreed to allow the administration to fix broken parts of any existing fences on up to 40 miles of our 3,000 mile border. 

The other big wins, according to Mulvaney, are: 

1) more defense spending, which is fantastic news, because I was worried Boeing and Lockheed Martin CEOs were falling behind Mark Zuckerberg with their gluttonous salaries; and 

2) school choice, an obsession of Washington wonks that is hated out in America, where parents move to high-tax towns for the express purpose of avoiding schools full of disaffected urban youth, and the disaffected urban youth don't want to spend two hours on a bus every day. 

But Mulvaney assures us that this monstrosity of a spending bill has set things up beautifully for the next budget negotiation in October. 

That has become the GOP's official motto: "Next time!" 

We can never win this time. Instead, Republicans' idea is always to surrender this time, in hopes that their gentlemanliness will be rewarded by their mortal enemies next time. Then, next time comes, and Republicans again surrender in hopes of currying favor with the Democrats and the media for the next time.

Mulvaney's most disturbing comment was to say that what upset Trump the most was the Democrats' "spiking the football" on this deal. 

Apparently, Trump's fine with no wall -- and everything else in a bill straight out of George Soros' dream journal -- if only the Democrats hadn't been so rude as to tell the public about it. When your main complaint is that the other side is gloating too much, maybe you're not that great a negotiator. 

Yeah, sure, it's only 100 days in, it's an artificial deadline, the media is dying to say Trump has failed and so on. 

Except: Planning for the wall should have begun on Nov. 9, and a spade should have been put into the earth to begin building it the day after Trump's inauguration. Now, it's 100 days later, and we still don't have the whisper of a prospect of a wall. 

Moreover, this isn't one random bill funding Planned Parenthood (which this bill does). This is the budget deal. There won't be another one like it until next October. 

That's a spectacular failure. Democrats have got to be pinching themselves, thinking, Am I dreaming this? 

It's theoretically possible that Trump could still build a wall, but he's just massively lengthened the odds of ever prevailing. Sure, you can let the other team build a 20-point lead in first half and still come back to beat them, but it's a lot easier if you don't go into halftime 20 points down. 

Trump entered the presidency with the only kind of power that matters. He didn't owe Wall Street a thing. He didn't owe anyone -- not donors, lobbyists nor any political party. What he had was the people, passionately on his side. 

But as soon as he got into office, Trump started giving away his miraculous, unprecedented power. Hey, Wall Street! Even though you didn't give me any money, is it too late to be your friend? 

No amount of abandoning his supporters will get Trump anywhere with Wall Street, Hollywood or the media. Their ferocity will simply shift to ridicule. 

Admittedly, Trump has the enormous handicap of having to work through congressional Republicans, who are feckless cowards. If Speaker Ryan and Senate Leader Mitch McConnell had been around for Reagan's firing of the air traffic controllers, they would have been hysterically screaming, No! You can't do that -- the planes will crash! 

This isn't new information. We knew Washington Republicans were useless. That's why we elected such a comically improbable president as Donald J. Trump. 

The deal was that we were getting the Hollywood version of a New York businessman: an uncouth, incurious rube -- who would be ruthless in getting whatever he wanted. 

In addition to being the only candidate for president in either party taking America's side on trade, immigration, jobs and crime, what set Trump apart was his promise that we would finally win. 

Remember? There would be so much winning, we were going to get "sick and tired of winning," and beg him, "Please, please, we can't win anymore. ... It's too much. It's not fair to everybody else." 

We're not winning. We're losing, and we're losing on the central promise of Trump's campaign. 

How would Trump, the businessman, react if an underling charged with developing a new golf course could never break ground? 

What if the subordinate's progress reports sounded like this: I have given 21 speeches to various chambers of commerce and neighborhood groups, assuring them that there's going to be a golf course. Everywhere I go, I say, "Don't worry about it. It's going to be built!" I have started a commission to study developing a golf course. I have put up a sign saying, "Golf course coming!" And I have caved, and caved, and caved -- so now our opponents know what good guys we are. 

Trump would fire that employee so fast your head would spin. 

We want the ruthless businessman we were promised. 


Wednesday, May 03, 2017

Book Review: 'The Pursuit of Power: Europe, 18-15-1914' by Richard J. Evans

Rise to Dominance

By Donald Critchlow — April 17, 2017, Issue
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The Pursuit of Power: Europe, 1815–1914, by Richard J. Evans (Viking, 848 pp., $40)

At the end of the Napoleonic wars in 1815, Europe lay devastated. A century later, a new Europe had been created, organized around powerful nation-states. It featured expanded suffrage; better diets and health for its citizens; greater rights for the majority of the rural population, women, and religious minorities, notably Jews; increased levels of literacy for the masses; and advanced transportation, communication, and technological systems. By 1914, Europe stood as a global power, with colonies all over the world. Little did Europeans know — as British historian Richard Evans observes in his magisterial, nearly encyclopedic study of their continent’s 19th-century rise — that the world stood on the verge of an incomprehensible catastrophe.

An estimated 5 million people perished during the Napoleonic wars, including one in five Frenchmen born between 1790 and 1795. This was followed by a devastating harvest in 1816, which caused grain prices to skyrocket. Cholera, spread from trade and troop movements in India, broke out in Europe in the 1820s and returned in 1848–49; typhus and other diseases remained persistent public-health problems. In 1815, Austria stood as the most powerful state on the Continent, but hopes for a balance of power in Europe eroded owing to the emergence of a powerful and unified Germany and nationalist rebellions in Central Europe. Greece and Italy became unified nations. Poland, divided by the great powers of Austria, Prussia, and Russia, was the most notable nation that failed to find independence.

The French Revolution left a legacy of social conflict, social equality, and revolutionary outbursts in 1848 and again in the 1870s. Utopian socialism expressed itself in French thinkers such as Fourier and Saint-Simon, while revolutionary Communist ideology was given powerful coherence by Karl Marx; and Mikhail Bakunin provided justification for terrorism by anarchists and nihilists.

Liberals across Europe called for legal and constitutional reform to expand the electorate and allow freedom of the press and recognition of political parties. These reform efforts were most successful in England and, for a brief period in the 1840s, in France. Revolutionary upheavals that swept across Europe in 1848 brought moderate liberals and diehard conservatives “closer together,” Evans observes, “in a shared fear of the masses.” A new breed of politicians, such as Cavour in Italy, Bismarck in Germany, Louis Napoleon III in France, and Disraeli in England, realized that, in Evans’s words, “the preservation of order and stability required radical measures to co-opt the masses into support of the state”; “nationalism was becoming increasingly powerful, indeed unstoppable, and in their different ways they sought to exploit it for their own purposes.”

The rise of nationalism proved integral not just to national-unification movements but also to the strength of colonialism and empires. This coincided with reorganized armies and arms races. The Franco–Prussian War revealed the superiority of the Prussian military. The Prussian king, Wilhelm I, and his prime minister, Bismarck, used the war to unify Germany, setting the stage for the First World War.

In this century of political turmoil, Europe also underwent a technological and economic transformation, with England playing a critical role in industrial innovation, international trade, and finance. By 1890, Britain had a greater tonnage of shipping than the rest of the world put together. British capitalists and engineers financed and supervised the building of an extensive railway system throughout Europe. Chemical and pharmaceutical industries boomed in England, Germany, and France. Electrical companies produced new sources of power for industry and for private citizens. Cities, once squalid and disease-ridden, were provided with hygienic water supplies and improved public health. The middle class grew in numbers and influence as European economies grew.

Evans maintains that Europe surged ahead owing to “specific historical circumstances” — not to its “intrinsic superiority” (Evans’s phrase describing the opinion of some other historians, including Niall Ferguson). Evans discusses Europe’s rise with much erudition and at great narrative length but does not actually detail what he means by the “specific historical circumstances” that were crucial to this advancement. Here he might have turned to historian David Landes, who named three factors that enabled Europe to become a global economic power in this period: a deeply rooted sense of individualism, the rule of law, and property rights. Evans often passes over these factors or suggests them only by implication. In The Wealth and Poverty of Nations (1998), a work not cited by Evans, Landes provides great evidence that Europe’s economic advancement was the direct result of a unique culture founded on political competition, economic freedom, and favorable attitudes toward science and religion, as well as the comparative advantages of its climate.

Evans balances descriptions of material advances in Europe with discussion of growing economic inequality and the pursuit of empire, the latter of which he roots in xenophobia and racism. He dedicates The Pursuit of Power to the late Eric Hobsbawm, a Marxist historian who was quick to note the barbarities in modern European culture and the social inequalities produced by capitalism. Few historians can match Hobsbawm in literary ability, but Evans provides a wider historical understanding of the long 19th century by reaching beyond Europe’s great powers to include the whole continent as far as Russia.

Drawing on recent scholarship on private life, popular and literary culture, and the environment, Evans weaves a rich tapestry of unparalleled historical transformation. In detail and inclusiveness, Evans exceeds Hobsbawm. Evans is neither a historical materialist nor an economic determinist; he understands the role of freedom and accident in history.

His focus, as far-reaching as it is, does tend to downplay the positive role played by religion in this period. Evans emphasizes the growth of secularism that came from the advancement of science, Darwinian evolutionary theory, and literary and cultural criticism. He pays less analytical attention to the role that religion, especially Protestant Evangelical revivalism, played in tempering capitalist greed and inspiring social reform. The 19th century, particularly in England, was swept by religious revivals. This religious spirit fostered moral reform, including anti-slavery, temperance, women’s-rights, and anti-animal-cruelty movements. The wealthy were inspired with a philanthropic impulse to create benevolent societies and to promote better conditions for workers, the indigent, and the ill. Polish national identity survived in large part because of the Catholic Church. Evans discusses these efforts but overlooks the possibility that the 19th century was as much an age of religion as one of secularism.

Evans maintains that, in the course of mass emigration to other parts of the world, “Europe’s social and cultural limits became blurred.” Perhaps, but at the same time British, French, and German literature spread to Asia, Africa, and Latin America; European educational systems were implemented throughout the world; and ideas of Western democracy and the rule of law inspired national reformers in India, China, and Japan, and throughout Africa and the Middle East. Scientific and medical knowledge developed in Europe transformed the world. The impact of European literary, political, technological, and scientific contributions suggests less a “cultural blurring” than a clear, sharp transformation.

The nation-state and the corresponding rise of nationalism characterized the 19th century. Patriotic spirit within the masses of each nation presented the Left in Europe (and the United States) with a political problem: For all their talk of international solidarity, socialist parties and left-wing intellectuals confronted a deeply rooted patriotic spirit within the masses, tapped by right-wing and centrist parties. However much nationalism was founded on what Hobsbawm called “invented traditions” and created national myths, it presented an intractable problem for the Left, as evidenced in the First World War — and today: Nationalism has found new expression in politics following the Great Recession of 2009 and is manifested in Brexit in Britain, Marine Le Pen in France, and anti-immigrant and anti-EU politics throughout Europe.

If the 19th century can be characterized by the rise of the nation-state and nationalism, the 21st century, at least in its first decades, illustrates the power of patriotic expression, a power not easily erased by the global economic integration set in motion two centuries earlier.

– Mr. Critchlow, a professor of history at Arizona State University, is the author of Future Right: The Forging of a New Republican Majority.